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

Low Self-Perceived Need for PrEP and Behavioral Indications of MSM Who Recently Refused Daily PrEP: A Mixed Methods Study in Three U.S. Cities

Pre-exposure prophylaxis (PrEP) reduces sexual risk for HIV transmission by 99% when used appropriately, but remains underutilized among gay, bisexual, and other men who have sex with men (MSM). In this mixed-method study, we describe reasons for PrEP refusal associated with low self-perceived need for PrEP among MSM who recently declined daily oral PrEP when offered by a provider. Data are from a quantitative behavioral survey of MSM (N = 93) living in Atlanta, Chicago, and Raleigh-Durham, who also either responded to an in-depth interview (n = 51) or participated in one of 12 focus groups (n = 42). Themes of low self-perceived need for PrEP were: low self-perceived risk for HIV acquisition (33% of respondents); confidence in remaining HIV-negative (35%); using condoms (81%); limiting number of partners and choosing partners carefully (48%); asking partners about their HIV status before having sex (45%); engaging in safer sexual positions or oral sex (28%); being in a monogamous relationship or exclusivity with one partner (26%); and regular HIV testing (18%). Low self-perceived risk for HIV acquisition and high confidence in other prevention strategies were important factors related to low self-perceived need in MSM refusing daily oral PrEP when offered. Providers should continue to discuss the benefits of PrEP as a safe and highly effective option for HIV prevention.

Using a Geosocial Networking App to Investigate New HIV Infections and Related Risk Factors Among Student and Nonstudent Men Who Have Sex With Men in Chengdu, China: Open Cohort Study

BACKGROUND

In China, condomless sex among men who have sex with men (MSM) is the primary route of HIV infection in young people. Chengdu is a hotspot for reported HIV cases among young people nationwide. Extensive use of geosocial networking (GSN) smartphone apps has dramatically changed the pattern of sexual behavior among young MSM (YMSM). However, data on HIV incidence and the risk behavior of YMSM using the GSN app are still obscure.

OBJECTIVE

This study aims to analyze and understand the HIV incidence and its risk factors among YMSM using GSN apps in Chengdu, China.

METHODS

An open cohort study was conducted among YMSM aged 18-24 years through a gay GSN smartphone app in Chengdu, China, from July 2018 to December 2020. Every participant completed a web-based questionnaire on sociodemographic characteristics, sexual behaviors, and other related statuses; made a reservation for a web-based HIV testing; and then voluntarily got tested at the designated testing site. At least one additional HIV test was taken via the app during the study period, and participants were evaluated at the end of the study or at the time of HIV seroconversion. By dividing the sum of the observed HIV seroconversions by the observed person-years, HIV incidence was calculated and compared between the student and nonstudent MSM. Univariate and multivariate (Cox proportional hazards regression) analyses were used to discuss the risk factors for new HIV infections.

RESULTS

In the study cohort, 24 seroconversions occurred among 625 YMSM who took at least two HIV tests through the app during the study period, contributing to 505 observed person-years. The HIV incidence rate per 100 person-years was 4.75 (95% CI 2.89-6.61) among all MSM, 3.60 (95% CI 1.27-5.93) among student MSM, and 5.88 (95% CI 2.97-8.79) among nonstudent MSM. In addition, the HIV incidence per 100 person-years was 11.11 (95% CI 4.49-17.73) among those who had resided in the area for 6 months or less and 7.14 (95% CI 1.52-12.77) among those with senior high school or less education. Two or more sexual partners (adjusted hazards ratio [HR] 3.63, 95% CI 1.08-12.23) in the preceding 6 months was a risk factor for new HIV infections. Consistent condom use for anal sex (adjusted HR 0.38, 95% CI 0.16-0.88) and insertive anal sex only (adjusted HR 0.10, 95% CI 0.01-0.75) in the preceding 6 months were protective factors for new HIV infections.

CONCLUSIONS

The rate of new HIV infections among YMSM who actively used GSN smartphone apps was high, especially among migrant nonstudent MSM. Targeted interventions on GSN smartphone apps should be implemented to provide demand-adapted prevention and services to reduce the threat of HIV.

The relevance of communal altruism for sexual minority men in contemporary contexts

There are many reasons why individuals engage in prosocial behavior; communal sexual altruism is based on the notion that some practice safer sex in the interest of promoting the well-being of their community/in-group. Given that definitions of what constitutes "safer sex" have changed with advances in human immunodeficiency virus (HIV) prevention, we investigated the importance of communal sexual altruism (herein "altruism") among urban gay, bisexual, and other sexual minority men (GBM) in the contemporary context. Using a sample of 2449 GBM we examined the association of both safer-sex-related attitudes (e.g., HIV treatment optimism-skepticism) and behaviors (e.g., condomless anal sex [CAS]) with altruism scores. Higher altruism scores were associated with a lower likelihood of CAS and a greater frequency of discussing HIV status with new partners. These findings demonstrate that many GBM are motivated to engage in several kinds of behaviors that improve the well-being of their in-group (i.e., the GBM community).

Sexual Practice Changes Post-HIV Diagnosis Among Men Who Have Sex with Men in the United States: A Systematic Review and Meta-analysis

Men who have sex with men (MSM) often change sexual behaviors following HIV diagnosis. This systematic review examined such changes, including sero-adaptive behaviors (i.e., deliberate safer-sex practices to reduce transmission risk) to better understand the magnitude of their association with HIV diagnosis. We searched four databases (1996-2017) and reviewed references from other systematic reviews. We included studies conducted in the United States that compared sexual behavior among HIV-infected "aware" versus "unaware" MSM. We meta-analytically pooled RRs and associated 95% confidence intervals (CI) using random-effects models, and assessed risk of bias and evidence quality. Twenty studies reported k = 131 effect sizes on sexual practices outcomes, most of which reported changes in unprotected sex (k = 85), and on sex with at-risk partners (k = 76); 11 reported sero-adaptive behaviors. Unprotected anal intercourse with an HIV-uninfected/unknown-status partner was less likely among aware MSM (insertive position: k = 2, RR 0.26, 95% CI 0.17, 0.41; receptive position: k = 2, RR 0.53, 95% CI 0.37, 0.77). Risk of not always serosorting among aware MSM (k = 3) was RR = 0.92 (0.83, 1.02). Existing evidence, although low-quality, suggests that HIV-infected MSM tend to adopt safer sexual practices once aware of their diagnosis. Variation in reporting of outcomes limits their comparability. Sero-adaptive behavior data are sparse.

Men's Sexual Interest in Feminine Trans Individuals across Cultures

Feminine trans individuals (i.e., individuals who were assigned male at birth but who have a feminine gender presentation and identity) are present in many cultures. In some cultures, these individuals identify as (trans) women. Many of these individuals undergo medical treatments to feminize their bodies (e.g., breast augmentation), but most do not undergo vaginoplasties and therefore have penises. In many non-Western cultures, feminine trans individuals identify as a non-binary gender (i.e., neither man, nor woman). Many of these individuals do not surgically augment their bodies. Across cultures, some men express sexual interest in feminine trans individuals. Are manifestations of sexual interest in feminine trans individuals consistent across Western and non-Western cultural settings? Our review suggests that, across cultures, most of these men are also sexually attracted to cisgender individuals. Many are sexually attracted to cisgender women or to cisgender members of both sexes. A small subset is sexually attracted to cisgender men. Men who are sexually interested in feminine trans individuals commonly report being primarily insertive during anal sex. Additionally, they tend to report that their sexual interest in these individuals is motivated by attraction to femininity or to the combination female- and male-typical characteristics.

PrEP in the Context of Other HIV Risk Reduction Strategies Among Men Who Have Sex with Men: Results from the Flash! PrEP in Europe Survey

Combination HIV prevention covers a range of biomedical, behavioral, and socio-structural interventions. Despite the growing availability of pre-exposure prophylaxis (PrEP), it is not always accessible in European Centre for Disease Prevention and Control reporting countries and may not meet the needs of all at-risk populations. Based on the Flash! PrEP in Europe data, multiple correspondence analysis and hierarchical clustering were used to identify patterns in HIV prevention strategies among 9980 men who have sex with men (MSM). PrEP interest was evaluated among four identified clusters: (A) "high condom use, sometimes Treatment as Prevention (TasP)"; (B) "mix of methods, infrequent condom use"; (C) "high condom use, tendency to choose partners based on serological status" and (D) "moderate use of condoms mixed with other prevention strategies". Clusters B and D had higher PrEP interest. These results suggest that MSM use a range of behavioral and biomedical risk reduction strategies that are often combined. On-demand PrEP may meet the needs of MSM who infrequently use condoms and other prevention methods.

