Serosorting can potentially increase HIV transmissions

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.

Multilevel elements associated with HIV serosorting for sexual encounters: a scoping literature review

A scoping literature review to identify the multilevel HIV serosorting related elements was developed. Articles from EBSCO, PubMed, PsyNET and Science Direct with serosort* or serosorting at the tittle or abstract, written in English or Spanish were included. No restriction in type of population or design were applied. 239 records were retrieved after duplicates removed, but 181 references were extracted for full-text review. Individual level: HIV knowledge, serostatus, risk perceptions, abilities to disclose and for condom use negotiation, motivations, use of drugs, stigma, attitudes toward condom use, and perceptions/beliefs about the HIV and related treatments, HIV infection rates/testing and behavioral factors. Interpersonal level: social networks, abilities (sexual behavior negotiation, and communication). Community level: stigma, social norms, access to HIV related services. Structural level: political context, HIV related funding and public policies. HIV Serosorting is not solely an interpersonal behavior it involves multilevel elements that must be acknowledged by professionals and stakeholders.

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.

"Losing the Phobia:" Understanding How HIV Pre-exposure Prophylaxis Facilitates Bridging the Serodivide Among Men Who Have Sex With Men

The use of HIV serostatus information has played a pivotal role in partner selection norms. A phenomenon known as serosorting is the practice of selecting a partner based on a perception that they are of the same HIV status in order to avoid transmission from one partner to the other. An understudied aspect of serosorting is that it has a divisive effect-one accepts or rejects a potential partner based on a singular characteristic, the partner's HIV status, and thus excludes all others. This division has been formally referred to as the HIV serodivide. In this study, we explored partner selection strategies among a group of HIV-negative, young men who have sex with men (n = 29) enrolled in a PrEP demonstration project in Northern California. We found that trends in serosorting were in fact shifting, and that a new and opposite phenomenon was emerging, something we labeled "seromixing" and that PrEP use played a part in why norms were changing. We present three orientations in this regard: (1) maintaining the phobia: in which men justified the continued vigilance and exclusion of people living with HIV as viable sex or romantic partners, (2) loosening/relaxation of phobia: among men who were reflecting on their stance on serosorting and its implications for future sexual and/or romantic partnerships, and (3) losing the phobia: among men letting go of serosorting practices and reducing sentiments of HIV-related stigma. The majority of participants spoke of changing or changed attitudes about intentionally accepting rather than rejecting a person living with HIV as a sex partner. For those who maintained strict serosorting practices, their understandings of HIV risk were not erased as a result of PrEP use. These overarching themes help explain how PrEP use is contributing to a closing of the HIV serodivide.

Randomised controlled trial of a sexual risk reduction intervention for STI prevention among men who have sex with men in the USA

OBJECTIVES

Novel interventions to address sexual risk taking and slow rates of STIs are urgently needed, in particular among black men who have sex with men (MSM) in the USA. Serosorting, or limiting condomless sex acts to partners of the same HIV status, is commonly practised among MSM, yet can lead to STI and remains largely unaddressed by public health agencies.

METHODS

A two-arm, randomised controlled trial was conducted from 2012 to 2015. This trial assessed the effects of a single-session, sexual partner selection and risk decision intervention (experimental arm) versus a single-session, Centers for Disease Control and Prevention-based, sexual risk reduction intervention (control arm) on psychosocial measures, sexual risk taking and STI.

RESULTS

At study follow-ups, multiple beneficial changes were observed on sexual risk beliefs measures (ie, changes in serosorting and condom use beliefs, and HIV risk perceptions) and sexual risk taking among the experimental arm relative to the control arm. Overall main effects, however, of the intervention on STI outcomes on year-long follow-ups were non-significant. There was evidence for short-term effects on STI outcomes, and self-report of multiple STIs and STI symptoms demonstrated positive effects over the follow-up period.

CONCLUSIONS

Brief interventions to address sexual risk taking can result in short-term beneficial outcomes and can be incorporated into currently existing infrastructure at healthcare agencies. Additional intervention will be necessary for demonstrating long-term results.

TRIAL REGISTRATION NUMBER

NCT02128594.

Beyond Condoms: Risk Reduction Strategies Among Gay, Bisexual, and Other Men Who Have Sex With Men Receiving Rapid HIV Testing in Montreal, Canada

Gay, bisexual, and other men who have sex with men (MSM) have adapted their sexual practices over the course of the HIV/AIDS epidemic based on available data and knowledge about HIV. This study sought to identify and compare patterns in condom use among gay, bisexual, and other MSM who were tested for HIV at a community-based testing site in Montreal, Canada. Results showed that while study participants use condoms to a certain extent with HIV-positive partners and partners of unknown HIV status, they also make use of various other strategies such as adjusting to a partner's presumed or known HIV status and viral load, avoiding certain types of partners, taking PEP, and getting tested for HIV. These findings suggest that MSM who use condoms less systematically are not necessarily taking fewer precautions but may instead be combining or replacing condom use with other approaches to risk reduction.

Serosorting and Sexual Risk for HIV Infection at the Ego-Alter Dyadic Level: An Egocentric Sexual Network Study Among MSM in Nigeria

The objective of this egocentric network study was to investigate engagement in serosorting by HIV status and risk for HIV between seroconcordant and serodiscordant ego-alter dyads. Respondent-driving sampling was used to recruit 433 Nigerian men who have sex with men (MSM) from 2013 to 2014. Participant (ego) characteristics and that of five sex partners (alters) were collected. Seroconcordancy was assessed at the ego level and for each dyad. Among 433 egos, 18 % were seroconcordant with all partners. Among 880 dyads where participants knew their HIV status, 226 (25.7 %) were seroconcordant, with 11.7 % of HIV positive dyads seroconcordant and 37.0 % of HIV negative dyads seroconcordant. Seroconcordant dyads reported fewer casual sex partners, less partner concurrency, and partners who had ever injected drugs, but condom use did not differ significantly. Serosorting may be a viable risk reduction strategy among Nigerian MSM, but awareness of and communication about HIV status should be increased. Future studies should assess serosorting on a partner-by-partner basis.

