Commercial lubricant use among HIV-negative men who have sex with men in Los Angeles: implications for the development of rectal microbicides for HIV prevention

Acceptability of PC-1005 Gel Administered Rectally to HIV-1 Seronegative Adults at Three Different Volume Levels (MTN-037)

Multipurpose prevention technologies (MPT) have been increasingly researched for their dual-purpose preventative properties against HIV and other STIs. The acceptability of PC-1005, a topical MPT candidate, was explored among men and women participating in the MTN-037 Phase I trial at two U.S. sites (Pittsburgh, PA, and Birmingham, AL). We triangulated quantitative and qualitative assessments of the acceptability of three volumes (4 mL, 16 mL, 32 mL) of PC-1005 administered rectally (N = 12; 6 males, 6 females). Participants rated overall gel acceptability on a scale of 1-10, with a median of 7.17 (SD = 2.04) and had positive feelings about all three dose volumes, citing them to be very comfortable or comfortable (dose 1 = 91.7%; dose 2 = 91.7%; dose 3 = 83.3%). High acceptability of and comfort with all three dose volumes shows promise for PC-1005 as an MPT to prevent HIV and STIs, warranting future clinical development.

Behavior intention to use routine opt-out HIV testing in primary care settings among men who have sex with men in China

The opt-out option has the advantages of potentially normalizing HIV testing and hence remove stigma involved in HIV testing among men who have sex with men (MSM). The present study investigated behavioral intention to use free routine opt-out HIV testing in primary care settings and associated factors among MSM in Hong Kong, China. A cross-sectional survey was conducted among 336 MSM recruited from multiple sources during October 2015 and September 2016. Of the participants, 37.2% intended to use free routine opt-out HIV testing in primary care settings in the next 12 months if it was made available. Adjusted for significant background variables, variables on positive attitudes, perceived subjective norm (i.e., perceived support from male partners for taking up routine opt-out testing) and perceived descriptive norm (i.e., perceived >60% of peers would use this option) were significantly associated with behavioral intention use such testing option. In addition, had ever tested for HIV, and perceived level of trust of health professionals in primary care settings were also significant. Routine opt-out HIV testing is a potential useful means to increase HIV testing coverage among MSM in Hong Kong. Policy makers should consider allocating resources to pilot and implement this testing option.

Lubricant Use and Rectal Chlamydial and Gonococcal Infections Among Men Who Engage in Receptive Anal Intercourse

BACKGROUND

Use of lubricants during anal intercourse is very common among men who have sex with men. However, few studies have evaluated associations between specific lubricants and rectal sexually transmitted infections (STIs).

METHODS

Between July 2012 and October 2013, we conducted a cross-sectional study of men who have sex with men recruited from an urban, public sexual health clinic. In a self-administered survey, participants identified the lubricants used and frequency of lubricant use in the previous three months. Among men reporting any receptive anal intercourse (RAI) in the previous 3 months, we used multivariable binomial regression models to analyze associations between recent use of 9 specific lubricants and prevalent rectal chlamydia, rectal gonorrhea, and either rectal infection.

RESULTS

Twenty-five percent of the 146 participants had rectal chlamydial infection and 21% had rectal gonococcal infection; 37% had either (chlamydial or gonococcal) infection. Three-quarters reported always or almost always using lubricant during recent receptive anal intercourse. After adjustment for age, race, human immunodeficiency virus status, and condom use, Gun Oil (adjusted prevalence ratio [aPR], 1.99; 95% confidence interval [CI], 1.04-3.80) and Slick (aPR, 3.55; 95% CI, 1.38-9.12) were significantly associated with prevalent gonococcal infection. No lubricants were significantly associated with prevalent rectal chlamydia, but in analyses of either rectal infection, precum (aPR, 1.68; 95% CI, 1.06-2.66), Vaseline (aPR, 1.70; 95% CI, 1.10-2.64), and baby oil (aPR, 2.26; 95% CI, 1.43-3.57) were all significantly associated with prevalent rectal infection.

