Anal Douche Practices and Willingness to Use a Rectal Microbicide Enema for HIV Prevention and Associated Factors Among an Internet Sample of HIV-Negative and HIV-Discordant Male Couples in the US

History of Rectal Product Use and Country of Residence Influence Preference for Rectal Microbicide Dosage Forms Among Young Sexual and Gender Minorities: A Multi-country Trial Comparing Placebo Douche, Suppository, and Insert Products

The DESIRE Study (MTN-035) explored product preference among three placebo rectal microbicide (RM) formulations, a rectal douche (RD), a suppository, and an insert, among 210 sexually active transgender people and men who have sex with men in five counties: the United States, Peru, Thailand, South Africa, and Malawi. Participants used each product prior to receptive anal sex (RAS) for 1 month, following a randomly assigned sequence, then selected their preferred product via computer assisted self-interview. In-depth interviews examined reasons for preference. We compared product preference and prior product use by country to explore whether geographic location and experience with the similar products impacted preference. A majority in the United States (56%) and Peru (58%) and nearly half in South Africa (48%) preferred the douche. Most in Malawi (59%) preferred the suppository, while half in Thailand (50%) and nearly half in South Africa (47%) preferred the insert. Participants who preferred the douche described it as quick and easy, already routinized, and serving a dual purpose of cleansing and protecting. Those who preferred the insert found it small, portable, discreet, with quick dissolution. Those who preferred the suppository found the size and shape acceptable and liked the added lubrication it provided. Experience with product use varied by country. Participants with RD experience were significantly more likely to prefer the douche (p = 0.03). Diversifying availability of multiple RM dosage forms can increase uptake and improve HIV prevention efforts globally.

Acceptability of a Dapivirine Gel Administered Rectally to HIV-1 Seronegative Adults (MTN-033 Study)

We triangulated quantitative and qualitative assessments to evaluate participants' acceptability of 0.05% dapivirine rectal microbicide (RM) gel administered via two separate modalities (a rectal applicator and an artificial phallus for use as a coital simulation device) as part of a Phase I trial (N = 14) among men who have sex with men (MSM) randomized using a 1:1 ratio. Overall, participants reported favorable acceptability of the gel (n = 11; 78.6%), the same or more at the end of the study compared to when they started the study. Additionally, when discussing their preferred administration modality, they noted that both methods had positive qualities but also potential areas of improvement. Our findings underscore the need to create multiple delivery methods for a future microbicide gel (i.e., with and without the need for an applicator) and highlight the importance of offering MSM choices in how biomedical HIV prevention strategies are delivered.

Prevalence and Correlates of Rectal Douching and Enema Use Among Black Sexual Minority Men and Black Transwomen in the Deep South

HIV/STI disparities are highest among Black sexual minority men (BSMM) and Black transwomen (BTW) in the Deep South. Exploring the prevalence and correlates of rectal douching and enema use could provide insights into risk factors and HIV/STI prevention opportunities among these groups. This study explored the prevalence and correlates of rectal douching and enema using Poisson regression models among 375 BSMM and BTW in Jackson, MS, and Atlanta GA. Approximately 95% reported their gender as male/man; 5.6% self-identified as transwomen. Most reported being single (73.1%) and were unemployed (56.0%); 36.1% were previously diagnosed with HIV. In multivariable models, BSMM and BTW who reported that their typical sexual position during anal sex was "bottom" (aPR = 2.39, 95% CI = 1.48, 3.84) or "versatile" (aPR = 2.46, 95% CI = 1.44, 4.17) had a higher prevalence of rectal douching and enema use than those who reported "top." Deeper understanding of the contexts of rectal douching, enema use, and sexual positioning practices is needed.

Rectal Douching Practices Associated with Anal Intercourse: Implications for the Development of a Behaviorally Congruent HIV-Prevention Rectal Microbicide Douche

Tenofovir administration via rectal douching results in higher rectal-mucosa drug concentration than oral administration. Many who engage in receptive anal intercourse (RAI) use cleansing rectal douches. To inform development of a behaviorally-congruent tenofovir douche, 4751 individuals ≥ 18 years-old, born male, from all US states/territories, who engaged in anal intercourse responded to an online survey. Of those who reported RAI in the prior 3 months, 80% douched beforehand, 82% within 1 h, mean 2.9 consecutive applications; 27% douched afterwards, 83% within 1 h, mean 1.7 consecutive applications. Among multidose users, 78% applied doses within 2 min, and 76% retained liquid < 1 min. Most used tap water (89%) in an enema bottle (50%) or rubber bulb (43%), and douched for cleanliness (97%), to avoid smelling bad (65%), and to enhance pleasure (24%). 98% reported high likelihood of using an HIV-prevention douche. An ideal product will protect within a user's typical number of applications, within 1 h, and be dissolvable in tap water.

