Sexual risk of HIV transmission is missed by traditional methods of data collection

HIV-Related Sexual Risk Among Transgender Men Who Are Gay, Bisexual, or Have Sex With Men

BACKGROUND

This study is among the first to examine factors associated with HIV-related sexual risk among transgender men and other transmasculine persons who are gay, bisexual, or have sex with men (T-GBMSM).

METHODS

In 2009-2010, 433 transgender people in Ontario, Canada, participated in a multimode respondent-driven sampling survey, including 158 T-GBMSM. Analyses were weighted using respondent-driven sampling II methods to adjust for differential recruitment probabilities; confidence intervals (CI) were adjusted for clustering by shared recruiter. Prevalence ratios (PR) for associations with past-year high sexual risk (condomless intercourse outside a seroconcordant monogamous relationship) were estimated using average marginal predictions from logistic regression.

RESULTS

Of T-GBMSM (mean age = 29.8; 52% living full time in felt gender; 25% Aboriginal or persons of color; 0% self-reported HIV positive), 10% had high sexual risk activity in the past year. Among the 34% with a past-year cisgender (non-transgender) male sex partner, 29% had high sexual risk. In multivariable analyses, older age, childhood sexual abuse (adjusted PR, APR = 14.03, 95% CI: 2.32 to 84.70), living full time in one's felt gender (APR = 5.20, 95% CI: 1.11 to 24.33), and being primarily or exclusively attracted to men (APR = 5.54, 95% CI: 2.27 to 13.54) were each associated with sexual risk. Of psychosocial factors examined, past-year stimulant use (APR = 4.02, 95% CI: 1.31 to 12.30) and moderate depressive symptoms (APR = 5.77, 95% CI: 1.14 to 29.25) were associated with higher sexual risk.

CONCLUSIONS

T-GBMSM seem to share some HIV acquisition risk factors with their cisgender counterparts. HIV prevention interventions targeting T-GBMSM who are predominantly attracted to men and interventions addressing sequelae of childhood sexual abuse may be warranted.

The Road Less Travelled: Exploring Gay and Bisexual Men's Explanations of 'Uncommon' Routes of HIV Transmission

Although there are practices other than condomless anal intercourse that may result in HIV transmission among gay and bisexual men, very little is known about these 'uncommon' transmission explanations. To address this topic, the free text survey responses from 465 HIV positive gay men in Australia were thematically analysed; 123 participants offered uncommon explanations for their seroconversion. Men described several sexual acts they believed led to infection, categorised as adventurous sex (e.g., fisting) and foreplay (e.g., oral sex). Participants also identified mediating factors associated with their seroconversion, either internal (e.g., cum/pre-cum) or external (e.g., sores, illness) to sex. Finally, contextual forces associated with infection were also explored, namely physical spaces (e.g., sex on premises venues) or mental states (e.g., depression). While some uncommon explanations are unlikely to have resulted in HIV transmission, these accounts reveal the diverse and intersecting ways that men attempt to make sense of their seroconversion.

Australian Gay Men Describe the Details of Their HIV Infection Through a Cross-Sectional Web-Based Survey

Background

With emerging opportunities for preventing human immunodeficiency virus (HIV) transmission, it remains important to identify those at greatest risk of infection and to describe and understand the contexts in which transmissions occur. Some gay and bisexual men with recently diagnosed HIV infection are initially unable to identify high-risk behaviors that would explain their HIV infection. We explored whether Web-based data collection could assist them in identifying the circumstances of their infection.

Objective

To assess the capacity of a Web-based survey to collect reliable self-report data on the event to which gay and bisexual men ascribe their HIV infection.

Methods

The HIV Seroconversion Study included a Web-based survey of gay and bisexual men with recently diagnosed HIV infection in Australia. Participants were asked if they could identify and describe the event they believe led to their infection. Men were also asked about their sexual and other risk practices during the 6 months before their diagnosis.