CONCLUSIONS

Several lubricants were significantly associated with increased prevalence of rectal STI. Longitudinal studies are needed to examine any causal relationship between specific lubricants and STI acquisition.

Preference of Oral Tenofovir Disoproxil Fumarate/Emtricitabine Versus Rectal Tenofovir Reduced-Glycerin 1% Gel Regimens for HIV Prevention Among Cisgender Men and Transgender Women Who Engage in Receptive Anal Intercourse with Men

Oral pre-exposure prophylaxis (PrEP) can prevent HIV transmission. Yet, some may prefer not to take systemic daily medication. MTN-017 was a 3-period, phase 2 safety and acceptability study of microbicide gel applied rectally either daily or before and after receptive anal intercourse (RAI), compared to daily oral tablet. At baseline, cisgender men and transgender women who reported RAI (N = 187) rated the daily oral regimen higher in overall liking, ease of use, and likelihood of future use than the gel regimens. After trying all three, 28% liked daily oral the least. Gel did not affect sexual enjoyment (88%) or improved it (7-8%). Most partners had no reaction to gel use. Ease of gel use improved significantly between the first and the last few times of daily use. A rectal gel used before and after RAI may constitute an attractive alternative to daily tablet. Experience with product use may increase acceptability.

Lubricant Provides Poor Rectal Mucosal HIV Coverage

Given the rising HIV incidence in men who have sex with men (MSM) despite repeatedly proven effectiveness of oral HIV pre-exposure prophylaxis, behaviorally congruent periodic dosing strategies, such as dosing microbicides as lubricants, are now in demand. Rectal microbicide gel studies largely administer gels using vaginal applicators, which have not been well received and do not mimic lubricant use. We compared rectal gel manually dosed as lubricant with applicator dosing in five healthy, HIV-negative MSM who received 10 or 3.5 ml of ^99mTc-DTPA-radiolabeled hydroxyethyl cellulose universal placebo gel intrarectally. After washout, participants received 10 ml of radiolabeled Wet^® Original^® lubricant to apply to the anus with fingers and/or a phallus in a manner typical of sexual lubricant use with a partner, followed by simulated receptive anal intercourse. Single-photon emission computed tomography with transmission computed tomography was performed 4 h after each gel administration. Manual dosing was associated with more variable rectosigmoid distribution, 4.4-15.3 cm from the anorectal junction, compared with more uniform distribution, 5.9-7.4 and 5.3-7.6 cm after 10 and 3.5 ml applicator dosing, respectively. A significantly smaller fraction of the initial 10 ml dose was retained within the colon after manual dosing, 3.4%, compared with 94.9% and 88.4% after 10 and 3.5 ml applicator dosing, respectively (both p < .001). Manual dosing of a sexual lubricant delivered a small, variable fraction of the dose with variable rectosigmoid distribution compared with applicator dosing. These results raise concern that dosing a rectal microbicide gel as a sexual lubricant may not provide adequate or predictable mucosal coverage for HIV protection.

Lessons for Rectal Microbicide Development From an Acceptability Trial of a Placebo Gel Applied Prior to Receptive Anal Intercourse

Rectal microbicides, formulated as a gel to be applied before and/or after intercourse, are promising HIV prevention agents and are now in Phase II trials. However, both an optimal formulation and a practical delivery system are needed to ensure that the target population will use the product once efficacy is demonstrated. The precise dynamics of lubricant application by gay and bisexual men who practice anal sex and the qualities they seek in these products are underexplored. As part of a Phase I microbicide acceptability and adherence study conducted in one Puerto Rican and two continental U.S. cities, we recruited 124 young men who have sex with men (YMSM) with a history of unprotected receptive anal intercourse (RAI) and provided them with 40 rectal applicators containing a placebo gel to use prior to RAI during a 12-week period as a proxy for an eventual rectal microbicide. Ninety-five YMSM completed the trial. Their varied preferences as to product viscosity, durability, residue, and mode of application provide important lessons for the design of a product that will be satisfactory to users. Despite many reservations, the participants used the product frequently and found ways to overcome a range of obstacles. A successful rectal microbicide product may need to be presented in a range of viscosities to attract a broad client base.

