Less decrease in risk behaviour from pre-HIV to post-HIV seroconversion among MSM in the combination antiretroviral therapy era compared with the pre-combination antiretroviral therapy era

Behaviour changes following HIV diagnosis among men who have sex with men in the era of treatment as prevention: data from a prospective study

We described the longitudinal changes in sexual behaviour and associated factors among newly diagnosed with HIV men who have sex with men participating in a prospective observational study from a London HIV clinic (2015-2018). Participants self-completed questionnaires at baseline, months 3 and 12. Information collected included socio-demographic, sexual behaviour, health, lifestyle and social support. Trends in sexual behaviours over one year following diagnosis and associated factors were assessed using generalized estimating equations with logit link. Condomless sex (CLS) dropped from 62.2% at baseline to 47.6% at month-three but increased again to 61.8% at month-12 (p-trend = 0.790). Serodiscordant-CLS increased between month-three and month-12 (from 13.1% to 35.6%, p-trend < 0.001). The prevalence of serodiscordant-CLS with high risk of transmitting to their partners at month-three was 10.7%. CLS was higher among men who reported recreational drug use (adjusted Odds Ratio (aOR) 3.03, 95%CI 1.47-6.24, p = 0.003), those with undetectable viral load (aOR 2.17, 95%CI 1.22-3.84, p = 0.008) and those who agreed with a statement "condoms are not necessary when HIV viral load is undetectable" (aOR 3.41, 95%CI 1.58-7.38, p = 0.002). MSM continued to engage in CLS after HIV diagnosis, which coincided with U = U publications and increased throughout the study.

Estimating Partnership Duration among MSM in Belgium-A Modeling Study

Mathematical modeling is widely used for describing infection transmission and evaluating interventions. The lack of reliable social parameters in the literature has been mentioned by many modeling studies, leading to limitations in the validity and interpretation of the results. Using data from the European MSM Internet survey 2017, we developed a network model to describe sex acts among MSM in Belgium. The model simulates daily sex acts among steady, persistent casual and one-off partners in a population of 10,000 MSM, grouped as low- or high-activity by using three different definitions. Model calibration was used to estimate partnership duration and homophily rates to match the distribution of cumulative sex partners over 12 months. We estimated an average duration between 1065 and 1409 days for steady partnerships, 4-6 and 251-299 days for assortative high- and low-activity individuals and 8-13 days for disassortative persistent casual partnerships, respectively, varying across the three definitions. High-quality data on social network and behavioral parameters are scarce in the literature. Our study addresses this lack of information by providing a method to estimate crucial parameters for network specification.

Prevention of HIV in the MSM Population: A Cultural-Historical Comparison of Sweden and the Netherlands

The aim of this article is to compare the cultural-historical events and decisions regarding how to deal with the higher risks of HIV in MSM, and more specifically, gay populations in Sweden and the Netherlands. A narrative literature was used, based on 46 scientific articles and 20 additional semi-scientific resources. The themes of the arrival of HIV and AIDS, blood donations, offender/victim, the balance of risks with respect to the statistical probabilities and the human factor, and finally, prevention were discussed. It is concluded that certain context-specific historical events (the Dutch Bloody Sunday and the Swedish gay sauna ban) and culturally determined processes (trust in others in the Netherlands, and disapproval of casual sex in Sweden) have led to some important differences in how HIV and AIDS and the higher risks for gay men and MSM have been dealt with. In the Netherlands, there is a stronger protective attitude when it comes to the freedom and autonomy of MSM both when it comes to decisions about sexual behavior and to sharing any positive HIV status. In Sweden, on the other hand, there is a stronger tendency to enforce informing others of their HIV status. In both countries, despite efforts to prevent this, HIV has increased stigma for gay men and other MSM.

The impact of the COVID-19 pandemic on hepatitis B virus vaccination and transmission among men who have sex with men: a mathematical modelling study

Background

Methods

Results

Conclusions

Effects of Case Management on Risky Sexual Behaviors and Syphilis Among HIV-Infected Men Who Have Sex With Men in China: A Randomized Controlled Study

BACKGROUND

The prevalence of syphilis is very high in human immunodeficiency virus (HIV)-positive men who have sex with men (MSM), and effective interventions are needed to educate HIV-positive individuals about behavioral and biological risk factors. Therefore, we developed a standard case management process and conducted a randomized controlled study to investigate the impact on risky sexual behaviors and syphilis in HIV-positive MSM.

METHODS

Men who have sex with men (n = 220) were enrolled and randomized to the case management intervention group and the control group between May 2016 and January 2017. The control group received routine HIV-related care. In addition to routine HIV-related care, those in the intervention group regularly received extended services from a well-trained case manager. Epidemiological information was collected during the baseline face-to-face interviews by a trained investigator. Serological tests for syphilis and assessments of risky sexual behaviors were performed at baseline and 6 and 12 months after the initiation of treatment.

RESULTS

The syphilis incidence rates in the intervention and control groups were 11.3 per 100 person-years and 20.6 per 100 person-years, respectively. The multivariable-adjusted hazard ratio (95% confidence inter) for syphilis in case management group was 0.34 (0.14-0.87). The percentages of participants who resumed risky sexual behaviors in both groups were significantly reduced (P < 0.05) but did not significantly differ between the 2 groups.

CONCLUSIONS

A case management intervention reduced the incidence of syphilis in HIV-positive MSM. We should further increase the content of case management on the basis of providing routine HIV-related care to those people.

Offering a choice of daily and event-driven preexposure prophylaxis for men who have sex with men in the Netherlands: a cost-effectiveness analysis

OBJECTIVES

To assess the cost-effectiveness of a preexposure prophylaxis (PrEP) programme offering a choice of daily and event-driven PrEP for men who have sex with men (MSM) in the Netherlands.

METHODS

We used an agent-based transmission model and an economic model to simulate a programme offering only daily PrEP and a programme offering daily and event-driven PrEP. Use of PrEP medication and preference for daily versus event-driven PrEP were estimated from the Amsterdam PrEP Demonstration Project (AMPrEP). We calculated costs, quality-adjusted life-years (QALY), and incremental cost-effectiveness ratios (ICER), over 2018-2027. An ICER less than €20 000 per QALY gained was considered cost-effective.

RESULTS

Using AMPrEP data, we estimated that 27% of PrEP users chose event-driven PrEP with a median of 12 pills per month; daily PrEP users used a median of 30 pills per month. With PrEP, 3740 HIV infections were averted and 1482 QALYs were gained over 2018-2027, compared to the scenario without PrEP. The probability of the PrEP programme being cost-effective (compared to not having a PrEP programme) increased from 91% with daily PrEP to 94% with a choice of daily and event-driven PrEP. The probability of being cost-saving increased from 42% with only daily PrEP to 48% with choice of daily and event-driven PrEP.

CONCLUSIONS

A daily PrEP programme for MSM would be cost-effective. Providing a choice of daily and event-driven PrEP can result in savings and is more likely to be cost-effective and cost-saving, compared to a programme offering only daily PrEP.

Ending risk-group HBV vaccination for MSM after the introduction of universal infant HBV vaccination: A mathematical modelling study

BACKGROUND

Risk-group HBV vaccination for men who have sex with men (MSM) was introduced in the Netherlands in 2002, followed by universal infant vaccination in 2011, that will enable termination of risk-group vaccination over time. The introduction of pre-exposure prophylaxis (PrEP) for HIV prevention might result in increased HBV testing and vaccination against HBV. The aim of this study was to investigate the impact of the transition from risk-group to universal HBV vaccination, accounting for improvements in HBV testing and treatment, as well as the introduction of PrEP.

METHODS

We developed a mathematical model for HBV transmission among MSM. Universal vaccination was modelled by assigning some MSM (5-15% in 2028 increasing to 80-90% in 2033 and thereafter) to be vaccinated when they become sexually active. We investigated different scenarios assuming 0.5% extra vaccination rate and 0.5% extra testing rate due to PrEP consultations; and 5% of HIV-negative MSM on PrEP, that will reduce the probability of HBV acquisition by 88%.

RESULTS

Universal vaccination resulted in a reduction of 24% (interquartile range; 22-25%) of the total number of HBV infections among MSM estimated to occur from 2020 to 2070. With universal vaccination, terminating risk-group vaccination in 2030 or 2040 resulted in 30% or 10% more HBV infections over 2020-2070, respectively, compared to continuation of risk-group vaccination until 2070. With PrEP and continued risk-group vaccination, the total number of HBV infections over 2020-2070 was reduced by 13%.