Using HIV Sequence and Epidemiologic Data to Assess the Effect of Self-referral Testing for Acute HIV Infection on Incident Diagnoses in San Diego, California

BACKGROUND

Because recently infected individuals disproportionately contribute to the spread of human immunodeficiency virus (HIV), we evaluated the impact of a primary HIV screening program (the Early Test) implemented in San Diego.

METHODS

The Early Test program used combined nucleic acid and serology testing to screen for primary infection targeting local high-risk individuals. Epidemiologic, HIV sequence, and geographic data were obtained from the San Diego County Department of Public Health and the Early Test program. Poisson regression analysis was performed to determine whether the Early Test program was temporally and geographically associated with changes in incident HIV diagnoses. Transmission chains were inferred by phylogenetic analysis of sequence data.

RESULTS

Over time, a decrease in incident HIV diagnoses was observed proportional to the number primary HIV infections diagnosed in each San Diego region (P < .001). Molecular network analyses also showed that transmission chains were more likely to terminate in regions where the program was marketed (P = .002). Although, individuals in these zip codes had infection diagnosed earlier (P = .08), they were not treated earlier (P = .83).

CONCLUSIONS

These findings suggests that early HIV diagnoses by this primary infection screening program probably contributed to the observed decrease in new HIV diagnoses in San Diego, and they support the expansion and evaluation of similar programs.

Relationship Dynamics and Sexual Risk Reduction Strategies Among Heterosexual Young Adults: A Qualitative Study of Sexually Transmitted Infection Clinic Attendees at an Urban Chicago Health Center

Few studies have examined risk-reduction alternatives to consistent condom use for HIV prevention among heterosexual young adults. We used qualitative methodology to explore risk reduction strategies and contextual factors influencing attempts to reduce risk in an urban, high morbidity sexually transmitted infection (STI) clinic. Focus groups were conducted October-December 2014 with heterosexually identified men (n = 13) and women (n = 20) aged 18-29 seeking STI screening at an urban clinic. Groups were audio recorded, transcribed verbatim, and analyzed for thematic content using Atlas.ti software. Quantitative information included sociodemographics, HIV/STI testing history, and 6-month sexual behaviors. Among 33 predominantly African-American participants with a median age of 22, risk-reduction strategies included monogamy agreements, selective condom use with casual and high-risk partners, and frequent HIV/STI testing, though testing was commonly used as a post-hoc reassurance after risk exposure. Many men and women used implicit risk assessment strategies due to mistrust or difficulty communicating. Concurrency was common but rarely discussed within partnerships. Despite attempts to reduce risk, monogamy agreements were often poorly adhered to and not openly discussed. Alcohol and substance use frequently interfered with safer sexual decisions. Participants were aware of HIV/STI risk and commonly practiced risk-reduction strategies, but acknowledged faulty assumptions and poor adherence. This work provides insights into risk-reduction approaches that are already used and may be strengthened as part of effective HIV/STI prevention interventions.

Racial differences in the accuracy of perceived partner HIV status among men who have sex with men (MSM) in Atlanta, Georgia

We compared perceptions of partner HIV status to HIV test results in a cross-sectional study of sexual networks of men who have sex with men (MSM) in Atlanta. We then examined differences between black and white MSM in the predictive value of perceived partner status. We recruited men ("seeds") using time-space venue sampling. These seeds then referred up to three partners, who could also refer partners. All participants reported sexual behavior and HIV status for recent partners and received HIV tests. For partners who enrolled, we compared laboratory diagnoses to their partner's perception of their status. Black MSM who perceived themselves to be HIV negative were more likely than perceived-negative white MSM to have a positive partner among those they perceived to be HIV negative or whose status was unknown to them (OR=6.6). Furthermore, although frequency of unprotected anal intercourse (UAI) was similar by race, black men were more likely to have had UAI with an unknown-positive partner (OR=9.3).

Prevalence of unprotected anal intercourse among men who have sex with men in China: an updated meta-analysis

OBJECTIVE

The purpose of this review was to assess the prevalence of unprotected anal intercourse (UAI) among men who have sex with men (MSM) in China.

METHODS

A comprehensive search was conducted including online databases like "Wanfang", Chinese National Knowledge Infrastructure, PubMed and manual searches. Analyses using random-effects models were performed to estimate the prevalence of UAI among MSM in China.

RESULTS

Sixty-two articles reporting eighty-two studies were selected. The pooled prevalence rates of UAI with any male partner, with regular male partners, with non-regular male partners, with casual male partners, and with commercial male partners among MSM were 53%(95%CI: 51-56%), 45%(95%CI: 39-51%), 34%(95%CI: 24-45%), 33%(95%CI: 30-36%), 12% (95%CI: 5-26%), respectively. A cumulative meta-analysis found that the pooled UAI prevalence decreased over time.

CONCLUSIONS

Although the prevalence of UAI with male partners among MSM in China presents a decreasing trend over the past decade, the concomitant rise in HIV prevalence and incidence indicates that current prevention intervention efforts are insufficient to effectively contain the spread of HIV. Therefore, the persistently high prevalence of risky sexual behaviors underscores the need for innovative and effective prevention strategies among MSM.

Is serosorting effective in reducing the risk of HIV infection among men who have sex with men with casual sex partners?

BACKGROUND

We investigated the prevalence and protective value of serosorting [ie, establishing HIV concordance in advance to practice unprotected anal intercourse (UAI)] with casual partners (CP) among HIV-negative men who have sex with men (MSM) using longitudinal data from 2007 to 2011.

