Exploring and Adapting a Conceptual Model of Sexual Positioning Practices and Sexual Risk Among HIV-Negative Black Men Who Have Sex With Men

Cultural acceptability of STI screening guidelines and sexual positioning assessments among black sexual minority men

AIM

To identify attitudes towards HIV/STI screening guidelines and explore the acceptability of assessing sexual positioning practices among Black sexual minority men (SMM).

BACKGROUND

Risks for HIV/STIs vary by sexual positioning practices. However, clinicians and Black SMM do not always discuss sexuality with each other. Therefore, HIV/STI screening and testing remain suboptimal.

DESIGN

Qualitative study using focus groups.

METHODS

Data were obtained from 12 focus groups and one in-depth interview conducted in Baltimore, MD among HIV-negative Black SMM between October 2019 and May 2020 (N = 39). Groups were stratified into three age categories: 18-24, 25-34 and 35+. Participants were given the "5 P's" from the CDC's 2015 Sexual History Screening Guidelines and asked to discuss attitudes towards existing questions regarding sexual positioning practices. Themes were identified using an electronic pile sorting approach.

RESULTS

Most identified as homosexual/gay/same gender-loving (68%), were employed (69%) and single (66%). Additionally, 34% had ever been diagnosed with an STI, of whom 38% had a history of repeated STI acquisition in their lifetime. Participants across age groups said clinicians should use the words "top" and "bottom" to demonstrate cultural familiarity and build trust. Some said that screening for sexual positioning was unnecessary and intrusive; others said that questions should be justified. Younger men wanted clinicians to ask questions in ways that make them feel cared for.

DISCUSSION

Guidelines should include language for clinicians to use culturally specific language and better ways to prepare Black SMM patients for screening.

IMPACT TO NURSING PRACTICE

Some Black SMM will not discuss sexual positioning practices without clinicians' demonstration of cultural understanding and respect. Screening should incorporate culturally responsive language, justification and convey care.

REPORTING METHOD

Consolidated criteria for reporting qualitative research (COREQ).

NO PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public involvement in the design or drafting of this discursive paper.

The Syndemic of Substance Use, High-Risk Sexual Behavior, and Violence: A Qualitative Exploration of the Intersections and Implications for HIV/STI Prevention Among Key Populations in Lagos, Nigeria

Background

Key populations (KP) are defined groups with an increased risk of HIV due to specific higher risk behaviours. KP who use substances engage in risky behaviors that may play a co-active role in HIV transmission and acquisition in Nigeria. This qualitative study explored the 'syndemics' of substance use, sexual risk behavior, violence and HIV infection among KP who use substances.

Methods

Nineteen sexually active men who have sex with men [MSM] and 18 female sex workers [FSW] aged 16 years and older who use substances were purposively selected to participate in sixteen in-depth interviews and two focus groups. We utilized a syndemic framework to explore the interaction of socio-economic factors, substance use and high-risk sexual practices. The interviews were audio-recorded, transcribed, organized in NVIVO 11 and analyzed using thematic analysis.

Results

Majority (95%) were non-injection substance users (primarily alcohol and marijuana); a few KP also used cocaine and heroin. Sixty percent of participants were between 16-24 years. Substance use utilities and trajectories were heavily influenced by KP social networks. They used substances as a coping strategy for both physical and emotional issues as well as to enhance sex work and sexual activities. Key HIV/STI risk drivers in the settings of substance use during sexual intercourse that emerged from this study include multiple sexual partnerships, condom-less sex, transactional sex, intergenerational sex, double penetration, rimming, and sexual violence. Poverty and adverse socio-economic conditions were identified as drivers of high-risk sexual practices as higher sexual risks attracted higher financial rewards.

Conclusions and Recommendations

Findings indicate that KP were more inclined to engage in high-risk sexual practices after the use of substances, potentially increasing HIV risk. The syndemic of substance use, high-risk sexual behavior, adverse socio-economic situations, and violence intersect to limit HIV prevention efforts among KP. The behavioural disinhibition effects of substances as well as social and structural drivers should be considered in the design of targeted KP HIV prevention programs. HIV intervention programs in Nigeria may yield better outcomes if they address the nexus of sexual risk behavior and substance use as well as knowledge and appropriate use of HIV prophylaxis.