CONCLUSIONS

Universal HBV vaccination can lead to a major reduction in HBV incidence among MSM in the future. The reduction becomes smaller when ending risk-group HBV vaccination, but larger by PrEP use for HIV prevention. Efforts to keep high levels of HBV vaccination, testing, and treatment have to be continued in the coming decades in order to eliminate HBV as a health threat for MSM.

Preexposure prophylaxis for men who have sex with men in the Netherlands: impact on HIV and Neisseria gonorrhoeae transmission and cost-effectiveness

OBJECTIVES

To assess the impact of a preexposure prophylaxis (PrEP) programme for high-risk men who have sex with men (MSM), which includes gonorrhoea testing and treatment, on the transmission of HIV and Neisseria among MSM in the Netherlands and the cost-effectiveness of such programme with and without risk compensation (in the form of reduced condom use).

METHODS

We developed a stochastic agent-based transmission model of HIV and gonorrhoea. We simulated a capped (max 2.5% of MSM) and uncapped (5.5% of MSM in 2018 declining to 3% in 2027) daily PrEP programme for high-risk MSM, with 3-monthly HIV and gonorrhoea testing, with and without risk compensation. Epidemiological outcomes were calculated from the transmission model and used in an economic model to calculate costs, quality-adjusted life-years (QALY), and incremental cost-effectiveness ratios (ICER), over 2018-2027, taking a healthcare payer perspective.

RESULTS

Without risk compensation, PrEP can lead to a reduction of 61 or 49% in the total number of new HIV infections in 2018-2027, if the programme is uncapped or capped to 2.5% of MSM, respectively. With risk compensation, this reduction can be 63 or 46% in the uncapped and capped programmes, respectively. In all scenarios, gonorrhoea prevalence decreased after introducing PrEP. Without risk compensation, 92% of simulations were cost-effective (of which 52% cost-saving). With risk compensation, 73% of simulations were cost-effective (of which 23% was cost-saving).

CONCLUSION

A nationwide PrEP programme for high-risk MSM can result in substantial reductions in HIV and gonorrhoea transmission and be cost-effective, even with risk compensation.

Impact of frequent testing on the transmission of HIV and N. gonorrhoeae among men who have sex with men: a mathematical modelling study

OBJECTIVES

To investigate the impact and efficiency of combined testing for HIV and other STIs on HIV and STI transmission among men who have sex with men (MSM) and to assess what subgroups of MSM should be targeted for frequent testing.

METHODS

We developed an agent-based transmission model that simulates infection with HIV or Neisseria gonorrhoeae (NG) among MSM. We examined scenarios with increased percentages of MSM getting tested six monthly, among all MSM or only specific subgroups of MSM (defined according to recent gonorrhoea, number of partners and engagement in condomless anal intercourse (CAI)) and scenarios with reduced intervals between HIV/STI tests.

RESULTS

The most efficient strategies were those with increased percentage of MSM getting tested every 6 months among MSM with a recent gonorrhoea diagnosis; or among MSM who had CAI and ≥10 partners; or MSM who had ≥10 partners. Over 10 years, these strategies resulted in 387-718 averted HIV infections and required 29-164 additional HIV tests per averted HIV infection or one to seven additional gonorrhoea tests per averted NG infection. The most effective strategy in reducing HIV transmission was the one where the intervals between tests were reduced by half, followed by the strategy with increased percentage of MSM getting tested every 6 months among all MSM. Over 10 years, these strategies resulted in 1362 and 1319 averted HIV infections, but required 663 and 584 additional HIV tests per averted HIV infection, respectively.

CONCLUSIONS

Targeting MSM with recent gonorrhoea diagnosis or MSM with many partners is efficient in terms of HIV/STI tests needed to prevent new HIV or NG infections. Major reductions in HIV incidence can be achieved with consistent HIV/STI testing every 6 months among larger groups, including low-risk MSM. To impede HIV transmission, frequent testing should be combined with other prevention measures.

Impact of early antiretroviral treatment on sexual behaviour: a randomised comparison

Background:

Antiretroviral treatment (ART) reduces HIV infectiousness but the effect of early ART on sexual behaviour is unclear.

Methods:

We assessed, within the START randomized trial that enrolled HIV-positive adults with CD4⁺ cell count greater than 500 cells/μl, the effect of early (immediate) versus deferred ART on: condomless sex with HIV-serodifferent partners (CLS-D); all condomless sex (CLS); HIV transmission-risk sex (CLS-D-HIV risk, defined as CLS-D and: not on ART or started ART <6 months ago or viral load greater than 200 copies/ml or no viral load in past 6 months), during 2-year follow-up. Month-12 CLS-D (2010–2014) was the primary outcome.

Results:

Among 2562 MSM, there was no difference between immediate and deferred arms in CLS-D at month 12 [12.6 versus 13.1%; difference (95% CI): −0.4% (−3.1 to 2.2%), P = 0.75] or month 24, or in CLS. Among 2010 heterosexual men and women, CLS-D at month 12 tended to be higher in the immediate versus deferred arm [10.8 versus 8.3%; difference:2.5% (−0.1 to 5.2%), P = 0.062]; the difference was greater at month 24 [9.3 versus 5.6%; difference: 3.7% (1.0 to 6.4%), P = 0.007], at which time CLS was higher in the immediate arm (20.7 versus 15.7%, P = 0.013). CLS-D-HIV risk at month 12 was substantially lower in the immediate versus deferred arm for MSM [0.2 versus 11%; difference: −10.7% (−12.5 to −8.9%), P < 0.001] and heterosexuals [0.6% versus 7.7%; difference: −7.0% (−8.8 to −5.3%), P < 0.001], because of viral suppression on ART.

Conclusion:

A strategy of early ART had no effect on condomless sex with HIV-serodifferent partners among MSM, but resulted in modestly higher prevalence among heterosexuals. However, among MSM and heterosexuals, early ART resulted in a substantial reduction in HIV-transmission-risk sex, to a very low absolute level.

Cost-effectiveness of increased HIV testing among MSM in The Netherlands

OBJECTIVES

To assess the cost-effectiveness of increased consistent HIV testing among MSM in the Netherlands.

METHODS

Among MSM testing at sexually transmitted infection clinics in the Netherlands in 2014-2015, approximately 20% tested consistently every 6 months. We examined four scenarios with increased percentage of MSM testing every 6 months: a small and a moderate increase among all MSM; a small and a moderate increase only among MSM with at least 10 partners in the preceding 6 months. We used an agent-based model to calculate numbers of HIV infections and AIDS cases prevented with increased HIV testing. These numbers were used in an economic model to calculate costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) due to increased testing, over 2018-2027, taking a healthcare payer perspective.

RESULTS

A small increase in the percentage testing every 6 months among all MSM resulted in 490 averted HIV infections and an average ICER of &OV0556;27 900/QALY gained. A moderate increase among all MSM, resulted in 1380 averted HIV infections and an average ICER of &OV0556;36 700/QALY gained. Both were not cost-effective, with a &OV0556;20 000 willingness-to-pay threshold. Increasing the percentage testing every 6 months only among MSM with at least 10 partners in the preceding 6 months resulted in less averted HIV infections than increased testing among all MSM, but was on average cost-saving.

CONCLUSION

Increased HIV testing can prevent considerable numbers of new HIV infections among MSM, but may be cost-effective only if targeted at high-risk individuals, such as those with many partners.

Impact of sexual trajectories of men who have sex with men on the reduction in HIV transmission by pre-exposure prophylaxis

Changes in sexual risk behavior over the life course in men who have sex with men (MSM) can influence population-level intervention efficacy. Our objective was to investigate the impact of incorporating sexual trajectories describing long-term changes in risk levels on the reduction in HIV prevalence by pre-exposure prophylaxis (PrEP) among MSM. Based on the Amsterdam Cohort Study data, we developed two models of HIV transmission in a population stratified by sexual behavior. In the first model, individuals were stratified into low, medium and high risk levels and did not change their risk levels. The second model had the same stratification but incorporated additionally three types of sexual behavior trajectories. The models assumed universal antiretroviral treatment of HIV⁺ MSM, and PrEP use by high risk HIV^- MSM. We computed the relative reduction in HIV prevalence in both models for annual PrEP uptakes of 10% to 80% at different time points after PrEP introduction. We then investigated the impact of sexual trajectories on the effectiveness of PrEP intervention. The impact of sexual trajectories on the overall prevalence and prevalence in individuals at low, medium and high risk levels varied with PrEP uptake and time after PrEP introduction. Compared to the model without sexual trajectories, the model with trajectories predicted a higher impact of PrEP on the overall prevalence, and on the prevalence among the medium and high risk individuals. In low risk individuals, there was more reduction in prevalence during the first 15 years of PrEP intervention if sexual trajectories were not incorporated in the model. After that point, at low risk level there was more reduction in the model with trajectories. In conclusion, our study predicts that sexual trajectories increase the estimated impact of PrEP on reducing HIV prevalence when compared to a population where risk levels do not change.