METHODS

Men of the Amsterdam Cohort Studies were tested biannually for HIV-1 antibodies and filled in questionnaires about sexual behavior in the preceding 6 months. HIV incidence was examined among men who practiced UAI, UAI with serosorting, or consistent condom use, using Poisson regression.

RESULTS

Of 445 MSM with CPs, 31 seroconverted for HIV during a total follow-up of 1107 person-years. Overall observed HIV incidence rate was 2.8/100 person-years. Consistent condom use was reported in 64%, UAI in 25%, and UAI with serosorting in 11% of the 2137 follow-up visits. MSM who practiced serosorting were less likely to seroconvert [adjusted incidence rate ratio (aIRR) = 0.46; 95% confidence interval (CI): 0.13 to 1.59] than MSM who had UAI, but more likely to seroconvert than MSM who consistently used condoms (aIRR = 1.32; 95% CI: 0.37 to 4.62), although differences in both directions were not statistically significant. MSM who consistently used condoms were less likely to seroconvert than MSM who had UAI (aIRR = 0.37; 95% CI: 0.18 to 0.77).

DISCUSSION

The protective effect for serosorting we found was not statistically significant. Consistent condom use was found to be most protective against HIV infection. Larger studies are needed to demonstrate whether serosorting with CPs offers sufficient protection against HIV infection, and if not, why it fails to do so.

HIV-negative gay men's accounts of using context-dependent sero-adaptive strategies

We enrolled 166 gay and bisexual men who tested HIV-negative at a community sexual health clinic in Vancouver, British Columbia, into a year-long mixed-methods study. A subsample of participants who reported recent condomless anal sex (n = 33) were purposively recruited into an embedded qualitative study and completed two in-depth qualitative interviews. Analysis of baseline interviews elicited three narratives relevant to men's use of context- or relationally-dependent HIV-risk management strategies: (1) seroadaptive behaviours such as partner testing and negotiated safety agreements used with primary sexual partners, (2) serosorting and seroguessing when having sex with new partners and first-time hookups and (3) seroadaptive behaviours, including one or more of seropositioning/strategic positioning, condom serosorting and viral load sorting, used by participants who knowingly had sex with a serodiscordant partner. Within men's talk about sex, we found complex and frequently biomedically-informed rationale for seroadaptation in men's decisions to have what they understood to be various forms of safe or protected condomless anal sex. Our findings support the need for gay men's research and health promotion to meaningfully account for the multiple rationalities and seroadaptive strategies used for having condomless sex in order to be relevant to gay men's everyday sexual decision-making.

Seroadaptation among men who have sex with men: emerging research themes

Seroadaptation describes a diverse set of potentially harm-reducing behaviors that use HIV status to inform sexual decision making. Men who have sex with men (MSM) in many settings adopt these practices, but their effectiveness at preventing HIV transmission is debated. Past modeling studies have demonstrated that serosorting is only effective at preventing HIV transmission when most men accurately know their HIV status, but additional modeling is needed to address the effectiveness of broader seroadaptive behaviors. The types of information withwhichMSMmake seroadaptive decisions is expanding to include viral load, treatment status, and HIV status based on home-use tests, and recent research has begun to examine the entire seroadaptive process, from an individual's intentions to seroadapt to their behaviors to their risk of acquiring or transmitting HIV and other STIs. More research is needed to craft clear public health messages about the risks and benefits of seroadaptive practices.

"You're an open target to be abused": a qualitative study of stigma and HIV self-disclosure among Black men who have sex with men

The HIV/AIDS epidemic is a health crisis among Black men who have sex with men (MSM). HIV-related stigma presents a primary barrier to sexual communication and effective HIV prevention. Using in-depth, qualitative interviews conducted with 20 HIV-positive Black MSM between 2007 and 2008 in Chicago, Illinois, we explored the themes related to HIV-related stigma and the underlying messages HIV-positive Black MSM receive regarding their status. Stigmatizing messages stem from family, churches, and the gay community and from negative, internalized, beliefs HIV-positive Black MSM held about infected individuals before their own infection. HIV stigma influences sexual silence around HIV disclosure, especially to sexual partners.

Stigma trajectories among people living with HIV (PLHIV) embarking on a life time journey with antiretroviral drugs in Jinja, Uganda

Background

Stigma is a barrier to HIV prevention and treatment. There is a limited understanding of the types of stigma facing people living with HIV (PLHIV) on antiretroviral therapy (ART). We describe the stigma trajectories of PLHIV over a 5-year period from the time they started ART.

Methods

Longitudinal qualitative in-depth interviews were conducted with 41 members of The AIDS Support Organisation (TASO) from 2005 to 2008 in Jinja, Uganda, who were part of a pragmatic cluster-randomised trial comparing two different modes of ART delivery (facility and home). Participants were stratified by gender, ART delivery arm and HIV stage (early or advanced) and interviewed at enrolment on to ART and then after 3, 6, 18 and 30 months. Interviews focused on stigma and ART experiences. In 2011, follow-up interviews were conducted with 24 of the participants who could be traced. Transcribed texts were translated, coded and analyzed thematically.

Results

Stigma was reported to be very high prior to starting ART, explained by visible signs of long-term illnesses and experiences of discrimination and abuse. Early coping strategies included: withdrawal from public life, leaving work due to ill health and moving in with relatives. Starting ART led to a steady decline in stigma and allowed the participants to take control of their illness and manage their social lives. Better health led to resumption of work and having sex but led to reduced disclosure to employers, colleagues and new sexual partners. Some participants mentioned sero-sorting in order to avoid questions around HIV sero-status. A rise in stigma levels during the 18 and 30 month interviews may be correlated with decreased disclosure. By 2011, ART-related stigma was even more pronounced particularly among those who had started new sexual relationships, gained employment and those who had bodily signs from ART side-effects.