Top, Bottom, and Versatile Orientations among Adolescent Sexual Minority Men

Sexual role preference or self-label (i.e., top, versatile, or bottom) has been well studied in samples of sexual minority men (SMM) but lacks research among adolescent sexual minority men (ASMM). In response, data were collected from 302 ASMM (15-18 years old), measuring sexual self-label, relationship and sexual experience, sexually explicit media use, use of geosocial networking applications, penis size satisfaction, and gender atypicality. Results showed there was no significant difference in the distribution of sexual position self-identity in ASMM when compared with data from published, adult samples. A model that associated sexual socialization factors with adopting any self-label was significant, with greater number of partners, previous geosocial networking app use, and more relationship experience being positive predictors of having a label. Additionally, a model that tested the convergent validity between self-label and enacted sexual behaviors was significant. Both receptive and insertive sex enactments were highly correlated with corresponding labels. Lastly, gender atypicality and penis size satisfaction were significant predictors of sexual position self-identity. Data from our study supports sexual self-labeling occurring before adulthood, during adolescence for SMM. Furthermore, it shows that socialization factors (e.g., partner frequency, using apps) are important in the development of sexual position self-identity in this population.

Getting Clear About Rectal Douching Among Men Who Have Sex With Men

Receptive anal sex is the primary means through which HIV is transmitted among men who have sex with men (MSM). Recently, researchers have begun investigating the role that rectal douching may play in amplifying risk for transmission. Yet, there is limited research on the frequency with which MSM douche, the products they use, and how this may vary across sociodemographic characteristics. A U.S. national sample of 4745 MSM completed an online survey that assessed their douching behavior, demographic characteristics, sexual behavior, and their anal sexual positioning (i.e., top, bottom, versatile). Nearly two-thirds (65.8%) had engaged in rectal douching in the last three months. Among those who douched, water was commonly reported (84.2%) and 20.1% reported using commercial enemas (e.g., Fleet), as well as water and soap (15.0%)-numbers exceed 100% as some participants reported more than one. Men who douched reported significantly more receptive and insertive condomless anal sex acts in the prior 3 months. One-in-ten men reported rectal bleeding after douching. Compared to HIV-negative participants who had not taken PrEP, participants had higher odds of reporting douching in the past 3 months if they were HIV-negative and currently on PrEP (AOR = 1.82), HIV-negative and previously used PrEP (AOR = 1.58), and HIV-positive (AOR = 1.83). Douching was common in this sample. Given that douching could amplify risk for HIV transmission, healthcare providers should discuss douching safety with their patients, with a focus on harm reduction (e.g., reduce risk of bleeding, as opposed to abstinence from douching).

Sexual Risk Profiles Among Black Sexual Minority Men: Implications for Targeted PrEP Messaging

Black gay, bisexual, and other Black sexual minority men (BSMM) continue to experience some of the largest sexual health disparities in the U.S. Engaging BSMM in PrEP is crucial to improving sexual health outcomes and reducing disparities. However, knowledge of the profiles of sexual risk and PrEP initiation among this group is limited. This study used latent class analysis to identify HIV risk and PrEP initiation patterns among BSMM in the HPTN 073 Study (n = 226). Guided by current Centers for Disease Control screening guidelines, latent class indicators included relationship status, condom use, number of sexual partners, substance use, sexually transmitted infection (STI) history, and partner HIV status. Age and PrEP initiation were used in a multinomial regression to identify correlates of class membership. Three latent classes were identified: Single, Condomless Partners, Single, Multiple Partners, and Serodiscordant Partners. Single, Condomless Partners had the highest conditional probabilities of having greater than three male partners, substance use before sex, and receiving an STI diagnosis. Serodiscordant Partners had a 100% conditional probability of condomless sex and having a male partner living with HIV. BSMM who initiated PrEP were less likely to be classified as Single, Condomless Partners than Serodiscordant Partners (AOR = 0.07, 95% CI = 0.02, 0.66). Findings support the need for culturally relevant tailored and targeted messaging for BSMM with multiple sexual risk indicators.

TRUST: Assessing the Efficacy of an Intervention to Increase HIV Self-Testing Among Young Black Men Who have Sex with Men (MSM) and Transwomen

HIV testing among young Black MSM and transwomen (YBMSM/TW) is the gateway to biomedical HIV prevention or treatment. HIV self-testing (HST) is a method that may increase consistent HIV testing. TRUST, a brief, peer-based behavioral intervention, was designed to increase uptake of consistent (every three months) HST among YBMSM/TW in New York City. To test the efficacy of the intervention, we randomized 200 friend pairs into either the intervention condition (TRUST) or a time and attention control condition. A modified intent-to-treat analysis found that self-reported HST at 3-month follow-up was statistically significantly higher (uOR 2.29; 95% CI 1.15, 4.58) and at 6-month follow-up was marginally statistically significantly higher (uOR 1.94; 95% CI 1.00, 3.75) in the intervention arm as compared with the control arm. There were no statistically significant differences by arm at 9- or 12-month follow-up. TRUST, a culturally-congruent intervention to increase HST among YBMSM/TW, had short-term impact on past-three month HST.

