Trends in HIV prevalence and HIV testing among young MSM: five United States cities, 1994-2011

Acceptability of an automated directly observed therapy (DOT) application for PrEP adherence support among young men who have sex with men: a qualitative exploration

Pre-exposure prophylaxis (PrEP) adherence remains a challenge among young men who have sex with men (MSM). We developed and tested a smartphone application ("app"), "DOT Diary", which combines automated directly observed therapy (DOT) with information about PrEP protection levels, pill-taking reminders, a sexual behavior diary, and a PrEP dosing calendar. To contextualize trial results, we qualitatively explored participants' app experiences. The trial enrolled 100 young MSM in San Francisco and Atlanta. Participants were randomized 2:1 to DOT Diary versus standard-of-care and followed for 24 weeks. Interviews were conducted with 24 intervention participants. Data were analyzed using a memo-writing approach. Most expressed overall satisfaction with the app ("it was good for its purpose"), despite concerns about technical glitches. The most popular app features were the monthly calendar showing days PrEP was taken and information about level of protection based on pills taken. The DOT component helped participants establish PrEP routines. The reminders were "annoying but effective" at motivating dosing. Opinions about the sexual behavior diary varied. Overall, DOT Diary was acceptable; participants were willing to use it daily to record pill-taking. Critical components included the information about PrEP protection levels and calendar, while others may be modified to improve future success.Trial registration: ClinicalTrials.gov identifier: NCT03771638.

Cascade analysis of awareness, willingness, uptake and adherence with regard to PrEP among young men who have sex with men (YMSM) in China: A comparison between students and non-students

INTRODUCTION

In China, young men who have sex with men (YMSM) are one of the groups most at risk of HIV/AIDS. The uptake of pre-exposure prophylaxis (PrEP) among YMSM has not been well documented. A cascade analysis of awareness, willingness, use and adherence with regard to PrEP was conducted separately among YMSM students and non-students.

METHODS

From 20 October to 30 December 2021, all adolescents aged 16-24 years were selected for the study from among MSM recruited from 31 provincial administrative regions in mainland China. Participants were included in a cross-sectional study of awareness, willingness, use and adherence with regard to PrEP among YMSM. Logistic regression modelling was used to identify factors associated with the four outcomes.

RESULTS

Among 1014 student and 866 non-student YMSMs, respectively, 88.07% and 81.64% had heard of PrEP; 58.16% and 50.35% were willing to use PrEP; 7.59% and 7.62% had used PrEP; and 3.16% and 3.58% had adhered to PrEP. Among students, those living in high-risk areas and pilot cities and those who had engaged in commercial sex and group sex had a positive effect on PrEP use, and the same trends were found among non-students living in high-risk areas and pilot cities and those who had engaged in group sex. 'Daily oral' and 'flexible' PrEP use positively influenced adherence among both groups.

CONCLUSIONS

A differentiation strategy of PrEP promotion should be implemented among YMSM. Material support for students, such as financial resources, should increase, while non-students should increase their level of perception of HIV risk.

HIV in Three Groups of Young People from Medellín: General Population, Organizations for People with Socioeconomic Vulnerability, and Men Who Have Sex with Other Men

Introduction

In Colombia, there are no studies that analyze the effect of socioeconomic vulnerability and belonging to the group of men who have sex with other men (MSM) on the prevalence of HIV in young people.

Objective

To compare the prevalence of HIV in three groups of young people from Medellín-Colombia: general population, socioeconomic vulnerability and MSM.

Methods

This cross-sectional analytical study included 2449 young people from the general population, 1736 from institutions that serve young people in situations of socioeconomic vulnerability, and 2269 MSM. The prevalence of infection in each group was determined, statistical differences were identified using Pearson's Chi-square and Trend's Chi-square, and crude and adjusted odds ratios were estimated using logistic regression with 95% confidence intervals. Analyses were performed in SPSS 29.0.

Results

HIV prevalence was 0.8% in the general population group, 1.3% in young people with socioeconomic vulnerability, and 5.6% in MSM. The groups with the highest HIV were as follows: (i) in MSM it was 4.1 compared to the general population, (ii) between 25-28 years of age it was 2.9 times compared to those under 20 years, (iii) in men it was 10 times that registered in women, (iv) in young people with primary, secondary, technical and university studies it was 7.1; 6.7; 11.0 and 14.5 times that found in those who did not register studies, (v) in affiliates of the subsidized health regime it was 2.2 times and in those without affiliation 2.4 times compared to the infection in affiliates of the contributory health regime.

Conclusion

HIV prevalence was high, and explained by socioeconomic vulnerability, having sex between men, gender, age, education, and health affiliation, demonstrating the intersectionality of determinants of the health system, socioeconomic status, and determinants individuals in the occurrence of HIV in young people in Medellín.

Assessing the Prevalence and Determinants of Exposure-Influenced HIV Testing among a Sample of Pre- and Post-Exposure Prophylaxis-Naïve Young Men Who Have Sex with Men in the United States

Self-initiated Human Immunodeficiency Virus (HIV) testing after potential sexual exposure to HIV (i.e., exposure-influenced HIV testing) has high utility in detecting individuals with the highest probabilities of HIV seroconversion. We conducted a cross-sectional study among a sample of sexually active, pre/post-exposure prophylaxis (PrEP/PEP)-naïve young men who have sex with men (YMSM) in two US cities to assess the determinants (e.g., demographic, psychosocial, sexual, substance use, and HIV prevention characteristics) of exposure-influenced HIV testing (never/rarely vs. mostly/always) in their lifetime. Of 261 YMSM, only 26.5% reported mostly/always seeking exposure-influenced prior to the study. Multivariable analyses showed that younger age, sexual orientation non-disclosure, perceived HIV stigma, internalized homophobia, lower general resilience, and lower social support were associated with a lower likelihood of mostly/always seeking exposure-influenced HIV testing. YMSM who never/rarely sought exposure-influenced HIV testing were more likely to use recreational drugs before sex, binge alcohol, and have group sex; while less likely to be aware of PrEP, test for sexually transmitted infections, or use condoms compared to those mostly/always seeking exposure-influenced HIV testing. Exposure-influenced HIV testing is suboptimal among YMSM with elevated risk for HIV. Our findings provide important implications for designing targeted interventions to promote exposure-influenced HIV testing among high-risk YMSM.

Acceptability and uptake of HIV self-testing in emergency care settings: A systematic review and meta-analysis

BACKGROUND

Emergency departments (ED) interface with large numbers of patients that are often missed by conventional HIV testing approaches. ED-based HIV self-testing (HIVST) is an innovative engagement approach which has potential for testing gains among populations that have failed to be reached. This systematic review and meta-analysis evaluated acceptability and uptake of HIVST, as compared to standard provider-delivered testing approaches, among patients seeking care in ED settings.

METHODS

Six electronic databases were systematically searched (Dates: January 1990-May 2021). Reports with data on HIVST acceptability and/or testing uptake in ED settings were included. Two reviewers identified eligible records (κ= 0.84); quality was assessed using formalized criteria. Acceptability and testing uptake metrics were summarized, and pooled estimates were calculated using random-effects models with assessments of heterogeneity.

RESULTS

Of 5773 records identified, seven met inclusion criteria. The cumulative sample was 1942 subjects, drawn from three randomized control trials (RCTs) and four cross-sectional studies. Four reports assessed HIVST acceptability. Pooled acceptability of self-testing was 92.6% (95% confidence interval [CI]: 88.0%-97.1%). Data from two RCTs demonstrated that HIVST significantly increased testing uptake as compared to standard programs (risk ratio [RR] = 4.41, 95% CI: 1.95-10.10, I2  = 25.8%). Overall, the quality of evidence was low (42.9%) or very low (42.9%), with one report of moderate quality (14.2%).

CONCLUSIONS

Available data indicate that HIVST may be acceptable and may increase testing among patients seeking emergency care, suggesting that expanding ED-based HIVST programs could enhance HIV diagnosis. However, given the limitations of the reports, additional research is needed to better inform the evidence base.

HIV testing preferences, barriers and facilitators to receiving HIV services among young Black sexual minority men

Young Black sexual minority men (YBSMM) represent a high-priority population for HIV prevention research. HIV testing is a critical public health tool to prevent HIV transmission and is an integral component of health care for high-priority populations. The present study uses Andersen's model of health care utilization as a framework to explore the HIV testing preferences of YBSMM and the barriers and facilitators to receiving HIV services as a means to increase regular HIV testing. A sample of 57 YBSMM (M =19 years) in Washington, DC responded to closed and open-ended questions regarding preferences for HIV testing across various venues. Approximately 61% of the sample reported a previous HIV test and 12% reported a positive result. Participants were most willing to receive free HIV testing at medical establishments and schools. Concerns for privacy were most notable for testing at churches, malls, and schools. Identified barriers to receiving HIV services included cost, stigma, privacy, and access whereas identified facilitators included low cost and support. The findings encourage integrating regular HIV testing into the health care regiment of YBSMM and increasing youth's autonomy over their sexual health.