Seroadaptive Strategy Patterns of Young Black Gay, Bisexual, and Other Men Who Have Sex With Men in Atlanta, Georgia

BACKGROUND

Young Black gay, bisexual, and other men who have sex with men (YBMSM) are disproportionally affected by HIV. Seroadaptive strategies-modification of sexual behavior based on an individual's perceived serostatus, the perceived status of the partner, and/or HIV transmission risk by the type of sex act-are often used to reduce the risk of HIV transmission or acquisition.

METHODS

We used demographic, behavioral, and clinical data from Ele[MEN]t, a prospective cohort study of YBMSM aged 18-29 years in Atlanta, GA, conducted during 2015-2019. The prevalence of seroadaptive strategies at baseline was reported, and latent class analysis was used to identify the latent classes of strategies for both YBMSM known and not known to be living with HIV. Latent classes were compared by key behavioral and clinical characteristics to validate our findings.

RESULTS

In a 4-class model, the most common latent class of YBMSM not known to be living with HIV (32.4%) was characterized by all individuals reporting only having sex with men not perceived to be living with HIV. The most common latent class of YBMSM known to be living with HIV (48.2%) was characterized by a combination of serosorting strategies, including using condoms for anal sex with partners not known to be living with HIV and avoiding sex with men not known to be living with HIV.

CONCLUSIONS

YBMSM use various patterns of strategies to reduce their HIV transmission or acquisition risk. Our study highlights the need for targeted HIV prevention recommendations based on individual behaviors.

A Behavioral Cascade of HIV Seroadaptation Among US Men Who Have Sex with Men in the Era of PrEP and U = U

Seroadaptive behaviors help reduce HIV risk for some men who have sex with men (MSM), and have been well documented across MSM populations. Advancements in biomedical prevention have changed the contexts in which seroadaptive behaviors occur. We thus sought to estimate and compare the prevalence of four stages of the "seroadaptive cascade" by PrEP use in the recent era: knowledge of own serostatus, knowledge of partner serostatus; serosorting (matching by status), and condomless anal intercourse. Serosorting overall appeared to remain common, especially with casual and one-time partners. Although PrEP use did not impact status discussion, it did impact serosorting and the likelihood of having condomless anal intercourse. For respondents not diagnosed with HIV and not on PrEP, condomless anal intercourse occurred in just over half of relationships with HIV-positive partners who were not on treatment. Biomedical prevention has intertwined with rather than supplanted seroadaptive behaviors, while contexts involving neither persist.

Sexual Risk Profiles Among Black Sexual Minority Men: Implications for Targeted PrEP Messaging

Black gay, bisexual, and other Black sexual minority men (BSMM) continue to experience some of the largest sexual health disparities in the U.S. Engaging BSMM in PrEP is crucial to improving sexual health outcomes and reducing disparities. However, knowledge of the profiles of sexual risk and PrEP initiation among this group is limited. This study used latent class analysis to identify HIV risk and PrEP initiation patterns among BSMM in the HPTN 073 Study (n = 226). Guided by current Centers for Disease Control screening guidelines, latent class indicators included relationship status, condom use, number of sexual partners, substance use, sexually transmitted infection (STI) history, and partner HIV status. Age and PrEP initiation were used in a multinomial regression to identify correlates of class membership. Three latent classes were identified: Single, Condomless Partners, Single, Multiple Partners, and Serodiscordant Partners. Single, Condomless Partners had the highest conditional probabilities of having greater than three male partners, substance use before sex, and receiving an STI diagnosis. Serodiscordant Partners had a 100% conditional probability of condomless sex and having a male partner living with HIV. BSMM who initiated PrEP were less likely to be classified as Single, Condomless Partners than Serodiscordant Partners (AOR = 0.07, 95% CI = 0.02, 0.66). Findings support the need for culturally relevant tailored and targeted messaging for BSMM with multiple sexual risk indicators.

Increasing the HIV testing among MSM through HIV test result exchange mechanism: study protocol for a cluster randomized controlled trial

Background

HIV testing is an essential gateway to HIV prevention and treatment thus controlling the HIV epidemic. More innovative interventions are needed to increase HIV testing among men who have sex with men (MSM) since their testing rate is still low. We proposed an online HIV test results exchange mechanism whereby the one without a certified online HIV report will be asked to test HIV for exchanging HIV report with others. The exchange mechanism is developed as an extension to the existing online HIV testing service system. Through the extended system, MSM can obtain certified online HIV reports and exchange their reports with friends via WeChat. This study aims to assess effectiveness of the exchange mechanism to increase the HIV testing rate among MSM.

Methods

This study will use a cluster randomized controlled trial (RCT) design. Participants are recruited based on the unit of individual social network, the sender and the receivers of the HIV report. An individual social network is composed of one sender (ego) and one or more receivers (alters). In this study, MSM in an HIV testing clinic are recruited as potential egos and forwarded online reports to their WeChat friends voluntarily. Friends are invited to participate by report links and become alters. Ego and alters serve as a cluster and are randomized to the group using the certified online HIV report with exchange mechanism (intervention group) or without exchange mechanism (control group). Alters are the intervention targeting participants. The primary outcome is HIV testing rate. Other outcomes are sexual transmitted infections, sexual behaviors, HIV testing norms, stigma, risk perception and HIV report delivery. The outcomes will be assessed at baseline and follow-up questionnaires. Analysis will be according to intention to treat approach and using mixed-effect models with networks and individuals as random effects.

Discussion

This is the first study to evaluate the effectiveness of an HIV test result exchange mechanism to increase the HIV testing among MSM. This assessment of the intervention will also provide scientific evidence on other potential effects. Findings from this study will yield insights for sustainability driven by communities' intrinsic motivation.

Trail registration: ClinicalTrials.gov NCT03984136. Registered 12 June 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06484-y.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Attitudes and Perceptions About Disclosing HIV and Syphilis Results Using Smarttest, a Smartphone App Dedicated to Self- and Partner Testing

We explored interest in disclosing test results through a smartphone app dedicated to self- and partner testing for HIV/syphilis. Fifty-nine cisgender men and transgender women each participated in an in-person survey and interview. We examined their interests in sharing test results by audience (e.g., partners, physicians) and by positive versus negative test result. Participants wanted the ability to share results, with notable interest in disclosing negative results to sexual partners and on social media and forwarding positive results to physicians. Participants envisioned smartphone sharing as a means to normalize testing, to notify partners of results, and to expedite linkage to care. Some questioned the authenticity of results shared by smartphone, while others voiced optimism that a personalized, authenticated app could ensure the security and veracity of results. Smartphone testing apps for HIV/syphilis may facilitate disclosure, partner notification, and linkage to care, but need to address concerns about the security and veracity of results.

HIV incidence among men who have sex with men using geosocial networking smartphone application in Beijing, China: an open cohort study

Background

Sexual transmission among men who have sex with men (MSM) is the dominant route of HIV transmission in China. Extensive use of geosocial networking (GSN) smartphone application (app) has dramatically changed the pattern of sexual behaviors and HIV risk among MSM, but data on HIV incidence and the changing risk behaviors of GSN app-using MSM are limited. We aims to assess the HIV incidence and its correlates among gay GSN app-using MSM in China.

Methods

We constructed an open cohort which was initiated and maintained using a GSN app to assess the HIV incidence among app-using MSM, recruited from June 2017 to December 2018. MSM completed an online questionnaire on their sociodemographic characteristics, sexual behaviors, recreational drug use and sexually transmitted infections status. Then each man had an HIV test, and those tested negatives were enrolled into the cohort. Participants completed follow-ups with additional HIV tests though the app during the study period, and were censored at HIV seroconversion or study end date. HIV incidence was calculated by dividing the sum of observed HIV seroconversions by the observed person-time. Univariate (Chi-square test and Fisher’s exact test) and multivariate (proportional hazards regression) analyses were used to examine correlates of HIV incidence.

Results

A total of 6957 HIV negative MSM were enrolled in the open cohort, 37 seroconversions occurred among 1937 men contributing 1065 observed person-years: HIV incidence was 3.47 per 100 person-years [95% confidence interval (CI): 2.37–4.57]. More than five sexual partners [hazard ratio (HR) = 2.65, 95% CI: 1.04–6.67], and sex with HIV positive partners (HR = 3.82, 95% CI: 1.16–12.64) in the preceding six months were positively associated with HIV seroconversion. Consistent condom use for anal sex (HR = 0.27, 95% CI: 0.07–0.96), and reporting insertive anal sex only (HR = 0.23, 95% CI: 0.08–0.62) in the preceding six months were protective factors for HIV seroconversion.

Conclusions

Tailored interventions targeting app-using MSM are urgently needed given their high risk of HIV. As a new tool for accessing MSM at higher HIV risk, GSN smartphone app could play an important role in HIV research among MSM.