Behavioral changes following HIV seroconversion during the historical expansion of HIV treatment in the United States

OBJECTIVES

To identify the ways in which HIV seroconversion impacts subsequent health behaviors in the context of evolving HIV treatment technologies.

DESIGN

Prospective cohort study.

METHODS

We assessed changes in health and HIV risk behaviors following HIV seroconversion both before and after HIV treatment access (i.e. HAART) in the United States by drawing from the Multicenter AIDS Cohort Study, which collected data from men who have sex with men (MSM) (n = 4616) in four US cities from 1984 to 2008. Longitudinal regression analyses with individual fixed effects accounted for time-invariant, unobservable determinants of risk behaviors. Further analyses assessed the sensitivity of our results to controlling for indicators of physical and mental health (e.g. CD4 cell count, depression) and differential attrition by higher risk individuals.

RESULTS

Among those who seroconverted during observation (n = 558), HIV seroconversion was associated with reduced odds of subsequent engagement in sex with at least two partners [adjusted odds ratio [adjusted odds ratio (aOR): 0.371; confidence interval (CI): 0.263-0.523], insertive anal sex with at least two partners (aOR: 0.360; CI: 0.219-0.591), and heavy drinking (aOR: 0.704; CI: 0.508-0.977). Seroconversion after HAART availability and treatment initiation was associated with further reduced odds of engaging in these behaviors. CD4 cell count, depression, and attrition did not change these results.

CONCLUSION

Specific health and HIV risk behaviors declined following seroconversion, especially with treatment availability and utilization. These positive behavior changes following HIV seroconversion provide evidence for continued investment in the HIV care continuum, including support for HIV testing and engagement in clinical care and treatment.

The association between lifetime polytobacco use and intention to quit among HIV-positive cigarette smokers

BACKGROUND

This secondary analysis aims to describe, over time, the relationship between HIV disease progression and intention to quit cigarette smoking among current monocigarette users with and without a lifetime history of polytobacco use.

METHODS

Participants completed a baseline assessment at the time of HIV care initiation and four follow-up assessments (3, 6, 9, and 12-months). Assessments included biochemically verified smoking status and audio computer-assisted self-interviews assessing psychosocial, substance use, and clinical variables known to influence smoking behaviors. Using linear and generalized linear fixed-effects models, we modeled the covariance structure for the repeated outcome measures (intention to quit and 7-day point prevalence smoking abstinence) across the study time points and included a three-way interaction term to examine the effects of disease stage and tobacco product use.

RESULTS

Participants (N = 357) were 73.1% male, 67.3% black/African American, and had a mean (SD) age of 38.7 (10.6) years. At baseline, lifetime polytobacco users reported significantly worse HIV-related symptoms and burdens, illness perception, social support, and nicotine dependence. Intention to quit, but not smoking abstinence, was predicted by a three-way interaction between time from HIV care initiation, disease progression, and tobacco product use (p = .04). Overall, progressive HIV was associated with greater intention to quit smoking cigarettes. However, the relationship differed over time between the two tobacco product groups.

CONCLUSION

Future studies should consider tailoring the timing of cessation interventions upon disease stage and lifetime history of polytobacco use.

Meta-Analysis of Alcohol and Serodiscordant Condomless Sex Among People Living with HIV

While observational studies have found that alcohol consumption is associated with serodiscordant condomless sex among people living with HIV (PLHIV), no meta-analysis has yet examined this trend. We conducted a meta-analysis to synthesize empirical evidence on the association between alcohol and condomless sex with partners at risk of HIV acquisition. To meet inclusion criteria, studies: (1) specifically targeted PLHIV or provided stratified data for HIV-infected participants; (2) provided a quantitative measure of alcohol use; (3) provided a quantitative measure of condomless sex with serodiscordant partners; and (4) reported the results of statistical tests examining the relationship between alcohol use and serodiscordant condomless sex. Using random-effects models, weighted effect sizes were calculated. Three separate analyses were conducted to examine serodiscordant condomless sex in association with any alcohol consumption, binge/problematic drinking, and alcohol in a sexual context. A total of 36 independent effect sizes from 27 studies (including 25,065 HIV-infected participants) were pooled in the meta-analysis. Any alcohol consumption, binge/problematic drinking, and alcohol use in a sexual context were each associated with condomless sex with serodiscordant partners [OR 1.64 (95% CI 1.46-1.85); OR 1.65 (95% CI 1.14-2.39); OR 2.88 (95% CI 2.01-4.12), respectively]. Meta-analytic findings demonstrate a consistent positive relationship between alcohol use and serodiscordant condomless sex among PLHIV. Future public health programming for HIV-infected individuals needs to address the role of alcohol consumption in sexual risk-taking behavior.

Peer counselling versus standard-of-care on reducing high-risk behaviours among newly diagnosed HIV-positive men who have sex with men in Beijing, China: a randomized intervention study

INTRODUCTION

Reducing high-risk behaviours (i.e. multiple partnership, condomless anal/vaginal sex, alcohol use before sex, illicit drug use) after HIV diagnosis is critical for curtailing HIV transmission. We designed an intervention to explore peer- counselling in reducing high-risk behaviours among newly diagnosed HIV-positive Chinese men who have sex with men (MSM).

METHODS

We randomized 367 newly diagnosed HIV-positive men to either standard-of-care (SOC; n = 183) or peer-counselling intervention (n = 184), and followed them for 12 months (visit at 0-, 3-, 6-, 9- and 12-month). SOC participants received counselling on high-risk behaviour reduction by clinic staff. Intervention participants received both SOC and peer counselling. A generalized estimating equation was used to compare pre-post diagnosis high-risk behaviour change; logistic regression was used to assess the likelihood of practicing high-risk behaviours between intervention and SOC participants. Both intent-to-treat and per-protocol (full-dosage) approaches were used for the analyses.

RESULTS

For pre- and post-diagnosis comparisons, multiple partnership fell from 50% to 16% (p < 0.001), alcohol use before sex from 23% to 9% (p = 0.001), illicit drug use from 33% to 6% (p < 0.001), condomless anal sex from 47% to 4% (insertive from 23% to 2%; receptive from 36% to 3%; p < 0.001). In the intent-to-treat analysis accounting for repeated measures, peer counselling was more likely to reduce insertive anal sex (AOR = 0.65; 95% CI: 0.45 to 0.94), condomless anal sex (AOR = 0.27; 95% CI: 0.10 to 0.64) and illicit drug use (AOR = 0.32; 95% CI: 0.16 to 0.64). In the per-protocol analysis, peer counselling was associated with a lower likelihood of using illicit drug (OR = 0.23; 95% CI: 0.07 to 0.81) and having condomless vaginal sex with women (OR = 0.12; 95% CI: 0.07 to 0.98).

CONCLUSIONS

We observed a 14 to 43% decrease in the prevalence of selected high-risk behaviours after HIV diagnosis. Peer counselling had a greater impact in reducing condomless anal sex with men, illicit drug use and condomless vaginal sex with women over time. Future studies with exclusive peer-counselling arm are necessary to test its efficacy and effectiveness among Chinese MSM. Clinical Trial Number: NCT01904877.

Opt-Out Referral of Men Who Have Sex With Men Newly Diagnosed With HIV to Partner Notification Officers: Results and Yield of Sexual Partners Being Contacted

BACKGROUND

Given its potential for reducing the proportion of people with human immunodeficiency virus (HIV) unaware of their diagnosis, partner notification for HIV has been underutilized. This study aimed to determine if the implementation of opt-out referral of men who have sex with men, newly diagnosed with HIV, to partner notification officers (PNO) increased the proportion of sexual partners notified.

METHODS

In April 2013, all individuals newly diagnosed with HIV at the Melbourne Sexual Health Centre, Australia were referred to Department of Health PNO to facilitate partner notification. The number of sexual partners reported by men and the proportion contacted in the 12 months before (opt-in period) and after (opt-out period) this policy change were determined through review of the clinical PNO records.