Trajectories of and disparities in HIV prevalence among Black, white, and Hispanic/Latino men who have sex with men in 86 large U.S. metropolitan statistical areas, 1992-2013

PURPOSE

The challenges of producing adequate estimates of HIV prevalence among men who have sex with men (MSM) are well known. No one, to our knowledge, has published annual estimates of HIV prevalence among MSM over an extended period and across a wide range of geographic areas.

METHODS

This article applies multilevel modeling to data integrated from numerous sources to estimate and validate trajectories of HIV prevalence among MSM from 1992 to 2013 for 86 of the largest metropolitan statistical areas in the United States.

RESULTS

Our estimates indicate that HIV prevalence among MSM increased, from an across-metropolitan statistical area mean of 11% in 1992 to 20% in 2013 (S.D. = 3.5%). Our estimates by racial/ethnic subgroups of MSM suggest higher mean HIV prevalence among black and Hispanic/Latino MSM than among white MSM across all years and geographic regions.

CONCLUSIONS

The increases found in HIV prevalence among all MSM are likely primarily attributable to decreases in mortality and perhaps also to increasing HIV incidence among racial/ethnic minority MSM. Future research is needed to confirm this. If true, health care initiatives should focus on targeted HIV prevention efforts among racial/ethnic minority MSM and on training providers to address cross-cutting health challenges of increased longevity among HIV-positive MSM.

Individual- and Partnership-Level Correlates of Protective Barrier Use in a Sample of Transmasculine Adults with Diverse Sexual Partnerships

The sexual partnerships of transmasculine adults-who were assigned female at birth and identify on the masculine gender continuum-remain understudied. This includes characteristics of transmasculine adults' sexual partnerships associated with engaging in HIV/sexually transmitted infection (STI) sexual risk behavior. This study examined individual- and partnership-level factors of transmasculine adults' sexual partnerships associated with using a protective barrier during sexual activity. Data came from cross-sectional surveys administered to 141 transmasculine adults. Participants provided demographic and sexual health information for up to three sexual partners from the past 12 months (n = 259 partnerships). Generalized estimating equations (GEEs) were used to investigate individual- and partnership-level factors associated with any use of a protective barrier during five sexual behaviors. Transmasculine participants engaged in an array of sexual behaviors with diverse sexual partners. Individual- and partnership-level factors of transmasculine adults' sexual partnerships were associated with their protective barrier use; however, these associations varied in statistical significance across the five sexual behaviors. At the individual level, younger participants had lower odds of protective barrier use during fingering or fisting. At the partnership level, protective barrier use was associated with a sexual partnership's configuration and the gender identity of a sexual partner. Relative to participants with cisgender female partners, those with cisgender male partners generally had lower odds of using a protective barrier. Study findings highlight the importance of studying factors associated with HIV/STI risk behavior located beyond the individual. These findings may have implications for improving measurements of HIV/STI-related risk for transmasculine adults.

A Theoretically Based Mobile App to Increase Pre-Exposure Prophylaxis Uptake Among Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial

Background

HealthMindr is a mobile phone HIV prevention app for men who have sex with men (MSM). In a previous pilot study, HealthMindr was found to be acceptable among users and to demonstrate preliminary effectiveness for increasing pre-exposure prophylaxis (PrEP) uptake among MSM. PrEP is a highly effective HIV prevention intervention; however, uptake remains low.

Objective

The aim of this study will be to assess the efficacy of a mobile app for increasing PrEP uptake among MSM in the southern United States.

Methods

In this randomized controlled trial, we will assess the efficacy of HealthMindr for increasing PrEP uptake among MSM in the following three southern US cities: Atlanta, Georgia; Jackson, Mississippi; and Washington, DC. In total, 657 men will be recruited and randomized to intervention and control arms in a 2:1 ratio. Participants in the intervention arm will receive access to the full HealthMindr app, with information and resources about PrEP (eg, frequently asked questions, risk assessment tool, and PrEP provider locator), other HIV prevention information, ability to order free HIV/sexually transmitted infection test kits, and additional resources related to substance use and mental health. Participants in the control arm will use the HealthMindr app but will only have access to the study timeline and a message center to communicate with study staff. Participants will complete quarterly surveys to assess self-reported PrEP uptake over 12 months of follow-up. Self-reported PrEP uptake will be verified by dried blood spot testing and/or uploading a photograph of a PrEP prescription.

Results

Participant recruitment began in January 2020.

Conclusions

This trial will determine whether the HealthMindr app can increase PrEP uptake among MSM in the southern United States.

Trial Registration

ClinicalTrials.gov NCT03763942; https://clinicaltrials.gov/ct2/show/NCT03763942

International Registered Report Identifier (IRRID)

PRR1-10.2196/16231

Sex work, discrimination, drug use and violence: a pattern for HIV risk among transgender sex workers compared to MSM sex workers and other MSM in Guatemala

The risk of HIV infection is higher among transgender women and cisgender men who have sex with men (MSM) compared to the general population due in part to social and contextual factors. This study aimed to determine the prevalence and association of alcohol and drug abuse, discrimination and violence among transgender sex workers compared to cisgender male sex workers and cisgender men who had not received money for sex in Guatemala City. In 2010, transgender women and cisgender men who had had sex with men or transgender women were recruited into a cross-sectional behavioural survey. Among transgender women, 86% received money for sex in the past year. Transgender sex workers were more likely to use drugs and binge drink, three times as likely to be discriminated against and eight times as likely to be forced to have sex compared to non-sex worker men. Male sex workers were twice as likely to use illicit drugs or experience physical violence and six times as likely to experience forced sex compared to non-sex worker men. Transgender and male sex workers would benefit from harm reduction for substance use, violence prevention, response and strategies to mitigate discrimination.

Online sex partner seeking and HIV testing frequency among young Black sexual minority men

Dating apps are a novel means of delivering HIV prevention messages. Young black sexual minority men (YBSMM) app users are at high risk for HIV and could benefit from frequent testing. Understanding testing behaviors among YBSMM is critical to inform tailored prevention interventions. We analyzed testing behaviors of 273 YBSMM, comparing typical testing frequency between app users and non-users using odds ratios. Overall, testing rates were high. App users were more likely than non-users to test at least every 12 months. App-using YBSMM exhibit high compliance with testing guidelines, which may indicate future successful uptake of biomedical preventions, such as Pre-Exposure Prophylaxis.

Global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017

BACKGROUND

Understanding the patterns of HIV/AIDS epidemics is crucial to tracking and monitoring the progress of prevention and control efforts in countries. We provide a comprehensive assessment of the levels and trends of HIV/AIDS incidence, prevalence, mortality, and coverage of antiretroviral therapy (ART) for 1980-2017 and forecast these estimates to 2030 for 195 countries and territories.

METHODS

We determined a modelling strategy for each country on the basis of the availability and quality of data. For countries and territories with data from population-based seroprevalence surveys or antenatal care clinics, we estimated prevalence and incidence using an open-source version of the Estimation and Projection Package-a natural history model originally developed by the UNAIDS Reference Group on Estimates, Modelling, and Projections. For countries with cause-specific vital registration data, we corrected data for garbage coding (ie, deaths coded to an intermediate, immediate, or poorly defined cause) and HIV misclassification. We developed a process of cohort incidence bias adjustment to use information on survival and deaths recorded in vital registration to back-calculate HIV incidence. For countries without any representative data on HIV, we produced incidence estimates by pulling information from observed bias in the geographical region. We used a re-coded version of the Spectrum model (a cohort component model that uses rates of disease progression and HIV mortality on and off ART) to produce age-sex-specific incidence, prevalence, and mortality, and treatment coverage results for all countries, and forecast these measures to 2030 using Spectrum with inputs that were extended on the basis of past trends in treatment scale-up and new infections.