Estimating HIV transmissions in a large U.S. clinic-based sample: effects of time and syndemic conditions

INTRODUCTION

Little is known about onward HIV transmissions from people living with HIV (PLWH) in care. Antiretroviral therapy (ART) has increased in potency, and treatment as prevention (TasP) is an important component of ending the epidemic. Syndemic theory has informed modelling of HIV risk but has yet to inform modelling of HIV transmissions.

METHODS

Data were from 61,198 primary HIV care visits for 14,261 PLWH receiving care through the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) at seven United States (U.S.) sites from 2007 to 2017. Patient-reported outcomes and measures (PROs) of syndemic conditions - depressive symptoms, anxiety symptoms, drug use (opiates, amphetamines, crack/cocaine) and alcohol use - were collected approximately four to six months apart along with sexual behaviours (mean = 4.3 observations). Counts of syndemic conditions, HIV sexual risk group and time in care were modelled to predict estimated HIV transmissions resulting from sexual behaviour and viral suppression status (HIV RNA < 400/mL) using hierarchical linear modelling.

RESULTS

Patients averaged 0.38 estimated HIV transmissions/100 patients/year for all visits with syndemic conditions measured (down from 0.83, first visit). The final multivariate model showed that per 100 patients, each care visit predicted 0.05 fewer estimated transmissions annually (95% confidence interval (CI): 0.03 to 0.06; p < 0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; p < 0.0005), 0.34 (95% CI: 0.20 to 0.49; p < 0.0005) and 0.22 (95% CI: 0.09 to 0.35; p < 0.005) fewer estimated HIV transmissions/100 patients/year than cisgender men who have sex with men (MSM). Each within-patient syndemic condition predicted 0.18 estimated transmissions/100 patients/year (95% CI: 0.12 to 0.24; p < 0.0005). Each between-syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; p < 0.0005).

CONCLUSIONS

Estimated HIV transmissions among PLWH receiving care in well-resourced U.S. clinical settings varied by HIV sexual risk group and decreased with time in care, highlighting the importance of TasP efforts. Syndemic conditions remained a significant predictor of estimated HIV transmissions notwithstanding the effects of HIV sexual risk group and time in care.

Combination HIV Prevention Strategies Among Montreal Gay, Bisexual, and Other Men Who Have Sex with Men in the PrEP Era: A Latent Class Analysis

Pre-exposure prophylaxis (PrEP) became publicly available in Quebec for gay, bisexual and other men who have sex with men (GBM) in 2013. We used baseline data from Engage, a cohort of GBM recruited by respondent-driven sampling, to examine patterns of combination HIV prevention use among Montreal GBM since PrEP became available. Latent class analysis, stratified by HIV status, was used to categorize GBM by self-reported use of biomedical and behavioural prevention strategies. Correlates of resulting classes were identified using multinomial logistic regression. Among HIV-negative/unknown GBM (n = 968), we identified four classes: low use of prevention (32%), condoms (40%), seroadaptive behaviour (21%), and biomedical (including PrEP; 7%). Those using prevention (condoms, seroadaptive behaviour, and biomedical) had a higher number of anal sex partners and were more likely to report a recent sexually transmitted infection diagnosis. GBM using biomedical prevention also had a higher level of formal education. Among GBM living with HIV (n = 200), we identified three classes: mainly antiretroviral treatment (ART) with viral suppression (53%), ART with viral suppression and condoms (19%), and ART with viral suppression and seroadaptive behaviour (18%). Again, the number of anal sex partners was higher among those using condoms and seroadaptive behaviours. Our findings show antiretroviral-based prevention, either alone or in combination with other strategies, is clearly a component of the HIV prevention landscape for GBM in Montreal. Nevertheless, PrEP uptake remains low, and there is a need to promote its availability more widely.

Culture-embedded drivers and barriers to (non) condom use among Filipino MSM: a critical realist inquiry

This qualitative study examines the drivers and barriers of condom use among Filipino men who have sex with men (MSM) using a critical realist inquiry (i.e., shared meanings, norms, and practices related to condom use). Thematic analysis was used to analyze interviews of 105 MSM participants across 21 cities in the Philippines. Key findings showed three social structures that shape how participants view sexual partners as safe (linked to non-condom use) or unsafe (linked to condom use). First, classism is linked to relative economic social position of sexual partner (lower socio-economic class as unsafe; higher socio-economic class as safe). Second, heteronormativity is linked to relationship arrangements (multiple partner as unsafe; exclusive partner as safe) and identity categories (bisexuals as unsafe; straight men are safe). Third, body-ism is linked with notions of health (looks sick as unsafe; looks healthy as safe) and appearance (not good looking as unsafe). Sexual partners perceived as good looking can be construed as either safe or unsafe. Discussion points highlight importance of understanding the cultural and material contexts of looking and sounding educated, looking healthy, looking physically attractive vis-à-vis promoting condom use.

Substance Use, HIV Serostatus Disclosure, and Sexual Risk Behavior in People Living with HIV: An Event-Level Analysis

People living with HIV (PLWH) face difficult decisions about disclosing their HIV status to new sexual partners. Alcohol and other drug use could impact these decision-making processes and subsequent sexual risk behavior. We sought to examine the event-level relationships between substance use, HIV disclosure, and condom use in PLWH and their first-time HIV-negative or unknown status sexual partners. Adult PLWH were recruited from care settings in a southeastern U.S. city. Participants reported their sexual behavior for 28 consecutive days via text message prompts. We employed multilevel covariation in a causal system to examine the event-level relations between substance use and condom use. We proposed that this relationship would be mediated by HIV disclosure and moderated by viral suppression status. A total of 243 participants (83% male, 93% Black) reported 509 sexual events with first-time HIV-negative/unknown status sexual partners. Substance use at the time of sex was negatively associated with disclosure in PLWH with suppressed viral load (OR 0.29, β = - 1.22, 95% CI [- 2.42, - 0.03], p = .045), but differentially associated with condom use in PLWH with detectable versus undetectable viral load. In PLWH with viral suppression, participants who always disclosed versus who never disclosed their HIV status were more likely to use condoms (β = 1.84, 95% CI [0.35, 3.53], p = .017), but inconsistent disclosers were less likely to use a condom after disclosing (OR 0.22, 95% CI [0.07, 0.68], p = .008). Event-level analysis offers a more nuanced understanding of the proximal (substance use, HIV disclosure) and person-level (substance use, viral load) determinants of HIV transmission risk behavior in PLWH.

Lack of sexual behavior disclosure may distort STI testing outcomes

BACKGROUND

Men who have sex with men (MSM) globally have a high burden of curable sexually transmitted infections (STIs). MSM do not frequently receive rectal STI testing because of several barriers, such as not being out (disclosure of sexual behavior). We evaluate whether Chinese MSM select an STI test (rectal vs urethral) appropriate for their sexual behavior (insertive and/or receptive), and the interactions with being out.

METHODS

This was a secondary analysis of data from a cross sectional MSM survey conducted at a multisite randomized controlled trial (RCT) (December 2018 to January 2019) around uptake of gonorrhea and chlamydia testing among Chinese MSM (N = 431). We collected socio demographics, relevant medical and sexual history, and disclosure of sexual behavior (outness). We estimated the decision to test and test choice, and the extent to which disclosure plays a role in decision making.

RESULTS

Among 431 MSM, mean age was 28 years (SD = 7.10) and 65% were out to someone. MSM who indicated versatile sexual behavior and were out to someone had a 26.8% (95%CI = 6.1, 47.5) increased likelihood for selecting the rectal test vs the ure thral test, compared to those versatile and not out. Versatile MSM out to their health provider outside of the study context had a 29.4% (95%CI = 6.3, 52.6) greater likelihood for selecting the rectal STI test vs the urethral test, compared to versatile MSM not out to their health provider.

CONCLUSIONS

Sexual behavior and outness may affect gonorrhea and chlamydia testing provision. Apart from clinicians, community based efforts may reduce stigma based barriers to testing.