Conclusion

This study has shown that while ART comes with health benefits which help individuals to get rid of previously stigmatising visible signs, an increase in stigma may be noticed after about five years on ART, leading to reduced disclosure. ART adherence counselling should reflect changing causes and manifestations of stigma over time.

Seroadaptation in a sample of very poor Los Angeles area men who have sex with men

Data from 635 very poor men who have sex with men (MSM) were used to identify seroadaptation with 1,102 male partners reported between 2005 and 2007 in Los Angeles as part of the Sexual Acquisition and Transmission of HIV Cooperative Agreement Program. The mean age of the sample was 41.7 years; 53 % had experienced homelessness in the past year. Condoms were reported in 51 % of sexual events involving anal intercourse. HIV seroconcordance was reported in 41 % of sexual partnerships among HIV-positive participants. HIV-positive men were more likely to have oral-only or unprotected receptive anal intercourse and less likely to have unprotected insertive anal intercourse with HIV-negative or unknown partners compared to HIV-positive partners. Even in the face of poverty, HIV-positive MSM report mitigating risks of HIV-transmission though seroadaptation in the context of modest rates of condom use.

HIV prevalence and sexual risk behaviors associated with awareness of HIV status among men who have sex with men in Paris, France

A cross-sectional survey, using self-sampled finger-prick blood on blotting paper and anonymous behavioral self-administrated questionnaires was conducted in Paris in 2009 among MSM attending gay venues. Paired biological results and questionnaires were available for 886 participants. HIV seroprevalence was 17.7 % (95 % CI: 15.3-20.4). Four groups were identified according to their knowledge of their HIV biological status. Among the 157 found to be seropositive, 31 (19.7 %) were unaware of their status and reported high levels of sexual risk behaviors and frequent HIV testing in the previous 12 months. Among the 729 MSM diagnosed HIV-negative, 183 were no longer sure whether they were still HIV-negative, or had never been tested despite the fact that they engaged in at-risk sexual behaviors. This study provides the first estimate of HIV seroprevalence among MSM in Paris and underlines the specific need for combined prevention of HIV infection in this MSM population.

Serosorting and HIV/STI Infection among HIV-Negative MSM and Transgender People: A Systematic Review and Meta-Analysis to Inform WHO Guidelines

We conducted a systematic review and meta-analysis to assess the association between serosorting and HIV infection, sexually transmitted infections (STIs), and quality of life among men who have sex with men (MSM) and transgender people. Two reviewers independently screened abstracts and abstracted data. Meta-analyses were conducted using random effects models. Of 310 citations reviewed, 4 observational studies, all with MSM, met inclusion criteria. Compared to consistent condom use, serosorting was associated with increased risk of HIV (3 studies, odds ratio (OR): 1.80, 95% confidence interval (CI):1.21–2.70) and bacterial STIs (1 study, OR: 1.62, 95% CI: 1.44–1.83). Compared to no condom use, serosorting was associated with reduced risk of HIV (3 studies, OR: 0.46, 95% CI: 0.25–0.83) and bacterial STIs (1 study, OR: 0.81, 95% CI: 0.73–0.91). Among HIV-negative MSM, condom use appears to be more protective against HIV and STIs than serosorting and should be encouraged. However, serosorting may be better than no condom use as a harm reduction strategy.

Changes in seroadaptive practices from before to after diagnosis of recent HIV infection among men who have sex with men

OBJECTIVE

We assessed changes in sexual behavior among men who have sex with men (MSM), before and for several years after HIV diagnosis, accounting for adoption of a variety of seroadaptive practices.

METHODS

We collected self-reported sexual behavior data every 3 months from HIV-positive MSM at various stages of HIV infection. To establish population level trends in sexual behavior, we used negative binomial regression to model the relationship between time since diagnosis and several sexual behavior variables: numbers of (a) total partners, (b) potentially discordant partners (PDP; i.e., HIV-negative or unknown-status partners), (c) PDPs with whom unprotected anal intercourse (UAI) occurred, and (d) PDPs with whom unprotected insertive anal intercourse (uIAI) occurred.

RESULTS

A total of 237 HIV-positive MSM contributed 502 interviews. UAI with PDPs occurred with a mean of 4.2 partners in the 3 months before diagnosis. This declined to 0.9 partners/3 months at 12 months after diagnosis, and subsequently rose to 1.7 partners/3 months at 48 months, before falling again to 1.0 partners/3 months at 60 months. The number of PDPs with whom uIAI occurred dropped from 2.4 in the pre-diagnosis period to 0.3 partners/3 months (an 87.5% reduction) by 12 months after enrollment, and continued to decline over time.

CONCLUSION

Within months after being diagnosed with HIV, MSM adopted seroadaptive practices, especially seropositioning, where the HIV-positive partner was not in the insertive position during UAI, resulting in a sustained decline in the sexual activity associated with the highest risk of HIV transmission.

Seroadaptive practices: association with HIV acquisition among HIV-negative men who have sex with men

BACKGROUND

Although efficacy is unknown, many men who have sex with men (MSM) attempt to reduce HIV risk by adapting condom use, partner selection, or sexual position to the partner's HIV serostatus. We assessed the association of seroadaptive practices with HIV acquisition.

METHODOLOGY/PRINCIPAL FINDINGS

We pooled data on North American MSM from four longitudinal HIV-prevention studies. Sexual behaviors reported during each six-month interval were assigned sequentially to one of six mutually exclusive risk categories: (1) no unprotected anal intercourse (UAI), (2) having a single negative partner, (3) being an exclusive top (only insertive anal sex), (4) serosorting (multiple partners, all HIV negative), (5) seropositioning (only insertive anal sex with potentially discordant partners), and (6) UAI with no seroadaptive practices. HIV antibody testing was conducted at the end of each interval. We used Cox models to evaluate the independent association of each category with HIV acquisition, controlling for number of partners, age, race, drug use, and intervention assignment. 12,277 participants contributed to 60,162 six-month intervals with 663 HIV seroconversions. No UAI was reported in 47.4% of intervals, UAI with some seroadaptive practices in 31.8%, and UAI with no seroadaptive practices in 20.4%. All seroadaptive practices were associated with a lower risk, compared to UAI with no seroadaptive practices. However, compared to no UAI, serosorting carried twice the risk (HR = 2.03, 95%CI:1.51-2.73), whereas seropositioning was similar in risk (HR = 0.85, 95%CI:0.50-1.44), and UAI with a single negative partner and as an exclusive top were both associated with a lower risk (HR = 0.56, 95%CI:0.32-0.96 and HR = 0.55, 95%CI:0.36-0.84, respectively).