FINDINGS

Global HIV mortality peaked in 2006 with 1·95 million deaths (95% uncertainty interval 1·87-2·04) and has since decreased to 0·95 million deaths (0·91-1·01) in 2017. New cases of HIV globally peaked in 1999 (3·16 million, 2·79-3·67) and since then have gradually decreased to 1·94 million (1·63-2·29) in 2017. These trends, along with ART scale-up, have globally resulted in increased prevalence, with 36·8 million (34·8-39·2) people living with HIV in 2017. Prevalence of HIV was highest in southern sub-Saharan Africa in 2017, and countries in the region had ART coverage ranging from 65·7% in Lesotho to 85·7% in eSwatini. Our forecasts showed that 54 countries will meet the UNAIDS target of 81% ART coverage by 2020 and 12 countries are on track to meet 90% ART coverage by 2030. Forecasted results estimate that few countries will meet the UNAIDS 2020 and 2030 mortality and incidence targets.

INTERPRETATION

Despite progress in reducing HIV-related mortality over the past decade, slow decreases in incidence, combined with the current context of stagnated funding for related interventions, mean that many countries are not on track to reach the 2020 and 2030 global targets for reduction in incidence and mortality. With a growing population of people living with HIV, it will continue to be a major threat to public health for years to come. The pace of progress needs to be hastened by continuing to expand access to ART and increasing investments in proven HIV prevention initiatives that can be scaled up to have population-level impact.

FUNDING

Bill & Melinda Gates Foundation, National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH.

The prevalence of HIV among MSM in China: a large-scale systematic analysis

BACKGROUND

The prevalence of HIV among men who have sex with men (MSM) has become a significant public health challenge. The aim was to comprehensively estimate the national prevalence of HIV among MSM and its time trends through a large-scale systematic analysis.

METHODS

Systematic search of Cochrane Library, PubMed, EMBASE, CNKI, VIP, and Wanfang Data databases without language restriction for studies on the prevalence of HIV among MSM published before Dec.31, 2018. Studies were eligible for inclusion if they were published in the peer-reviewed literature and used validated assessment methods to assess the prevalence of HIV among MSM. Estimates were pooled using random-effects analysis.

RESULTS

Data were extracted from 355 cross-sectional studies (571,328 individuals) covered 59 cities from 30 provinces and municipalities of China. The overall national prevalence of HIV among MSM from 2001 to 2018 was estimated to be 5.7% (95% CI: 5.4-6.1%), with high between-study heterogeneity (I2 = 98.0%, P <  0.001). Our study showed an increased tendency in the HIV prevalence as time progressed by meta-regression analysis (I2 = 95.9%, P <  0.0001). HIV prevalence was the highest in those aged 50 years and older with HIV prevalence of 19.3% (95%CI: 13.1-27.4%, N = 13). HIV was more prevalent in the illiterate population (16.8%), than in those who had received an education. Although the internet was a major venue for Chinese MSM seeking male sex partners (35.6, 95%CI: 32.3-39.9%, N = 101), seeking MSM in bathhouses/saunas had the highest associated prevalence of HIV (13.4, 95%CI: 10.3-17.1%, N = 22). The HIV prevalence among MSM varied by location: compared with other regions in China, HIV was highly prevalent among MSM in the southwest (10.7, 95%CI: 9.3-12.2%, N = 91). Compared to participants who sometimes or always used condoms, participants who had never used a condom in the past 6 months had a higher risk of HIV infection, with odds ratios of 0.1 (95%CI: 0.08-0.14).

CONCLUSIONS

Our analysis provided reliable estimates of China's HIV burden among MSM, which appears to present an increasing national public health challenge. Effective government responses are needed to address this challenge and include the implementation of HIV prevention.

Sexual Risk Behaviors in Adolescent Sexual Minority Males: A Systematic Review and Meta-Analysis

Although adolescent sexual minority males (ASMM) are at increased risk for human immunodeficiency virus (HIV) in the United States (US), studies that estimate sexual risk behaviors that contribute to HIV risk in ASMM are limited. We completed a systematic review and meta-analysis to compile available data and estimate the prevalence of risk behaviors in this population. We searched four databases for key terms related to ASMM, defined as males aged 14 through 19 who identified as gay or bisexual, reported sex with a male in their lifetime, and/or were considered sexual minority by the study. Articles eligible for inclusion were in English, from US studies, and reported quantitative data on sexual risk behaviors among ASMM. We extracted data from eligible articles and meta-analyzed outcomes reported in three or more articles using random effects. Of 3864 articles identified, 21 were eligible for data extraction. We meta-analyzed nine outcomes. Sixty-two percent of adolescent males self-identifying as gay or bisexual ever had sex with a male, and 67% of participants from ASMM studies recently had sex. Among ASMM who had sex in the last 6 months or were described as sexually active, 44% had condomless anal intercourse in the past 6 months, 50% did not use a condom at last sex, and 32% used alcohol or drugs at their last sexual experience. Available data indicate that sexual risk behaviors are prevalent among ASMM. We need more data to obtain estimates with better precision and generalizability. Understanding HIV risk in ASMM will assist in intervention development and evaluation, and inform behavioral mathematical models.

Effects of mobile health on HIV risk reduction for men who have sex with men

Mobile health (M-Health) has become a novel method for HIV prevention and the effects need to be promoted. The study purpose was to exam how a smartphone application (app) reduces HIV risky behaviour in men who have sex with men (MSM). The Safe Behaviour and Screening (SBS) app was developed, and included five features: record, output, and resources connection; information provision; testing services; interaction; and online statistics. A random assignment was used. The experimental group used the SBS app for six months. The control group did not use any intervention. There were 130 participants in the experimental group, and 135 in the control group. The average age of all subjects was 27.38 (SD = 5.56). Compared to the control group, the experimental group had significantly higher mean score of safe behaviour knowledge, motivation, and skills; percentage of condom use during anal intercourse; frequency of searching for testing resources and getting HIV and syphilis tests. The frequency of anal intercourse and recreational drug usage were significantly lower in the experimental group. The SBS app could decrease the HIV risky behaviour among MSM and be applied to HIV prevention and nursing intervention.

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.

Beliefs About the End of AIDS, Concerns About PrEP Functionality, and Perceptions of HIV Risk as Drivers of PrEP Use in Urban Sexual Minority Men: The P18 Cohort Study

Using cross-sectional data from an ongoing cohort study of young gay, bisexual, and other men who have sex with men (N = 492), we examined the extent to which cognitive factors such as beliefs about the end of AIDS, concerns about the manner in which PrEP works, and perceptions about risk of contracting HIV, are related to PrEP uptake and use. While almost all participants indicted awareness of PrEP, a mere 14% had ever used PrEP. Those with lower concerns about the side effects of PrEP and greater belief that treatment and PrEP would eliminate AIDS were also more likely to have ever used PrEP. Our findings support the ongoing challenges of PrEP uptake as means of curtailing HIV in young sexual minority men, and suggest that beyond the structural factors, consideration must be given to further educating the population as a means of adjusting potentially faulty beliefs, concerns, and perceptions which may influence PrEP utilization.

Statistical adjustment of network degree in respondent-driven sampling estimators: venue attendance as a proxy for network size among young MSM

We introduce a new venue-informed network degree measure, which we applied to respondent-driven sampling (RDS) estimators. Using data collected from 746 young MSM in 2014-2016 in Chicago, IL, and Houston, TX, we estimated the population seroprevalence of HIV and syphilis and risk/protective behaviors, using RDS estimates with self-reported network size as a standard degree measure as well as our proposed venue-informed degree measure. The results indicate that the venue-informed degree measure tended to be more efficient (smaller variance) and less biased than the other measure in both cities sampled. Venue attendance-adjusted network size may provide a more reliable and accurate degree measure for RDS estimates of the outcomes of interest.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

High Substance Use and HIV Risk Behavior Among Young Argentine Men Who Have Sex with Men

In the United States young men who have sex with men have higher rates of substance use, higher HIV incidence, and less frequent HIV testing than their heterosexual counterparts and older MSM. Less is known about comparable populations in Latin America. As part of an epidemiological study, MSM were recruited through Respondent Driven Sampling in the metropolitan area of Buenos Aires, Argentina and answered a computerized behavioral survey. From the total of 500 MSM enrolled, a sub-sample of 233 aged 18-25 was analyzed. The sample was concentrated among lower socioeconomic strata, and only 16% identified as gay. Nearly half reported male, female, and transvestite sexual partners. Reported substance use was widespread ranging from 61% for marijuana to 20% for pasta base (cocaine sulfate). Seventy percent of the sample had never been tested for HIV infection; 3% tested positive for HIV and 8% for syphilis during the study.

