Anal sex role segregation and versatility among men who have sex with men: EXPLORE Study

Identifying patterns of sexual behaviors and PrEP uptake characteristics among MSM who were eligible for PrEP: A national cross-section study

Men who have sex with men (MSM) are at a high risk of HIV infection and should be offered effective preventive measures, such as pre-exposure prophylaxis (PrEP). However, PrEP uptake among eligible MSM was not as high as desired. Diverse research findings on how risky sexual behaviors affect PrEP uptake highlight the necessity for a comprehensive investigation. Understanding the interconnectedness of different sexual behaviors is crucial for evaluating their impact on PrEP uptake among eligible MSM. Using a proportional sampling method, we recruited 5877 MSM aged 16 years and above in mainland China according to PrEP eligibility criteria. Through latent class analysis (LCA), three distinct sexual behavior patterns were identified among eligible MSM. Demographic variances and PrEP uptake among the three distinct sexual behavior patterns were examined using chi-squared tests and multinomial logistic regression. LCA revealed three patterns: low-risk (4,815 MSM), medium-risk (516 MSM), and high-risk (546 MSM). MSM aged 25 years or older with a monthly income of ≥¥8,000 were more likely to be in the medium-risk group. Those from areas with high HIV prevalence and engaging as "top" in anal sex were more likely to be in the medium- and high-risk groups. The medium- and high-risk groups had a higher willingness, uptake, and adherence rates for PrEP than the low-risk group. LCA is effective in identifying diverse sexual behavior patterns among MSM, aiding targeted interventions to enhance PrEP uptake. Addressing demographic variations and tailoring interventions for specific risk groups are crucial for promoting PrEP dissemination and reducing HIV infection risk in eligible MSM.

Why does age at HIV infection correlate with set point viral load? An evolutionary hypothesis

BACKGROUND

Set-point viral load (SPVL) correlates with the age at which people acquire HIV. Although immunosenescence may seem like a parsimonious explanation for this, it does not easily explain the observation that the relationship between age and SPVL attenuates when accounting for source partner SPVL. Here we propose an alternative explanation that encompasses this latter finding: that decreasing risk of acquisition with older age generates a selection bottleneck that selects for more virulent strains with age.

METHODS

We adapted a previously published model of HIV transmission and evolution (EvoNetHIV), parameterized here for men who have sex with men (MSM). We conducted a series of simulation experiments that vary seven behavioral or clinical parameters that affect exposure risk as people age. We conducted regressions to determine the mean increase in SPVL per 10-year increase in seroconversion age, with and without source SPVL in the model.

RESULTS

All runs generated significant relationships between seroconversion age and SPVL when not including source SPVL. All saw attenuated relationships, most to near 0, with source SPVL included. Four of our behavioral measures (relational duration, age-related homophily, coital frequency, and mean age at relationship formation) had clear effects on this relationship, all in the hypothesized direction. Combining multiple forms of behavioral heterogeneity yielded an increase of 0.056 log10 copies/mL SPVL per 10-year increase in seroconversion age, nearly as large as that seen in two empirical studies of age-SPVL correlations in MSM.

CONCLUSION

The higher virulence of HIV among those infected later in life may be partly explained by a combination of selective bottlenecks and behavioral heterogeneity by age. Variation in the strength of this effect across populations may be in part due to different behavioral, epidemiological and clinical conditions, and not require assumptions about differences in patterns of immunosenescence among populations.

Identity and Relational Factors Associated with Sexual Role and Positioning for Anal Sex among Colombian Sexual Minority Men

This study aimed to identify Top, Bottom, and Versatile sexual role identities and anal sex behavior profiles using latent class analysis in a sample of 942 sexual minority men living in Bogotá. A Versatile-insertive and receptive class (52.2%) was the most prevalent of the four resulting classes, whereas the least common was a class (1.7%) that did not use labels and had a low probability of anal sex. We examined whether identity and relational factors (i.e., sexual orientation, LGBT collective identity, and partner type) were associated with profiles. Gay identity was associated with versatile and receptive classes and bisexual identity was associated with insertive and versatile classes. LGBT collective identity was associated with the class characterized by Bottom identity and receptive positioning. Partner type was not associated with class membership, but versatile behaviors were more common among encounters with a main partner. Models using data at different timescales offered consistent patterns of behavior between the last encounter and the past three months, though the versatile class in the three-month model split into two classes based on frequency of versatile positioning. Findings highlight the relationship between sexual identity and positioning and can inform interventions for sexual health education and identity development.

