Knowledge and willingness to use pre-exposure prophylaxis among men who have sex with men in Northeastern Brazil

Factors Associated with PrEP Stigma Among Gay, Bisexual, and Other Men Who Have Sex with Men (gbMSM): A Systematic Review

Gay, bisexual, and other men who have sex with men (gbMSM) are disproportionately affected by HIV. While pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV acquisition, uptake of PrEP among gbMSM is low, which may in part be due to stigma associated with PrEP use. This systematic review aimed to explore experiences of PrEP stigma and to identify factors associated with this. Four databases were searched for papers including terms relating to (i) gbMSM, (ii) PrEP, and (iii) stigma, with narrative synthesis used to analyze results. After screening, 70 studies were included in the final analysis. Experiences of PrEP stigma were found to be characterized by a number of stereotypes and came from a range of sources. Five categories of factors were associated with stigma: (i) healthcare-related factors, (ii) cultural and contextual factors, (iii) sociodemographic factors, (iv) peer-discussion, and (v) psychosocial factors. These findings suggest that stigma can be a common experience for gbMSM. However, some are more at risk than others. Interventions aimed at reducing PrEP stigma may be useful in increasing uptake.

HIV epidemic, prevention technologies, and the new generations: trends and opportunities for epidemic response

The United Nations has underscored the possibility of ending the HIV epidemic as a public health problem. However, an increase in the incidence among adolescents and youth has indicated a greater distance between HIV responses and the specificities of the new generations, which can maintain the epidemic for an extended period. Regards this matter, it is debated that the provision of a range of preventive methods, even if highly effective, and a conservatism that has internalized stigma within government policies, hinder the proper and essential dialogue between current preventive policies and the needs of the new generations. These generations are marked by a social representation of AIDS as a mild disease, by new gender and sexuality performances, and by the search for a more critical role in affective and sexual encounters, which includes frequent use of dating apps and substances. The hierarchy of the delivery of prevention methods is presented as a proposal for a new policy, prioritizing pre-exposure prophylaxis (PrEP) and addressing the social determinants of the HIV epidemic, including strategies to mitigate stigma. The importance of the participation of adolescents and youth in constructing the policy and the need for an intersectoral response are also reinforced.

Same-Day Initiation of Oral Pre-Exposure Prophylaxis is High Among Adolescent Men Who Have Sex With Men and Transgender Women in Brazil

PURPOSE

This study analyzed the sociodemographic and behavioral characteristics of adolescent men who have sex with men (aMSM) and transgender women (aTGW) initiating oral pre-exposure prophylaxis (PrEP) in human immunodeficiency virus (HIV) prevention clinics.

METHODS

PrEP1519 is a prospective, multicenter, open-label PrEP demonstration cohort study of aMSM and aTGW aged 15-19 years living in three large Brazilian capital cities. For this analysis, we included adolescents who enrolled in PrEP1519 from February 2019 to August 2021. Adolescents who visited PrEP clinics were classified into four groups based on PrEP eligibility and on their decision to use PrEP: (1) ineligible for same-day PrEP initiation; (2) eligible for same-day PrEP initiation, initiated PrEP at first visit; (3) eligible for PrEP initiation, initiated PrEP after the first visit; and (4) eligible for same-day PrEP initiation but declined. The groups that were eligible for same-day PrEP initiation were compared using the Chi-square and Fisher's exact tests.

RESULTS

Of the 1,254 adolescents enrolled in the PrEP1519 study, 61 (4.9%) were considered ineligible for same-day PrEP initiation. Of the 1,193 eligible for same-day PrEP initiation, 1,113 (93.3%) initiated PrEP [1,054 initiated PrEP in the first visit (88.3%) and 59 in subsequent visits (4.9%)] and 80 (6.7%) did not. Despite 90% of the PrEP decliners reporting a low risk of HIV infection, most reported condomless anal sex in the past six months (70%).