A serological divide: men who have sex with men's attitudes on HIV risk reduction strategies

The expanding HIV risk reduction toolkit increases options for men who have sex men (MSM), but increasing options in combination with different preferences may complicate promoting risk reduction. To investigate what strategies MSM prefer, data of 3310 participants in the online survey "Men & Sexuality" (Median age = 37 years, 320 (9.7%) HIV positive) was analysed. Questions assessed attitudes towards HIV risk reduction strategies. Participants had the most positive attitudes regarding PrEP and HIV testing, while withdrawal and strategic positioning were least preferred (all p's < .001). Condoms were seen as acceptable to partners and effective but scored low on sexual pleasure. HIV-positive participants were more negative about condoms and more positive about viral load sorting than HIV-negative participants (F_(12,3297) = 5.09, p < .001, [Formula: see text] = .02). Findings highlight a preference for HIV risk reduction strategies (PrEP and HIV testing) that do not diminish sexual pleasure and can be applied independent of sexual partners. A serological divide was apparent: HIV-negative MSM were less negative about condoms than HIV-positive MSM, suggesting that condom promotion remains a viable strategy for HIV-negative MSM. Taken together, results indicate a need for personalized approaches to the promotion of HIV risk reduction strategies, accounting for individual preferences and strategy effectiveness.

Network-Level Correlates of Sexual Risk Among Male Sex Workers in the United States: A Dyadic Analysis

BACKGROUND

Male sex workers (MSWs) are at increased risk of HIV infection in the United States. Research is limited on sexual and drug use network characteristics of MSWs.

SETTING

Community-based organization and health center in 2 US Northeast cities.

METHODS

One hundred MSWs completed a behavioral assessment and sexual and drug network inventory. Using dyadic analyses, we assessed whether network characteristics, including sex worker-male client age, race, and HIV status homophily and risk multiplexity (ie, overlap in drug-use and sex networks), were associated with condom use.

RESULTS

MSW participants' mean age was 33.6. Two-thirds identified as Black or Latino, 12% identified as heterosexual, and 90% reported recent drug use. Participants reported an average of 5.3 male clients in the past month (SD = 3.4), and having anal sex with 74% of these clients, at a rate of 2.2 times per month (SD = 4.6). Participants reported inconsistent condom use during anal sex with 53% of clients. In multivariable models, inconsistent condom use was more common in relationships with presumed HIV status homophily [odds ratio (OR): 1.25; 95% confidence interval (CI): 1.07 to 1.46] and sexual and drug network multiplexity (OR: 1.19; 95% CI: 1.09 to 1.30); and less common within relationships where the client is older than the MSW participant (OR: 0.83; 95% CI: 0.74 to 0.93). Number of multiplex relationships was positively associated with number of condomless anal sex acts with male clients (incidence rate ratio: 1.35; 95% CI: 1.19 to 1.54).

CONCLUSIONS

Network characteristics may contribute to disproportionate HIV risk among MSWs. Modeling studies should include network characteristics when simulating HIV transmission, and future HIV interventions should address the role of networks.

Does Stigma Toward Anal Sexuality Impede HIV Prevention Among Men Who Have Sex With Men in the United States? A Structural Equation Modeling Assessment

INTRODUCTION

Men who have sex with men (MSM) are suboptimally engaged in efficacious HIV interventions, due in part to stigma.

AIM

We sought to validate the Anal Health Stigma Model, developed based on theory and prior qualitative data, by testing the magnitude of associations between measures of anal sex stigma and engagement in HIV prevention practices, while adjusting for covariates.

METHODS

We conducted a cross-sectional online survey of 1,263 cisgender MSM living in the United States and analyzed data with structural equation modeling. We tested a direct path from Anal Sex Stigma to Engagement in HIV Prevention alongside 2 indirect paths, 1 through Anal Sex Concerns and another through Comfort Discussing Anal Sexuality with Health Workers. The model adjusted for Social Support, Everyday Discrimination, and Sociodemographics.

MAIN OUTCOME MEASURE

Engagement in HIV Prevention comprised an ad hoc measure of (i) lifetime exposure to a behavioral intervention, (ii) current adherence to biomedical intervention, and (iii) consistent use of a prevention strategy during recent penile-anal intercourse.

RESULTS

In the final model, anal sex stigma was associated with less engagement (β = -0.22, P < .001), mediated by participants' comfort talking about anal sex practices with health workers (β = -0.52; β = 0.44; both P < .001), adjusting for covariates (R² = 67%; χ²/df = 2.98, root mean square error of approximation = 0.040, comparative fit index = 0.99 and Tucker-Lewis index = 0.99). Sex-related concerns partially mediated the association between stigma and comfort (β = 0.55; β = 0.14, both P < .001). Modification indices also supported total effects of social support on increased comfort discussing anal sex (β = 0.35, P < .001) and, to a lesser degree, on decreased sex-related concerns (β = -0.10; P < .001).

CLINICAL IMPLICATIONS

Higher stigma toward anal sexuality is associated with less engagement in HIV prevention, largely due to discomfort discussing anal sex practices with health workers.

STRENGTH & LIMITATIONS

Adjustment for mediation in a cross-sectional design cannot establish temporal causality. Self-report is vulnerable to social desirability and recall bias. Online samples may not represent cisgender MSM in general. However, findings place HIV- and health-related behaviors within a social and relational context and may suggest points for intervention in health-care settings.

CONCLUSION

Providers' willingness to engage in discussion about anal sexuality, for example, by responding to questions related to sexual well-being, may function as social support and thereby bolster comfort and improve engagement in HIV prevention. Kutner BA, Simoni JM, King KM, et al. Does Stigma Toward Anal Sexuality Impede HIV Prevention Among Men Who Have Sex With Men in the United States? A Structural Equation Modeling Assessment. J Sex Med 2020;17:477-490.

Exploring the role of sex-seeking apps and websites in the social and sexual lives of gay, bisexual and other men who have sex with men: a cross-sectional study

Background The objective of this study was to explore the relationship between online sex-seeking, community/social attachment and sexual behaviour.

METHODS

Respondent-driven sampling was used to recruit 774 sexually active gay and bisexual men in Vancouver, Canada, aged ≥16 years. Multivariable logistic regression compared men who had used online sex-seeking apps/websites in the past 6 months (n=586) with those who did not (n=188).

RESULTS

Multivariable results showed that online sex seekers were more likely to be younger [adjusted odds ratio (aOR)=0.95, 95% CI: (0.93-0.96)], college educated [aOR=1.60, 95% CI: (1.07, 2.40)], have more Facebook friends [aOR=1.07, 95% CI: (1.01, 1.13)], spend more social time with other gay men [aOR=1.99, 95% CI: (1.33-2.97)], and were less likely to identify emotionally with the gay community [aOR=0.93, 95% CI: (0.86-1.00)]. Further, they had displayed high sensation-seeking behaviour [aOR=1.08, 95% CI: (1.03-1.13)], were more likely to engage in serodiscordant/unknown condomless anal sex [aOR=2.34, 95% CI: (1.50-3.66)], use strategic positioning [aOR=1.72, 95% CI: (1.08-2.74)], ask their partner's HIV-status prior to sex [aOR=2.06, 95% CI: (1.27-3.37)], and have ever been tested for HIV [aOR=4.11, 95% CI: (2.04-8.29)].

CONCLUSION

These findings highlight the online and offline social behaviour exhibited by gay and bisexual men, pressing the need for pro-social interventions to promote safe-sex norms online. We conclude that both Internet and community-based prevention will help reach app/web users.

Awareness and Perceived Effectiveness of HIV Treatment as Prevention Among Men Who Have Sex with Men in New York City

To assess perceptions of HIV treatment as prevention (TasP), we conducted an online survey of MSM in New York City (n = 732) asking them to rate the effectiveness of different strategies to reduce HIV risk during serodiscordant condomless anal sex between men. Only 6.1% reported not knowing what TasP was, with significantly less awareness among non-gay-identified MSM, men with less education, men who reported fewer anal sex partners in the prior 3 months, and HIV-negative/unaware men who had never used PrEP. The strategy most frequently perceived to offer "a lot" or "complete" protection from HIV was daily PrEP (70.0%), followed by TasP (39.1%), intermittent PrEP (16.6%), strategic positioning (15.8%), and withdrawal before ejaculation (10.8%). Men who were HIV positive, who had ever used PrEP, and who identified as gay/homosexual were significantly more likely to see TasP as effective. Further studies should investigate MSM's apparent skepticism towards TasP.

Efficacy of a Clinic-Based Safer Sex Program for Human Immunodeficiency Virus-Uninfected and Human Immunodeficiency Virus-Infected Young Black Men Who Have Sex With Men: A Randomized Controlled Trial

OBJECTIVE

To test the efficacy of a single-session, clinic-based intervention designed to promote condom use among young black men who have sex with men (YBMSM).

METHODS

Six hundred YBMSM were enrolled in a randomized controlled trial, using a 12-month observation period. An intent-to-treat analysis was performed, with multiple imputation for missing data.