Sexual Role Identity and Anal Sex Positioning among Brazilian, Colombian, and Dominican Immigrant Sexual Minority Men

Sexual role identities for anal sex and anal sex positionings are often conflated in research. This study aimed to identify profiles of sexual minority men based on sexual role identity and anal sex positioning and determine correlates of these profiles, including individual (i.e., HIV-status identity, condom use, partner type, sexual orientation) and cultural (i.e., same-race partnering, country of birth, acculturation) factors. A sample of Brazilian, Colombian, and Dominican immigrant sexual minority men (n = 480) living in New York City were surveyed about identity and positioning at the two most recent encounters. Individual and cultural factors were examined as correlates of profiles identified through latent class analysis. Four latent classes were identified: No Labels (12%), Receptive Bottoms (16%), Insertive Tops (23%), Insertive and Receptive Versatiles (49%). We found a concordance rate of ~70% between identity and behavior. A proportion (12%) of behaviorally versatile men chose not to use sexual role labels. Living with HIV was associated with receptive and versatile classes, sex with main partners was associated with versatility, and sexual orientation differed across classes. Identity and behavior should not be used interchangeably in research or applied domains, particularly given the complexities of versatility and men who prefer to not use labels.

Inter-partner Agreement of Condom Use and Sexual Positioning in Male Couples

Accurate, reliable self-reports of sexual behavior are a crucial component of valid HIV risk-estimation and behavioral intervention evaluation, yet this data's reliability remains understudied. The goal of this study was to describe interpartner agreement on recent receptive anal intercourse (AI) and condomless receptive AI frequencies, among a sample of male couples. We quantified interpartner agreement on self-reported receptive AI and condomless receptive AI (absolute and relative to AI frequency), and position and condom use during a couple's most recent AI, using cross-sectional data from male partners (US, 2016-2017; N = 718 individuals). Proportional and statistical agreement (intraclass correlation coefficients (ICC), kappa (k)) were assessed. Observed agreement for receptive AI frequency was 49.44% (ICC (95% CI): 0.82(0.79, 0.84)) and for relative receptive frequency, 59.05% (ICC: 0.96 (0.85, 0.96). Agreement on condomless receptive AI was 90.21% (ICC: 0.78 (0.75, 0.82), and for relative condomless receptive AI, 91.15% (ICC: 0.80 (0.77, 0.83). Most recent AI position agreement was 89.42% (k (95% CI): 0.84 (0.80, 0.88)), and condom use, 98.89% (k: 0.82 (0.87, 0.98)). Observed agreement was higher among those who reported consistent positioning and condom use. Further research on self-reported sexual behavior data is needed to improve research validity and intervention effectiveness.

Getting Clear About Rectal Douching Among Men Who Have Sex With Men

Receptive anal sex is the primary means through which HIV is transmitted among men who have sex with men (MSM). Recently, researchers have begun investigating the role that rectal douching may play in amplifying risk for transmission. Yet, there is limited research on the frequency with which MSM douche, the products they use, and how this may vary across sociodemographic characteristics. A U.S. national sample of 4745 MSM completed an online survey that assessed their douching behavior, demographic characteristics, sexual behavior, and their anal sexual positioning (i.e., top, bottom, versatile). Nearly two-thirds (65.8%) had engaged in rectal douching in the last three months. Among those who douched, water was commonly reported (84.2%) and 20.1% reported using commercial enemas (e.g., Fleet), as well as water and soap (15.0%)-numbers exceed 100% as some participants reported more than one. Men who douched reported significantly more receptive and insertive condomless anal sex acts in the prior 3 months. One-in-ten men reported rectal bleeding after douching. Compared to HIV-negative participants who had not taken PrEP, participants had higher odds of reporting douching in the past 3 months if they were HIV-negative and currently on PrEP (AOR = 1.82), HIV-negative and previously used PrEP (AOR = 1.58), and HIV-positive (AOR = 1.83). Douching was common in this sample. Given that douching could amplify risk for HIV transmission, healthcare providers should discuss douching safety with their patients, with a focus on harm reduction (e.g., reduce risk of bleeding, as opposed to abstinence from douching).