DISCUSSION

Same-day PrEP initiation among aMSM and aTGW was high, highlighting that this strategy was important to promote PrEP initiation among adolescents with increased vulnerability to HIV in Brazil.

Pre-exposure prophylaxis uptake for high-risk men who have sex with men in China: a multi-city cross-sectional survey

BACKGROUND

Pre-exposure prophylaxis (PrEP) is a proven biomedical strategy to prevent HIV transmission among men who have sex with men (MSM). Despite oral PrEP is safe and effective in MSM, the use of PrEP has been discouraging, especially in high-risk MSM. And there are no relevant studies showing the use of PrEP in high-risk MSM. The purpose of this study was to get the rate of PrEP use and the factors influencing PrEP use among high-risk MSM.

METHODS

A cross-sectional study was conducted through an electronic questionnaire on the "i guardian Platform", and "snowballing" method was used to recruit MSM in six cities in China, including Beijing, Shenzhen, Chengdu, Changsha, Jinan and Nanjing in China, from January to April 2021. Univariate and multivariate logistic regression analysis were used to analyze the factors associated with the use of PrEP among high-risk MSM who had heard about PrEP.

RESULTS

Among the 1865 high-risk MSM who had heard of PrEP, the rates of those who were willing to use PrEP, had knowledge awareness of PrEP, and had used PrEP were 96.7%, 24.7%, and 22.4%, respectively. Multivariate logistic regression analysis of PrEP use in high-risk MSM showed that more PrEP was used by those who were 26 years or older (OR = 1.86, 95%CI 1.17 ~ 2.99), had master degree or above (OR = 2.37, 95% CI 1.21 ~ 4.72), had unstable work (OR = 1.86, 95% CI 1.16 ~ 2.96), had tested five or more HIV times in the past year (OR = 3.09, 95% CI 1.65 ~ 6.04), had consulted PrEP (OR = 22.05, 95% CI 14.87 ~ 33.91) and had PrEP knowledge awareness (OR = 1.90, 95% CI 1.41 ~ 2.55) (P < 0.05).

CONCLUSIONS

The rate of PrEP use in high-risk MSM was relatively low. PrEP was used more by high-risk MSM with unstable jobs, higher education, frequent HIV testing, and PrEP counseling. Public education on PrEP for MSM should continue to be enhanced to help them use PrEP in a timely and accurate manner.

Reaching Out to Adolescents at High Risk of HIV Infection in Brazil: Demand Creation Strategies for PrEP and Other HIV Combination Prevention Methods

Using baseline data from the PrEP1519 cohort, in this article we aimed to analyze: (i) the effectiveness of demand creation strategies (DCS) to enroll adolescent men who have sex with men (AMSM) and adolescent transgender women (ATGW) into an HIV combination prevention study in Brazil; (ii) the predictors of DCS for adolescents' enrollment; and (iii) the factors associated with DCS by comparing online and face-to-face strategies for enrollment. The DCS included peer recruitment (i.e., online and face-to-face) and referrals from health services and non-governmental organizations (NGOs). AMSM and ATGW who agreed to participate in the study could opt to enroll in either PrEP (PrEP arm) or to use other prevention methods (non-PrEP arm). Bivariate and multivariate analyses were conducted and logistic regression odds ratios were estimated. The DCS reached 4529 AMSM and ATGW, the majority of which were derived online (73.8%). Of this total, 935 (20.6%) enrolled to participate (76.6% in PrEP arm and 23.4% in non-PrEP arm). The effectiveness of enrolling adolescents into both arms was greater via direct referrals (235/382 and 84/382, respectively) and face-to-face peer recruitment (139/670 and 35/670, respectively) than online (328/3342). We found that a combination under DCS was required for successful enrollment in PrEP, with online strategies majorly tending to enroll adolescents of a higher socioeconomic status. Our findings reinforce the need for DCS that actively reaches out to all adolescents at the greatest risk for HIV infection, irrespective of their socioeconomic status.