Comparison of Home-Based Oral Fluid Rapid HIV Self-Testing Versus Mail-in Blood Sample Collection or Medical/Community HIV Testing By Young Adult Black, Hispanic, and White MSM: Results from a Randomized Trial

We aimed to determine in a randomized trial if young adult black, Hispanic, and white men-who-have-sex-with-men (YMSM) are more likely to complete home-based oral fluid rapid HIV self-testing than either mail-in blood sample collection or medical facility/community organization-based HIV testing. Stratified by race/ethnicity, participants were randomly assigned to use a free oral fluid rapid HIV self-test (n = 142), a free mail-in blood sample collection HIV test (n = 142), or be tested at a medical facility/community organization of their choice (n = 141). Of the 425 participants, completion of assigned test (66% oral fluid vs. 40% mail-in blood sample vs. 56% medical facility/community), willingness to refer (36% oral fluid vs. 20% mail-in blood sample vs. 26% medical facility/community), and legitimate referrals (58% oral fluid vs. 43% mail-in blood sample vs. 43% medical facility/community) were greater in the oral fluid rapid HIV self-test than the mail-in blood sample collection HIV test arm, but not the medical facility/community testing arm. There were no differences in assigned test completion by race/ethnicity. Although free home-based oral fluid rapid HIV self-testing showed moderate promise in facilitating HIV testing among black, Hispanic, and white YMSM, it did not lead to greater testing than directing these YMSM to medical facility/community HIV testing venues. ClinicalTrials.gov Identifier: NCT02369627.

Relationship between the use of gay mobile phone applications and HIV infection among men who have sex with men in Ningbo, China: a cross-sectional study

In recent years, there has been a significant increase in the use of gay mobile phone applications (gay apps) and HIV prevalence among men who have sex with men (MSM) in China. The aim of this study was to investigate whether there was a relationship between the use of gay apps and HIV infection and provide a targeted intervention to MSM. A cross-sectional study was conducted. Chinese MSM who were over 18 years old and had self-reported homosexual intercourse in the past six months were interviewed in 2016. Proportions were used for categorical variables and determinants of HIV infection were assessed using univariate and multivariate regression. Of the 403 participants, nearly 66.0% reported having used gay apps to seek sexual partners in the past six months. A higher proportion of the gay app users were younger than 19 years old, single, had high school education, were earning less than 115 GBP income per month, and identified themselves as homosexual. Compared to app non-users, a greater proportion of app users reported a higher frequency of male-male sexual contact (≥1 time/week: 57.5% versus 39.4%, p < 0.01), multiple male sex partners (34.2% versus 11.7%, p < 0.001), and unprotected sex with men (51.5% versus 36.5%, p < 0.01) in the past six months. The prevalence of HIV among app users was 7.9%. HIV infection was significantly associated with being an app user (adjusted odds ratio = 5.2, 95% CI = 1.1-24.3). It is suggested that the use of gay apps, especially Blued, is popular among Chinese MSM and is associated with high-risk sexual behaviors and HIV infection. Therefore, there is an urgent need to promote HIV testing and HIV prevention through gay apps to decrease the risk of HIV infection among Chinese MSM.

Patterns of HIV testing practices among young gay and bisexual men living in Scotland: a qualitative study

Background

Increasing overall rates, and frequency, of HIV testing in populations at risk is a key public health objective and a critical dimension of HIV prevention efforts. In the UK, men who have sex with men (MSM) remain one of the communities most at risk of HIV and, within this, young gay men are a key risk group. Understanding HIV testing practices is important in the development of interventions to promote testing among young gay and bisexual men.

Methods

Qualitative interviews were conducted with thirty young gay and bisexual men (aged 18–29) in Scotland. Thematic analysis of men’s accounts of their approach to HIV testing identified three overarching patterns of testing: ‘habitual’, ‘reactive’ and ‘ad hoc’.

Results

This qualitative study, the first to explore patterns of HIV testing practices among young gay and bisexual men in the UK, contributes novel findings around the role of social support and ‘community’ in shaping young men’s approaches to HIV testing. The findings suggest that social support can play an important role in encouraging and facilitating HIV testing among young gay men, however, social norms of non-testing also have the potential to act as a barrier to development of a regular routine. Men with habitual testing practices framed HIV testing as both a personal and ‘community’ responsibility, and more effective than testing in response to risk events or emergent symptoms. Men who reported reactive testing practices described testing for HIV primarily in response to perceived exposure to sexual risk, along with ‘transitional moments’ such as starting, ending or changes to a relationship. Among young men who reported testing on an ad hoc basis, inconvenience and disruptions to HIV testing practices, particularly where men lacked social support, acted as a barrier to developing a routine of regular testing.

Conclusions

Our findings suggest that interventions which seek to increase rates of HIV testing and testing frequency among young gay and bisexual men should include a specific focus on promoting and supporting positive testing practices within young men’s friendship groups and wider gay communities.

CDC-funded HIV testing, HIV positivity, and linkage to HIV medical care in non-health care settings among young men who have sex with men (YMSM) in the United States

In the United States, HIV infection disproportionately affects young gay, bisexual, and other men who have sex with men, aged 13-24 years (collectively referred to as YMSM), specifically black YMSM. Knowledge of HIV status is the first step for timely and essential prevention and treatment services. Because YMSM are disproportionately affected by HIV, the number of CDC-funded HIV testing events, overall and newly diagnosed HIV positivity, and linkage to HIV medical care among YMSM in non-health care settings were examined from 61 health department jurisdictions. Differences by age and race/ethnicity were analyzed. Additionally, trends in number of HIV testing events and newly diagnosed HIV positivity were examined from 2011 to 2015. In 2015, 42,184 testing events were conducted among YMSM in non-health care settings; this represents only 6% of tests in non-health care settings. Overall and newly diagnosed HIV positivity was 2.8% and 2.1%, respectively, with black/African-American YMSM being disproportionately affected (5.6% for overall; 4% for newly diagnosed); 71% of YMSM were linked within 90 days. The newly diagnosed HIV positivity among YMSM decreased from 2.8% in 2011 to 2.4% in 2015, and the number of newly diagnosed YMSM also decreased. Further targeted testing efforts among YMSM are needed to identify undiagnosed YMSM, specifically black YMSM.

Multiplex Competition, Collaboration, and Funding Networks Among Health and Social Organizations: Toward Organization-based HIV Interventions for Young Men Who Have Sex With Men

BACKGROUND

Young men who have sex with men (YMSM) have the highest rates of human immunodeficiency virus (HIV) infection in the United States. Decades into the HIV epidemic, the relationships that YMSM-serving health and social organizations have with one another has not been studied in depth.

OBJECTIVES

The aim of this study was to examine the competition, collaboration, and funding source structures of multiplex organization networks and the mechanisms that promote fruitful relationships among these organizations.

RESEARCH DESIGN

The study data collection method was a survey of health and social organizations from 2013-2014 in 2 cities, Chicago, IL and Houston, TX.

SUBJECTS

Study participants were representatives from 138 health and social organizations.

MEASURES

Responses to survey questions were used to reconstruct competition, collaboration, and combined competition-collaboration networks.

RESULTS

While taking into consideration the collaborative relationships among organizations, we provide statistical evidence that organizations of similar type, similar social media use patterns, comparable patterns of funding, and similar network contexts tended to compete with one another. This competition was less likely to be accompanied by any sort of collaboration if the organizations shared common funding sources.

CONCLUSIONS

Competition that excludes potential collaboration may be detrimental to mobilizing the collective efforts that serve local YMSM communities. System-level interventions may provide promising approaches to scaling-up HIV prevention and treatment efforts so as to encourage organizations to form partnerships with otherwise competing providers.

Prospective Effects of a Syndemic on HIV and STI Incidence and Risk Behaviors in a Cohort of Young Men Who Have Sex with Men

Young men who have sex with men continue to be highly affected by HIV. To improve understanding of the role that multiple co-occurring health issues (i.e., syndemics) play in HIV acquisition, sophisticated modeling methods are needed. The purpose of this study was to use structural equation modeling to understand the structure of the syndemic and to test its longitudinal association with condomless anal sex. Data are from a longitudinal study of 450 YMSM. A primary syndemic component comprised of substance use, violence, and internalizing mental health factors significantly predicted the number of condomless anal sex partners in the full sample. Analyses exploring associations by race/ethnicity found a significant association among White YMSM, but not among Black or Latino YMSM. Higher-order factor modeling suggests these psychosocial factors form a syndemic in all racial/ethnic groups, but the syndemic, as conceptualized here, may be less relevant to racial/ethnic minority YMSM.