CONCLUSIONS/SIGNIFICANCE

Seroadaptive practices appear protective when compared with UAI with no seroadaptive practices, but serosorting appears to be twice as risky as no UAI. Condom use and limiting number of partners should be advocated as first-line prevention strategies, but seroadaptive practices may be considered harm-reduction for men at greatest risk.

Risk reduction practices in men who have sex with men in Switzerland: serosorting, strategic positioning, and withdrawal before ejaculation

The aim of this study was to identify predictors of intentional use of the HIV risk reduction practices of serosorting, strategic positioning, and withdrawal before ejaculation during unprotected anal intercourse (UAI) with casual partners. A cross-sectional survey pertaining to the Swiss HIV behavioral surveillance system, using an anonymous self-administered questionnaire, was conducted in 2007 in a self-selected sample of men having sex with other men (MSM). Analysis was restricted to participants with UAI with casual partner(s) (N = 410). Logistic regression was used to estimate factors associated with intentional use of serosorting, strategic positioning, and withdrawal before ejaculation. In the previous 12 months, 71% of participants reported having UAI with a casual partner of different or unknown HIV-status. Of these, 47% reported practicing withdrawal, 38% serosorting, and 25% strategic positioning. In the 319 participants with known HIV-status, serosorting was associated with frequent Internet use to find partners (OR = 2.32), STI (OR = 2.07), and HIV testing in the past 12 months (OR = 1.81). Strategic positioning was associated with HIV-status (OR = 0.13) and having UAI with a partner of different or unknown HIV-status (OR = 3.57). Withdrawal was more frequently practiced by HIV-negative participants or participants reporting high numbers of sexual partners (OR = 2.48) and having UAI with a partner of unknown or different serostatus (OR = 2.08). Risk reduction practices are widely used by MSM, each practice having its own specificities. Further research is needed to determine the contextual factors surrounding harm reduction practices, particularly the strategic or opportunistic nature of their use.

Modeling seroadaptation and sexual behavior among HIV+ study participants with a simultaneously multilevel and multivariate longitudinal count model

Longitudinal behavioral intervention trials to reduce HIV transmission risk collect complex multilevel and multivariate data longitudinally for each subject with important correlation structures across time, level, and variables. Accurately assessing the effects of these trials are critical for determining which interventions are effective. Both numbers of partners and numbers of sex acts with each partner are reported at each time point. Sex acts with each partner are further differentiated into protected and unprotected acts with correspondingly differing risks of HIV/STD transmission. These trials generally also have eligibility criteria limiting enrollment to participants with some minimal level of risky sexual behavior tied directly to the outcome of interest. The combination of these factors makes it difficult to quantify sexual behaviors and the effects of intervention. We propose a multivariate multilevel count model that simultaneously models the number of partners, acts within partners, and accounts for recruitment eligibility. Our methods are useful in the evaluation of intervention trials and provide a more accurate and complete model for sexual behavior. We illustrate the contributions of our model by examining seroadaptive behavior defined as risk reducing behavior that depends on the serostatus of the partner. Several forms of seroadaptive risk reducing behavior are quantified and distinguished from nonseroadaptive risk reducing behavior.

MSM: resurgent epidemics

PURPOSE OF REVIEW

The present review discusses the recent finding on behavioral risk factors for HIV transmission from cohort studies in MSM.

RECENT FINDINGS

HIV incidence among MSM has been increasing in many countries around the world. Some data support early detection and widespread use of antiretroviral treatment (ART) to decrease HIV incidence. However, suboptimal ART adherence could lead to relapse of viremia and new transmission events. Condom use for unprotected anal sex among MSM remains an important prevention tool, but use remains low in many parts of the world. Seroadaptive behaviors by MSM, such as serosorting, may also decrease condom use. However, when serosorting is practiced by MSM who receive frequent HIV testing, the risk of HIV acquisition is reduced. Serosorting and other characteristics of sexual networks, such as concurrency, may be major determinants of transmission for HIV and sexually transmitted infections among MSM. Worldwide, detailed evaluation of the factors related to rising MSM HIV incidence, as well as access to testing and care, is limited by stigma and criminalization of HIV and homosexuality.

SUMMARY

Cohort studies of MSM remain an important strategy to characterize the behavioral factors that drive HIV transmission and how use of ART for prevention and treatment may affect both the risk of HIV transmission and acquisition by MSM.

HIV serosorting among HIV-positive men who have sex with men is associated with increased self-reported incidence of bacterial sexually transmissible infections

BACKGROUND

We aimed to quantify the frequency of HIV serosorting among men who have sex with men (MSM) in Germany, and evaluate the association of serosorting with other sexual risk management approaches (RMA) and with the frequency of bacterial sexually transmissible infections (STI).

METHODS

An anonymous, self-administered questionnaire was distributed through German online sexual networking sites and medical practices in 2006. The analysis was based on 2985 respondents who reported an HIV test result. Based on two questions on RMA, serosorting was classified as tactical (an event-based decision) or strategic (a premeditated search for a seroconcordant partner). The analysis was stratified by HIV serostatus and seroconcordant partnership status.