Effect of rectal douching/enema on rectal gonorrhoea and chlamydia among a cohort of men who have sex with men on HIV pre-exposure prophylaxis

OBJECTIVES

Rectal douching/enema (RD) is a common practice among men who have sex with men (MSM) in preparation for sex. RD can break down the rectal mucosal barrier and potentially affect the rectal microbiome. The objective of this study was to understand if RD is associated with acquiring rectal infections (RI) with rectal gonorrhoea (NG) and/or chlamydia (CT).

METHODS

From 2013 to 2015, 395 adult HIV-uninfected MSM were enrolled in a randomised controlled study for pre-exposure prophylaxis (PrEP) adherence with routine sexual risk survey and testing. Using data from this cohort, baseline differences by RI were assessed using Pearson's χ² and Wilcoxon-Mann-Whitney test. Association between RD and RI was modelled using multivariable logistic regression adjusted for potential confounders (sexual behaviour, substance use and age) selected a priori. Effect modification by number of male partners and sensitivity analysis to rule out reverse causality were also conducted.

RESULTS

Of 395 participants, 261 (66%) performed RD and 133 (33%) had at least one NG/CT RI over 48 weeks. Number of condomless anal receptive sex (med: 4, p<0.001), male partners (med:6, p<0.001) and substance use (any of methamphetamine/hallucinogens/dissociative/poppers) (p<0.001) were associated with increased odds of RI. Controlling for potential confounders, odds of prevalent RI were 3.59 (p<0.001, 95% CI 1.90 to 6.78) and incident RI 3.87 (p=0.001, 95% CI 1.78 to 8.39) when douching weekly or more compared with not douching. MSM with more than six male partners had 5.34 (p=0.002, 95% CI 1.87 to 15.31) increased odds of RI when douching weekly or more compared with not douching.

CONCLUSION

Rectal hygiene with RD is a common practice (66%) among HIV-uninfected MSM on PrEP in this study, which increases the odds of acquiring rectal NG and/or CT independent of sexual risk behaviour, substance use and other factors. This suggests interventional approaches targeting rectal hygiene products and practices could reduce sexually transmitted infections.

Rectal Douching Associated with Receptive Anal Intercourse: A Literature Review

To inform the development of HIV-prevention rectal douches, we reviewed the scientific literature and online instructional videos on rectal douching associated with receptive anal intercourse (RAI). Up to 88% of men who practice RAI ever have douched, while 43-64% have douched recently. Of them, 87-97% douche before RAI and 13-48% afterwards. Water, occasionally mixed with soap or salt, is used most often, although up to 31% of men use commercial products. Douching is more common among individuals reporting substance use, sexually transmitted infections, or being HIV-infected. Scant literature is available on women's rectal douching practices, but it is apparently less frequent than among men (32 vs. 70%). Videos advise using 2-3 doses of liquid and retaining it for 10-30 s before expelling. These findings can inform the development of a safe and acceptable rectal douche for HIV prevention.

Rectal Douching Among Men Who Have Sex with Men in Paris: Implications for HIV/STI Risk Behaviors and Rectal Microbicide Development

Rectal douching is a common but potentially risky practice among MSM; MSM who douche may be ideal candidates for rectal microbicides as HIV prevention. Herein we explored rectal douching and its association with condomless receptive anal intercourse (CRAI), group sex, rates of HIV and other STIs, and likelihood to use rectal microbicide gels. We recruited a sample of 580 MSM from a geosocial-networking smartphone application in Paris, France in 2016. Regression models estimated adjusted risk ratios (aRRs) for associations between rectal douche use and (1) engagement in CRAI, (2) group sex, (3) self-reported HIV and STI diagnoses, and (4) likelihood to use rectal microbicide gels for HIV prevention. 54.3% of respondents used a rectal douche or enema in the preceding 3 months. Douching was significantly associated with CRAI (aRR: 1.77), participation in group sex (aRR: 1.42), HIV infection (aRR: 3.40), STI diagnosis (aRR: 1.73), and likelihood to use rectal microbicide gels (aRR: 1.78). Rectal douching is common among MSM, particularly those who practice CRAI, and rectal microbicide gels may be an acceptable mode of HIV prevention for MSM who use rectal douches.