Epidemiology of Acquired Immune Deficiency Syndrome and Cerebrovascular Disease in a Post Antiretroviral Era

BACKGROUND

People with acquired immune deficiency syndrome (AIDS) develop ischemic stroke through distinct mechanisms. These include infections such as syphilis, tuberculosis, varicella, and other conditions such as cocaine abuse, endocarditis, and hypercoagulability. The effect of improved awareness, detection, and treatment with highly active antiretroviral therapy (HAART) on the incidence and outcome of AIDS patients with stroke is unknown.

METHODS

Data from the Nationwide Inpatient Sample from 1995 to 2010 were analyzed. Patients with ischemic stroke and AIDS were identified using ICD-9 (International Classification of Diseases) codes. Time trends for demographics, survival, and frequency of AIDS-associated conditions were analyzed.

RESULTS

Proportion of AIDS among stroke patients increased significantly during the study. Median age of all strokes decreased from 75 years in 1995 to 72 years in 2010. Conversely, median age for men with stroke and AIDS increased from 43 years to 53 years; and for women with stroke and AIDS, from 41 years to 51 years. Death rates from stroke in the AIDS patients declined. In recent years, the death rates from stroke are similar to patients without HIV/AIDS. Stroke patients with AIDS had increased odds of syphilis (odds ratio [OR]: 33.50), varicella (OR: 48.34), tuberculosis (OR: 137.48), endocarditis (OR: 5.19), cocaine abuse (OR: 26.05), and hypercoagulability (OR: 4.82).

CONCLUSIONS

In the HAART era, the median age of incident stroke in AIDS has increased and the mortality from stroke has improved. Research should focus on optimal management of dyslipidemia while on HAART. Whether HAART can reduce the incidence and improve survival of stroke needs to be explored.

Preferences for oral fluid rapid HIV self-testing among social media-using young black, Hispanic, and white men-who-have-sex-with-men (YMSM): implications for future interventions

OBJECTIVES

We assessed preferences of social media-using young black, Hispanic and white men-who-have-sex-with-men (YMSM) for oral fluid rapid HIV self-testing, as compared to other currently available HIV testing options. We also identified aspects of the oral fluid rapid HIV self-test that might influence preferences for using this test instead of other HIV testing options and determined if consideration of HIV testing costs and the potential future availability of fingerstick rapid HIV self-testing change HIV testing preferences.

STUDY DESIGN

Anonymous online survey.

METHODS

HIV-uninfected YMSM across the United States recruited from multiple social media platforms completed an online survey about willingness to use, opinions about and their preferences for using oral fluid rapid HIV self-testing and five other currently available HIV testing options. In a pre/post questionnaire format design, participants first indicated their preferences for using the six HIV testing options (pre) before answering questions that asked their experience with and opinions about HIV testing. Although not revealed to participants and not apparent in the phrasing of the questions or responses, the opinion questions concerned aspects of oral fluid rapid HIV self-testing (e.g. its possible advantages/disadvantages, merits/demerits, and barriers/facilitators). Afterward, participants were queried again about their HIV testing preferences (post). After completing these questions, participants were asked to re-indicate their HIV testing preferences when considering they had to pay for HIV testing and if fingerstick blood sample rapid HIV self-testing were an additional testing option. Aspects about the oral fluid rapid HIV self-test associated with increased preference for using the test (post-assessment vs pre-assessment of opinion topics) were identified through multivariable regression models that adjusted for participant characteristics.

RESULTS

Of the 1975 YMSM participants, the median age was 22 years (IQR 20-23); 19% were black, 36% Hispanic, and 45% white; and 18% previously used an oral fluid rapid HIV self-test. Although views about oral fluid rapid HIV self-testing test were favorable, few intended to use the test. Aspects about the oral fluid rapid HIV self-test associated with an increased preference for using the test were its privacy features, that it motivated getting tested more often or as soon as possible, and that it conferred feelings of more control over one's sexual health. Preferences for the oral fluid rapid HIV self-test were lower when costs were considered, yet these YMSM were much more interested in fingerstick blood sampling than oral fluid sampling rapid HIV self-testing.

CONCLUSIONS

Despite the perceived advantages of the oral fluid rapid HIV self-test and favorable views about it by this population, prior use as well as future intention in using the test were low. Aspects about oral fluid rapid HIV self-testing identified as influential in this study might assist in interventions aimed to increase its use among this high HIV risk population as a means of encouraging regular HIV testing, identifying HIV-infected persons, and linking them to care. Although not yet commercially available in the United States, fingerstick rapid HIV self-testing might help motivate YMSM to be tested more than oral fluid rapid HIV self-testing.

Risk Factors Associated With Repeated HIV Testing Among Internet-Using Men Who Have Sex With Men

Men who have sex with men (MSM) represent a disproportionately impacted risk group for HIV incidence among at-risk U.S.

POPULATIONS

Few studies have identified risk factors associated with HIV testing frequency both within and outside of traditional health care settings. MSM enrolled in a prospective cohort were mailed at-home specimen collection kits and followed for a year. Incidence density rate ratios (IDRR) of testing were calculated, and generalized estimating equations were used to analyze the association between HIV testing and behavioral factors. The incidence rate of testing was higher among Black MSM than White MSM (IDRR: 1.3, 95% confidence interval CI [1.1, 1.5]) and higher among MSM who reported 3+ condomless anal intercourse partners (CAI) than MSM who reported no CAI (IDRR: 1.6, 95% CI [1.3, 2.0]). Increasing availability of HIV testing outside traditional health care settings, including at-home testing kits, in conjunction with targeted behavioral interventions and biomedical treatment preventions is needed.

School-Based HIV/STD Testing Behaviors and Motivations Among Black and Hispanic Teen MSM: Results From a Formative Evaluation

BACKGROUND

This evaluation explores experiences with, and motivations for, human immunodeficiency virus (HIV) and sexually transmitted disease (STD) testing among black and Hispanic school-aged young men who have sex with men (YMSM).

METHODS

Participants were recruited at community-based organizations that serve YMSM in New York City, Philadelphia, and San Francisco. Eligible participants were 13- to 19-year-old black or Hispanic males who reported attraction to or sexual behavior with other males and/or identified as gay or bisexual, and attended at least 90 days of school in the previous 18 months. Participants (N = 415) completed web-based questionnaires and/or in-depth interviews (N = 32).

RESULTS

In the past year, 72.0% of questionnaire participants had been tested for HIV, 13.5% of them at school or school clinic. Participants reported that they would be more likely to get an HIV test if they could be tested close to or at school (34.4%), and 64.4% would use HIV testing if offered in schools. Most interview participants reported willingness to use school-based services if they were offered nonjudgmentally, privately, and confidentially by providers with experience serving YMSM.

CONCLUSION

Schools can provide opportunities to make HIV and STD testing accessible to school-aged YMSM, but the services must be provided in ways that are comfortable to them.

Formative Work to Develop a Tailored HIV Testing Smartphone App for Diverse, At-Risk, HIV-Negative Men Who Have Sex With Men: A Focus Group Study

Background

Although gay, bisexual, and other men who have sex with men (MSM) are disproportionately affected by human immunodeficiency virus (HIV) infection, few test for HIV at regular intervals. Smartphone apps may be an ideal tool to increase regular testing among MSM. However, the success of apps to encourage regular testing among MSM will depend on how frequently the apps are downloaded, whether they continue to be used over months or years, and the degree to which such apps are tailored to the needs of this population.

Objective

The primary objectives of this study were to answer the following questions. (1) What features and functions of smartphone apps do MSM believe are associated with downloading apps to their mobile phones? (2) What features and functions of smartphone apps are most likely to influence MSM’s sustained use of apps over time? (3) What features and functions do MSM prefer in an HIV testing smartphone app?

Methods

We conducted focus groups (n=7, with a total of 34 participants) with a racially and ethnically diverse group of sexually active HIV-negative MSM (mean age 32 years; 11/34 men, 33%, tested for HIV ≥10 months ago) in the United States in Miami, Florida and Minneapolis, Minnesota. Focus groups were digitally recorded, transcribed verbatim, and deidentified for analysis. We used a constant comparison method (ie, grounded theory coding) to examine and reexamine the themes that emerged from the focus groups.

Results

Men reported cost, security, and efficiency as their primary reasons influencing whether they download an app. Usefulness and perceived necessity, as well as peer and posted reviews, affected whether they downloaded and used the app over time. Factors that influenced whether they keep and continue to use an app over time included reliability, ease of use, and frequency of updates. Poor performance and functionality and lack of use were the primary reasons why men would delete an app from their phone. Participants also shared their preferences for an app to encourage regular HIV testing by providing feedback on test reminders, tailored testing interval recommendations, HIV test locator, and monitoring of personal sexual behaviors.