Perceived Risk of HIV Infection and Acceptability of PrEP among Men Who Have Sex with Men in Brazil

The HIV epidemic affects men who have sex with men (MSM) disproportionally in Brazil, and pre-exposure prophylaxis (PrEP) is effective for preventing HIV in this population. However, low perceived risk of HIV may influence the acceptability and decision to use PrEP. This study estimated the association between self-perception of HIV risk and acceptability of daily oral PrEP among Brazilian MSM. Respondent-driven sampling (RDS) was used for behavioral and biological surveillance to recruit 4,176 MSM 18 years or over in 12 Brazilian cities in 2016. Results were weighted using Gile's estimator in RDS Analyst software. Adjusted odds rations (OR) with 95% confidence intervals were calculated using multivariate logistic regression. Acceptability of daily oral PrEP was high (69.7%) among the 3,544 MSM available for analysis. Most participants self-reported low or moderate risk of HIV infection (67.2%) and a small proportion (9.3%) reported high risk. A dose-response relationship was observed between acceptability of PrEP and self-reported risk: PrEP acceptability was 1.88 times higher (OR 1.8; 95% CI: 1.24-2.85) among MSM whose perceived risk of HIV infection was low or moderate, and 5 times higher (OR 5.68; 95% CI: 2.54-12.73) among those who self-reported high risk compared to MSM reporting no HIV risk. MSM with the highest risk perception of HIV reported higher rates of PrEP acceptability. Given the availability of daily oral PrEP in the public health care system in Brazil, we suggest emphasizing counseling about self-perception of HIV risk as part of routine HIV prevention services.

PrEP perception and experiences of adolescent and young gay and bisexual men: an intersectional analysis

Studies indicate gaps in knowledge about the barriers to access and adhere to HIV pre-exposure prophylaxis (PrEP) in adolescents. In this article, we explore the perceptions and experiences of young gay, bisexual, and other men who have sex with men (YGBMSM) of the search, use and adherence to PrEP, considering their positions according to social markers of difference such as race/skin color, gender, sexuality, and social status. Intersectionality provides theoretical and methodological tools to interpret how the interlinking of these social markers of difference constitutes barriers and facilitators in the PrEP care continuum. The analyzed material is part of the PrEP1519 study and is comprised of 35 semi-structured interviews with YGBMSM from two Brazilian capitals (Salvador and São Paulo). The analyses suggest connections between social markers of difference, sexual cultures, and the social meanings of PrEP. Subjective, relational and symbolic aspects permeate the awareness of PrEP in the range of prevention tools. Willingness to use and adhere to PrEP is part of a learning process, production of meaning, and negotiation in the face of getting HIV and other sexually transmittable infections and the possibilities of pleasure. Thus, accessing and using PrEP makes several adolescents more informed about their vulnerabilities, leading to more informed decision-making. Interlinking the PrEP continuum of care among YGBMSM with the intersections of the social markers of difference may provide a conceptual framework to problematize the conditions and effects of implementing this prevention strategy, which could bring advantages to HIV prevention programs.

Between risk and pleasure: reflections on HIV prevention and care in the current context of PrEP use by men who have sex with men

This study offers a set of reflections on the relationship between risk and pleasure in the field of HIV prevention and care, as it mediates new biomedical prevention/care technologies, particularly pre-exposure prophylaxis (PrEP), among men who have sex with men (MSM). We begin by investigating some studies about condomless sex between men, more specifically barebacking and PrEP use among young MSM. We base our analysis on the assumption that PrEP, as one of these new actants, has reconfigured the field of HIV prevention/care, especially in relation to the dimensions of risk and pleasure, with the potential to considerably reduce the chances of HIV infection while enabling maximum pleasure and a sense of greater safety and freedom. Despite this progress, we also problematize some of the ambivalences, tensions, and moral conflicts that still exist in the field of prevention, especially the potential for condomless sex. Finally, taking a praxiographic perspective on health care and foregrounding the situated practices of human and non-human actors/actants in interaction, we consider HIV/AIDS prevention as a more fluid, non-linear, erratic phenomenon that involves multiple types of knowledge, feelings, and participations, and is open to different kinds of experimentation. Besides a “logic of choice”, we hold that health care is a permeable, continuous process that is enacted in situated practices and may produce different effects in response to a heterogeneous network of interactions.