RESULTS

Compared with the reference group, human immunodeficiency virus (HIV)-infected men in the intervention group had 64% greater odds of reporting consistent condom use for anal receptive sex over 12 months (estimated odds ratio, 1.64; 95% confidence interval, 1.23-2.17, P = 0.001). Also, compared with the reference group, HIV-uninfected men in the intervention group had more than twice the odds of reporting consistent condom use for anal receptive sex over 12 months (estimated odds ratio, 2.14; 95% confidence interval, 1.74-2.63, P < 0.001). Significant intervention effects relative to incident sexually transmitted diseases were not observed.

CONCLUSIONS

A single-session, clinic-based, intervention may help protect HIV-uninfected YBMSM against HIV acquisition and HIV-infected YBMSM from transmitting the virus to insertive partners.

Predictors of willingness to accept pre-marital HIV testing and intention to sero-sort marital partners; risks and consequences: Findings from a population-based study in Cameroon

Introduction

The objectives of this study was to investigate and compare levels of acceptability of pre-marital HIV testing; and intention to sero-sort future marital and its associated factors among unmarried adults in two cities in Cameroon.

Methods

A population-based survey was conducted simultaneously in the cities of Kumba and Buea, located in the Southwest region of Cameroon. Data were collected from September to October 2016 by trained interviewers who administered questionnaires to eligible and consenting unmarried adults aged 21–35 years. Data were weighted and logistic regression analyses performed to identify significant predictors. The level of statistical significance was set at p< = 0.05.

Results

A total of 1,406 respondents (767 in Kumba and 639 in Buea) participated in the study. In the pooled sample, the median age of respondents was 26 years (IQR = 23–29) and over half (54.8%) were males. Over 90% of respondents in both cities indicated their willingness to accept pre-marital HIV testing. Respondents who had previously tested for HIV in Kumba (AOR = 7.87; 95%CI, 4.02–15.44) were significantly more likely to accept premarital HIV testing than those who had never tested for HIV. In Kumba, older age (AOR = 0.42; 95%CI, 0.18–0.96) and those unemployed (AOR = 0.22; 95% CI, 0.06–0.76) were significantly less likely to accept pre-marital HIV testing. In Buea males (AOR = 0.64 95% CI, 0.45–0.89) who would test HIV negative would be significantly less likely to accept to marry an HIV positive partner. In Buea, respondents who indicated a moderate risk of contracting HIV (AOR = 1.71; 95%CI, 1.09–2.66, p = 0.018) were significantly more likely to accept to marry an HIV positive partner. The major limitation of the study was that a hypothetical situation was used to ask respondents about their willingness to accept pre-marital HIV testing rather than actual HIV test acceptance.

Conclusions

Most respondents expressed their willingness to undergo pre-marital HIV testing. However, majority of respondents who would test HIV negative would refuse to marry their partner who tests HIV positive. These findings suggest that interventions to reduce HIV infection and fight against stigma and discrimination should be reinforced at community level.

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.

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

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

Sexual behaviours and sexually transmitted infection outcomes in a cohort of HIV-negative men who have sex with men attending sexual health clinics in England

Men who have sex with men (MSM) attending sexual health (SH) clinics are at high risk for HIV acquisition and are disproportionately affected by sexually transmitted infections (STIs). We collected standardised behavioural data from MSM attending clinics to characterise sexual behaviours and identify predictors for HIV and STIs. In 2012–2013, HIV-negative MSM attending five SH clinics in England reported sexual behaviours in the previous three months via a self-administered questionnaire. Behaviours were linked to the individual’s clinical records using national surveillance. The prevalence and incidence of bacterial STIs (gonorrhoea, Chlamydia, lymphogranuloma venereum and syphilis) and incidence of HIV were calculated. Adjusted odds ratios and hazard ratios with 95% confidence interval (CI) were reported for significant predictors. Of 1278 HIV-negative MSM, 54% were of white ethnicity and UK-born and 43% were 25–34 years old. Almost all men reported at least one partner in the last three months. Half reported condomless anal sex and 36% condomless receptive anal intercourse (CRAI). Incidence of bacterial STIs was 46/100 (95%CI 39–54) person years (py) and of HIV was 3.1/100 (95%CI 1.7–5.6) py. A STI at baseline and CRAI with increasing numbers of partners were associated with both incident infections. In this cohort of MSM high-risk behaviours and STIs were prevalent. Engagement in CRAI increased the likelihood of subsequent infection, while men diagnosed with a bacterial STI were at increased risk of a future STI. Clinical and behavioural risk assessments to determine an individual’s risk of infection could allow a more nuanced prevention approach that has greater success in reducing transmission.

Prevalence of and Factors Associated with the Use of HIV Serosorting and Other Biomedical Prevention Strategies Among Men Who Have Sex with Men in a US Nationwide Survey

PrEP and treatment-as-prevention (TasP) are biomedical strategies to reduce HIV transmission. Some men who have sex with men (MSM) are combining biomedical strategies with HIV serosorting-termed "biomed matching" when both partners are either on PrEP or TasP, or "biomed sorting" when one partner is using PrEP and the other TasP. Nevertheless, there is limited data on the extent of biomed matching/sorting in large geographically diverse samples. In 2016-2017, 5021 MSM from across the US were surveyed about their HIV status and HIV viral load/PrEP use, as well as that of their recent casual male partners. For each participant, we calculated the proportion of his partners who were (1) HIV-positive and undetectable, (2) HIV-positive and detectable/unknown, (3) HIV unknown/undiscussed, (4) HIV-negative on PrEP, (5) HIV-negative, not on PrEP. In total, 66.6% (n = 3346) of participants were HIV-negative and not on PrEP, 11.9% (n = 599) on PrEP, 14.1% (n = 707) HIV-positive and undetectable, 1.1% (n = 55) HIV-positive and viral load detectable/unknown, and 6.2% (n = 313) HIV unsure/unknown. A participant's own HIV and PrEP status/was significantly associated with that of his partners (all p < 0.001), evincing evidence of both serosorting and biomed matching. Among men on PrEP and those who were HIV-undetectable, there was also some evidence to suggest these participants dually engaged in biomed matching as well as biomed sorting. We found evidence of biomed matching and sorting, which may compound its effectiveness for those using it (i.e., both partners bring biomedical protection). Unintended consequences of biomed matching/sorting include that men not using a biomedical strategy may be less likely to benefit from a partner's use of the strategy-potentially further driving disparities in HIV infections. Public health campaigns might be well served to highlight not only the benefits that biomedical HIV prevention strategies provide for their users (e.g., "being on PrEP protects me from getting HIV"), but also the benefits that a user brings to his partners (e.g., "my use of PrEP means my partners won't get HIV"), and the benefits of being with a partner who is using a biomedical strategy (e.g., "my partner's use of PrEP/TasP protects me from HIV").

National Trends in Sexual Behavior, Substance Use and HIV Testing Among United States Men Who have Sex with Men Recruited Online, 2013 Through 2017

The American Men's Internet Survey (AMIS) is conducted annually with 10,000 men age 15 + who have sex with men (MSM). Modeling was used with 39,863 AMIS surveys from 4 cycles between December 2013 to February 2017 to identify temporal trends in sexual behavior, substance use, and testing behavior (within 12 months preceding interview) stratified by participants' self-reported HIV status. HIV-negative/unknown status MSM had significant increases in condomless anal intercourse (CAI), marijuana use, use of other illicit substances, sexually transmitted infection (STI) diagnoses, and HIV or STI testing (testing only increased among MSM age 25 +). HIV-negative/unknown status MSM had significant decrease in CAI with an HIV-positive or unknown status partner. HIV-positive MSM had significant increases in CAI, methamphetamine use, and STI diagnoses/testing. Although encouraging, the few indicators of improvement in HIV/STI sexual health practices are not consistently seen across sub-groups of MSM and may be counteracted by growing proportions of MSM engaging in CAI and acquiring STIs.

Per-partner condom effectiveness against HIV for men who have sex with men

OBJECTIVE

Few studies have examined condom effectiveness for HIV prevention among MSM. We estimated condom effectiveness per partner in four cohorts of MSM during 1993-2003 (JumpStart, Vaccine Preparedness Study, VAX004 and Project Explore).

METHODS

We used logistic regression to estimate the increase in odds of new HIV infection per HIV-positive partner for condom-protected receptive anal intercourse (PRAI; partners with whom condoms were always used) and condomless (unprotected) receptive anal intercourse (URAI; partners with whom condoms were sometimes or never used). To estimate condom effectiveness for preventing HIV transmission, we applied the concept of excess odds, the odds ratio minus 1. The condom failure rate was estimated as the excess odds per PRAI partner divided by the excess odds per URAI partner. Condom effectiveness was then 1 minus the failure rate.

RESULTS

The excess odds of HIV infection per HIV-positive partner were 83% for URAI and 7% for PRAI. The resulting failure rate (9%) indicated per-partner condom effectiveness of 91% (95% confidence interval 69-101).