Acceptability and Preferences for Hypothetical Rectal Microbicides among a Community Sample of Young Men Who Have Sex with Men and Transgender Women in Thailand: A Discrete Choice Experiment

Rectal microbicides (RMs) may offer substantial benefits in expanding HIV prevention options for key populations. From April to August 2013, we conducted Tablet-Assisted Survey Interviewing, including a discrete choice experiment, with participants recruited from gay entertainment venues and community-based organizations in Chiang Mai and Pattaya, Thailand. Among 408 participants, 74.5 % were young men who have sex with men, 25.5 % transgender women, with mean age = 24.3 years. One-third (35.5 %) had ≤9th grade education; 63.4 % engaged in sex work. Overall, 83.4 % reported they would definitely use a RM, with more than 2-fold higher odds of choice of a RM with 99 versus 50 % efficacy, and significantly higher odds of choosing gel versus suppository, intermittent versus daily dosing, and prescription versus over-the-counter. Sex workers were significantly more likely to use a RM immediately upon availability, with greater tolerance for moderate efficacy and daily dosing. Engaging key populations in assessing RM preferences may support biomedical research and evidence-informed interventions to optimize the effectiveness of RMs in HIV prevention.

Rectal 1% Tenofovir Gel Use Associates with Altered Epidermal Protein Expression

Rectal use of a 1% tenofovir (TFV) gel is currently being evaluated for HIV prevention. While careful assessment of mucosal safety of candidate microbicides is a primary concern, tools to assess mucosal toxicity are limited. Mass spectrometry-based proteomics is a sensitive and high-throughput technique that can provide in-depth information on inflammation processes in biological systems. In this study, we utilized a proteomics approach to characterize mucosal responses in study participants involved in a phase 1 clinical trial of a rectal TFV-based gel. Project Gel was a phase 1 randomized (1:1), double-blind, multisite, placebo-controlled trial in which 24 participants received rectal TFV or a universal placebo [hydroxyethyl cellulose (HEC)] over a course of 8 daily doses. Rectal mucosal swabs were collected after 0, 1, and 8 doses and were analyzed by label-free tandem mass spectrometry. Differential protein expression was evaluated using a combination of paired (time-effects) and unpaired (across study arm) t-tests, and multivariate [least absolute shrinkage and selection operator (LASSO)] modeling. Within the TFV arm, 7% (17/249, p < .05) and 10% (25/249, p < .05) of total proteins changed after 1 and 8 daily applications of TFV gel, respectively, compared to 3% (7/249, p < .05) and 6% (16/249, p < .05) in the HEC arm. Biofunctional analysis associated TFV use with a decrease in epidermal barrier proteins (adj. p = 1.21 × 10⁻¹⁰). Multivariate modeling identified 13 proteins that confidently separated TFV gel users (100% calibration and 96% cross-validation accuracy), including the epithelial integrity factors (FLMNB, CRNN, CALM), serpins (SPB13, SPB5), and cytoskeletal proteins (VILI, VIME, WRD1). This study suggested that daily rectal applications of a 1% TFV gel may be associated with mucosal proteome changes involving epidermal development. Further assessment of more extended use of TFV-gel is recommended to validate these initial associations.