Condom-Associated Erectile Function, But Not Other Domains of Sexual Functioning, Predicts Condomless Insertive Anal Sex Among Young Men Who Have Sex with Men

Condoms effectively prevent against HIV, especially when used in conjunction with biomedical strategies such as PrEP and viral suppression. However, consistent use of condoms in the real world has been a continual health promotion challenge, even among populations at highest risk, such as young men who have sex with men (YMSM). Inconsistent condom use may be related to poor sexual functioning, but limited research exists. The analytic sample comprised 688 racially diverse YMSM aged 16-29 (M = 22.9 years) living in Chicago, IL (19.2% living with HIV). Using multivariable logistic regression, we examined longitudinal associations between condom-associated sexual functioning (erectile function, orgasm satisfaction, global satisfaction, and anal discomfort) and condomless insertive anal sex (CIAS) and condomless receptive anal sex (CRAS) 6 months later. CIAS at Time 2 was associated with condom-associated erectile function at the bivariate and multivariable levels, even after controlling for CIAS at Time 1 (p < .05). Condom-associated erectile function, orgasm satisfaction, and global satisfaction predicted Time 2 CRAS in bivariate models, but none remained significant in the multivariable models. Age, having had a serious partner in the past 6 months, and HIV/PrEP status at Time 2 were significant predictors of CIAS/CRAS in some but not all models. Future interventions to improve consistent condom use should specifically highlight information and skills on how to use condoms within real-world contexts rather than from a clinical perspective. Our results also support the importance of biomedical strategies for those who have continued problems with sexual functioning when using condoms.

Longitudinal Event-Level Analysis of Gay and Bisexual Men's Anal Sex Versatility: Behavior, Roles, and Substance Use

Gay and bisexual Men Who Have Sex with Men (GBM) are sexually unique in that they can practice penile-anal sex versatility, i.e. engage in insertive and receptive anal sex. Individual-level versatility is extensively researched both as a sexual behavior linked to HIV/STI transmission, and as a GBM identity that can change over time. However, there is a dearth of research on event-level versatility (ELV), defined as taking the receptive and insertive role in the same sexual encounter. We analyzed event-level data from 644 GBM in the Momentum Health Study from February 2012-February 2017 to identify factors associated with ELV prevalence, the relationship between ELV and anal sex role preference, and sero-adaptive and sexualized drug use strategies. Univariate analysis revealed ELV prevalence rates between 15% and 20%. A multivariate generalized linear mixed model indicated ELV significantly (p < .05) associated with versatile role preference and condomless sex. However, the majority of ELV came from GBM reporting insertive or receptive role preferences, and there was significantly higher condom use among sero-discordant partners, indicating sero-adaptation. Multivariate log-linear modeling identified multiple polysubstance combinations significantly associated with ELV. Results provide insights into GBM sexual behavior and constitute empirical data useful for future HIV/STI transmission pattern modeling.

HIV incidence among gay men and other men who have sex with men in 2020: where is the epidemic heading?

The goal to effectively prevent new HIV infections among gay, bisexual, and other men who have sex with men (MSM) is more challenging now than ever before. Despite declines in the late 1990s and early 2000s, HIV incidence among MSM is now increasing in many low- and high-income settings including the US, with young, adolescent, and racial/ethnic minority MSM being among those at highest risk. Potentiating HIV risks across all settings are individual-, network-, and structural-level factors such as stigma and lack of access to pre-exposure prophylaxis (PrEP) and antiretroviral treatment as prevention. To make a sustained impact on the epidemic, a concerted effort must integrate all evidence-based interventions that will most proximally decrease HIV acquisition and transmission risks, together with structural interventions that will support improved coverage and retention in care. Universal HIV treatment, increased access to HIV testing, and daily oral PrEP have emerged as integral to the prevention of HIV transmission, and such efforts should be immediately expanded for MSM and other populations disproportionately affected by HIV. Respect for human rights and efforts to combat stigma and improve access to prevention services are needed to change the trajectory of the HIV pandemic among MSM.