CONCLUSION

The increase in odds of new HIV infection per HIV-positive partner for receptive anal intercourse was reduced by 91% for each partner with whom condoms were always used.

Correlates of Serosorting and Knowledge of Sexual Partner's HIV Status Among Men Who have Sex with Men in Ukraine

Ukraine has among the highest rates of newly diagnosed HIV infections in the WHO European region. Men who have sex with men (MSM) is the least studied group in the context of the HIV epidemics in Ukraine. The present paper aims to estimate the prevalence and correlates of knowledge of sexual partner's HIV status and potentially discordant anal intercourse (failure to serosort) among MSM. Data of the cross-sectional study among 8100 MSM in Ukraine in 2013 were used for this analysis. Less than half of the participants (42.5%) reported that they knew the HIV serostatus of their most recent male sexual partner, and about 13% of participants reported failure to serosort during their most recent anal sexual intercourse with a male partner. Targeted interventions can be implemented to increase knowledge about sexual partner's HIV status, both among HIV-negative and HIV-positive MSM, to reduce the risk of HIV acquisition and transmission.

Sex Practices by HIV Awareness and Engagement in the Continuum of Care Among MSM: A National HIV Behavioral Surveillance Analysis in 21 U.S. Cities

Using National HIV Behavioral Surveillance (NHBS) cross-sectional survey and HIV testing data in 21 U.S. metropolitan areas, we identify sex practices among sexually active men who have sex with men (MSM) associated with: (1) awareness of HIV status, and (2) engagement in the HIV care continuum. Data from 2008, 2011, and 2014 were aggregated, yielding a sample of 5079 sexually active MSM living with HIV (MLWH). Participants were classified into HIV status categories: (1) unaware; (2) aware and out of care; (3) aware and in care without antiretroviral therapy (ART); and (4) aware and on ART. Analyses were conducted examining sex practices (e.g. condomless sex, discordant condomless sex, and number of sex partners) by HIV status. Approximately 30, 5, 10 and 55% of the sample was classified as unaware, aware and out of care, aware and in care without ART, and aware and on ART, respectively. Unaware MLWH were more likely to report condomless anal sex with a last male partner of discordant or unknown HIV status (25.9%) than aware MLWH (18.0%, p value < 0.0001). Unaware MLWH were 3 times as likely to report a female sex partner in the prior 12 months as aware MLWH (17.3 and 5.6%, p-value < 0.0001). When examining trends across the continuum of care, reports of any condomless anal sex with a male partner in the past year (ranging from 65.0 to 70.0%), condomless anal sex with a male partner of discordant or unknown HIV status (ranging from 17.7 to 21.3%), and median number of both male and female sex partners were similar. In conclusion, awareness of HIV and engagement in care was not consistently associated with protective sex practices, highlighting the need for continued prevention efforts.

A Latent Class Analysis of Seroadaptation Among Gay and Bisexual Men

Initial research into seroadaptive strategies suggests that, individually, they are potentially effective behavioral methods to reduce risk of HIV transmission. Combining strategies, therefore, has the potential to increase risk reduction. The aim of this study was to determine how gay and bisexual men (GBM) combine strategies. To this end, a total of 774 sexually active GBM, aged ≥16 years, in Metro Vancouver, Canada, were recruited. Grouped by self-reported HIV status, latent class analysis of self-reported condom use, strategic positioning, anal sex avoidance, serosorting, viral-load sorting, and withdrawal were conducted. Multinomial logistical regression identified explanatory variables of class membership (i.e., sensation seeking, treatment optimism, sexual altruism, relationship status, number of partners, anal sex preference). Four latent classes were identified: Condom Users, Multiple Prevention Users, Viral-Load Sorters, and Serosorters. The majority of HIV-negative/unknown men (72 %) and a large proportion of HIV-positive men (42 %) belonged to the Condom Users class. Class membership was associated with age, relationship status, treatment optimism, sexual altruism, sensation seeking, number of recent male anal sex partners, and recent condomless anal sex with a serodiscordant or unknown-status partner. Understanding these distinct patterns allows for tailored interventions addressing GBM's sexual health needs.

HIV serostatus knowledge and serostatus disclosure with the most recent anal intercourse partner in a European MSM sample recruited in 13 cities: results from the Sialon-II study

Background

Knowledge of HIV status can be important in reducing the risk of HIV exposure. In a European sample of men-who-have-sex-with-men (MSM), we aimed to identify factors associated with HIV serostatus disclosure to the most recent anal intercourse (AI) partner. We also aimed to describe the impact of HIV serostatus disclosure on HIV exposure risks.

Methods

During 2013 and 2014, 4901 participants were recruited for the bio-behavioural Sialon-II study in 13 European cities. Behavioural data were collected with a self-administered paper questionnaire. Biological specimens were tested for HIV antibodies. Factors associated with HIV serostatus disclosure with the most recent AI partner were examined using bivariate and multilevel multivariate logistic regression analysis. We also describe the role of serostatus disclosure for HIV exposure of the most recent AI partner.

Results

Thirty-five percent (n = 1450) of the study participants reported mutual serostatus disclosure with their most recent AI partner or disclosed having HIV to their partner. Most of these disclosures occurred between steady partners (74%, n = 1077). In addition to the type of partner and HIV diagnosis status, other factors positively associated with HIV serostatus disclosure in the multilevel multivariate logistic regression model were recent testing, no condom use, and outness regarding sexual orientation. Disclosure rates were lowest in three south-eastern European cities.

Following condom use (51%, n = 2099), HIV serostatus disclosure (20%, n = 807) was the second most common prevention approach with the most recent AI partner, usually resulting in serosorting. A potential HIV exposure risk for the partner was reported by 26% (111/432) of HIV antibody positive study participants. In 18% (20/111) of exposure episodes, an incorrect HIV serostatus was unknowingly communicated. Partner exposures were equally distributed between steady and non-steady partners.

Conclusions

The probability of HIV exposure through condomless AI is substantially lower after serostatus disclosure compared to non-disclosure. Incorrect knowledge of one’s HIV status contributes to a large proportion of HIV exposures amongst European MSM. Maintaining or improving condom use for anal intercourse with non-steady partners, frequent testing to update HIV serostatus awareness, and increased serostatus disclosure particularly between steady partners are confirmed as key aspects for reducing HIV exposures amongst European MSM.

Electronic supplementary material

The online version of this article (10.1186/s12879-017-2814-x) contains supplementary material, which is available to authorized users.

Sociodemographic and Clinical Factors Associated With Increasing Bacterial Sexually Transmitted Infection Diagnoses in Men Who Have Sex With Men Accessing Care at a Boston Community Health Center (2005-2015)

Background

The reasons why bacterial sexually transmitted infections (BSTIs) are increasing in US men who have sex with men (MSM) have not been fully characterized.

Methods

An open cohort of MSM accessing medical care at a Boston community health center was used to assess secular trends in BSTI diagnoses. Frequency of infection and the estimated population size were used to calculate diagnosis rates. Poisson models were fit for multivariable analyses.

Results

Between 2005 and 2015, 19 232 men had at least 1 clinic visit. Most (72.4%) were white; 6.0% were black, and 6.1% were Latino. Almost half had documented self-report of identifying as gay (42.6%) or bisexual (3.2%). Most had private health insurance (61.7%); 5.4% had Medicare, 4.6% had Medicaid, and 8.4% reported no insurance. Between 2005 and 2015, BSTI diagnoses increased more than 8-fold. In 2015, of 1319 men who were diagnosed with at least 1 BSTI; 291 were diagnosed with syphilis, 554 with gonorrhea (51.4% rectal, 31.0% urogenital), and 679 with chlamydia (69.1% rectal, 34.3% urogenital). In 2015, 22.7% of BSTIs were diagnosed among HIV-infected patients (15.4% of the clinic population), and 32.8% of BSTIs were diagnosed among HIV-uninfected patients using pre-exposure prophylaxis (PrEP; 10.1% of all men in care). In multivariable analyses, age 18 to 24 years, being HIV-infected, using PrEP, being nonwhite, or reporting Medicaid or not reporting having private insurance or Medicare were independently associated with being diagnosed with a new BSTI.

Conclusions

Over the past decade, BSTI diagnosis rates increased in HIV-infected and uninfected MSM, with disproportionate increases in PrEP users, racial and ethnic minority MSM, those aged 25 to 34 years, and those without stable health insurance, warranting focused education, screening, and accessible services for these key subpopulations.