Conclusions

Mobile apps for HIV prevention have proliferated, despite relatively little formative research to understand best practices for their development and implementation. The findings of this study suggest key design characteristics that should be used to guide development of an HIV testing app to promote regular HIV testing for MSM. The features and functions identified in this and prior research, as well as existing theories of behavior change, should be used to guide mobile app development in this critical area.

Optimizing HIV pre-exposure prophylaxis implementation among men who have sex with men in a large urban centre: a dynamic modelling study

INTRODUCTION

Once-daily tenofovir/emtricitabine-based pre-exposure prophylaxis (PrEP) can reduce HIV acquisition in men who have sex with men (MSM), by 44% in the iPrEx trial, and reaching up to 99% with high adherence. We examined the potential population-level impact and cost-effectiveness of different PrEP implementation strategies.

METHODS

We developed a dynamic, stochastic compartmental model of HIV transmission among the estimated 57,400 MSM in Toronto, Canada. Parameterization was performed using local epidemiologic data. Strategies examined included (1) uniform PrEP delivery versus targeting the highest risk decile of MSM (with varying coverage proportions); (2) increasing PrEP efficacy as a surrogate of adherence (44% to 99%); and (3) varying HIV test frequency (once monthly to once yearly). Outcomes included HIV infections averted and the incremental cost ($CAD) per incremental quality-adjusted-life-year (QALY) gained over 20 years.

RESULTS

Use of PrEP among all HIV-uninfected MSM at 25, 50, 75 and 100% coverage prevented 1970, 3427, 4317, and 4581 infections, respectively, with cost/QALY increasing from $500,000 to $800,000 CAD. Targeted PrEP for the highest risk MSM at 25, 50, 75 and 100% coverage prevented 1166, 2154, 2816, and 3012 infections, respectively, with cost/QALY ranging from $35,000 to $70,000 CAD. Maximizing PrEP efficacy, in a scenario of 25% coverage of high-risk MSM with PrEP, prevented 1540 infections with a cost/QALY of $15,000 CAD. HIV testing alone (Q3 months) averted 898 of infections with a cost savings of $4,000 CAD per QALY.

CONCLUSIONS

The optimal implementation strategy for PrEP over the next 20 years at this urban centre is to target high-risk MSM and to maximize efficacy by supporting PrEP adherence. A large health benefit of PrEP implementation could come from engaging undiagnosed HIV-infected individuals into care.

The challenges of preexposure prophylaxis for bacterial sexually transmitted infections

Preexposure prophylaxis (PrEP) against HIV is currently the subject of great interest, as clinical trials have shown high efficacy in terms of decreasing transmission among men who have sex with men. Because the prevalence of bacterial sexual transmitted infections (STIs) is increasing within this community, a recent pilot study demonstrated the efficacy of reducing transmission of bacterial STIs by administering PrEP with daily doxycycline to men who have sex with men. This creative initiative raises several questions which are discussed in this review. Relevant information should be drawn from the huge amount of available epidemiologic data to identify those who could benefit from such prophylactic treatment. The choice of antimicrobial agents is crucial, as antimicrobial susceptibility of STI agents is heterogeneous. Finally, we discuss challenges to improve the control of STIs through the use of PrEP.

Rates of Prevalent HIV Infection, Prevalent Diagnoses, and New Diagnoses Among Men Who Have Sex With Men in US States, Metropolitan Statistical Areas, and Counties, 2012-2013

Background

In the United States, men who have sex with men (MSM) increasingly represent the majority of people living with and acquiring human immunodeficiency virus (HIV) infection. Local and federal surveillance programs estimate the number of persons living with an HIV diagnosis, persons living with HIV infection, and new diagnoses. Given the absence of population-based estimates of the number of MSM for US states, metropolitan statistical areas (MSAs), or counties, it is not possible to accurately estimate rates using these indicators at these levels, inhibiting the ability to understand HIV burden and to direct prevention efforts.

Objective

To synthesize recently published estimates of MSM population size with publicly available HIV surveillance data, in order to estimate the prevalence of HIV diagnosis and infection and the rate of new diagnoses, at the national, state, MSA, and county levels.

Methods

The number of MSM living with HIV infection in 2012 (prevalence), living with an HIV diagnosis in 2012 (diagnosed prevalence), and newly diagnosed with HIV infection in 2013 (new diagnosis), at state, MSA, and county levels, were obtained from publicly available data from AIDSVu.org and the US Centers for Disease Control and Prevention. The estimated number of MSM living in every US county was calculated using recently published methodology that utilized data from the National Health and Nutrition Examination Survey and American Community Survey. Estimated county-level MSM counts were aggregated to form MSA- and state-level totals. From this, we estimated HIV prevalence, diagnosed prevalence, and new diagnosis rates.

Results

The estimated HIV prevalence among MSM in the United States in 2012 was 15.0% (666,900/4,452,772), the diagnosed HIV prevalence in 2012 was 11.1% (493,453/4,452,772), and the new diagnosis rate for 2013 was 0.7 per 100 MSM. For diagnosed prevalence at the state level, 6 states had both <15,000 cases and diagnosed prevalence rates of ≥15%, all in the South. Five highly populated states had ≥15,000 cases and rates between 10% and 15%. Georgia was the only state with ≥15,000 cases and ≥15% diagnosed prevalence rate. Of the 25 MSAs with the highest diagnosed prevalence rates in the United States, 21 were in the South and 6 had diagnosed prevalence of ≥25%. County-level data showed high diagnosed prevalence rates in both urban and rural counties of the South.

Conclusions

HIV infection is hyperendemic among MSM in many areas of the United States, particularly in the South. Our data emphasize the priorities for HIV prevention and care set forth in the United States National HIV/AIDS Strategy (NHAS) and provide updatable local estimates of NHAS indicators. Jurisdictions can use these results to direct resources, programs, and policies to optimally benefit the health of MSM.

An evaluation of factors associated with sexual risk taking among Black men who have sex with men: a comparison of younger and older populations

In the United States, rates of human immunodeficiency virus (HIV) infection are highest among Black men who have sex with men (BMSM). Prior research indicates that younger BMSM in particular (i.e., BMSM 29 years of age and younger) are most at risk for HIV infection, and that HIV incidence in this subpopulation has risen in recent years. It remains unclear, however, why younger BMSM, relative to BMSM 30 years of age and older, are at increased risk for HIV infection. For the current study, we surveyed 450 BMSM located in the Atlanta, GA metropolitan and surrounding areas. We assessed BMSM's depressive symptoms, substance use during sex, psycho-social risk factors (i.e., HIV risk perceptions, condom use self-efficacy, internalized homophobia, and perceived HIV stigmatization), and sexual risk taking (i.e., condomless anal intercourse [CAI]). We found that younger BMSM (YBMSM) and older BMSM (OBMSM) differed with respect to factors associated with CAI. In multivariable models, alcohol use before or during sex, lower educational attainment, and sexual orientation (i.e., bisexual sexual orientation) were significantly associated with increased CAI for YBMSM, while HIV risk perceptions and internalized homophobia were significantly, negatively associated with CAI among OBMSM. Rates of engaging in CAI were similar across the two age cohorts; however, factors related to CAI varied by these two groups. Findings emphasize the need to consider targeted interventions for different generational cohorts of BMSM.

Frequency of HIV testing among gay and bisexual men in the UK: implications for HIV prevention

Objectives

The aim of the study was to explore HIV testing frequency among UK men who have sex with men (MSM) in order to direct intervention development.

Methods

Cross‐sectional surveys were completed by 2409 MSM in Edinburgh, Glasgow and London in 2011 and a Scotland‐wide online survey was carried out in 2012/13. The frequency of HIV testing in the last 2 years was measured.

Results

Overall, 21.2% of respondents reported at least four HIV tests and 33.7% reported two or three tests in the last 2 years, so we estimate that 54.9% test annually. Men reporting at least four HIV tests were younger and less likely to be surveyed in London. They were more likely to report higher numbers of sexual and anal intercourse partners, but not “higher risk” unprotected anal intercourse (UAI) with at least two partners, casual partners and/or unknown/discordant status partners in the previous 12 months. Only 26.7% (238 of 893) of men reporting higher risk UAI reported at least four tests. Among all testers (n = 2009), 56.7% tested as part of a regular sexual health check and 35.5% tested following a risk event. Differences were observed between surveys, and those testing in response to a risk event were more likely to report higher risk UAI.