Clinical Trials Registration ClinicalTrial.gov NCT04210271.

Health care access, health care utilisation and sexual orientation disclosure among Black sexual minority men in the Deep South

Background Black gay, bisexual, and other sexual minority men (BSMM) account for 39.1% of new HIV infections among men who have sex with men and 78.9% of newly diagnosed cases among Black men. Health care access, health care utilisation and disclosing sexuality to providers are important factors in HIV prevention and treatment. This study explored the associations among sexual orientation disclosure, health care access and health care utilisation among BSMM in the Deep South.

METHODS

Secondary analysis of existing data of a population-based study in Jackson, Mississippi, and Atlanta, Georgia, was conducted among 386 BSMM. Poisson regression models were used to estimate prevalence ratios (PR) between sexual orientation disclosure to healthcare providers, health care access and health care utilisation.

RESULTS

The mean (±s.d.) age of participants was 30.5 ± 11.2 years; 35.3% were previously diagnosed with HIV and 3.7% were newly diagnosed with HIV. Two-thirds (67.2%) self-identified as homosexual or gay; 70.6% reported being very open about their sexual orientation with their healthcare providers. After adjustment, BSMM who were not open about their sexual orientation had a lower prevalence of visiting a healthcare provider in the previous 12 months than those who were very open with their healthcare provider (PR 0.42; 95% confidence interval 0.18-0.97).

CONCLUSION

Clinics, hospitals and other healthcare settings should promote affirming environments that support sexuality disclosure for BSMM.

Motivations for opioid and stimulant use among drug using black sexual minority men: A life course perspective

INTRODUCTION

HIV-related disparities persist among U.S. Black sexual minority men (BSMM). Generational differences in drug use trends and the HIV/AIDS epidemic have created different risk trajectories for BSMM. This study explored age-related differences in the profiles, motivations, and contexts of opioid and stimulant use among drug using BSMM.

METHODS

Participants were recruited using active and passive strategies and in-depth qualitative interviews were conducted among 30 BSMM in Baltimore, MD from December 2018 to March 2019. Exploratory drug testing was conducted to confirm drug use and identify the presence of synthetic materials. Thematic analysis was conducted guided by Life Course theoretical domains.

RESULTS

Participants' ages ranged from 25-63 (mean age 41, SD = 12.4); 40 % were under age 35, 60 % were age 35 and older. Most (86.7 %) were living with HIV. Older BSMM attributed drug use initiation to social trends and sexual partners; younger men shared that prescription painkiller use led to misuse to address emotional pain. Across age groups, childhood sexual abuse and other major events along the life course increased BSMM's drug use as a coping strategy.

DISCUSSION AND CONCLUSION

HIV and drug use interventions should support BSMM through targeted mental health services and trauma-informed healthcare models.

Latent classes of partner-seeking venues and sexual risk among men who have sex with men in Paris, France

In France, men who have sex with men (MSM) experience the highest HIV incidence. MSM who use multiple venues such as bars and smartphone apps to find sexual partners have greater HIV and sexually transmitted infection risk than those who use a single physical or online venue. To explore the role of venues and sexual behavior on HIV risk, we used latent class analysis to highlight underlying profiles of 580 MSM in Paris, France. Three latent classes emerged: Multi-venue Users (19%), Non-serosorting App Users (49%), and Serosorting App Users (32%). Multi-venue Users had the highest probabilities of condomless receptive anal intercourse (CRAI) and condomless insertive anal intercourse (CIAI), group sex, and meeting partners at venues such as bars or online. Non-serosorting App Users had the lowest probabilities of CRAI, CIAI, and condomless serosorting. Serosorting App Users had an 87% chance of condomless serosorting. MSM reporting a pre-exposure prophylaxis history had 14 and 5 times the odds of being classified as Multi-venue Users and Serosorting App Users than Non-serosorting App Users. MSM were 3% more likely to be Multi-venue Users than Non-serosorting App Users for every one-year increase in age. Interventions addressing sexual risk behaviors among MSM in France should consider tailored risk-reduction and prevention messaging.

The Unanticipated Benefits of PrEP for Young Black Gay, Bisexual, and Other Men Who Have Sex with Men

Pre-exposure prophylaxis (PrEP) is effective at reducing new HIV infections among adherent users. However, there are potential benefits of PrEP beyond HIV prevention that remain understudied, particularly among young Black gay, bisexual, and other men who have sex with men (MSM). In 2018, we conducted six focus groups (n = 36) in four midwestern cities: Milwaukee, WI; Minneapolis, MN; Detroit, MI; and Kansas City, MO with current and former PrEP users who identified as Black MSM. The focus groups covered medical care and provider experiences, patterns of PrEP use and adherence, relationships while on PrEP, and PrEP stigma. Results revealed four unanticipated benefits of PrEP for young Black MSM: (1) improved engagement in medical care, (2) reduced sexual and HIV anxiety, (3) increased sexual comfort and freedom, and (4) positive sexual relationships with people living with HIV. Findings from this study fill a gap in our understanding of the potential benefits of PrEP beyond HIV prevention. Public health campaigns and messaging around PrEP should incorporate such benefits to reach young Black MSM who may be motivated by benefits beyond HIV prevention.