Pre-exposure prophylaxis use, HIV knowledge, and internalized homonegativity among men who have sex with men in Brazil: A cross-sectional study

Background

Pre-exposure prophylaxis (PrEP) use in Brazil remains low despite free national access. We explored associations of HIV knowledge and internalized homonegativity with PrEP use among PrEP-eligible men who have sex with men (MSM).

Methods

Brazilian Hornet users completed an online, cross-sectional survey in February-March 2020. We included cis-men ≥18 years old who reported recent sex with men and were PrEP-eligible per the following: condomless anal intercourse, partner(s) living with HIV, transactional sex, and/or sexually transmitted infection. Our outcome was current PrEP use, defined by the response, "I am currently taking PrEP." Key predictors included the HIV/AIDS Knowledge Assessment (HIV-KA) and Reactions to Homosexuality Scale (RHS); higher scores indicate greater knowledge and greater internalized homonegativity, respectively. Scales were standardized for analysis. Associations with current PrEP use were estimated using adjusted odds ratios (aOR) with 95% confidence intervals (95%CI).

Findings

Among 2398 PrEP-eligible MSM, n = 370 (15·4%) reported current PrEP use. Increasing HIV-KA scores were associated with greater odds of PrEP use (aOR 1·70 [95%CI 1·41-2·04], p < 0·001), and increasing RHS scores with lower odds of PrEP use (aOR 0·83 [95%CI 0·73-0·96], p = 0·010). PrEP use was lower among 18-24 versus 40+-years-old MSM (aOR 0·43 [95%CI 0·27-0·69], p = 0·005), and in Black versus White/Asian respondents (aOR 0·51 [95%CI 0·31-0·85], p = 0·040).

Interpretation

Among PrEP-eligible Brazilian MSM, HIV knowledge was associated with increased PrEP use and internalized homonegativity with decreased use. Wider dissemination of HIV prevention knowledge and addressing stigma experienced by MSM could promote increased PrEP use.

Funding

National Institute of Mental Health, Fiocruz, Conselho Nacional de Desenvolvimento Científico e Tecnológico.

Perception of discrimination due to sexual orientation and associated factors among men who have sex with men in 12 Brazilian cities

Discrimination due to sexual orientation (DDSO) has an important association with health outcomes among men who have sex with men (MSM). This study aimed to analyze factors associated with DDSO among MSM in 12 Brazilian cities. This is a cross-sectional study with 4,176 MSM participants recruited in 2016 which used a respondent-driven sampling method in 12 Brazilian cities. DDSO levels were previously identified by a latent class analysis based on 13 variables from the discrimination section. An ordinal logistic regression was used to assess associations with these DDSO levels, and weighted ordinal odds ratios (OR) and their respective 95% confidence intervals (95%CI) were estimated using Gile’s estimator. Most participants were young (< 25 years old) black or of mixed-race (pardo), single individuals who had a religious affiliation, primary or incomplete secondary education, and a high and average socioeconomic status. More than half (65%) reported DDSO in the 12 months prior to this study. We observed an independent association among the four latent DDSO classes and the following variables: age < 25 years old (OR = 1.66; 95%CI: 1.21-2.27), white skin color (OR = 1.43; 95%CI: 1.02-2.01), history of sexual (OR = 2.33; 95%CI: 1.58-3.43) and physical violence (OR = 3.08; 95%CI: 2.11-4.49), disclosure of their sexual orientation as MSM to their fathers (OR = 2.00; 95%CI: 1.47-2.72), experienced suicidal ideation in the two weeks prior to this study (OR = 2.09; 95%CI: 1.46-2.98), and use of any illicit drugs in the last six months (OR = 1.61; 95%CI: 1.19-2.18). Our results indicate that contextual factors may contribute to high DDSO levels among MSM in Brazil. Public health policies toward human rights surveillance and protection among MSM must be urgently addressed.