Conclusions

Guidelines recommend that all MSM test annually and those at “higher risk” test more frequently, but our findings suggest neither recommendation is being met. Additional efforts are required to increase testing frequency and harness the opportunities provided by biomedical HIV prevention. Regional, demographic and behavioural differences and variations in the risk profiles of testers suggest that it is unlikely that a “one size fits all” approach to increasing the frequency of testing will be successful.

Partner Preference Among Men Who Have Sex with Men: Potential Contribution to Spread of HIV Within Minority Populations

PURPOSE

Human immunodeficiency virus (HIV) disproportionately affects men who have sex with men (MSM) in the United States. Most prior research into drivers of HIV transmission has focused on individual characteristics rather than on dyadic-level behaviors such as sex partner selection. This article explores racial/ethnic preferences in sex and relationship partner selection among MSM to further contextualize the spread of HIV within minority groups.

METHODS

Participants were recruited through a mobile application (app) for men to meet other men in 2015 and completed an online survey on behaviors related to HIV risk. All analyses on the sample of 530 MSM were conducted in 2015.

RESULTS

There was significant homophily in partner selection within racial/ethnic minorities, but not for white MSM. In general, mobile app-using MSM reported a general preference for white and Hispanic men and a dispreference for black and Asian men, both for sex and relationship partners.

CONCLUSION

Racial/ethnic preferences were found to drive intentions to form partnerships within this sample. Combined with the stigma many of these racial/ethnic minorities may also feel from homophobic attitudes within their own racial/ethnic communities, these MSM may be at particular risk for social isolation. These partner preferences likely affect the structure of the sexual networks of MSM and may contribute to increased clustering within high HIV incident sexual networks.

Building a Mobile HIV Prevention App for Men Who Have Sex With Men: An Iterative and Community-Driven Process

BACKGROUND

Gay, bisexual, and other men who have sex with men (MSM) account for a disproportionate burden of new HIV infections in the United States. Mobile technology presents an opportunity for innovative interventions for HIV prevention. Some HIV prevention apps currently exist; however, it is challenging to encourage users to download these apps and use them regularly. An iterative research process that centers on the community's needs and preferences may increase the uptake, adherence, and ultimate effectiveness of mobile apps for HIV prevention.

OBJECTIVE

The aim of this paper is to provide a case study to illustrate how an iterative community approach to a mobile HIV prevention app can lead to changes in app content to appropriately address the needs and the desires of the target community.

METHODS

In this three-phase study, we conducted focus group discussions (FGDs) with MSM and HIV testing counselors in Atlanta, Seattle, and US rural regions to learn preferences for building a mobile HIV prevention app. We used data from these groups to build a beta version of the app and theater tested it in additional FGDs. A thematic data analysis examined how this approach addressed preferences and concerns expressed by the participants.

RESULTS

There was an increased willingness to use the app during theater testing than during the first phase of FGDs. Many concerns that were identified in phase one (eg, disagreements about reminders for HIV testing, concerns about app privacy) were considered in building the beta version. Participants perceived these features as strengths during theater testing. However, some disagreements were still present, especially regarding the tone and language of the app.

CONCLUSIONS

These findings highlight the benefits of using an interactive and community-driven process to collect data on app preferences when building a mobile HIV prevention app. Through this process, we learned how to be inclusive of the larger MSM population without marginalizing some app users. Though some issues in phase one were able to be addressed, disagreements still occurred in theater testing. If the app is going to address a large and diverse risk group, we cannot include niche functionality that may offend some of the target population.

Understanding Engagement in HIV Risk and Prevention Research Among Black Young Men Who Have Sex with Men and Transgender Women in the District of Columbia

PURPOSE

To develop optimal methods to study sexual health among black young men who have sex with men and transgender women (BYMSM/TW).

METHODS

We conducted a mixed-methods prospective study to identify recruitment and retention strategies for BYMSM/TW (age 16-21) in Washington D.C., and describe HIV risk behaviors and context.

RESULTS

Incentivized peer referral was highly productive, and 60% of BYMSM/TW were retained for 3 months. Participants reported high levels of sexual risk, homophobia, racism, and maternal support.

CONCLUSION

BYMSM/TW studies should utilize a combination of peer-based, in-person, and technology-based recruiting strategies. Additional research is needed to leverage mobile technology and social media to enhance retention.

Incidence of HIV Infection in Young Gay, Bisexual, and Other YMSM: The P18 Cohort Study

CONTENT

HIV infections continue to rise in a new generation of young gay, bisexual, and other young men who have sex with men (YMSM) despite 3 decades of HIV prevention and recent biomedical technologies to deter infection.

OBJECTIVES

To examine the incidence of HIV and the demographic, behavioral, and structural factors associated with incident infections.

DESIGN

A prospective cohort study.

PARTICIPANTS

Six hundred YMSM who were aged 18-19 years at baseline.

RESULTS

At baseline, 6 prevalent cases of HIV were detected. Over the course of 36 months and 6 additional waves of data collection, we identified 43 (7.2%) incident cases of HIV. Incident infections were marginally higher among those residing in neighborhoods with higher rates of HIV prevalence. Using Cox proportional hazards models, we detected that hazard ratios (HRs) for time to HIV seroconversion were significantly higher for black YMSM (HR = 7.46) and mixed/other race YMSM (HR = 7.99), and older age at sexual debut with another man was associated with a lower risk of HIV seroconversion (HR = 0.50), whereas low perceived familial socioeconomic status was marginally associated with an increased risk for HIV seroconversion (HR = 2.45).

CONCLUSIONS

These findings support the disparities for HIV that exist within the population of sexual minority men and suggest that we attend to behavioral, structural, and social conditions to effectively tailor HIV prevention for a new generation of YMSM with keen eyes to the conditions faced by racial and ethnic minority YMSM, which heightened their risk for acquiring HIV.

Sexual behaviours of homosexual and bisexual men in France: a generational approach

Objective

In high-income countries, the social and epidemiological contexts surrounding homosexuality and AIDS have changed profoundly in recent decades. This work sought to examine key indicators of the long-term sexual trajectories of successive generations of men who have sex with men (MSM) in France.

Methods

We performed a longitudinal analysis of the French Gay Press surveys, which were self-administered socio-behavioural questionnaires, repeated from 1985 to 2011 in the gay press, and on the internet in 2004 and 2011. An age-cohort analysis using graphical representations and multivariate logistic regressions was conducted among participants aged 18-59 (N=38 821).

Results

First sexual intercourse occurred more often with a male partner in younger generations than in older ones: 76.0% in MSM who turned 18 in 1956-1959, 75.6% in 1980-1983, 83.7% in 2008-2011, p_overall=0.0002). Every generation showed the same pattern of sexual trajectory between 1985 and 2011: globally, the frequency of masturbation increased from the 1985 survey to the early 1990s and then decreased from the late 1990s to the end of the study period. Inversely, the frequency of oral and anal sex decreased in the mid-1980s and increased from 1990 to 2011. The frequency of both oral sex and anal intercourse is currently quite high, regardless of generation (>95% and around 80%, respectively). Compared to their predecessors, recent generations of young MSM reported more frequent oral and anal sex, but fewer male partners in the previous 12 months.

Discussion

While the increased frequency of first intercourse with a man over successive generations since the 1970s may be related to reduced social pressure for heterosexuality, there is evidence that sexual norms among MSM are widespread, with practices spreading across age groups and generations. Although AIDS profoundly affected sexual practices in the 1980s, further AIDS-related events (discovery of HIV antiretroviral drugs and their use in prevention) do not appear to have accentuated ongoing trends in sexual practices.

Testing for HIV among men who have sex with men needs a paradigm shift in Australia, given the minimal increase between 2003 and 2013 in Melbourne, Australia

Background Increasing the frequency of HIV testing in men who have sex with men (MSM) will reduce the incidence of HIV. Trends in HIV testing among MSM in Melbourne, Australia over the last 11 years have been investigated.

METHODS

A retrospective study was conducted using electronic medical records of the first presentation of MSM who attended the Melbourne Sexual Health Centre between 2003 and 2013. Factors associated with HIV testing (year, demographic characteristics and sexual practices) were examined in multivariable logistic regression analyses. Jonckheere-Terpstra tests were used to examine the significance of trends in the mean time since the last HIV test.