Latent Classes of Sexual Positioning Practices and Sexual Risk Among Men Who Have Sex with Men in Paris, France

HIV/STI risk varies by sexual positioning practices; however, limited data have characterized the behavioral profiles of men who have sex with men (MSM) in France. This study used latent class analysis (LCA) to explore sexual risk profiles among MSM in Paris, France. LCA was used to classify sexual positioning and serosorting profiles among MSM in Paris (n = 496). Age, HIV status, relationship status, substance use, group sex, and PrEP history were used in a multinomial regression model predicting class membership. Three latent classes were identified: majority top/serosorters, versatile/low partners, and majority bottom/some serosorters. Majority top/serosorters had the highest probability of condomless serosorting; majority bottom/some serosorters had the highest mean number of partners (~ 12 partners) for condomless receptive anal intercourse. HIV-positive MSM were more likely to be classified as majority bottom/some serosorters than versatile/low partners (AOR 7.61; 95% CI 2.28, 25.3). Findings support the need for tailored and targeted interventions for highest-risk individuals.

Exploring and Adapting a Conceptual Model of Sexual Positioning Practices and Sexual Risk Among HIV-Negative Black Men Who Have Sex With Men

Estimates show a 50% lifetime human immunodeficiency virus (HIV) risk among Black men who have sex with men (BMSM) in the United States(U.S.). Studying the dynamics of sexual positioning practices among BMSM could provide insights into the disparities observed among U.S. groups of men who have sex with men (MSM). This study explored sexual positioning dynamics among HIV-negative BMSM and how they aligned with a theoretical model of sexual positioning and HIV/sexually transmitted infection (STI) risk among MSM. In-depth qualitative interviews were conducted with 29 HIV-negative BMSM between ages 25 and 35 in Los Angeles. Comments related to sexual behaviors were reviewed for relevance regarding oral or anal sexual positioning practices. Data presented represent the range of themes related to decision making regarding sexual positioning. Personal preference, partner attraction, HIV avoidance, and feeling obligated to practice partner preferences influenced sexual positioning. Drug use also affected decision making and was sometimes preferred in order to practice receptive anal intercourse. These variables build on the conceptual model of sexual positioning practices and sexual risk, and add understanding to the relationship between preferences, practices, and risk management. Future research on risk among HIV-negative BMSM should quantify the relative impact of personal preferences, partner attraction, partner type, compromise, and substance use on sexual positioning practices and risk.

Cross-sectional study of urethral exposures at last sexual episode associated with non-gonococcal urethritis among STD clinic patients

OBJECTIVE

Although Chlamydia trachomatis (CT) and Mycoplasma genitalium (MG) are major causes of non-gonococcal urethritis (NGU), up to 50% of cases are of unknown aetiology. We sought to identify urethral exposures at last sexual episode associated with NGU and non-CT/non-MG NGU to identify anatomical sites from which aetiologically relevant micro-organisms may be acquired.

METHODS

We enrolled STD clinic patients with and without NGU assigned male sex at birth and age ≥16 into a cross-sectional study. NGU was urethral symptoms or visible discharge plus ≥5 polymorphonuclear leucocytes without Neisseria gonorrhoeae. Urine was tested for CT and MG (Aptima). We used logistic regression to estimate the association between urethral exposures at last sex and NGU separately among cisgender men and transgender women who have sex with men (MSM/TGWSM) and cisgender men who have sex with women (MSW).

RESULTS

Between 8 August 2014 and 1 November 2017, we enrolled 432 patients, including 183 MSM/TGWSM (118 NGU+, 65 NGU-) and 249 MSW (126 NGU+, 123 NGU-). The mean age was 34; 59% were white. CT and MG were detected in 72 (30%) and 49 (20%) NGU+ participants, respectively. Compared with MSM/TGWSM reporting only non-urethral exposures at last sex, those reporting insertive anal intercourse (IAI) only (adjusted OR (AOR)=4.46, 95% CI 1.09 to 18.19) and IAI with insertive oral sex (IOS) (AOR=7.88, 95% CI 2.67 to 23.26) had higher odds of NGU. MSM/TGWSM reporting IOS only had no significant increased odds (AOR=1.67, 95% CI 0.58 to 4.85). Compared with MSW whose only urethral exposure at last sex was vaginal sex (VS), MSW reporting IOS and VS had similar odds of NGU (OR=0.84, 95% CI 0.50 to 1.41). The results were similar for non-CT/non-MG NGU.