Government communication pieces on HIV pre-exposure (PrEP) and post-exposure (PEP) prophylaxis (2016-2019): analysis of their content and circulation among gay men, trans women/travestis, and sex workers

Abstract This article analyzes the advertisement of pre-exposure (PrEP) and post-exposure (PEP) prophylaxis treatment for HIV considering the historical role of AIDS prevention campaigns in Brazil. A total of 24 pieces of communication on PrEP, PEP, and CP (Combined Prevention), produced from 2016 to 2019 and published on the website and social media of the Brazilian Ministry of Health were analyzed in addition to the testimony of 30 users of prophylaxis - including gays, trans women/travestis, and sex workers - in the metropolitan region of Rio de Janeiro. The materials were classified according to type, year, audience, and access information, and the results were interpreted from four axes: contextualization of the communication pieces and the experience of the interlocutors with the information; sexuality and risk; gender, emotions, and moralities; and condom displacements. The analysis indicated the erasure of expressions of sexuality and the predominance of an abstract and structured language, presupposing a rational and individualistic public, with condoms associated with “sexual risk.” Users’ reports regarding the advertisement of information on these prophylaxis reveals its insufficiency. We conclude that the potential of information and communication campaigns, guided by the sociocultural reality of social segments, has been little explored, compromising access to prophylaxis. Thus, the biomedicalization of prevention and the advance of conservatism in Brazil hinder the Brazilian response to AIDS.

Peças de comunicação governamentais sobre as profilaxias pré (PrEP) e pós-exposição (PEP) ao HIV (2016-2019): análise de seus conteúdos e circulação entre gays, mulheres trans/travestis e trabalhadoras sexuais

Resumo Este artigo analisa a divulgação das profilaxias pré (PrEP) e pós-exposição (PEP) ao HIV, considerando o papel histórico das campanhas de prevenção à aids. São utilizadas 24 peças de comunicação sobre PrEP, PEP e PC (Prevenção Combinada), produzidas entre 2016 e 2019 e publicadas no site e mídias sociais do Ministério da Saúde, e o depoimento de 30 usuários(as) das profilaxias - que incluem gays, mulheres trans/travestis e profissionais do sexo - na região metropolitana do Rio de Janeiro. As peças foram classificadas quanto ao tipo, ano, público e informação de acesso, e os resultados foram interpretados a partir de três eixos: sexualidade e risco; gênero, emoções e moralidades; deslocamentos do preservativo. A análise indicou o apagamento das expressões de sexualidade e o predomínio de uma linguagem abstrata e esquemática, pressupondo um público racional e individualista, com o preservativo associado à ideia de “risco sexual”. Os relatos dos(as) usuários(as) quanto à divulgação de informações sobre essas profilaxias evidenciaram sua insuficiência. Concluímos que ocorre uma baixa exploração do potencial das campanhas de comunicação, orientadas pela realidade sociocultural dos segmentos sociais, comprometendo o acesso às profilaxias. Assim, a biomedicalização da prevenção e o avanço do conservadorismo prejudicam a resposta brasileira à aids.

Willingness, preferred ways and potential barriers to use pre-exposure prophylaxis for HIV prevention among men who have sex with men in China

OBJECTIVE

To explore willingness and preferred ways to use HIV pre-exposure prophylaxis (PrEP), factors associated with willingness, and potential barriers to PrEP use among men who have sex with men (MSM) in Changsha, China.

DESIGN

A cross-sectional survey was conducted from 25 June to 31 August 2019. Two hundred and fifty-five MSM were recruited from three community-based organisations (CBOs) in Changsha City. Willingness and potential barriers to use PrEP were examined using researcher-created scales. Univariate and multivariate logistic regression was used to analyse the factors associated with willingness to use PrEP. P values <0.05 were considered significant.