Quantifying the Harms and Benefits from Serosorting Among HIV-Negative Gay and Bisexual Men: A Systematic Review and Meta-analysis

We conducted a systematic review and meta-analysis of the association between serosorting and HIV infection among HIV-negative men who have sex with men (MSM). Compared to no condomless anal sex (i.e., consistent condom use or no anal sex), serosorting was associated with increased HIV risk (RR = 1.64, 95% CI 1.37-1.96). Compared to condomless discordant anal sex, serosorting was associated with reduced HIV risk (RR = 0.46, 95% CI 0.33-0.65). Serosorting may be an important harm reduction strategy when condoms are not consistently used, but can be harmful if HIV-negative MSM who consistently use condoms shift to using serosorting as their primary prevention strategy. The protective effects of serosorting and ways in which MSM are operationalizing serosorting are becoming more complex as additional factors affecting risk are considered (e.g., durable viral load suppression, PrEP). Understanding the potential risk and benefit of serosorting continues to be important, particularly within the context of other prevention strategies.

Operationalizing the Measurement of Seroadaptive Behaviors: A Comparison of Reported Sexual Behaviors and Purposely-Adopted Behaviors Among Men who have Sex with Men (MSM) in Seattle

Seroadaptive behaviors are traditionally defined by self-reported sexual behavior history, regardless of whether they reflect purposely-adopted risk-mitigation strategies. Among MSM attending an STD clinic in Seattle, Washington 2013-2015 (N = 3751 visits), we used two seroadaptive behavior measures: (1) sexual behavior history reported via clinical computer-assisted self-interview (CASI) (behavioral definition); (2) purposely-adopted risk-reduction behaviors reported via research CASI (purposely-adopted definition). Pure serosorting (i.e. only HIV-concordant partners) was the most common behavior, reported (behavioral and purposely-adopted definition) by HIV-negative respondents at 43% and 60% of visits, respectively (kappa = 0.24; fair agreement) and by HIV-positive MSM at 30 and 34% (kappa = 0.25; fair agreement). Agreement of the two definitions was highest for consistent condom use [HIV-negative men (kappa = 0.72), HIV-positive men (kappa = 0.57)]. Overall HIV test positivity was 1.4 but 0.9% for pure serosorters. The two methods of operationalizing behaviors result in different estimates, thus the choice of which to employ should depend on the motivation for ascertaining behavioral information.

A Single Question to Examine the Prevalence and Protective Effect of Seroadaptive Strategies Among Men Who Have Sex With Men

BACKGROUND

Seroadaptive behaviors among men who have sex with men (MSM) are common, but ascertaining behavioral information is challenging in clinical settings. To address this, we developed a single seroadaptive behavior question.

METHODS

Men who have sex with men 18 years or older attending a sexually transmitted disease clinic in Seattle, WA, from 2013 to 2015, were eligible for this cross-sectional study. Respondents completed a comprehensive seroadaptive behavior questionnaire which included a single question that asked HIV-negative MSM to indicate which of 12 strategies they used in the past year to reduce their HIV risk. HIV testing was performed per routine clinical care. We used the κ statistic to examine agreement between the comprehensive questionnaire and the single question.

RESULTS

We enrolled HIV-negative MSM at 3341 (55%) of 6105 eligible visits. The agreement between the full questionnaire and single question for 5 behaviors was fair to moderate (κ values of 0.34-0.59). From the single question, the most commonly reported behaviors were as follows: avoiding sex with HIV-positive (66%) or unknown-status (52%) men and using condoms with unknown-status partners (53%); 8% of men reported no seroadaptive behavior. Men tested newly HIV positive at 38 (1.4%) of 2741 visits. HIV test positivity for the most commonly reported behaviors ranged from 0.8% to 1.3%. Men reporting no seroadaptive strategy had a significantly higher HIV test positivity (3.5%) compared with men who reported at least 1 strategy (1.3%; P = 0.02).

CONCLUSIONS

The single question performed relatively well against a comprehensive seroadaptive behaviors assessment and may be useful in clinical settings to identify men at greatest risk for HIV.

Distribution of Behavioral Patterns Before Infection Among San Francisco Men Who Have Sex With Men Newly Infected With HIV in 2014

BACKGROUND

Despite continued reductions in the number of HIV cases reported among San Francisco men who have sex with men (MSM) and the HIV-prevention potential offered by pharmaceutical tools such as pre-exposure prophylaxis (PrEP), there are uncertainties, particularly given reported decreases in consistent condom use. A key uncertainty is what groups of MSM should be targeted. This study estimates the distribution of behavioral patterns before infection among San Francisco MSM newly infected with HIV in 2014.

METHODS

We used a novel modeling approach. The approach uses estimates from the National HIV Behavioral Surveillance System for MSM, the Medical Monitoring Project, 2 trials of PrEP, and a meta-analysis of per-act risks of HIV infection.

RESULTS

The modeling study suggests that 76% of newly HIV-infected MSM in 2014 were individuals with no discernible strategy in the 6 months before infection: that is, they had condomless receptive anal intercourse with one or more partners not perceived to be HIV uninfected. An estimated 7% of newly infected MSM were serosorters before infection.

CONCLUSIONS

Prevention efforts in San Francisco must reach HIV-uninfected MSM with no discernible behavioral strategy, a group that constitutes 8% of HIV-uninfected MSM in the city. Our study suggests that if all HIV-uninfected, San Francisco MSM with no discernible strategy had been on PrEP in 2014, there would have been 70% fewer HIV infections among San Francisco MSM. Uncertainty analysis suggests that PrEP's impact may be maximized by encouraging PrEP persistence and concomitant reductions in sexual risk behaviors.

"You just can't trust everybody": the impact of sexual risk, partner type and perceived partner trustworthiness on HIV-status disclosure decisions among HIV-positive black gay and bisexual men

HIV remains an intractable public health concern in the USA, with infection rates notably concentrated among Black gay and bisexual men. Status disclosure by HIV-positive individuals can be an important aspect of risk reduction but doing so poses dilemmas concerning privacy, stigma and self-protection, especially among populations subjected to multiple types of stigmatisation. Understanding the factors related to the disclosure process can help to inform prevention efforts. Using exploratory in-depth interviews, this qualitative study examines the disclosure process among a sample of twenty HIV-positive Black gay and bisexual men (mean age = 40) recruited through a non-profit health centre in a mid-western city in the USA. Data were analysed using a thematic analysis approach with HIV-disclosure as an a priori sensitising concept. Fears of stigma and secondary disclosure within social networks were critical barriers to talking about HIV with sexual partners and disclosure decisions involved a complex process centred on three primary themes: degree of sexual risk, partner type and perceived partner trustworthiness. The unique combinations of these contextual factors resulted in increased or decreased likelihood of disclosure. A conceptual model explicating a potential process by which these contextual factors influence disclosure decisions is presented.

"Knowing Your Status and Knowing Your Partner's Status Is Really Where It Starts": A Qualitative Exploration of the Process by Which a Sexual Partner's HIV Status Can Influence Sexual Decision Making

Gay and bisexual men are at disproportionate risk for human immunodeficiency virus (HIV) infection. While prevention efforts often emphasize consistent condom use, there is growing evidence that men are using seroadaptive safer-sex strategies, such as serosorting and seropositioning. This qualitative analysis of 204 HIV-negative and HIV-positive gay and bisexual men explored the ways that a sexual partner's HIV status can influence safer-sex strategies and sexual decisions. The majority of the respondents reported that they were influenced by their partners' HIV status. Those respondents who reported no influence discussed adhering to safer-sex rules that were not dependent on partner status and a lack of concern about HIV. Conversely, respondents who reported influence identified three primary areas of influence: psychological impacts, partner preference and selection, and specific behavioral intentions and strategies. A conceptual model explicating a potential process by which respondents use partner serostatus information in shaping sexual decisions is presented.

Seroadaptive Strategies of Vancouver Gay and Bisexual Men in a Treatment as Prevention Environment

British Columbia's treatment as prevention policy has provided free access to highly active antiretroviral therapy (HAART) to all HIV-positive provincial residents since 1996. One outcome is an increase in HIV-positive gay and bisexual men (GBM) with suppressed viral loads. Previous cross-sectional analyses indicated that some Vancouver GBM now recognize condomless anal sex with men on HAART who report a suppressed viral load as a seroadaptive strategy. To test the hypothesis that this new strategy, termed viral load sorting (VLS), is recognized and used among by GBM in the Momentum Health Study, we analyzed longitudinal data for HIV-negative/unknown (n = 556) and HIV-positive (n = 218) serostatus participants. Analyses indicated that both groups reported VLS, and that serostatus and Treatment Optimism Scale scores were significant determinants in frequency and use. Results exemplify the medicalization of sex and Rogers' Diffusion Of Preventative Innovations Model, and they have important implications for HIV research and GBM sexual decision-making.