Results

Most (403/506, 79.6%) gay and bisexual men with newly diagnosed HIV infection were able to identify and describe the circumstances that likely led to their infection. Among those who were initially unable to identify possible exposure events, many could nonetheless provide sensible information that ostensibly explained their seroconversion. Free-text responses allowed men to provide more detailed and contextual information, whereas questions about the totality of their sexual behavior before diagnosis provided opportunities for men to describe their sexual risk behavior in general. Overall, 84.0% indicated having engaged in condomless anal intercourse before their HIV diagnosis, including 71.8% in the receptive position.

Conclusions

This study demonstrates the effectiveness of using Internet-based technologies to capture sensitive information about the circumstances in which HIV infection occurs among gay and bisexual men. By providing a range of opportunities for relaying experience, this research reveals some of the complexity in how individuals come to understand and explain their HIV infection. These findings may assist in obtaining detailed sexual history in the clinical setting.

Asking only "Did you use a condom?" underestimates the prevalence of unprotected sex among perinatally HIV infected and perinatally exposed but uninfected youth

Among young adults who use condoms, incomplete condom use (putting a condom on after beginning or taking a condom off before finishing sex) and condom failure (condom breaking or slipping off during sex) are common. Therefore, sexual behavior surveys that ask only if a condom was used are likely to underestimate the actual prevalence of unprotected sex. This study examined data from 135 sexually active perinatally HIV-infected (PHIV+) youth and perinatally exposed but uninfected (PHIV-) youth, ages 13 to 24. Participants were asked whether they used a condom on their first and their most recent occasion of vaginal sex. Youth who reported using a condom were asked a follow-up question about whether there was any time during that occasion when sex was not protected by a condom. This follow-up question identified additional participants--almost double the proportions who initially said they did not use a condom--who had unprotected sex. Incomplete condom use was similar among PHIV+ and PHIV-youth, boys and girls, Latinos and African Americans, and younger and older youth. These findings illustrate the importance of asking specifically about whether any unprotected behavior occurred from start to finish of sex to achieve more valid estimates of sexual risk behavior.

Sexual Health of Trans Men Who Are Gay, Bisexual, or Who Have Sex with Men: Results from Ontario, Canada

Recent reports have addressed the sexual health of female-to-male transgender or transsexual people who are gay, bisexual, and/or have sex with men (trans GB-MSM) using urban convenience samples. The Trans PULSE Project conducted a multimode, respondent-driven sampling survey in Ontario, Canada, in 2009-2010. Weighted estimates were calculated for trans GB-MSM (n = 173) for sexual orientation, behavior, partners, and HIV-related risk, as well as for psychosocial stressors and sexual satisfaction. An estimated 63.3% (95% CI [50.4, 73.5]) of trans men were GB-MSM (173/227). Results indicate great diversity in sexual behavior and experiences. Implications for sexual health promotion, counseling, and medical care are addressed.

Behavioral interventions to reduce risk for sexual transmission of HIV among men who have sex with men

BACKGROUND

Men who have sex with men (MSM) remain at great risk for HIV infection. Program planners and policy makers need descriptions of interventions and quantitative estimates of intervention effects to make informed decisions concerning prevention funding and research. The number of intervention strategies for MSM that have been examined with strong research designs has increased substantially in the past few years.

OBJECTIVES

1. To locate and describe outcome studies evaluating the effects of behavioral HIV prevention interventions for MSM.2. To summarize the effectiveness of these interventions in reducing unprotected anal sex.3. To identify study characteristics associated with effectiveness.4. To identify gaps and indicate future research, policy, and practice needs.

SEARCH STRATEGY

We searched electronic databases, current journals, manuscripts submitted by researchers, bibliographies of relevant articles, conference proceedings, and other reviews for published and unpublished reports from 1988 through December 2007. We also asked researchers working in HIV prevention about new and ongoing studies.

SELECTION CRITERIA

Studies were considered in scope if they examined the effects of behavioral interventions aimed at reducing risk for HIV or STD transmission among MSM. We reviewed studies in scope for criteria of outcome relevance (measurement of at least one of a list of behavioral or biologic outcomes, e.g., unprotected sex or incidence of HIV infections) and methodologic rigor (randomized controlled trials or certain strong quasi-experimental designs with comparison groups).