RESULTS

HIV serosorting patterns were different for HIV-positive and HIV-negative participants. Tactical serosorting ranked second after RMA based on condom use (HIV-positive: 55.1%, HIV-negative: 45.1%; P < 0.001). While the overlap of strategic and tactical HIV serosorting among HIV-positive MSM was substantial (58.0%), HIV-negative strategic and tactical serosorting were more distinct (18.1% overlap). Among HIV-positive and HIV-negative respondents, tactical serosorting was associated with reduced condom use. Compared with respondents using RMA other than serosorting, HIV-positive men reporting serosorting had a three-fold increased risk for bacterial STI (strategic: odds ratio (OR) = 2.62; 95% confidence interval (CI): 1.76-3.89; tactical: OR = 3.19; 95% CI: 2.14-4.75; both for respondents without HIV seroconcordant partners).

CONCLUSIONS

HIV serosorting has emerged as a common RMA among MSM. For HIV-positive MSM, it may contribute to high rates of bacterial STI that may lead to elevated per-contact risks for HIV transmission.

Linkage and retention in HIV care among men who have sex with men in the United States

Men who have sex with men (MSM) continue to be disproportionately affected by human immunodeficiency virus (HIV) infection. While the MSM population does better than other HIV infection risk groups with regard to linkage to and retention in care, little is known about engagement in care outcomes for important subpopulations of MSM. There is also a dearth of research on engagement in care strategies specific to the MSM population. Key MSM subpopulations in the United States on which to focus future research efforts include racial/ethnic minority, young, and substance-using MSM. Health care systems navigation may offer a promising engagement in care strategy for MSM and should be further evaluated. As is the case for HIV-infected populations in general, future research should also focus on identifying the best metrics for measuring engagement in care.

Trouble with bleeding: risk factors for acute hepatitis C among HIV-positive gay men from Germany--a case-control study

OBJECTIVES

To identify risk factors for hepatitis C among HIV-positive men who have sex with men (MSM), focusing on potential sexual, nosocomial, and other non-sexual determinants.

BACKGROUND

Outbreaks of hepatitis C virus (HCV) infections among HIV-positive MSM have been reported by clinicians in post-industrialized countries since 2000. The sexual acquisition of HCV by gay men who are HIV positive is not, however, fully understood.

METHODS

Between 2006 and 2008, a case-control study was embedded into a behavioural survey of MSM in Germany. Cases were HIV-positive and acutely HCV-co-infected, with no history of injection drug use. HIV-positive MSM without known HCV infection, matched for age group, served as controls. The HCV-serostatus of controls was assessed by serological testing of dried blood specimens. Univariable and multivariable regression analyses were used to identify factors independently associated with HCV-co-infection.

RESULTS

34 cases and 67 controls were included. Sex-associated rectal bleeding, receptive fisting and snorting cocaine/amphetamines, combined with group sex, were independently associated with case status. Among cases, surgical interventions overlapped with sex-associated rectal bleeding.

CONCLUSIONS

Sexual practices leading to rectal bleeding, and snorting drugs in settings of increased HCV-prevalence are risk factors for acute hepatitis C. We suggest that sharing snorting equipment as well as sharing sexual partners might be modes of sexual transmission. Condoms and gloves may not provide adequate protection if they are contaminated with blood. Public health interventions for HIV-positive gay men should address the role of blood in sexual risk behaviour. Further research is needed into the interplay of proctosurgery and sex-associated rectal bleeding.

A novel approach to prevention for at-risk HIV-negative men who have sex with men: creating a teachable moment to promote informed sexual decision-making

OBJECTIVES

As a result of the impact of HIV among men who have sex with men (MSM), multiple strategies for reducing HIV risks have emerged from within the gay community. One common HIV risk reduction strategy limits unprotected sex partners to those who are of the same HIV status (serosorting). We tested a novel, brief, one-on-one intervention, based on informed decision-making and delivered by peer counselors, designed to address the limitations of serosorting (e.g., risk for HIV transmission).

METHODS

In 2009, we recruited a group of 149 at-risk men living in Atlanta, Georgia, and randomly assigned them to an intervention condition addressing serosorting or a standard-of-care control condition.

RESULTS

Men in the serosorting intervention reported fewer sexual partners (Wald χ(2) = 8.79, P < .01) at the study follow-ups. Behavioral results were also consistent with changes in psychosocial variables, including condom use self-efficacy and perceptions of risk for HIV transmission.

CONCLUSIONS

With the current intervention, service providers can offer risk reduction for men arguably at the highest risk for HIV infection in the United States. Addressing risks associated with serosorting in a feasible, low-cost intervention has the potential to significantly affect the HIV epidemic.

Perceived serosorting of injection paraphernalia sharing networks among injection drug users in Baltimore, MD

We examined perceived serosorting of injection paraphernalia sharing networks among a sample of 572 injection drug users (IDUs). There was evidence for serosorting of high-risk injection behaviors among HIV-negative IDUs, as 94% of HIV-negative IDUs shared injection paraphernalia exclusively with perceived HIV-negative networks. However, 82% of HIV-positive IDUs shared injection paraphernalia with perceived HIV-negative networks. The findings indicate a potential risk of rapid HIV transmission. Future prevention efforts targeting IDUs should address the limitation of serosorting, and focus on preventing injection paraphernalia sharing regardless of potential sharing networks' perceived HIV status.