RESULTS

Of 17578 MSM seen; 13489 attended for the first time during the study period. The proportion of first attendances who had previously tested and reported a HIV test in the last 12 months increased from 43.6% in 2003 to 56.9% in 2013 (adjusted ptrend=0.030), with a corresponding decrease in median time since the last HIV test from 19 months [interquartile range (IQR) 6-42] in 2003 to 10 months (IQR4-24) in 2013 (ptrend <0.001). The proportion of high-risk MSM (who reported unprotected anal intercourse and/or >20 partners in 12 months) who reported an HIV test in the last 12 months was unchanged (ptrend = 0.242).

CONCLUSIONS

Despite HIV testing becoming more frequent, the magnitude of change over the last decade is insufficient to substantially reduce HIV incidence. A paradigm shift is required to remove barriers to testing through strategies such as point-of-care rapid testing or access to testing without seeing a clinician.

Preferences for a Mobile HIV Prevention App for Men Who Have Sex With Men

Background

The Centers for Disease Control and Prevention recommends that sexually active men who have sex with men (MSM) in the United States test for human immunodeficiency virus (HIV) at least three times per year, but actual testing frequency is much less frequent. Though mHealth is a popular vehicle for delivering HIV interventions, there are currently no mobile phone apps that target MSM with the specific aim of building an HIV testing plan, and none that focuses on developing a comprehensive prevention plan and link MSM to additional HIV prevention and treatment resources. Previous research has suggested a need for more iterative feedback from the target population to ensure use of these interventions.

Objective

The purpose of this study is to understand MSM’s preferences for functionality, format, and design of a mobile phone-based HIV prevention app and to examine MSM’s willingness to use an app for HIV prevention.

Methods

We conducted focus group discussions with 38 gay and bisexual men, with two in-person groups in Atlanta, two in Seattle, and one online focus group discussion with gay and bisexual men in rural US regions. These discussions addressed MSM’s general preferences for apps, HIV testing barriers and facilitators for MSM, and ways that an HIV prevention app could address these barriers and facilitators to increase the frequency of HIV testing and prevention among MSM. During focus group discussions, participants were shown screenshots and provided feedback on potential app functions.

Results

Participants provided preferences on functionality of the app, including the type and delivery of educational content, the value of interactive engagement, and the importance of social networking as an app component. Participants also discussed preferences on how the language should be framed for the delivery of information, identifying that an app needs to be simultaneously fun and professional. Privacy and altruistic motivation were considered to be important factors in men’s willingness to use a mobile HIV prevention app. Finally, men described the potential impact that a mobile HIV prevention app could have, identifying individual, interpersonal, and community-based benefits.

Conclusions

In summary, participants described a comprehensive app that should incorporate innovative ideas to educate and engage men so that they would be motivated to use the app. In order for an app to be useful, it needs to feel safe and trustworthy, which is essential when considering the app’s language and privacy. Participants provided a range of preferences for using an HIV prevention app, including what they felt MSM need with regards to HIV prevention and what they want in order to engage with an app. Making an HIV prevention app enjoyable and usable for MSM is a difficult challenge. However, the usability of the app is vital because no matter how great the intervention, if MSM do not use the app, then it will not be useful.

Racial differences in the accuracy of perceived partner HIV status among men who have sex with men (MSM) in Atlanta, Georgia

We compared perceptions of partner HIV status to HIV test results in a cross-sectional study of sexual networks of men who have sex with men (MSM) in Atlanta. We then examined differences between black and white MSM in the predictive value of perceived partner status. We recruited men ("seeds") using time-space venue sampling. These seeds then referred up to three partners, who could also refer partners. All participants reported sexual behavior and HIV status for recent partners and received HIV tests. For partners who enrolled, we compared laboratory diagnoses to their partner's perception of their status. Black MSM who perceived themselves to be HIV negative were more likely than perceived-negative white MSM to have a positive partner among those they perceived to be HIV negative or whose status was unknown to them (OR=6.6). Furthermore, although frequency of unprotected anal intercourse (UAI) was similar by race, black men were more likely to have had UAI with an unknown-positive partner (OR=9.3).

HIV Prevention Messages Targeting Young Latino Immigrant MSM

Young Latino immigrant men who have sex with men (MSM) are at risk for HIV and for delayed diagnosis. A need exists to raise awareness about HIV prevention in this population, including the benefits of timely HIV testing. This project was developed through collaboration between University of WA researchers and Entre Hermanos, a community-based organization serving Latinos. Building from a community-based participatory research approach, the researchers developed a campaign that was executed by Activate Brands, based in Denver, Colorado. The authors (a) describe the development of HIV prevention messages through the integration of previously collected formative data; (b) describe the process of translating these messages into PSAs, including the application of a marketing strategy; (c) describe testing the PSAs within the Latino MSM community; and (c) determine a set of important factors to consider when developing HIV prevention messages for young Latino MSM who do not identify as gay.

Using the National HIV Behavioral Surveillance System to inform HIV prevention efforts in the United States

The National HIV Behavioral Surveillance system (NHBS) was designed to monitor HIV prevalence and risk factors for infection among higher-risk individuals, i.e., sexually active men who have sex with men who attend venues, injection drug users who injected in the past 12 months, and heterosexuals living in low socioeconomic urban areas. These groups were selected as priorities for behavioral surveillance since they represent the major HIV transmission routes and the populations with the highest HIV burden. NHBS contributes to the nation's program of HIV surveillance by being the only multi-site population-based system that provides estimates on key HIV prevention measures among high-risk HIV-negative individuals, HIV-positive individuals unaware of their infection, and HIV-positive individuals aware of their infection who are in and out of care. Accurate and precise data on the behaviors in these populations are critical for tracking the epidemic, planning effective responses, and monitoring and evaluating those responses. Reports in this supplement illustrate the uses of NHBS data at the national and local level and reflect ongoing efforts to improve the system and remains essential for characterizing and monitoring the burden of HIV infection and sexual and behavioral risks.

Achieving HIV risk reduction through HealthMpowerment.org, a user-driven eHealth intervention for young Black men who have sex with men and transgender women who have sex with men

Young, Black men who have sex with men and transgender women who have sex with men (YBMSM/TW) are at disproportionate risk for HIV and other sexually transmitted infections (HIV/STI). HealthMpowerment.org (HMP) is a mobile phone optimised online intervention that utilises behaviour change and gaming theories to reduce risky sexual behaviours and build community among HIV-positive and negative YBMSM/TW. The intervention is user-driven, provides social support, and utilises a point reward system. A four-week pilot trial was conducted with a diverse group of 15 YBMSM/TW. During exit interviews, participants described how HMP components led to behaviour changes such as asking partners' sexual history, increased condom use, and HIV/STI testing. The user-driven structure, interactivity, and rewards appeared to facilitate sustained user engagement and the mobile platform provided relevant information in real-time. Participants described the reward elements of exceeding their previous scores and earning points toward prizes as highly motivating. HMP showed promise for being able to deliver a sufficient intervention dose and we found a trend toward higher dose received and more advanced stages of behaviour change. In this pilot trial, HMP was well accepted and demonstrates promise for translating virtual intervention engagement into actual behaviour change to reduce HIV risk behaviours.

Attitudes towards and Beliefs about HIV Testing among Latino Immigrant MSM: A Comparison of Testers and Nontesters

Latino immigrant men who have sex with men (MSM) are at risk for HIV and delayed diagnosis. An exploratory study using qualitative interviews that assess the beliefs and attitudes of 54 Latino immigrant MSM in Seattle, Washington, is presented. The goal of this research is to determine whether attitudinal differences exist between participants who had and had not been tested and to use any insight into the development of a media campaign to promote testing. Over one-third of the men have never been tested for HIV. Nontesters are more likely to be men who have sex with men and women, have less knowledge about HIV risks, perceive their sexual behaviors as less risky, and deflect HIV-related stigma. Testers are more likely to be self-identified as being gays. Both groups believe that fear of a positive result is the main barrier to testing. Both groups believe that family members have negative attitudes towards HIV testing and that having Latino staff at HIV testing sites hinders confidentiality. Financial concerns with regard to the cost of testing were also expressed by both groups. Based on these insights, recommended strategies for the development of HIV prevention and testing campaigns are made.

Surveillance of human immunodeficiency virus suggests that younger men who have sex with men are at higher risk of infection, European Union, 2003 to 2012

In 2012, newly reported human immunodeficiency virus diagnoses in the European Union /European Economic Area remained stable at around 30,000 cases. Since 2003, cases in men who have sex with men (MSM) aged 20 to 29 years-old doubled, while the proportion of late presenters in this group remained stable. Persistent declines occurred among older MSM age groups, particularly that between 30 and 39 years-old. Interventions targeting younger MSM are needed to prevent a resurgence of the epidemic in Europe.