RESULTS

Overall, 111 men were diagnosed with HIV during the study period. Compared with men in the opt-in period (n = 51), men in the opt-out period (n = 60) were significantly more likely to accept assistance from the PNO (12 [24%] vs 51 [85%]; P < 0.001). A significantly higher proportion of reported partners were notified with opt-out referral (85/185, 45.9%; 95% confidence interval, 38.6-53.4) compared with opt-in referral (31/252, 12.3%; 95% confidence interval, 8.5-17.0) (P < 0.001).

DISCUSSION

Opt-out referral to PNO was associated with a substantially higher proportion of partners at risk of HIV being contacted.

Limited overlap between phylogenetic HIV and hepatitis C virus clusters illustrates the dynamic sexual network structure of Dutch HIV-infected MSM

OBJECTIVE

MSM are at increased risk for infection with HIV-1 and hepatitis C virus (HCV). Is HIV/HCV coinfection confined to specific HIV transmission networks?

DESIGN AND METHODS

A HIV phylogenetic tree was constructed for 5038 HIV-1 subtype B polymerase (pol) sequences obtained from MSM in the AIDS therapy evaluation in the Netherlands cohort. We investigated the existence of HIV clusters with increased HCV prevalence, the HIV phylogenetic density (i.e. the number of potential HIV transmission partners) of HIV/HCV-coinfected MSM compared with HIV-infected MSM without HCV, and the overlap in HIV and HCV phylogenies using HCV nonstructural protein 5B sequences from 183 HIV-infected MSM with acute HCV infection.

RESULTS

Five hundred and sixty-three of 5038 (11.2%) HIV-infected MSM tested HCV positive. Phylogenetic analysis revealed 93 large HIV clusters (≥10 MSM), 370 small HIV clusters (2-9 MSM), and 867 singletons with a median HCV prevalence of 11.5, 11.6, and 9.3%, respectively. We identified six large HIV clusters with elevated HCV prevalence (range 23.5-46.2%). Median HIV phylogenetic densities for MSM with HCV (3, interquartile range 1-7) and without HCV (3, interquartile range 1-8) were similar. HCV phylogeny showed 12 MSM-specific HCV clusters (clustersize: 2-39 HCV sequences); 12.7% of HCV infections were part of the same HIV and HCV cluster.

CONCLUSION

We observed few HIV clusters with elevated HCV prevalence, no increase in the HIV phylogenetic density of HIV/HCV-coinfected MSM compared to HIV-infected MSM without HCV, and limited overlap between HIV and HCV phylogenies among HIV/HCV-coinfected MSM. Our data do not support the existence of MSM-specific sexual networks that fuel both the HIV and HCV epidemic.

Development and validation of a risk score to assist screening for acute HIV-1 infection among men who have sex with men

BACKGROUND

Early treatment of acute HIV-1 infection (AHI) is beneficial for patients and could reduce onward transmission. However, guidelines on whom to test for AHI with HIV-1 RNA testing are lacking.

METHODS

A risk score for possible AHI based on literature and expert opinion - including symptoms associated with AHI and early HIV-1 - was evaluated using data from the Amsterdam Cohort Studies among men who have sex with men (MSM). Subsequently, we optimized the risk score by constructing two multivariable logistic regression models: one including only symptoms and one combining symptoms with known risk factors for HIV-1 seroconversion, using generalized estimating equations. Several risk scores were generated from these models and the optimal risk score was validated using data from the Multicenter AIDS Cohort Study.

RESULTS

Using data from 1562 MSM with 175 HIV-1 seroconversion visits and 17,271 seronegative visits in the Amsterdam Cohort Studies, the optimal risk score included four symptoms (oral thrush, fever, lymphadenopathy, weight loss) and three risk factors (self-reported gonorrhea, receptive condomless anal intercourse, more than five sexual partners, all in the preceding six months) and yielded an AUC of 0.82. Sensitivity was 76.3% and specificity 76.3%. Validation in the Multicenter AIDS Cohort Study resulted in an AUC of 0.78, sensitivity of 56.2% and specificity of 88.8%.

CONCLUSIONS

The optimal risk score had good overall performance in the Amsterdam Cohort Studies and performed comparable (but showed lower sensitivity) in the validation study. Screening for AHI with four symptoms and three risk factors would increase the efficiency of AHI testing and potentially enhance early diagnosis and immediate treatment.

Motives and barriers to safer sex and regular STI testing among MSM soon after HIV diagnosis

Background

Understanding why some recently with HIV diagnosed men who have sex with men (MSM) choose for safer sex and regular STI testing, whereas others do not, is important for the development of interventions that aim to improve the sexual health of those newly infected.

Methods

To gain insight into motives and barriers to condom use and regular STI testing among MSM soon after HIV diagnosis, 30 HIV-positive MSM participated in semi-structured qualitative interviews on sexual health behaviours in the first year after HIV diagnosis.

Results

Typical barriers to condom use soon after diagnosis were emotions such as anger, relief, and feelings of vulnerability. Additional barriers were related to pre-diagnosis patterns of sexual-social behaviour that were difficult to change, communication difficulties, and substance use. Barriers to STI testing revolved around perceptions of low STI risk, faulty beliefs, and burdensome testing procedures.

Conclusions

The great diversity of motives and barriers to condom use and STI testing creates a challenge to accommodate newly infected men with information, motivation, and communication skills to match their personal needs. An adaptive, tailored intervention can be a promising tool of support.

Global challenges in human immunodeficiency virus and syphilis coinfection among men who have sex with men

INTRODUCTION

Syphilis and human immunodeficiency virus (HIV) coinfection disproportionately affects men who have sex with men (MSM), and the rate of coinfection has been increasing over the last decade. HIV and syphilis coinfection is particularly challenging because the infections interact synergistically thereby increasing the risk of acquisition and transmission as well as accelerating disease progression. Areas covered: This paper reviews and summarizes the epidemiology, pathogenesis, diagnosis, clinical management and prevention of HIV and syphilis coinfection among MSM. Expert commentary: Research does not support a different syphilis treatment for coinfected individuals; however, coinfection may warrant a recommendation for antiretroviral therapy. In order to reverse the epidemic of syphilis and HIV coinfection, there needs to be greater awareness, improved cultural sensitivity among health care providers, improved access to preventative services and increased screening for syphilis and HIV.

Impact of Heterogeneity in Sexual Behavior on Effectiveness in Reducing HIV Transmission with Test-and-Treat Strategy

The WHO’s early-release guideline for antiretroviral treatment (ART) of HIV infection based on a recent trial conducted in 34 countries recommends starting treatment immediately upon an HIV diagnosis. Therefore, the test-and-treat strategy may become more widely used in an effort to scale up HIV treatment and curb further transmission. Here we examine behavioural determinants of HIV transmission and how heterogeneity in sexual behaviour influences the outcomes of this strategy. Using a deterministic model, we perform a systematic investigation into the effects of various mixing patterns in a population of men who have sex with men (MSM), stratified by partner change rates, on the elimination threshold and endemic HIV prevalence. We find that both the level of overdispersion in the distribution of the number of sexual partners and mixing between population subgroups have a large influence on endemic prevalence before introduction of ART and on possible long term effectiveness of ART. Increasing heterogeneity in risk behavior may lead to lower endemic prevalence levels, but requires higher coverage levels of ART for elimination. Elimination is only feasible for populations with a rather low degree of assortativeness of mixing and requires treatment coverage of almost 80% if rates of testing and treatment uptake by all population subgroups are equal. In this case, for fully assortative mixing and 80% coverage endemic prevalence is reduced by 57%. In the presence of heterogeneity in ART uptake, elimination is easier to achieve when the subpopulation with highest risk behavior is tested and treated more often than the rest of the population, and vice versa when it is less. The developed framework can be used to extract information on behavioral heterogeneity from existing data which is otherwise hard to determine from population surveys.

HIV is endemic in populations of MSM in Western countries. As ART reduces transmission risk, increased testing and treatment rates are expected to lower HIV incidence. However, concerns are that in MSM populations changing risk behavior may counteract the impact of ART on transmission. Using a mathematical model, we investigated how heterogeneity in sexual behavior influences the possible effects of a test-and-treat strategy on HIV prevalence and in particular the prospects of eliminating HIV from these populations. We demonstrated that behavioral heterogeneity plays an important role in determining the impact of ART on reducing HIV transmission. Knowledge of behavioral heterogeneity is key in setting intervention goals in populations of MSM.