DATA COLLECTION AND ANALYSIS

We used fixed and random effects models to summarize rate ratios (RR) comparing intervention and control groups with respect to count outcomes (number of occasions of or partners for unprotected anal sex), and corresponding prevalence ratios (PR) for dichotomous outcomes (any unprotected anal sex vs. none). We used published formulas to convert effect sizes and their variances for count and dichotomous outcomes where necessary. We accounted for intraclass correlation (ICC) in community-level studies and adjusted for baseline conditions in all studies. We present separate results by intervention format (small group, individual, or community-level) and by type of intervention delivered to the comparison group (minimal or no HIV prevention in the comparison condition versus standard or other HIV prevention in the comparison condition). We examine rate ratios stratified according to characteristics of participants, design, implementation, and intervention content. For small group and individual-level interventions we used a stepwise selection process to identify a multivariable model of predictors of reduction in occasions of or partners for unprotected anal sex. We used funnel plots to examine publication bias, and Q (a chi-squared statistic with degrees of freedom = number of interventions minus 1) to test for heterogeneity.

MAIN RESULTS

We found 44 studies evaluating 58 interventions with 18,585 participants. Formats included 26 small group interventions, 21 individual-level interventions, and 11 community-level interventions. Sixteen of the 58 interventions focused on HIV-positives. The 40 interventions that were measured against minimal to no HIV prevention intervention reduced occasions of or partners for unprotected anal sex by 27% (95% confidence interval [CI] = 15% to 37%). The other 18 interventions reduced unprotected anal sex by 17% beyond changes observed in standard or other interventions (CI = 5% to 27%). Intervention effects were statistically homogeneous, and no independent variable was statistically significantly associated with intervention effects at alpha=.05. However, a multivariable model selected by backward stepwise elimination identified four study characteristics associated with reduction in occasions of or partners for unprotected anal sex among small group and individual-level interventions at alpha=.10. The most favorable reductions in episodes of or partners for unprotected anal sex (33% to 35% decreases) were observed among studies with count outcomes, those with shorter intervention spans (<=1 month), those with better retention in the intervention condition than in the comparison condition, and those with minimal to no HIV prevention intervention delivered to the comparison condition. Because there were only 11 community-level studies we did not search for a multivariable model for community-level interventions. In stratified analyses including only one variable at a time, the greatest reductions (40% to 54% decreases) in number of episodes of or partners for unprotected anal sex among community-level interventions were observed among studies where groups were assigned randomly rather than by convenience, studies with shorter recall periods and longer follow-up, studies with more than 25% non-gay identifying MSM, studies in which at least 90% of participants were white, and studies in which the intervention addressed development of personal skills.

AUTHORS' CONCLUSIONS

Behavioral interventions reduce self-reported unprotected anal sex among MSM. These results indicate that HIV prevention for this population can work and should be supported. Results of previous studies provide a benchmark for expectations in new studies. Meta-analysis can inform future design and implementation in terms of sample size, target populations, settings, goals for process measures, and intervention content. When effects differ by design variables, which are deliberately selected and planned, awareness of these characteristics may be beneficial to future designs. Researchers designing future small group and individual-level studies should keep in mind that to date, effects of the greatest magnitude have been observed in studies that used count outcomes and a shorter intervention span (up to 1 month). Among small group and individual-level studies, effects were also greatest when the comparison condition included minimal to no HIV prevention content. Nevertheless, statistically significant favorable effects were also seen when the comparison condition included standard or other HIV prevention content. Researchers choosing the latter option for new studies should plan for larger sample sizes based on the smaller expected net intervention effect noted above. When effects differ by implementation variables, which become evident as the study is conducted but are not usually selected or planned, caution may be advised so that future studies can reduce bias. Because intervention effects were somewhat stronger (though not statistically significantly so) in studies with a greater attrition in the comparison condition, differential retention may be a threat to validity. Extra effort should be given to retaining participants in comparison conditions. Among community-level interventions, intervention effects were strongest among studies with random assignment of groups or communities. Therefore the inclusion of studies where assignment of groups or communities was by convenience did not exaggerate the summary effect. The greater effectiveness of interventions including more than 25% non-gay identifying MSM suggests that when they can be reached, these men may be more responsive than gay-identified men to risk reduction efforts. Non-gay identified MSM may have had less exposure to previous prevention messages, so their initial exposure may have a greater impact. The greater effectiveness of interventions that include efforts to promote personal skills such as keeping condoms available and behavioral self-management indicates that such content merits strong consideration in development and delivery of new interventions for MSM. And the finding that interventions were most effective for majority white populations underscores the critical need for effective interventions for MSM of African and Latino descent. Further research measuring the incidence of HIV and other STDs is needed. Because most studies were conducted among mostly white men in the US and Europe, more evaluations of interventions are needed for African American and Hispanic MSM as well as MSM in the developing world. More research is also needed to further clarify which behavioral strategies (e.g., reducing unprotected anal sex, having oral sex instead of anal sex, reducing number of partners, avoiding serodiscordant partners, strategic positioning, or reducing anal sex even with condom use) are most effective in reducing transmission among MSM, the messages most effective in promoting these behaviors, and the methods and settings in which these messages can be most effectively delivered.