CONCLUSIONS

Among MSM/TGWSM, IAI may lead to transmission of yet-unidentified rectal micro-organisms that cause non-CT/non-MG NGU, in addition to transmission of known pathogens. Sites of urethral exposure appear less important for understanding NGU risk among MSW due to minimal variation in behaviour.

Improving the impact of HIV pre-exposure prophylaxis implementation in small urban centers among men who have sex with men: An agent-based modelling study

Objectives

Identifying prescribing strategies that improve the efficiency of PrEP should increase its impact at the population level. This study identifies PrEP allocation criteria that most effectively reduce 10-year HIV incidence by 25%, in accordance with the US National HIV/AIDS Strategy’s goal for the proportionate reduction in new diagnoses.

Methods

We used a discrete-time stochastic agent-based model to simulate several PrEP engagement strategies. The model represented MSM aged 15–74 in Rhode Island and was calibrated to statewide prevalence from 2009–2014. We simulated HIV transmission in the absence of PrEP and compared the following PrEP engagement scenarios: 1) allocation to the current patient population; 2) random allocation; 3) allocation to MSM with greater than 5 sexual partners in one year; 4) allocation to MSM with greater than 10 sexual partners in one year.

For each scenario and coverage level we estimated the number and proportion of infections averted and the person-years on PrEP per averted infection.

Results

In 2014, HIV prevalence before PrEP implementation was between 4% and 5%. In the No PrEP scenario 826 new infections (95% simulation limits [SL]: 711, 955) occurred over 10 years, with an incidence rate of 3.51 per 1000 person-years (95% SL: 3.00, 4.08). Prevalence rose to 7.4% (95% SL: 6.7, 8.1). None of the PrEP scenarios reduced new HIV infections by 25% while covering less than 15% of the HIV-uninfected population. At 15% coverage, allocating PrEP to the current patient population, MSM with greater than 5 sexual partners in a year, and MSM with greater than 10 partners reduced new infections by at least 25%, requiring 161 (95% SL: 115, 289), 150 (95% SL: 107, 252), and 128 (95% SL: 100, 184) person-years on PrEP per averted infection, respectively.

Conclusions

Engaging MSM with high numbers of sexual partners would improve the population-level impact and efficiency of PrEP in settings where PrEP coverage remains low. However, the sustained population-level PrEP coverage needed to reduce new infections by 25% is substantially higher than current levels of PrEP uptake.

Awareness of Prevention Strategies and Willingness to Use Preexposure Prophylaxis in Brazilian Men Who Have Sex With Men Using Apps for Sexual Encounters: Online Cross-Sectional Study

Background

Geosocial networking (GSN) smartphone apps are becoming the main venue for sexual encounters among Brazilian men who have sex with men (MSM). To address the increased HIV incidence in this population, preexposure prophylaxis (PrEP) was recently implemented in the Brazilian public health system in the context of combined HIV prevention.

Objective

This study aimed to describe the characteristics of MSM using GSN apps for sexual encounters, their awareness of prevention strategies, and willingness to use PrEP.

Methods

This study was an online cross-sectional study conducted in 10 Brazilian state capitals from July 1 to July 31, 2016. The questionnaire was programmed on SurveyGizmo and advertised in two GSN apps used by MSM to find sexual partners (Hornet and Grindr). Inclusion criteria were >18 years of age, cisgender men, with an HIV-negative status. Eligible individuals answered questions on: demographics; behavior; and knowledge, preferences, and willingness to use PrEP, nonoccupational postexposure prophylaxis (nPEP), HIV self-testing (HIVST), and condoms. Logistic regression modeling was performed to assess the factors associated with daily oral PrEP willingness.