Sexual serosorting among women with or at risk of HIV infection

Serosorting, the practice of selectively engaging in unprotected sex with partners of the same HIV serostatus, has been proposed as a strategy for reducing HIV transmission risk among men who have sex with men (MSM). However, there is a paucity of scientific evidence regarding whether women engage in serosorting. We analyzed longitudinal data on women's sexual behavior with male partners collected in the Women's Interagency HIV Study from 2001 to 2005. Serosorting was defined as an increasing trend of unprotected anal or vaginal sex (UAVI) within seroconcordant partnerships over time, more frequent UAVI within seroconcordant partnerships compared to non-concordant partnerships, or having UAVI only with seroconcordant partners. Repeated measures Poisson regression models were used to examine the associations between serostatus partnerships and UAVI among HIV-infected and HIV-uninfected women. The study sample consisted of 1,602 HIV-infected and 664 HIV-uninfected women. Over the follow-up period, the frequency of seroconcordant partnerships increased for HIV-uninfected women but the prevalence of UAVI within seroconcordant partnerships remained stable. UAVI was reported more frequently within HIV seroconcordant partnerships than among serodiscordant or unknown serostatus partnerships, regardless of the participant's HIV status or types of partners. Among women with both HIV-infected and HIV-uninfected partners, 41% (63 HIV-infected and 9 HIV-uninfected) were having UAVI only with seroconcordant partners. Our analyses suggest that serosorting is occurring among both HIV-infected and HIV-uninfected women in this cohort.

Serosorting is associated with a decreased risk of HIV seroconversion in the EXPLORE Study Cohort

BACKGROUND

Seroadaptation strategies such as serosorting and seropositioning originated within communities of men who have sex with men (MSM), but there are limited data about their effectiveness in preventing HIV transmission when utilized by HIV-negative men.

METHODOLOGY/PRINCIPAL FINDINGS

Data from the EXPLORE cohort of HIV-negative MSM who reported both seroconcordant and serodiscordant partners were used to evaluate serosorting and seropositioning. The association of serosorting and seropositioning with HIV seroconversion was evaluated in this cohort of high risk MSM from six U.S. cities. Serosorting was independently associated with a small decrease in risk of HIV seroconversion (OR=0.88; 95%CI, 0.81-0.95), even among participants reporting ≥10 partners. Those who more consistently practiced serosorting were more likely to be white (p=0.01), have completed college (p=<0.0002) and to have had 10 or more partners in the six months before the baseline visit (p=0.01) but did not differ in age, reporting HIV-infected partners, or drug use. There was no evidence of a seroconversion effect with seropositioning (OR 1.02, 95%CI, 0.92-1.14).

SIGNIFICANCE

In high risk HIV uninfected MSM who report unprotected anal intercourse with both seroconcordant and serodiscordant partners, serosorting was associated with a modest decreased risk of HIV infection. To maximize any potential benefit, it will be important to increase accurate knowledge of HIV status, through increased testing frequency, improved test technology, and continued development of strategies to increase disclosure.

Prevalence and protective value of serosorting and strategic positioning among Black and Latino men who have sex with men

Self-reported HIV-negative black and Latino MSM who engaged in serosorting or strategic positioning were less likely to have unrecognized HIV infection than men who engaged in unprotected anal intercourse without using these risk-reduction strategies.

A strategy for selecting sexual partners believed to pose little/no risks for HIV: serosorting and its implications for HIV transmission

A common HIV/AIDS risk reduction strategy among men who have sex with men (MSM) is to limit their unprotected sex partners to those who are of the same HIV status, a practice referred to as serosorting. Decisions to serosort for HIV risk reduction are based on personal impressions and beliefs, and there is limited guidance offered on this community derived strategy from public health services. This paper reviews research on serosorting for HIV risk reduction and offers an evidence-based approach to serosorting guidance. Following a comprehensive electronic and manual literature search, we reviewed 51 studies relating to the implications of serosorting. Studies showed that HIV negative MSM who select partners based on HIV status are inadvertently placing themselves at risk for HIV. Infrequent HIV testing, lack of HIV status disclosure, co-occurring sexually transmitted infections, and acute HIV infection impede the potential protective benefits of serosorting. Public health messages should continue to encourage reductions in numbers of sexual partners and increases in condom use. Risk reduction messages should also highlight the limitations of relying on one's own and partner's HIV status in making sexual risk decisions.

Disclosure outcomes, coping strategies, and life changes among women living with HIV in Uganda

An HIV diagnosis is a life-changing event. Disclosure of HIV test results might be related to developing effective coping strategies. We conducted qualitative, in-depth interviews with 30 HIV-infected women in Uganda to explore links between HIV disclosure and coping strategies. Many women experienced an evolution in their ability to cope from initial shame to eventual acceptance. Factors that facilitated adaptive coping included being healthy, feeling responsible for children, support group participation, forming supportive relationships, and low perceived stigma and discrimination. HIV disclosure was often the first step in this coping process. Overall, 80% of the women had disclosed, with most reporting positive outcomes. Development of adaptive coping strategies and HIV serostatus disclosure are closely related, as they allow women to develop support networks and begin coming to terms with their diagnosis. Strategies are needed to safely support women who want to disclose their HIV test results.

HIV testing trends among gay men in Scotland, UK (1996-2005): implications for HIV testing policies and prevention

OBJECTIVE

To examine trends in the HIV testing behaviour of gay men in Scotland over a 10-year period.

METHODS

Seven cross-sectional surveys in commercial gay venues in Glasgow and Edinburgh (1996-2005). 9613 men completed anonymous, self-completed questionnaires (70% average response rate).

RESULTS

Among 8305 respondents included in these analyses, HIV testing increased between 1996 and 2005, from 49.7% to 57.8% (p<0.001). The proportion of men who had tested recently (in the calendar year of, or immediately before, the survey) increased from 28.4% in 1996 to 33.2% in 2005, when compared with those who have tested but not recently, and those who have never tested (adjusted odds ratio 1.31, 95% CI 1.13 to 1.52). However, among ever testers, there was no increase in rates of recent testing. Recent testing decreased with age: 31.3% of the under 25, 30.3% of the 25-34, 23.2% of the 35-44 and 21.2% of the over 44 years age groups had tested recently. Among men reporting two or more unprotected anal intercourse partners in the previous year, only 41.4% had tested recently.