Favorable Socioeconomic Status and Recreational Polydrug Use Are Linked With Sexual Hepatitis C Virus Transmission Among Human Immunodeficiency Virus-Infected Men Who Have Sex With Men

Increasing incident HCV infections were found between 2011-2014 after declining between 2008-2010 among HIV-infected men in a Community Health Center in Baltimore. The reemerging epidemic was associated with sexual transmission and polydrug use among MSM with favorable socioeconomic status.

Background. Sexual transmission of hepatitis C virus (HCV) among human immunodeficiency virus (HIV)-infected men who have sex with men (MSM) is an emerging issue. Studies addressing the temporal trends and risk factors associated with incident HCV in HIV-infected MSM in the community-based primary care settings in the United States are scarce.

Methods. Using a retrospective cohort study design, HCV incidence, defined as HCV antibody seroconversion, was determined in 1147 HIV-infected men receiving care at Chase Brexton Health Care clinics in Baltimore, Maryland between 2004 and 2014. Multivariate regression analyses were used to identify factors associated with incident HCV.

Results. There were 42 incident HCV infections during 5242 person-years (PY) of follow up (incidence rate [IR], 8.01/1000 PY). Thirty-seven (88%) of the incident infections were in MSM, of whom 31 (84%) reported no injection-drug use (IDU). The annual IRs for MSM were 13.1–15.8/1000 PY between 2004 and 2007, decreased to 2.7–6.2/1000 PY between 2008 and 2011, and increased to 10.4/1000 PY and 13.3/1000 PY in 2013 and 2014, respectively. Injection-drug use was strongly associated with incident HCV among all MSM (IR ratio [IRR], 14.15; P = .003); however, among MSM without IDU, entering care between 2010 and 2013 (IRR, 3.32; P = .01), being employed (IRR, 3.14; P = .03), and having a history of ulcerative sexually transmitted infections (IRR, 3.70; P = .009) or of polydrug use (IRR, 5.54; P = .01) independently predicted incident HCV.

Conclusions. In this cohort of HIV-infected men, a re-emerging HCV epidemic was observed from 2011 to 2014 among MSM. In addition to IDU, high-risk sexual behaviors, favorable socioeconomic status, and polydrug use fueled this increase in HCV infections.

Attitudes to and Understanding of Risk of Acquisition of HIV Over Time: Design and Methods for an Internet-based Prospective Cohort Study Among UK Men Who Have Sex With Men (the AURAH2 Study)

Background

The annual number of new human immunodeficiency virus (HIV) infections among men who have sex with men (MSM) has risen in the United Kingdom and, of those who are HIV positive, the proportion undiagnosed is high.

Objective

The prospective AURAH2 study aims to assess factors associated with HIV acquisition among MSM in the United Kingdom and to investigate changes over time within individuals in sexual behavior and HIV-testing practices.

Methods

AURAH2 is a prospective study among MSM without diagnosed HIV, aiming to recruit up to 1000 sexually active MSM attending sexual health clinics in London and Brighton in the United Kingdom. Participants complete an initial paper-based questionnaire, followed by online follow-up questionnaires every 4 months collecting sociodemographic, health and behavioral data, including sexual behavior, recreational and other drug use, HIV testing practices, and pre-exposure prophylaxis use, over a planned 3-year period.

Results

The study is ongoing.

Conclusions

The results from AURAH2 study will provide important insight into established and emerging risk behaviors that may be associated with acquisition of HIV in MSM in the United Kingdom, changes over time within individuals in sexual behavior, and information on HIV testing practices. These data will be crucial to inform future HIV prevention strategies.

Estimating HIV Incidence, Time to Diagnosis, and the Undiagnosed HIV Epidemic Using Routine Surveillance Data

BACKGROUND

Estimates of the size of the undiagnosed HIV-infected population are important to understand the HIV epidemic and to plan interventions, including "test-and-treat" strategies.

METHODS

We developed a multi-state back-calculation model to estimate HIV incidence, time between infection and diagnosis, and the undiagnosed population by CD4 count strata, using surveillance data on new HIV and AIDS diagnoses. The HIV incidence curve was modelled using cubic splines. The model was tested on simulated data and applied to surveillance data on men who have sex with men in The Netherlands.

RESULTS

The number of HIV infections could be estimated accurately using simulated data, with most values within the 95% confidence intervals of model predictions. When applying the model to Dutch surveillance data, 15,400 (95% confidence interval [CI] = 15,000, 16,000) men who have sex with men were estimated to have been infected between 1980 and 2011. HIV incidence showed a bimodal distribution, with peaks around 1985 and 2005 and a decline in recent years. Mean time to diagnosis was 6.1 (95% CI = 5.8, 6.4) years between 1984 and 1995 and decreased to 2.6 (2.3, 3.0) years in 2011. By the end of 2011, 11,500 (11,000, 12,000) men who have sex with men in The Netherlands were estimated to be living with HIV, of whom 1,750 (1,450, 2,200) were still undiagnosed. Of the undiagnosed men who have sex with men, 29% (22, 37) were infected for less than 1 year, and 16% (13, 20) for more than 5 years.

CONCLUSIONS

This multi-state back-calculation model will be useful to estimate HIV incidence, time to diagnosis, and the undiagnosed HIV epidemic based on routine surveillance data.

The impact of age, HIV serostatus and seroconversion on methamphetamine use

BACKGROUND

Characterizing methamphetamine use in relation to age, HIV serostatus and seroconversion is pertinent given the increasingly older age of the population with HIV and the intertwined epidemics of methamphetamine use and HIV.

OBJECTIVES

Study aims were to investigate whether (i) methamphetamine use differs by age and HIV serostatus, and (ii) receiving an HIV diagnosis impacts methamphetamine use among younger and older persons with HIV.

METHODS

This study examined methamphetamine use characteristics among 217 individuals with a lifetime methamphetamine dependence diagnosis who completed an in-person study assessment.

RESULTS

Multivariable regressions revealed that HIV serostatus uniquely attenuates methamphetamine use, such that persons with HIV report a smaller cumulative quantity (β = -0.16, p = 0.01) and a fewer number of days (β = -0.18, p = 0.004) of methamphetamine use than persons without HIV. Among the HIV+ sample, all participants persisted in methamphetamine use after receiving an HIV diagnosis, with about 20% initiating use after seroconversion. Repeated measures analysis of variance indicated that density of methamphetamine use (i.e. grams per day used) was greater among the younger, relative to the older, HIV+ group (p = 0.02), and increased for both age groups following seroconversion (p < 0.001).

CONCLUSION

These analyses indicate that although HIV serostatus may attenuate methamphetamine use behaviors, many people with HIV initiate, or persist in, methamphetamine use after receiving an HIV diagnosis. These findings raise the question of whether tailoring of prevention and intervention strategies might reduce the impact of methamphetamine and HIV across the age continuum.

Changes in sexual risk behavior among MSM participating in a research cohort in coastal Kenya

OBJECTIVE

To describe changes in sexual risk behavior among Kenyan MSM who received regular risk reduction counseling (RRC).

DESIGN

Data were derived from two cohorts of HIV-1-negative and HIV-1-positive MSM in Kenya. Behavioral data were collected at enrollment and at monthly or quarterly scheduled follow-up visits. At each visit, RRC was provided to all men and HIV-1 testing to seronegative men.

METHODS

Random effects logistic and Poisson regression models with time since study entry as main variable of interest were used to evaluate changes in number of sex partners and unprotected sex in the past week, and insertive, receptive, and unprotected anal intercourse in the past 3 months. Analyses were adjusted for HIV-1-status, calendar year of follow-up, and several baseline characteristics. Trends over follow-up time were allowed to differ by HIV-1-status. Men were censored when they seroconverted for HIV.

RESULTS

Number of regular and casual sex partners and unprotected anal intercourse decreased in both HIV-1-negative and HIV-1-positive men. Unprotected sex with both regular and casual sex partners decreased more strongly early in follow-up in HIV-1-positive men than in HIV-1-negative men. Decreases in insertive anal intercourse were found for HIV-1-positive men only, whereas decreases in receptive anal intercourse were found for HIV-1-negative men only.

CONCLUSION

MSM who were regularly exposed to RRC showed some reductions in sexual risk behavior, but it is uncertain if these reductions are sustained over time. As HIV-1 incidences in Kenyan MSM are very high, RRC should be supported by comprehensive biomedical interventions.