Results

During the study period, 8885 individuals provided consent and started the questionnaire. Of these, 23.05% (2048/8885) were ineligible, 6837 (6837/8885, 76.94%) initiated, and 5065 (5065/8885, 57.00%) completed the entire questionnaire and were included in the present analysis. Median age was 30 years (interquartile range: 25-36), most self-declared as MSM (4991/5065, 98.54%), white (3194/5065, 63.06%), middle income (2148/5065, 42.41%), and had 12 or more years of schooling (3106/5062, 61.36%). The majority of MSM (3363/5064, 66.41%) scored >10 points (high risk) on The HIV Incidence Risk for MSM Scale, but only 21.39% (1083/5064) had a low perceived likelihood of getting HIV in the next year. Daily use of apps for sex was reported by 35.58% (1798/5054). Most MSM (4327/5065, 85.43%) reported testing for HIV at least once in their lifetime and 9.16% (464/5065) used nPEP in the previous year. PrEP, nPEP, and HIVST awareness was reported by 57.89% (2932/5065), 57.39% (2907/5065), and 26.57% (1346/5065) of participants, respectively. Half of all respondents (2653/5065, 52.38%) were willing to use daily oral PrEP, and this finding was associated with higher numbers of male sexual partners (adjusted odds ratio [AOR] 1.26, 95% CI 1.09-1.47), condomless receptive anal intercourse (AOR 1.27, 95% CI 1.12-1.44), sex with HIV-positive partner versus no HIV-positive partner (one HIV-positive partner: AOR 1.36, 95% CI 1.11-1.67), daily use of apps for sexual encounters (AOR 1.48, 95% CI 1.17-1.87), high and unknown perceived likelihood of getting HIV in the next year (AOR 1.72, 95% CI 1.47-2.02 and AOR 1.39, 95% CI 1.13-1.70), sexually transmitted infection diagnosis (AOR 1.25, 95% CI 1.03-1.51), stimulant use (AOR 1.24, 95% CI 1.07-1.43), PrEP awareness (AOR 1.48, 95% CI 1.30-1.70), and unwillingness to use condoms (AOR 1.16, 95% CI 1.00-1.33).

Conclusions

Our results evidenced high-risk scores in the studied population, suggesting the importance of PrEP use. Those individuals presenting risky sexual behaviors were more willing to use PrEP. Nonetheless, only 58% (2932/5065) of individuals had heard about this prevention strategy. Efforts to increase awareness of new prevention strategies are needed, and mobile health tools are a promising strategy to reach MSM.

Sexual Roles, Risk Sexual Behaviours, and HIV Prevalence among Men who Have Sex with Men Seeking HIV Testing in Changsha, China

BACKGROUND

HIV infection is prevalent among men who have sex with men (MSM), and sexual roles may be important factors related to it. This study aims to describe the sexual roles, risky sexual behaviors and HIV prevalence among MSM, and to determine associated factors for HIV prevalence.

METHODS

A convenient sampling method was used to recruit participants in a non-government organization in Changsha, China. The participants were asked to complete a 38-item self-administered questionnaire regarding demographic characteristics and risky sexual behaviours before collecting blood samples for HIV testing. Chi-square tests and logistic regression analysis were conducted with the Statistical Package for the Social Sciences Version 18.0 and other indexes were statistically described.

RESULTS

A total of 601 MSMs who came to a local non-government organization for voluntary counseling and testing completed a pencil-and-paper survey and were tested for HIV. The overall HIV prevalence of this sample was 13.3%, and that of the bottoms (16.3%) was similar to the versatiles (15.9%) but higher than the tops (6.1%). Bivariate analyses showed that there were significant differences in age, marital status, monthly income, sexual orientation, age at first sex, sex of the first sex partner, sex with a woman in the last 6 months, oral sex with a man in the last 6 months and role of oral sex among 3 subgroups of MSM (p < 0.05). Multivariate analyses indicated that MSMs who played the role of either the bottoms or the versatiles were more likely to be HIV positive than the tops. While MSMs who used condoms in anal sex in the last 6 months, had sex with a woman in the last 6 months or had oral sex with a man in the last 6 months were less likely to be HIV positive.

CONCLUSION

Different sexual roles are associated with high-risk sexual behaviors among MSMs and their HIV infection status. Further research should target preventive interventions, and improve the effectiveness of the intervention according to the characteristics of the subgroups to reduce the HIV transmission among Chinese MSM.