CONCLUSIONS

HIV testing among gay men in Scotland increased between 1996 and 2005, and corresponds with the Scottish Government policy change to routine, opt-out testing in genitourinary medicine clinics. Testing rates remain low and compare unfavourably with near-universal testing levels elsewhere. The limited change and decline across age groups in recent HIV testing rates suggest few men test repeatedly or regularly. Additional, innovative efforts are required to increase the uptake of regular HIV testing among gay men.

Partner serostatus and disclosure stigma: implications for physical and mental health outcomes among HIV-positive adults

This pilot project examined the interaction between partners' serostatus and HIV disclosure-stigma in determining physical and mental health. Participants were 38 sexually active HIV-positive adults. Over 47% of participants reported exclusively seroconcordant partners in the past 30 days. There were no main effects of partner serostatus or disclosure stigma on any of the outcome variables. However, disclosure stigma moderated the relationship between partner serostatus and: number of symptoms reported, pain, physical functioning, quality of life, anxiety, illness intrusiveness, and role-functioning. Future research should explore the implications of partner serostatus for the physical and mental health of HIV-positive individuals.

Behavior change following diagnosis with acute/early HIV infection-a move to serosorting with other HIV-infected individuals. The NIMH Multisite Acute HIV Infection Study: III

Risk reductions behaviors are especially important during acute/early HIV infection, a period of high transmission risk. We examined how sexual behaviors changed following diagnosis of acute/early HIV infection. Twenty-eight individuals completed structured surveys and in-depth interviews shortly after learning of their infection and 2 months later. Quantitative analyses revealed significant changes after diagnosis, including reductions in total partners and decreases in the proportion of unprotected sex acts occurring with uninfected partners (serosorting). Qualitative findings indicated that these changes were motivated by concerns about infecting others. However, participants were less successful at increasing the frequency with which they used condoms. These results suggest that the initial diagnosis with HIV may constitute an important component of interventions to promote risk reduction during the acute/early stages of the disease.

HIV serosorting as a harm reduction strategy: evidence from Seattle, Washington

OBJECTIVE

We sought to estimate how serosorting may affect HIV prevalence and individual risk among men who have sex with men in Seattle, Washington, and how the results vary under different assumptions of HIV testing frequency, heterogeneity in sexual behavior, and condom use.

METHODS

We developed a deterministic mathematical model of HIV transmission dynamics. Data from the 2003 random digit dial study of men who have sex with men conducted in Seattle, Washington (n = 400) are used to parameterize the model.

RESULTS

Predicted population-level HIV prevalence as well as an individual's risk of HIV acquisition decreases when the odds of serosorting are increased in the mathematical model. In our model based on observed levels of serosorting, we predict an HIV prevalence of 16%. In contrast, if serosorting were eliminated in the population, we predict that HIV prevalence would increase to 24.5%. However, our findings depend on rates of condom use, mean anal sex contact rates, and HIV testing in the population.

CONCLUSION

Under realistic scenarios of sexual behavior and testing frequency for men who have sex with men in the United States, serosorting can be an effective harm reduction strategy.

Understanding differences in HIV sexual transmission among Latino and black men who have sex with men: The Brothers y Hermanos Study

HIV sexual transmission risk behaviors were examined among 1,065 Latino and 1,140 black men who have sex with men (MSM). Participants completed a computer-administered questionnaire and were tested for HIV infection. Of men who reported that their last HIV test was negative or that they had never been tested or did not get the result of their last test, 17% of black and 5% of Latino MSM tested HIV-positive in our study. In both ethnic groups, the three-month prevalence of unprotected anal intercourse (UAI) with HIV-negative or unknown serostatus partners was twice as high among men unaware of their HIV infection than men who knew they were HIV seropositive at the time of enrollment. UAI exclusively with HIV-positive partners was more prevalent among HIV-positive/aware than HIV-positive/unaware men. The findings advance understanding of the high incidence of HIV infection among black MSM in the U.S.

Formation of personal HIV disclosure policies among HIV-positive men who have sex with men

Given the increasing emphasis on "prevention with positives" programs designed to promote HIV transmission risk reduction among people living with HIV/AIDS, better understanding of influences upon serostatus disclosure in sexual situations is needed. Based on grounded theory analyses of individual interviews, this exploratory research hypothesizes and interprets how 15 HIV-positive men who have sex with men (MSM) formed personal HIV disclosure policies for sexual situations. Participants described five elements influencing development of their personal policies, including: (1) making sense of having been infected, (2) envisioning sex as an HIV-positive man, (3) sorting through feelings of responsibility for others, (4) responding to views of friends and the gay community, and (5) anticipating reactions and consequences of disclosure. The article concludes with implications for current initiatives for prevention with positives.

HIV transmission risk among HIV seroconcordant and serodiscordant couples: dyadic processes of partner selection

Selecting sex partners of the same HIV status or serosorting is a sexual risk reduction strategy used by many men who have sex with men. However, the effectiveness of serosorting for protection against HIV is potentially limited. We sought to examine how men perceive the protective benefits of factors related to serosorting including beliefs about engaging in serosorting, sexual communication, and perceptions of risk for HIV. Participants were 94 HIV negative seroconcordant (same HIV status) couples, 20 HIV serodiscordant (discrepant HIV status) couples, and 13 HIV positive seroconcordant (same HIV status) couples recruited from a large gay pride festival in the southeastern US. To account for nonindependence found in the couple-level data, we used multilevel modeling which includes dyad in the analysis. Findings demonstrated that participants in seroconcordant relationships were more likely to believe that serosorting reduces concerns for condom use. HIV negative participants in seroconcordant relationships viewed themselves at relatively low risk for HIV transmission even though monogamy within relationships and HIV testing were infrequent. Dyadic analyses demonstrated that partners have a substantial effect on an individual's beliefs and number of unprotected sex partners. We conclude that relationship partners are an important source of influence and, thus, intervening with partners is necessary to reduce HIV transmission risks.