SETTING

Three MSM inclusive CBOs in Changsha, Hunan Province, China.

PARTICIPANTS

255 HIV-negative MSM were recruited through their CBOs with snowball sampling.

RESULTS

Less than half of the participants (43.1%) had heard of PrEP and 15.3% were willing to use PrEP. The participants reported higher willingness to use event-driven PrEP (3.70±0.07) than daily PrEP (2.65±0.07). Higher self-rated risk and fear of contracting HIV (OR: 14.47, 95% CI 2.19 to 95.53), awareness of PrEP (OR: 4.20, 95% CI 1.64 to 10.73), sharing one's own sexual orientation with parents or siblings (OR: 2.52, 95% CI 1.54 to 7.20) and having a university education or above (OR:0.29, 95% CI 0.12 to 0.72) were associated with willingness to use PrEP. Only 12.2% of the sample was concerned about potential barriers to PrEP use.

CONCLUSION

Efforts to improve awareness and knowledge of PrEP, teach self-evaluation of HIV infection risk and provide social and emotional support for MSM are needed to scale up PrEP implementation in China.

PrEP Awareness, Use, Intention to Use, and Information Source Among Geosocial Networking Application Users in Mexico in 2018-2019

Pre-exposure prophylaxis (PrEP) has limited availability across Latin America, though access is increasing. We explored PrEP uptake in Mexico via an online survey completed by Spanish-speaking, Hornet geosocial networking application (GSN app) users without HIV (n = 2020). Most (81.3%) had heard of PrEP, 3.5% were current users, and 34.2% intended to take PrEP within six months. Current PrEP use was associated with PrEP eligibility (aOR 26.07 [95%CI 13.05-52.09], p < 0.001), recent STI testing (aOR 3.79 [95%CI 1.10-13.11], p = 0.035), and recent chemsex (aOR 3.02 [95%CI 1.02-8.93], p = 0.046). Recent STI testing was associated with hearing about PrEP from a doctor (aOR 3.26 [95%CI 1.98-5.36], p < 0.001), and those who lived in large cities were less likely to have learned about PrEP via Hornet (aOR 0.52 [95%CI 0.32-0.85], p = 0.009). Interventions to increase PrEP uptake in Mexico should build upon existing health networks and utilize GSN apps for PrEP information dissemination, particularly in less populated areas.

Willingness to use HIV pre-exposure prophylaxis and associated factors among men who have sex with men in Liuzhou, China

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) is a key component of HIV combination prevention strategies and has the potential to decrease the incidence of HIV in men who have sex with men (MSM). This study aimed to evaluate levels of PrEP acceptability and explore factors associated with willingness to use PrEP among MSM in Liuzhou, China.

METHODS

Between November 2017 and May 2019, a cross-sectional survey was conducted among 829 MSM. The study participants were recruited through a nonprobability sampling method. The participants' demographics, HIV/AIDS knowledge, sexual behaviors, drug use and HIV test history were collected. Multivariate logistic regression was performed to identify factors associated with willingness to use PrEP.

RESULTS

A total of 829 MSM completed the survey, and 30.28% (95% CI 27.3-33.4) were willing to use PrEP. In multivariate logistic regression, factors associated with a higher willingness to use PrEP included Zhuang or Han ethnic origin, recruitment through peer introduction or gay venues, pursuit of a higher education level, previous HIV testing and oral sex with a man. Conversely, having casual sex in the past 6 months was associated with a lower willingness to use PrEP.

CONCLUSIONS

MSM in Liuzhou reported a relatively low level of willingness to use PrEP. The results indicate the need for effective education, targeted intervention, and implementation strategies to promote PrEP acceptance among MSM.

The influence of HIV-related stigma on PrEP disclosure and adherence among adolescent girls and young women in HPTN 082: a qualitative study

Introduction

Stigma and disclosure concerns have been key barriers to oral pre‐exposure prophylaxis (PrEP) adherence for African adolescent girls and young women (AGYW) in efficacy trials. We aimed to understand the impact of these factors among African AGYW in an open‐label PrEP study.