Estimating HIV protective effects of method adherence with combinations of preexposure prophylaxis and condom use among African American men who have sex with men

BACKGROUND

Prevention of sexually acquired HIV infection now includes both consistent condom use and daily use of oral antiretroviral preexposure prophylaxis (PrEP). Persons at substantial HIV risk can now use one or both prevention methods, but a combined HIV protective effect has not been assessed.

METHODS

We use deterministic models to examine the impact of method adherence and rates of PrEP and male condom use on number of anticipated HIV infections. Analyses were based on hypothetical cohorts of 10,000 African American men who have sex with men (AAMSM), a population with the highest HIV incidence in the United States. Parameters used in the model (condom effectiveness, PrEP effectiveness, HIV incidence) were based on published findings.

RESULTS

Among AAMSM who never use PrEP, an estimated 323 annual HIV infections would occur among those who always use condoms, 1007 among sometimes condom users, and 1094 among never condoms users. Among AAMSM who never (or inconsistently) use condoms, 295 (272) infections would occur among those who report at least 90% PrEP adherence and 744 (684) infection occur with less than 50% adherence. Among AAMSM who are consistently (or sometimes) taking PrEP, the highest protection is seen with consistent condom use, 87 (220) HIV infections and 92.0% (79.9%) prevention effectiveness.

DISCUSSION

Among AAMSM with inconsistent or never condom use, the addition of PrEP at either modest or high adherence can increase HIV protection. For consistent condom users, any PrEP use can increase HIV protection. These analyses provide an approach for rethinking HIV risk management by calculating combined HIV protective effects of using one or more effective prevention methods.

Social media use and HIV transmission risk behavior among ethnically diverse HIV-positive gay men: results of an online study in three U.S. states

Though Black and Hispanic men who have sex with men (MSM) are at an increased risk for HIV, few HIV risk reduction interventions that target HIV-positive MSM, and even fewer that use technology, have been designed to target these groups. Despite similar rates of social media and technology use across racial/ethnic groups, online engagement of minority MSM for HIV prevention efforts is low. Since minority MSM tend to have less representation in online HIV prevention studies, the goals of this online anonymous study of HIV-positive gay-identified men were to test the feasibility of conducting targeted recruitment by race/ethnicity and sexual orientation, to assess technology and social media use, and to assess global HIV transmission risk. In 2011, an anonymous online survey was conducted among 463 members of an HIV-positive personals website. Emails were sent to a subset of HIV-positive male members who self-identified as gay. While 57 % were White, substantial proportions of participants were Black (20 %) or Hispanic (18 %). Median age was 46 (range 18-79). Men who reported using 3 or more websites or apps to meet sex partners were significantly more likely to report anal intercourse (AOR 4.43, p < .001) and condomless anal sex (CAS) (AOR 2.70, p < .05) in the past 3 months. The only predictor of CAS with HIV-negative or unknown status partners was being under age 30 (AOR 3.38, p < .01). This study helped to inform online targeted recruitment techniques, access to technology and social media use, and sexual risk among a diverse sample of HIV-positive gay men. Efficacy trials of technology-based HIV prevention interventions targeting high-risk minority HIV-positive MSM are warranted.

Chlamydia test results were associated with sexual risk behavior change among participants of the Chlamydia screening implementation in The Netherlands

OBJECTIVE

To examine the effect of a laboratory-confirmed Chlamydia trachomatis (Ct) test result on subsequent sexual risk behavior in a large population-based screening program.

METHODS

The study population consisted of 16- to 29-year-old participants of the Chlamydia Screening Implementation who completed Ct testing and questionnaires in 2 or more rounds. The influence of a Ct test result on sexual behavior was analyzed by generalized estimating equation models, in which the Ct test result of the previous round was the independent variable and 1 of the 8 sexual risk behavior indicators was the dependent variable, adjusted for covariates.

RESULTS

Of 48,910 Chlamydia Screening Implementation participants with completed questionnaires and test results, 14.1% (n = 6802) and 2.6% (n = 1272) completed 2 and 3 rounds, respectively, and were included in this study. Analysis showed that Ct positives less often reported to "never" use condoms with a casual partner (%change pretest/posttest = -5.7% [-10.3 to -0.9]), whereas Ct negatives less often reported to "always" use condoms with a casual partner (-4.6% [-6.4 to -2.8]; odds ratio [95% confidence interval], 1.75 [1.09 to 2.80]). Ct positives also had more sexual partners in the subsequent round than did participants with a Ct-negative test result (relative risk [95% confidence interval], 1.14 [1.01 to 1.29]).

CONCLUSIONS

Ct test results were associated with subsequent sexual risk behavior. In general, Ct positives were more likely to change their behavior after a Ct test result in a more positive and protective direction than Ct negatives, who were more likely to change their behavior toward more risky behavior. Effects over time after a Ct test should be investigated further, especially in the Ct negatives.

Delayed linkage to care in one-third of HIV-positive individuals in the Netherlands

OBJECTIVES

To determine time to linkage to HIV care following diagnosis and to identify risk factors for delayed linkage.

METHODS

Patients newly diagnosed with HIV at sexually transmitted infections (STI) clinics in the Netherlands were followed until linkage to care. Data were collected at the time of diagnosis and at first consultation in care, including demographics, behavioural information, CD4+ counts and HIV viral load (VL) measurements. Delayed linkage to care was defined as >4 weeks between HIV diagnosis and first consultation.

RESULTS

310 participants were included; the majority (90%) being men who have sex with men (MSM). For 259 participants (84%), a date of first consultation in care was known; median time to linkage was 9 days (range 0-435). Overall, 95 (31%) of the participants were not linked within 4 weeks of diagnosis; among them, 44 were linked late, and 51 were not linked at all by the end of study follow-up. Being young (<25 years), having non-Western ethnicity or lacking health insurance were independently associated with delayed linkage to care as well as being referred to care indirectly. Baseline CD4+ count, VL, perceived social support and stigma at diagnosis were not associated with delayed linkage. Risk behaviour and CD4+ counts declined between diagnosis and linkage to care.

CONCLUSIONS

Although most newly diagnosed patients with HIV were linked to care within 4 weeks, delay was observed for one-third, with over half of them not yet linked at the end of follow-up. Vulnerable subpopulations (young, uninsured, ethnic minority) were at risk for delayed linkage. Testing those at risk is not sufficient, timely linkage to care needs to be better assured as well.

Transmission risk behaviour at enrolment in participants in the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial

OBJECTIVES

A proportion of HIV-positive people have condomless sex. Antiretroviral treatment (ART) reduces infectiousness, but a substantial proportion of HIV-diagnosed people are not yet on ART. We describe baseline self-reported risk behaviours in ART-naïve Strategic Timing of AntiRetroviral Treatment (START) trial participants.

METHODS

All START participants completed a risk behaviour questionnaire. Data were collected on sociodemographics, lifestyle factors, health and wellbeing status and clinical status. Recent sexual behaviour and HIV transmission beliefs in the context of ART were also assessed. The primary interest was in condomless sex with serodifferent partners (CLS-D) in the past two months.

RESULTS

A total of 4601 of 4685 HIV-positive participants (98%) completed the questionnaire [2559 men who have sex with men (MSM), 803 heterosexual men and 1239 women]. Region of recruitment was Europe/Israel, 33%; South America/Mexico, 25%; Africa, 22%; other, 21%. Median age was 36 years [interquartile range (IQR) 29, 44 years]. Forty-five per cent reported white ethnicity and 31% black ethnicity. Two per cent had HIV viral load < 50 HIV-1 RNA copies/mL. Seventeen per cent (767 of 4601) reported CLS-D; 20% of MSM compared with 10% of heterosexual men and 14% of women. MSM were also more likely to report multiple CLS-D partners. Possible risk limitation measures (reported by more than half of those who had CLS-D) were seropositioning (receptive anal CLS-D only) or withdrawal (insertive anal CLS-D always without ejaculation). CLS-D was more commonly reported by participants from South America/Mexico and North America compared with Europe; among heterosexual men and women CLS-D was also more commonly reported among participants from Africa compared with Europe. Knowledge of ART impact on transmission risk was low.

CONCLUSIONS

A substantial minority recruited to the START study reported CLS-D at baseline. CLS-D reporting was higher in MSM than heterosexuals and varied significantly according to region of recruitment. A substantial proportion of MSM reporting CLS-D appear to take transmission risk limitation measures.