Patterns of a Rectal Microbicide Placebo Gel Use in a Preparatory Stage for a Phase I Trial Among Young Men Who Have Sex with Men

We examined young gay, bisexual, and other men who have sex with men's (YGBMSM) usage patterns of a pre-coital, applicator-administered rectal placebo gel. An ethnically diverse sample of 94 YGBMSM (aged 18-30 years) were asked to insert hydroxyethylcellulose placebo gel rectally before receptive anal intercourse (RAI) and report their gel use through an interactive voice response system (IVRS) across 12 weeks. We used trajectory analyses to characterize participants' use of the rectal gel over the 12 weeks, and examine whether these trajectories varied based on participants' sociodemographic characteristics, sexual behaviors, application and insertion behaviors, and experiences using the placebo gel. A cubic model was the best fit for these longitudinal data, with two distinct trajectories of gel use observed. The first trajectory ('High with Varying Gel Use per Week') represented YGBMSM (N = 38; 40.3%) who reported using the rectal gel on several occasions per week. The second trajectory ('Low and Consistent Gel Use per Week') represented participants (N = 56; 59.7%) who reported a consistent average use of one gel per week. Participants in the High with Varying Gel Use Trajectory reported trying out a greater number of positions when inserting the gel across the 12-weeks than peers in the Low and Consistent Gel Use Trajectory. YGBMSM reporting more RAI occasions during the trial were more likely be present in the High with Varying Gel Use Trajectory than peers in the Low and Consistent Gel Use Trajectory. Future research examining how to facilitate gel application and adherence among YGBMSM is merited.

How Best to Obtain Valid, Verifiable Data Online From Male Couples? Lessons Learned From an eHealth HIV Prevention Intervention for HIV-Negative Male Couples

Background

As interest increases in the development of eHealth human immunodeficiency virus (HIV)-preventive interventions for gay male couples, Web-based methods must also be developed to help increase the likelihood that couples enrolled and data collected from them represent true unique dyads. Methods to recruit and collect reliable and valid data from both members of a couple are lacking, yet are crucial for uptake of novel sexual health and HIV-prevention eHealth interventions. Methods to describe best practices to recruit male couples using targeted advertisements on Facebook are also lacking in the literature, yet could also help in this uptake.

Objective

The objective of our study was to describe challenges and lessons learned from experiences from two phases (developmental phase and online randomized controlled trial [RCT]) of an eHealth HIV-prevention intervention for concordant HIV-negative male couples in terms of (1) recruiting male couples using targeted advertisements on Facebook, (2) validating that data came from two partners of the couple, and (3) verifying that the two partners of the couple are in a relationship with each other.

Methods

The developmental phase refined the intervention via in-person focus groups, whereas the pilot-testing phase included an online RCT. For both phases, couples were recruited via targeted Facebook advertisements. Advertisements directed men to a study webpage and screener; once eligible, participants provided consent electronically. A partner referral system was embedded in the consenting process to recruit the relationship partner of the participant. Both men of the couple had to meet all eligibility criteria—individually and as a couple—before they could enroll in the study. Verification of couples’ relationships was assessed via the concurrence of predetermined screener items from both partners, done manually in the developmental phase and electronically in the pilot-testing phase. A system of decision rules was developed to assess the validity that data came from two unique partners of a couple.

Results

Several important lessons were learned from these experiences, resulting in recommendations for future eHealth studies involving male couples. Use of certain “interests” and types of images (eg, shirtless) in targeted Facebook advertisements should be avoided or used sparingly because these interests and types of images may generate adverse reactions from a broader audience. Development of a systematic approach with predetermined criteria and parameters to verify male couples’ relationships is strongly recommended. Further, researchers are encouraged to develop a system of decision rules to detect and handle suspicious data (eg, suspicious email addresses/names, multiple entries, same IP address used in multiple entries) to help validate the legitimacy of male couples’ relationships online.

Conclusions

These lessons learned combined with recommendations for future studies aim to help enhance recruitment efforts and the validity and reliability of collecting dyadic data from male couples for novel eHealth HIV-preventive interventions.