Individual-Level, Partnership-Level, and Sexual Event-Level Predictors of Condom Use During Receptive Anal Intercourse Among HIV-Negative Men Who Have Sex with Men in Los Angeles

We examined individual-level, partnership-level, and sexual event-level factors associated with condom use during receptive anal intercourse (RAI) among 163 low-income, racially/ethnically diverse, HIV-negative men who have sex with men (MSM) in Los Angeles (2007-2010). At baseline, 3-month, and 12-month visits, computer-assisted self-interviews collected information on ≤3 recent male partners and the last sexual event with those partners. Factors associated with condom use during RAI at the last sexual event were identified using logistic generalized linear mixed models. Condom use during RAI was negatively associated with reporting ≥ high school education (adjusted odds ratio [AOR] = 0.32, 95 % confidence interval [CI] 0.11-0.96) and methamphetamine use, specifically during RAI events with non-main partners (AOR = 0.20, 95 % CI 0.07-0.53) and those that included lubricant use (AOR = 0.20, 95 % CI 0.08-0.53). Condom use during RAI varies according to individual-level, partnership-level, and sexual event-level factors that should be considered in the development of risk reduction strategies for this population.

Pleasure, affection, and love among Black men who have sex with men (MSM) versus MSM of other races: countering dehumanizing stereotypes via cross-race comparisons of reported sexual experience at last sexual event

Black men have historically been stereotyped as hedonistic, aggressive, and animalistic in their sexual interactions. This study sought to describe pleasure, affection, and love experienced by Black men who have sex with men (MSM) during their last male-partnered sexual event and to examine differences relative to White, Latino, and Asian MSM. A total of 21,696 (793 Black, 18,905 White, 1,451 Latino, and 547 Asian) U.S. men ages 18-87 (M Age = 39) were recruited from social/sexual networking sites targeting MSM in 2010-2011. Participants reported multiple dimensions of sexual experience (pleasure, affection, and love) occurring at their last male-partnered sexual event, partner relationship, and sociodemographic characteristics. Across relationship categories, a sizeable percentage of Black MSM reported pleasure (72-87  % orgasmed, 57-82 % experienced high subjective pleasure) and affection (70-91 % kissed, 47-90 % cuddled). Love was primarily reported for events involving main partners (felt love for partner: 96 %; felt loved by partner: 97 %; verbalized love to partner: 89 %). Latent class analysis with MSM of all races, adjusting for partner relationship and sociodemographic characteristics, revealed three distinct profiles of sexual experience: affection and love (Class 1); affection in the absence of love (Class 2); and neither affection nor love (Class 3). Pleasure was probable across profiles. Some racial differences in profile probability were present, but no overall pattern emerged. Contrary to Black male stereotypes, Black MSM commonly reported pleasure, affection, and love at their last male-partnered sexual event and did not show a meaningful pattern of difference from other-race MSM in their likelihood of experiencing all three.

Interest in using rectal microbicides among Australian gay men is associated with perceived HIV vulnerability and engaging in condomless sex with casual partners: results from a national survey

OBJECTIVE

We assessed interest in using rectal microbicides to prevent HIV transmission among gay men in Australia.

METHODS

A national online survey was conducted in 2013. Interest in using rectal microbicides was measured on a seven-item scale (α=0.81). Factors independently associated with greater interest in using a microbicide were identified using multivariate logistic regression.

RESULTS

Data were collected from 1223 HIV-negative and untested men. Mean age was 31.3 years (SD=10.8, range 18-65); 77% were born in Australia and 25% reported any condomless anal sex with a casual partner in the previous 6 months. Overall, there was moderate interest in using rectal microbicides (M=3.33, range 1-5). In multivariate analysis, greater interest in using microbicides was independently associated with being born outside Australia (adjusted OR (AOR)=1.59; p=0.009), greater self-perceived likelihood of becoming HIV positive (AOR=3.40; p<0.001), less uncertainty about the efficacy of microbicides (AOR=0.65; p=0.009), any condomless anal sex with casual partners in the previous 6 months (AOR=1.78; p=0.03) and ever having received postexposure prophylaxis (AOR=1.53; p=0.04). Interest in using microbicides was not associated with age, number of male sex partners or the HIV status of regular male partners.

CONCLUSIONS

Interest in using rectal microbicides was associated with self-perceived vulnerability to HIV, engaging in sexual practices that increase the risk of HIV acquisition and less uncertainty about the efficacy of microbicides. There appears to be a group of men who would benefit from, and are highly motivated to use, a rectal microbicide product.