Examining the role of serostatus disclosure on unprotected sex among people living with HIV

Given the increasing prevalence of HIV, it is important to identify factors associated with safer sex behaviors between people living with HIV and their partners. Utilizing a diverse sample of 242 HIV-infected adults [n=69 men who have sex with men (MSM); n=68 men who have sex with women (MSW); n=105 women who have sex with men (WSM)], we examined the association between serostatus disclosure and unprotected anal or vaginal intercourse (UAVI) and the moderating effect of sexual behavior group on this association. Overall, 88.7% disclosed to their current partner. Approximately 18.8% of MSM, 17.7% of MSW, and 29.5% of WSM reported UAVI. Controlling for age, time since diagnosis, and partner serostatus, we found main effects on UAVI for disclosure and sexual behavior group; specifically, disclosure was inversely related to unprotected sex [AOR=0.09, 95% CI (0.02, 0.43), p<0.001], and MSM were less likely to engage in UAVI relative to WSM [AOR=0.11, 95% CI (0.17, 0.82), p<0.05]. However, the relationship between disclosure and UAVI was not moderated by sexual behavior group. Future strategies that aim to increase disclosure to partners may consider focusing on its value as a means by which to reduce sexual risk behavior.

Positive choices: outcomes of a brief risk reduction intervention for newly HIV-diagnosed men who have sex with men

Positive choices (PC), a brief sexual risk reduction intervention conducted with newly HIV-diagnosed men who have sex with men (MSM), was evaluated for preliminary efficacy. Participants were enrolled if they reported unprotected anal intercourse (UAI) in the three months prior to HIV diagnosis (n = 102). Three months after diagnosis, participants completed baseline assessments and were randomly assigned to receive the 3-session PC intervention or the comprehensive standard of care (C-SoC) at a community health center. Participants completed assessments at 3- (post intervention), 6-, and 9- months after baseline. Compared to C-SoC participants, PC participants significantly reduced the frequency of UAI with HIV serodiscordant (HIV negative or status unknown) partners over the 9-month follow-up period. No differences by condition were found in the frequency of UAI with all partners. The findings from this trial suggest that brief risk reduction approaches for newly-diagnosed MSM integrated into HIV care can benefit secondary HIV prevention efforts.

Sexual risk behaviour and viral suppression among HIV-infected adults receiving medical care in the United States

OBJECTIVE

To describe the prevalence and association of sexual risk behaviours and viral suppression among HIV-infected adults in the United States.

DESIGN

Cross-sectional analysis of weighted data from a probability sample of HIV-infected adults receiving outpatient medical care. The facility and patient response rates were 76 and 51%, respectively.

METHODS

We analysed 2009 interview and medical record data. Sexual behaviours were self-reported in the past 12 months. Viral suppression was defined as all viral load measurements in the medical record during the past 12 months less than 200 copies/ml.

RESULTS

An estimated 98 022 (24%) HIV-infected adults engaged in unprotected vaginal or anal sex; 50 953 (12%) engaged in unprotected vaginal or anal sex with at least one partner of negative or unknown HIV status; 23 933 (6%) did so while not virally suppressed. Persons who were virally suppressed were less likely than persons who were not suppressed to engage in vaginal or anal sex [prevalence ratio, 0.88; 95% confidence interval (CI), 0.82-0.93]; unprotected vaginal or anal sex (prevalence ratio, 0.85; 95% CI, 0.73-0.98); and unprotected vaginal or anal sex with a partner of negative or unknown HIV status (prevalence ratio, 0.79; 95% CI, 0.64-0.99).

CONCLUSION

The majority of HIV-infected adults receiving medical care in the U.S. did not engage in sexual risk behaviours that have the potential to transmit HIV, and of the 12% who did, approximately half were not virally suppressed. Persons who were virally suppressed were less likely than persons who were not suppressed to engage in sexual risk behaviours.

Translational HIV-1 research: from routine diagnostics to new virology insights in Amsterdam, the Netherlands during 1983-2013

An HIV-1 diagnostic laboratory was established in the Academic Medical Center (AMC) of the University of Amsterdam after the discovery of human immunodeficiency virus (HIV) as the cause of the acquired immunodeficiency syndrome (AIDS). The first AIDS patients were diagnosed here in 1981 and since 1983 we have tested the samples of 50992 patients using a variety of assays that greatly improved over the years. We will describe some of the basic results from this diagnostic laboratory and then focus on the spin-off in terms of the development of novel virus assays to detect super-infections and ultra-sensitive assays to measure the intracellular HIV-1 RNA load. We also review several original research findings in the field of HIV-1 virology that stem from initial observations made in the diagnostic unit. This includes the study of genetic defects in the HIV-1 genome and time trends of the replication fitness over 30 years of viral evolution, but also the description of novel HIV-1 variants in difficult-to-diagnose clinical specimen.

Disinhibition in risky sexual behavior in men, but not women, during four years of antiretroviral therapy in rural, southwestern Uganda

BACKGROUND

In resource-rich areas, risky sexual behavior (RSB) largely diminishes after initiation of anti-retroviral therapy, with notable exceptions among some populations who perceive a protected benefit from anti-retroviral therapy (ART). Yet, there is limited data about long-term trends in risky sexual behavior among HIV-infected people in sub-Saharan Africa after initiation of anti-retroviral therapy.

METHODS

We administered questionnaires every three months to collect sexual behavior data among patients taking ART in southwestern Uganda over four years of follow-up time. We defined RSB as having unprotected sex with an HIV-negative or unknown status partner, or unprotected sex with a casual partner. We fit logistic regression models to estimate changes in RSB by time on ART, with and without adjustment for calendar year and CD4 count.

RESULTS

506 participants were enrolled between 2005 and 2011 and contributed a median of 13 visits and 3.5 years of observation time. The majority were female (70%) and median age was 34 years (interquartile range 29-39). There was a decrease in the proportion of men reporting RSB from the pre-ART visit to the first post-ART visit (16.2 to 4.3%, p<0.01) but not women (14.1 to 13.3%, p = 0.80). With each year of ART, women reported decreasing RSB (OR 0.85 per year, 95%CI 0.74-0.98, p = 0.03). In contrast, men had increasing odds of reporting RSB with each year of ART to near pre-treatment rates (OR 1.41, 95%CI 1.14-1.74, p = 0.001), which was partially confounded by changes in calendar time and CD4 count (AOR = 1.24, 95%CI 0.92-1.67, p = 0.16).

CONCLUSIONS

Men in southwestern Uganda reported increasing RSB over four years on ART, to levels approaching pre-treatment rates. Strategies to promote long-term safe sex practices targeted to HIV-infected men on ART might have a significant impact on preventing HIV transmission in this setting.

HIV transmission in the United States: considerations of viral load, risk behavior, and health disparities

Ongoing HIV transmission is related to prevalence, risk behavior and viral load among persons with HIV. We assessed the contribution of these factors to HIV transmission with transmission rate models and data reported to National HIV Surveillance and published rates of risk behavior. We also estimated numbers of persons with risk behaviors and unsuppressed viral load among sexual risk groups. The transmission rate is higher considering risk behavior (18.5 infections per 100 people with HIV) than that attributed to unsuppressed viral load (4.6). Since persons without risk behavior or suppressed viral load presumably transmit HIV at very low rates, transmission can be attributed to a combination of these factors (28.9). Service needs are greatest for MSM; their number with unsuppressed viral load engaging in unprotected discordant sex was 8 times the number of male heterosexuals and more than twice the number of female heterosexuals with high-risk transmission potential. While all persons with HIV need optimal care, treatment as prevention is most relevant when risk behavior is present among persons with unsuppressed HIV viral load.

Risk patterns preceding diagnosis among newly HIV-diagnosed men who have sex with men in New York City

Men who have sex with men (MSM) are at high risk for contracting and transmitting HIV. They are increasingly encouraged to get tested, but understanding of the interplay between HIV testing and risk behavior is limited. One hundred fifty newly HIV-diagnosed (within past 3 months) MSM were recruited from a community clinic in New York City. Participants completed an interview assessing sexual behavior and substance use during the 3 months pre-diagnosis, current depressive symptoms, and prior HIV testing. HIV-related health characteristics at diagnosis were abstracted from medical records. Analyses examined factors associated with unprotected anal intercourse (UAI) in the 3 months pre-diagnosis, and with a negative HIV test in the 12 months pre-diagnosis. The sample was young (mean age=32.5, SD=8.8), ethnically diverse (62% racial/ethnic minority), low-income (71%≤$30,000/year), and educated (48% college/advanced degree). Most (95%) had a prior negative HIV test, 55% within the last 12 months. Significant risk behavior was reported, with 79% reporting UAI. UAI was associated with recent testing and use of substances during sexual behavior. Recent testing was associated with being employed/a student, having had UAI, and higher CD4 count. Implications for future research addressing perceived HIV risk, HIV testing utilization, and risk behavior are discussed.