A Person-Centered Approach to HIV-Related Protective and Risk Factors for Young Black Men Who Have Sex with Men: Implications for Pre-exposure Prophylaxis and HIV Treatment as Prevention

Although young Black men who have sex with men (YBMSM) are disproportionately affected by HIV, they may be more heterogeneous as a group than is typically appreciated. Thus, the present study used a person-centered data-analytic approach to determine profiles of HIV-related risk among YBMSM and whether these profiles could be distinguished by age, HIV status, and socioeconomic risk (i.e., socioeconomic distress). YBMSM (N = 1808) aged 18 to 29 years completed a survey of sociodemographic characteristics, HIV status, and HIV-related behavioral and attitudinal factors (i.e., safer-sex self-efficacy, negative condom attitudes, being in difficult sexual situations, being in difficult sexual relationships, HIV treatment optimism, perceived HIV stigma). Latent profile analysis was used to identify HIV risk profiles and whether age, HIV status, and socioeconomic distress were associated with these profiles. Four profiles emerged: low-, medium-, and high-risk profiles, respectively, and a mixed profile characterized by a tendency to be in difficult sexual situations and relationships while also reporting high safer-sex self-efficacy and low negative attitudes toward condom use. Difficult sexual situations emerged as the key defining indicator of whether a profile reflected higher or lower risk. Younger age, being HIV-positive, and socioeconomic distress were associated with having a higher-risk profile. Given that unique risk profiles emerged that were differentially predicted by sociodemographic characteristics and HIV status, these findings have implications for tailoring interventions to the needs of different subgroups of YBMSM. Also, disempowering or risky sexual situations and relationships among YBMSM must be addressed.

Latent Classes of Sexual Positioning Practices and Sexual Risk Among Men Who Have Sex with Men in Paris, France

HIV/STI risk varies by sexual positioning practices; however, limited data have characterized the behavioral profiles of men who have sex with men (MSM) in France. This study used latent class analysis (LCA) to explore sexual risk profiles among MSM in Paris, France. LCA was used to classify sexual positioning and serosorting profiles among MSM in Paris (n = 496). Age, HIV status, relationship status, substance use, group sex, and PrEP history were used in a multinomial regression model predicting class membership. Three latent classes were identified: majority top/serosorters, versatile/low partners, and majority bottom/some serosorters. Majority top/serosorters had the highest probability of condomless serosorting; majority bottom/some serosorters had the highest mean number of partners (~ 12 partners) for condomless receptive anal intercourse. HIV-positive MSM were more likely to be classified as majority bottom/some serosorters than versatile/low partners (AOR 7.61; 95% CI 2.28, 25.3). Findings support the need for tailored and targeted interventions for highest-risk individuals.

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

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

Examining the Sexual Health Consequences of Alcohol Consumption Among Black Gay and Bisexual Men

BACKGROUND

Black men who have sex with men (MSM) are disproportionately affected by HIV infection. Efforts are needed to understand correlates of HIV risk among this group. Alcohol consumption may have a role in HIV transmission given its association with condomless sex. This study aimed to examine the association between alcohol consumption (i.e., drinking before/during sex and levels of alcohol use problems) and condom use during lifetime, past 6 months, and the event (i.e., a specific sexual episode) level.

METHODS

Black MSM (N = 102) reported sexual behavior and condom use for lifetime, past 6 months, and the most recent condom and condomless sex events. The Alcohol Use Disorders Identification Test (AUDIT) determined alcohol use problems.

RESULTS

Ordinal and binary regression analyses analyzed associations between AUDIT scores and condomless sex (receptive and insertive). AUDIT scores were associated with a greater likelihood of condomless sex (lifetime receptive sex: OR = 1.06, p < 0.05; past 6 months insertive sex: odds ratio [OR] = 1.09, p < 0.01). At the event level, there was no greater likelihood of drinking during last condomless sex as compared to last condom sex, χ2 (1) = 0.18, p = 0.39.

CONCLUSIONS

There was evidence that an increase in alcohol use problems was associated with a greater likelihood of risky sexual behavior. Drinking before/during sex was not related to condom use. These findings contribute to understanding the nuanced relationship between alcohol use and sexual risk.