Methods

HPTN 082 was an open‐label PrEP study among AGYW (ages 16 to 24) in Harare, Zimbabwe, and Cape Town and Johannesburg, South Africa from 2016 to 2018. Women starting PrEP were randomized to standard adherence support (counselling, two‐way SMS, monthly adherence clubs) or standard support plus drug‐level feedback. Serial in‐depth interviews were conducted among 67 AGYW after 13‐week and 26‐week study visits to explore experiences of stigma, disclosure and PrEP adherence. We analysed data by coding transcripts and memo‐writing and diagramming to summarize themes.

Results

AGYW described stigma related to sexual activity (e.g. “people say I'm a prostitute”) and being perceived to be living with HIV because of taking antiretrovirals (e.g. “my husband's friends say I'm HIV infected”). Participants who anticipated stigma were reluctant to disclose PrEP use and reported adherence challenges. Disclosure also resulted in stigmatizing experiences. Across all sites, negative descriptions of stigma and disclosure challenges were more common in the first interview. In the second interview, participants often described disclosure as an “empowering” way to combat community‐level PrEP stigma; many said that they proactively discussed PrEP in their communities (e.g. became a “community PrEP ambassador”), which improved their ability to take PrEP and encourage others to use PrEP. These empowering disclosure experiences were facilitated by ongoing HPTN 082 study activities (e.g. counselling sessions, adherence clubs) in which they could discuss PrEP‐related stigma, disclosure and PrEP adherence issues.

Conclusions

Stigma and disclosure challenges were initial concerns for African AGYW newly initiating PrEP but many were empowered to disclose PrEP use over their first six months of PrEP use, which helped them cope with stigma and feel more able to take PrEP regularly. PrEP programmes can foster disclosure through community and clinic‐based discussion, adherence clubs and activities normalizing sexual behaviour and PrEP use, which can reduce stigma and improve PrEP adherence and thus effectiveness.

How heterogeneous are MSM from Brazilian cities? An analysis of sexual behavior and perceived risk and a description of trends in awareness and willingness to use pre-exposure prophylaxis

Background

Brazil has the largest population of individuals living with HIV/AIDS in Latin America, with a disproportional prevalence of infection among gays, bisexuals and other men who have sex with men (MSM). Of relevance to prevention and treatment efforts, Brazilian MSM from different regions may differ in behaviors and risk perception related to HIV.

Methods

We report on MSM living in 29 different cities: 26 Brazilian state capitals, the Federal District and two large cities in São Paulo state assessed in three web-based surveys (2016–2018) advertised on Grindr, Hornet and Facebook. Using logistic regression models, we assessed the association of risk behavior with HIV perceived risk as well as factors associated with high-risk behavior.

Results

A total of 16,667 MSM completed the survey. Overall, MSM from the North and Northeast were younger, more black/mixed-black, of lower income and lower education compared to MSM from the South, Southeast and Central-west. Though 17% had never tested for HIV (with higher percentages in the North and Northeast), condomless receptive anal sex (previous 6 months) and high-risk behavior as per HIV Incidence Risk scale for MSM were observed for 41 and 64%, respectively. Sexual behavior and HIV perceived risk had low variability by city and high-risk behavior was strongly associated with high HIV perceived risk. Younger age, being gay/homosexual, having a steady partner, binge drinking, report of sexually transmitted infection (STI) and ever testing for HIV were associated with increased odds of high-risk behavior. Awareness and willingness to use PrEP increased from 2016 to 2018 in most cities.

Conclusions

Overall, MSM socio-demographic characteristics were heterogeneous among Brazilian cities, but similarities were noted among the cities from the same administrative region with a marked exception of the Federal District not following the patterns for the Central-West. Combination HIV prevention is most needed among young men who self-identify as gay/homosexual, report binge drinking or prior STI.