Transmission of risk-group specific HIV-1 strains among Dutch drug users for more than 20 years and their replacement by nonspecific strains after switching to low-harm drug practices

OBJECTIVES

To characterize HIV-1 epidemiological networks of men having sex with men (MSM) and drug users (DUs) in the Netherlands for >30 years.

DESIGN AND METHODS

Previously, we demonstrated different origin of the HIV-1 epidemics in Dutch MSM and DUs. To achieve the study objectives, risk group-specific genetic markers in the pol gene were examined in 315 participants of the Amsterdam Cohort Studies on HIV/AIDS who were registered as HIV-1 infected in 1981-2011.

RESULTS

Phylogenetic analysis demonstrated circulation of distinct virus strains in the 2 networks, with 98% of viruses of MSM clustering together and apart from strains of 73% DUs. Nine genetic markers that significantly distinguished virus strains specific for DUs were identified, of which 3 were ≥90% conserved. Over the total observation period, only 6% of viruses (4 of MSM and 14 of DUs) clustered with those of the other risk group. Among these sequences, the 3 most conserved genetic markers of that other risk group were 87% conserved.All 4 cases of DU-specific viruses among MSM occurred in 1980s-early 1990s. Viruses nonspecific for DUs were causing new infections among DUs at the rate of 20% till 2002 and replaced DU-specific strains among new infections thereafter, coinciding with switching of DUs to low-harm drug practices.

CONCLUSIONS

Dutch MSM and DUs have remained separate epidemiological networks for decades, despite their geographical and behavioral overlap. Switching to low-harm drug practices among DUs resulted in new infections caused by HIV-1 strains originating from other risk groups.

Highly active antiretroviral therapy is associated with decreased incidence of sexually transmitted diseases in a Taiwanese HIV-positive population

There are reports of increased sexual risk behaviors in the HIV-positive population since the introduction of highly active antiretroviral therapy (HAART). Little is known about the effects of the case management (CM) program and HAART on sexually transmitted diseases (STDs) in Taiwan. HIV-positive subjects, who visited the outpatient clinics of Taoyuan General Hospital between 2007 and 2010, were enrolled. A total of 574 subjects and 14,462 person-months were reviewed. Incident STDs occurred in 104 (18.1%) subjects, and the incidence rate was 8.6 (95% confidence interval [CI], 7.1-10.5) per 100 person-years (PY). For men who have sex with men (MSM), heterosexual men and women, and injection drug users (IDU), 19.4 per 100 PY(95% CI, 15.7-24.0), 3.5 per 100 PY (95% CI, 1.4-7.3), and 1.1 per 100 PY (95% CI, 0.4-2.4) of STDs were noted, respectively; (MSM versus IDU and MSM versus heterosexual subjects, p<0.000001; heterosexual subjects versus IDU, p=0.061). Syphilis (59.6%) was the most common STD. Regular CM and no HAART (hazard ratio, 2.58; 95% CI, 1.14-5.84; p=0.02) was significantly associated with STDs in MSM. Though this retrospective study might underestimate the incidence of STDs and not draw the conclusion of causality, we concluded that the CM program and HAART are associated with lower acquisition of STDs in the Taiwanese HIV-positive population.

Resurgence of HIV infection among men who have sex with men in Switzerland: mathematical modelling study

BACKGROUND

New HIV infections in men who have sex with men (MSM) have increased in Switzerland since 2000 despite combination antiretroviral therapy (cART). The objectives of this mathematical modelling study were: to describe the dynamics of the HIV epidemic in MSM in Switzerland using national data; to explore the effects of hypothetical prevention scenarios; and to conduct a multivariate sensitivity analysis.

METHODOLOGY/PRINCIPAL FINDINGS

The model describes HIV transmission, progression and the effects of cART using differential equations. The model was fitted to Swiss HIV and AIDS surveillance data and twelve unknown parameters were estimated. Predicted numbers of diagnosed HIV infections and AIDS cases fitted the observed data well. By the end of 2010, an estimated 13.5% (95% CI 12.5, 14.6%) of all HIV-infected MSM were undiagnosed and accounted for 81.8% (95% CI 81.1, 82.4%) of new HIV infections. The transmission rate was at its lowest from 1995-1999, with a nadir of 46 incident HIV infections in 1999, but increased from 2000. The estimated number of new infections continued to increase to more than 250 in 2010, although the reproduction number was still below the epidemic threshold. Prevention scenarios included temporary reductions in risk behaviour, annual test and treat, and reduction in risk behaviour to levels observed earlier in the epidemic. These led to predicted reductions in new infections from 2 to 26% by 2020. Parameters related to disease progression and relative infectiousness at different HIV stages had the greatest influence on estimates of the net transmission rate.

CONCLUSIONS/SIGNIFICANCE

The model outputs suggest that the increase in HIV transmission amongst MSM in Switzerland is the result of continuing risky sexual behaviour, particularly by those unaware of their infection status. Long term reductions in the incidence of HIV infection in MSM in Switzerland will require increased and sustained uptake of effective interventions.

Increasing sexual risk behaviour among Dutch men who have sex with men: mathematical models versus prospective cohort data

Changes in risk behaviour among men who have sex with men (MSM) in the Netherlands were estimated by fitting a mathematical model to annual HIV and AIDS diagnoses in the period 1980-2009 and, independently, from rates of unprotected anal intercourse in a prospective cohort study in Amsterdam. The agreement between the two approaches was very good, confirming that in terms of incidence, increasing risk behaviour between MSM is offsetting benefits offered by enhanced testing and treatment.

Behavioral factors in assessing impact of HIV treatment as prevention

The recent NIH HPTN 052 study of using HIV treatment to prevent HIV transmission in serostatus discordant heterosexual partnerships has garnered much attention. In subsequent discussions, however, the topic of HIV-related risk behavior has been nearly absent. Here, we identify the critical roles that HIV-related risk behavior plays in determining the unmet needs, optimal targeting, and ultimate impact of treatment as prevention. We describe the size of the population at risk of HIV and three subgroups of persons living with HIV (PLWH) based on awareness of serostatus and risk behavior, and the corresponding HIV transmission rates to seronegative partners. For each of the subgroups of PLWH, we identify which approach is most relevant ("testing and linkage to care," "treatment as prevention," and/or "treatment as clinical care"). We observe that the impact of "treatment as prevention" on HIV incidence will depend heavily on which subgroup of PLWH is targeted for services.

Cost savings associated with testing of antibodies, antigens, and nucleic acids for diagnosis of acute HIV infection

Efforts to identify all persons infected with HIV in the United States are driven by the hope that early diagnosis will lower risk behaviors and decrease HIV transmission. Identification of HIV-infected people earlier in the course of their infection with HIV antigen/antibody (Ag/Ab) combination assays (4th-generation HIV assays) should help achieve this goal. We compared HIV RNA nucleic acid test (NAT) results to the results of a 4th-generation Ag/Ab assay (Architect HIV Ag/Ab Combo [HIV Combo] assay; Abbott Diagnostics) in 2,744 HIV antibody-negative samples. Fourteen people with acute HIV infection (HIV antibody negative/NAT positive) were identified; the HIV Combo assay detected nine of these individuals and was falsely negative in the remaining five. All five persons missed by the HIV Combo assay were in the stage of exponential increase in plasma virus associated with acute HIV infection (3, 7, 20, 35, 48). In contrast, most acutely infected persons detected by the HIV Combo assay demonstrated either a plateauing or decreasing plasma viral load. The HIV Combo assay also classified as positive five other samples which were negative by NAT. Taken together, the HIV Combo assay had a sensitivity of 73.7% and a specificity of 99.8%. Using published data, we estimated secondary transmission events had HIV infection in these five individuals remained undiagnosed. Screening of our population with NAT cost more than screening with the HIV Combo assay but achieved new diagnoses that we predict resulted in health care savings that far exceed screening costs. These findings support the use of more sensitive assays, like NAT, in HIV screening of populations with a high prevalence of acute HIV infection.