Brief Report: Rethinking Data Collection for HIV Prevention Trials

There is a strong push to conduct large-scale randomized controlled study designs in HIV prevention studies. In these randomized controlled studies, the primary research objective is typically to determine the treatment effect based on some biological outcome (eg, HIV infection). But many unused self-reported outcomes are also being collected. We illustrate the extent of this problem using the EXPLORE data as an example.

Engagement of Gay Men and Other Men Who Have Sex with Men (MSM) in the Response to HIV: A Critical Step in Achieving an AIDS-Free Generation

Men who have sex with men (MSM) continue to be at elevated risk for HIV acquisition and transmission secondary to biological and behavioral characteristics, social and sexual network characteristics, community environmental factors, and structural factors. HIV incidence rates remain high among MSM in both low- and high-income settings, and in both concentrated and more generalized HIV epidemic settings. While data quality tends to be poorer, the best estimates collectively suggest that MSM have up to 20 times the odds of living with HIV as compared to other reproductive aged adults across low- and middle-income countries. Recent prevention strategies to lower biological HIV transmission and acquisition risks, including the early use of antiretrovirals to decrease infectiousness for those living with HIV, and pre-exposure prophylaxis for those at significant risk of HIV acquisition, have demonstrated the potential to change the trajectory of the HIV epidemics among MSM. However, the coverage and effectiveness of these approaches is limited by structural factors including the punitive legal frameworks and institutional discrimination that contribute to limited uptake, challenges to adherence, and suboptimal health-seeking behaviors among MSM. More intensive efforts will be required to reach MSM who do not currently have access to relevant and effective prevention and treatment services or elect not to access these services given enacted and/or perceived stigma. Respect for human rights, including efforts to aggressively confront and combat the forms of stigma that are preventing us from achieving an AIDS-Free generation, are needed for all people including gay men and other MSM.

How Different are Men Who Do Not Know Their HIV Status from Those Who Do? Results from an U.S. Online Study of Gay and Bisexual Men

We compared self-described HIV-positive (31.6 %, n = 445), HIV-negative (56.8 %, n = 801), and HIV-unknown (11.6 %, n = 164) gay and bisexual men on sociodemographic and behavioral characteristics. Participants from across the U.S. were enrolled via a popular sexual networking website to complete an online survey. In total, 44.8 % of HIV-negative and HIV-unknown men said they had not been tested for HIV in the CDC-recommended last 6 months. HIV-unknown men significantly differed from HIV-negative and HIV-positive men in sexual behavior and HIV status disclosure patterns. HIV-unknown men were more willing than HIV-negative men to take PrEP; however, HIV-unknown men were significantly less likely than others to have health insurance or a primary care provider. Given the observed differences, researchers should consider analyzing men who are HIV-unknown distinctly from HIV-negative and HIV-positive men.

Lower HIV Risk Among Circumcised Men Who Have Sex With Men in China: Interaction With Anal Sex Role in a Cross-Sectional Study

BACKGROUND

Voluntary medical male circumcision reduces the risk of HIV heterosexual transmission in men, but its effect on male-to-male sexual transmission is uncertain.

METHODS

Circumcision status of men who have sex with men (MSM) in China was evaluated by genital examination and self-report; anal sexual role was assessed by questionnaire interview. Serostatus for HIV and syphilis was confirmed.

RESULTS

Among 1155 participants (242 were seropositive and 913 with unknown HIV status at enrollment), the circumcision rate by self-report (10.4%) was higher than confirmed by genital examination (8.2%). Male circumcision (by examination) was associated with 47% lower odds of being HIV seropositive [adjusted odds ratio (aOR): 0.53; 95% confidence interval (CI): 0.27 to 1.02] after adjusting for demographic covariates, number of lifetime male sexual partners, and anal sex role. Among MSM who predominantly practiced insertive anal sex, circumcised men had 62% lower odds of HIV infection than those who were uncircumcised (aOR: 0.38; 95% CI: 0.09 to 1.64). Among those whose anal sex position was predominantly receptive or versatile, circumcised men have 46% lower odds of HIV infection than did men who were not circumcised (aOR: 0.54; 95% CI: 0.25 to 1.14). Compared to uncircumcised men reporting versatile or predominantly receptive anal sex positioning, those who were circumcised and reported practicing insertive sex had an 85% lower risk (aOR: 0.15; 95% CI: 0.04 to 0.65). Circumcision was not associated clearly with lower syphilis risk (aOR: 0.91; 95% CI: 0.51 to 1.61).