Probability Sample Estimates of Bathhouse Sexual Risk Behavior

OBJECTIVE

Previous research links high rates of unprotected anal intercourse (UAI) with men who go to bathhouses; however, the literature provides no prevalence estimates. An exit survey of a probability sample was conducted to describe the prevalence of risk activity at the bathhouse.

METHODS

Data are from a 2-stage probability sample of men exiting a gay bathhouse (n = 400).

RESULTS

During their visit, 91.5% of men had oral sex and 44.2% had anal sex (11.1% reported UAI and 5.5% reported unprotected receptive anal intercourse). In the prior 3 months, 85% reported having anal sex, which was more likely to be unprotected when it occurred in a private home or hotel as opposed to a public setting (P < 0.001). Moreover, having UAI at home was a significant correlate of risk during the bathhouse visit (P < 0.001).

CONCLUSIONS

Most men at the bathhouse engaged in oral sex rather than anal sex, and most anal sex included use of condoms. Furthermore, men were more likely to have UAI in a private home than in any public setting. The bathhouse seems to have facilitated condom use when anal sex occurred on-site.

HIV intervention research for men who have sex with men: a 7-year update

We conducted a systematic review and meta-analysis to locate, characterize, and summarize effects of behavioral HIV prevention interventions for men who have sex with men (MSM). We found 54 interventions with 16,224 participants that were evaluated in 40 randomized trials and controlled observational studies with independent comparison groups. Formats included 26 small group interventions, 18 individual-level interventions, and 10 community-level interventions. Fifteen interventions focused on HIV-positive individuals including MSM. The 38 interventions that were compared with minimal or no HIV prevention interventions, reduced unprotected sex by 27% (95% confidence interval [CI] = 15-37%). The other 16 interventions reduced unprotected sex by 17% beyond changes observed in standard or other HIV prevention interventions (CI = 5-27%). Behavioral interventions reduce self-reported unprotected sex among MSM.

Prevention with HIV-seropositive men who have sex with men: lessons from the Seropositive Urban Men's Study (SUMS) and the Seropositive Urban Men's Intervention Trial (SUMIT)

SUMMARY

Men who have sex with men (MSM) are disproportionately affected by HIV, and HIV-seropositive (HIV-positive) MSM are an especially important group for prevention efforts. This article describes findings from the Seropositive Urban Men's Study (SUMS, N = 456) and the Seropositive Urban Men's Intervention Trial (SUMIT, N = 1168). These studies were conducted from 1996 to 2002 with racially diverse samples from New York and San Francisco. Patterns of sexual behavior often reflected an understanding of the relative risks of specific sexual practices and were generally consistent with harm reduction strategies to reduce the risk of HIV transmission to uninfected partners. Some men, however, continued to engage in behaviors that placed themselves and their partners at risk for exposure to HIV and other sexually transmitted infections. Correlates of unprotected sex included self-efficacy, personal responsibility, substance use, mental health, and contextual influences. Disclosure of HIV status was a difficult issue for many HIV-positive MSM. Most participants had disclosed to their main partner, but they disclosed to less than half of their non-main partners before first sex. The interest of HIV-positive MSM in prevention efforts, the design of the SUMIT intervention trial, and implications for future research and programmatic efforts are discussed.