Changes in Condomless Sex and Serosorting Among Men Who Have Sex With Men After HIV Diagnosis

BACKGROUND

Among men who have sex with men (MSM) diagnosed with HIV, high-risk sexual behaviors may decline in the year after diagnosis. The sustainability of these changes is unknown.

METHODS

We created a retrospective cohort (Seroconversion Cohort) of MSM attending an STD clinic in Seattle, Washington who tested HIV positive between 2001 and 2013 and had a negative HIV test <2 years before diagnosis. We randomly selected 1000 HIV-negative controls (men who always tested HIV negative) who were frequency-matched to the Seroconversion Cohort based on HIV diagnosis year. 12-month sexual behavior data were collected at each clinic visit. We examined condomless anal intercourse (CAI) with HIV-negative, HIV-positive, and HIV unknown-status partners before diagnosis and up to 4 years thereafter.

RESULTS

Of the 26,144 clinic visits where MSM tested for HIV, there were 655 (2.5%) new HIV diagnoses. Of these, 186 (28%) men had previously tested HIV negative and were included in the Seroconversion Cohort. The proportion (of the 186) reporting CAI with HIV-negative partners declined from 73% at diagnosis to 12% after diagnosis (P < 0.001), whereas CAI with HIV-positive partners increased (11%-67%; P < 0.001). The proportion who serosorted (ie, CAI only with HIV-concordant partners) did not change before or after diagnosis (34%-40%; P = 0.65). These 3 behaviors remained stable for up to 4 years after diagnosis. Among HIV-negative controls, serosorting and CAI with HIV-positive and HIV-negative partners was constant.

CONCLUSIONS

MSM substantially modify their sexual behavior after HIV diagnosis. These changes are sustained for several years and may reduce HIV transmission to HIV-uninfected men.

The Duality of Oral Sex for Men Who Have Sex with Men: An Examination Into the Increase of Sexually Transmitted Infections Amid the Age of HIV Prevention

Several studies suggest that the increase in sexually transmitted infections (STIs) among men who have sex with men (MSM) could be due, in part, to human immunodeficiency virus (HIV) risk reduction strategies, which include engaging in oral sex over anal sex. The aims of this study were to evaluate oral sex behaviors and STI diagnoses and to investigate the potential dual role of oral sex as being protective for HIV, yet perpetuating STI transmission among MSM. We analyzed records from 871 MSM presenting to the Rhode Island STI Clinic between 2012 and 2015. We compared outcomes in men engaging in two HIV protective oral sex behaviors: (1) HIV/STI outcomes by men engaging only in oral sex versus those that did not, and (2) HIV/STI outcomes by men engaging in condomless oral sex with 100% condom use for all other sex acts versus those that did not. Men engaging in HIV protective oral sex behaviors were more likely to be HIV negative compared to men not engaging in them (99% vs. 93%, p < 0.01). In contrast, there was no significant difference in STI diagnoses between those that engaged in HIV protective oral sex behaviors and those that did not. The findings provide evidence to support the unique duality of oral sex: decreased risk for HIV and perpetuation of STI risk. Promotion of routine STI testing, including extragenital sites, is critical to address STI prevention among MSM. In the age of HIV prevention, addressing the ambiguous risks of discrete sex acts would be beneficial for both HIV and STI prevention education for MSM.

Seroadaptive Strategies of Gay & Bisexual Men (GBM) with the Highest Quartile Number of Sexual Partners in Vancouver, Canada

Despite continued research among men with more sexual partners, little information exists on their seroadaptive behavior. Therefore, we examined seroadaptive anal sex strategies among 719 Vancouver gay and bisexual men (GBM) recruited using respondent-driven sampling. We provide descriptive, bivariable, and multivariable adjusted statistics, stratified by HIV status, for the covariates of having ≥7 male anal sex partners in the past 6 months (Population fourth quartile versus <7). Sensitivity Analysis were also performed to assess the robustness of this cut-off. Results suggest that GBM with more sexual partners are more likely to employ seroadaptive strategies than men with fewer partners. These strategies may be used in hopes of offsetting risk, assessing needs for subsequent HIV testing, and balancing personal health with sexual intimacy. Further research is needed to determine the efficacy of these strategies, assess how GBM perceive their efficacy, and understand the social and health impacts of their widespread uptake.

An Event-Level Analysis of the Interpersonal Factors Associated With Condomless Anal Sex Among Gay, Bisexual, and Other Men Who Have Sex With Men (MSM) With Online-Met Partners

The interpersonal determinants of condomless anal sex (CAS) within online-initiated sexual relationships remain poorly understood. Therefore, respondent-driven sampling was used to recruit a prospective cohort of sexually active gay, bisexual, and other men who have sex with men (MSM), aged ≥ 16 years in Vancouver, Canada. Follow-up occurred every 6 months, up to seven visits; at each visit participants reported their last sexual encounter with their five most recent partners. Stratified by self-reported HIV status, individual-level, interpersonal, and situational covariates of event-level CAS with partners met online were modeled using generalized estimating equations (GEE). CAS was reported during 32.4% (n = 1,015/3,133) of HIV-negative/unknown men's events, and 62.1% (n = 576/928) of HIV-positive men's events. Social (i.e., collective identity, altruism, network size social embeddedness) and situational (i.e., number of encounters, location, comparative age, seroconcordance, substance use) factors were identified as important correlates of CAS. Implications include the need for HIV prevention addressing social contexts associated with CAS.

Generational analysis of trends in unprotected sex in France among men who have sex with men: The major role of context-driven evolving patterns

OBJECTIVE

Using a generational approach, this study analyses how unprotected anal intercourse has evolved since 1991 in France across different generations of men who have sex with men (MSM) whose sexual lives began at different periods in the history of the HIV epidemic.

DESIGN

Data were collected from 18-59 year-old respondents to the French Gay Press surveys Enquêtes Presse Gay, conducted repeatedly between 1991 and 2011 (N = 32,196) using self-administered questionnaires distributed in gay magazines and over the internet.

METHODS

Trends in unprotected anal intercourse (i.e. condomless anal sex) with casual partners of unknown or different HIV serostatus (hereafter "UAId" in this manuscript) were studied. Responses were analysed according to year and then reorganised for age-cohort analyses by generation, based on the year respondents turned 18.

RESULTS

UAId rates fell from 1991 to 1997, and then rose from 13.4% in 1997 to 25.5% in 2011 among seronegative respondents, and from 24.8% to 63.3%, respectively, among seropositive respondents. Both in seropositive and seronegative respondents, UAId increased over time for all generations, indicative of a strong period effect.

CONCLUSION

Analyses of data from several generations of MSM who started their sexual lives at different time points in the HIV epidemic, revealed very similar trends in UAId between generations, among both seropositive and seronegative respondents. This strong period effect suggests that sexual behaviours in MSM are influenced more by contextual than generational factors. The fact that prevention practices are simultaneously observed in different generations and that there are most likely underlying prevention norms among MSM, suggests that PrEP could become widely accepted by all generations of MSM exposed to the risk of HIV.

Is Group Sex a Higher-Risk Setting for HIV and Other Sexually Transmitted Infections Compared With Dyadic Sex Among Men Who Have Sex With Men?

BACKGROUND

Group sex has been suggested as a potential high-risk setting for HIV and other sexually transmitted infections (STIs) among men who have sex with men (MSM). We investigated whether group sex is associated with lower condom use during anal sex and higher proportions of STIs compared with dyadic sex among HIV-negative MSM between 2009 and 2012.

METHODS

Cross-sectional data from 7 data waves of the Amsterdam Cohort Studies were used. The sample consisted of 465 MSM who either reported both group and dyadic sex (at n = 706 visits) or dyadic sex only (at n = 1339 visits) in the preceding 6 months. Logistic regression with generalized estimating equations was used to investigate the association between sexual setting (group vs. dyadic sex), condomless anal sex, and STI.

RESULTS

Group sex was reported at 35% (706/2045) of visits. Condomless sex was more often reported during dyadic than group sex (odds ratio, 3.64 95% confidence interval, 2.57-5.16). Men who had group sex were more likely diagnosed as having gonorrhea compared with men with dyadic sex (odds ratio, 1.71; 95% confidence interval, 1.08-2.97), but this effect was not retained in the multivariate model.

CONCLUSIONS

Results demonstrate within-person differences in sexual behavior during group and dyadic sex among MSM. Men were more likely to use condoms during group sex than during dyadic sex. Thus, for some, group sex may not necessarily be risky for HIV infection compared with dyadic sex. However, group sex may be a higher-risk setting for acquiring STIs other than HIV, such as gonorrhea. Group sex encounters should be recognized as distinct sexual settings with specific risk characteristics that need to be addressed accordingly.