CONCLUSIONS

Circumcised MSM were less likely to have acquired HIV, most pronounced among men predominantly practicing insertive anal intercourse. A clinical trial is needed.

Gender Expression and Risk of HIV Infection Among Black South African Men Who Have Sex with Men

To explore demographic, behavioral and psychosocial risk factors for HIV infection in South African MSM we recruited 480 MSM (aged 18 and 44 years) using respondent-driven sampling. Data were collected through individual computer-assisted face-to-face interviews. Participants were tested for HIV. RDS-adjusted HIV prevalence is 30.1 % (unadjusted 35.6 %). Few participants had ever engaged in both receptive and insertive anal sex; sex with women was frequently reported. Independent demographic and behavioral correlates of HIV infection include age, education, number of male sexual partners, ever having been forced to have sex, and ever having engaged in transactional sex; engagement in sex with women was a protective factor. Psychosocial risk factors independently associated with HIV infection were feminine identification, internalized homophobia, and hazardous drinking. Our findings confirm what has been found in other studies, but also suggest that the dynamics and context of sexual transmission among MSM in South Africa differ from those among MSM in Western countries.

Identifying risk: a comparison of risk between heterosexual-identifying bisexual men and other bisexual men in Vientiane, Laos

Men who have sex with men are a priority population for HIV control in Laos, but encompass men diverse in sexual orientation, gender identification, and behavior. Behaviorally bisexual men and their sexual partners were recruited in Vientiane, Laos, in 2010 using modified snowball sampling. Heterosexual-identifying bisexual men identified as exclusively/predominantly heterosexual and other bisexual men identified as bisexual or predominantly/exclusively homosexual. Sixty (68%) heterosexual-identifying and 38 (32%) other bisexual men were recruited; the median number of sex partners in the past year was eight and seven, respectively. Consistent condom use was low with regular (7%) and casual (35%) partners and did not differ by identity. More heterosexual-identifying (53%) than other bisexual (29%) men reported weekly alcohol consumption. Twelve (20%) heterosexual-identifying and 15 (54%) other bisexual men correctly answered all HIV-knowledge questions. High-risk behaviors for STI and HIV transmission were common. Targeted HIV prevention initiatives are needed, particularly to reach heterosexual-identifying bisexual men.

Risk factors for rectal lymphogranuloma venereum in gay men: results of a multicentre case-control study in the U.K

Objective

To identify risk factors for rectal lymphogranuloma venereum (rLGV) in men who have sex with men (MSM).

Design

A case-control study at 6 UK hospitals compared MSM with rLGV (cases) with rLGV-negative controls: MSM without potential rLGV symptoms (CGa) and separately, MSM with such symptoms (CGs).

Methods

Between 2008 and 2010, there were 90 rLGV cases, 74 CGa and 69 CGs recruited. Lifestyles and sexual behaviours in the previous 3 months were reported using internet-based computer-assisted self-interviews. Logistic regression was used to investigate factors associated with rLGV.

Results

Cases were significantly more likely to be HIV-positive (89%) compared with CGa (46%) and CGs (64%). Independent behavioural risks for rLGV were: unprotected receptive anal intercourse (adjusted OR (AOR)10.7, 95% CI 3.5 to 32.8), fisting another (AOR=6.7, CI 1.8 to 25.3), sex under the influence of gamma-hydroxybutyrate (AOR=3.1, CI 1.3 to 7.4) and anonymous sexual contacts (AOR=2.7, CI 1.2 to 6.3), compared with CGa; unprotected insertive anal intercourse (AOR=4.7, CI 2.0 to 10.9) and rectal douching (AOR=2.9 CI 1.3 to 6.6), compared with CGs. An incubation period from exposure to symptoms of 30 days was indicated.

Conclusions

Unprotected receptive anal intercourse is a key risk factor for rectal LGV with the likelihood that rectal-to-rectal transmission is facilitated where insertive anal sex also occurs. The association between HIV and rLGV appears linked to HIV-positive men seeking unprotected sex with others with the same HIV status, sexual and drug interests. Such men should be targeted for frequent STI screening and interventions to minimise associated risks.