The risk of stable partnerships: associations between partnership characteristics and unprotected anal intercourse among men who have sex with men and transgender women recently diagnosed with HIV and/or STI in Lima, Peru

Sexual network characteristics, condomless anal intercourse, and the HIV care cascade among MSM living with controlled versus uncontrolled HIV infection in Lima, Peru: a population-based cross-sectional analysis

Background

Despite high rates of HIV transmission among men who have sex with men (MSM) in Lima, Peru, limited data exist on the sexual network characteristics or risk factors for secondary HIV transmission among MSM with uncontrolled HIV infection. We report the frequency of serodiscordant, condomless anal intercourse (CAI) and associated sexual network characteristics among MSM in Lima with detectable HIV viremia and compare to those with undetectable viremia.

Methods

This cross-sectional analysis includes MSM who tested positive for HIV-1 during screening for a trial of partner management and STI control (June 2022-January 2023). Participants were tested for HIV, gonorrhoea, chlamydia, and syphilis, and completed questionnaires on their demographic characteristics, sexual identity and behaviour, sexual network structures and engagement in HIV care.

Findings

Of 665 MSM, 153 (23%) had detectable (>200 copies/mL) viremia. 75% (499/662) of men living with HIV were previously diagnosed, with 94% (n = 469/499) reporting that they were on ART, and 93% (n = 436/469) virally suppressed. 96% (n = 147/153) of men with detectable viremia reported serodiscordant CAI with at least one of their last three sexual partners, and 74% (n = 106/144) reported the same with all three of their recent partners. In contrast, 62% (n = 302/489) of men with undetectable viral load reported serodiscordant CAI with all of their last three partners (p < 0.01).

Interpretation

23% of men living with HIV in Peru had detectable viremia, of whom almost all (96%) reported recent serodiscordant CAI. The primary gap in the HIV care cascade lies in awareness of HIV serostatus, suggesting that improved access to HIV testing could be a key prevention strategy in Peru.

Funding

Funding for this study was provided by NIH/NIMH grants R01 MH118973 (PI: Clark) and R25 MH087222 (PI: Clark).

Factors associated with hepatitis A susceptibility among men who have sex with men using HIV pre-exposure prophylaxis in Northeastern Brazil: A cross-sectional study

Hepatitis A virus (HAV) infection has disproportionately affected more men who have sex with men (MSM), occurring in outbreaks, despite being vaccine-preventable. We determined the prevalence and factors associated with HAV susceptibility among cisgender MSM on HIV pre-exposure prophylaxis (PrEP) in Northeastern Brazil. From September 30, 2021 to June 19, 2023, 282 cisgender MSM receiving HIV PrEP were enrolled into this cross-sectional study. Sociodemographic and clinical information were collected. Blood samples were collected for screening of sexually transmitted infections (STIs) and serum samples were tested for IgM and total anti-HAV antibodies. Non-reactive results for total anti-HAV antibodies were found in 106 of 282 (37.6%) participants. Factors associated with HAV susceptibility included age <30 years (prevalence ratio [PR]: 2.02; 95% confidence interval [95% CI]: 1.61-2.53), having health insurance (PR: 1.39; 95% CI: 1.19-1.64), sex only with cisgender men (PR: 1.52; 95% CI: 1.23-1.89), non-steady partner (PR: 1.20; 95% CI: 1.01-1.43) and no lifetime history of STIs (PR: 1.25; 95% CI: 1.03-1.53). Identifying clinical correlates of HAV susceptibility in key populations is a fundamental step towards development of public policy focused on prevention, especially following the recent hepatitis A outbreak in Brazil.

Sexual network characteristics and partnership types among men who have sex with men diagnosed with syphilis, gonorrhoea and/or chlamydia in Lima, Peru

OBJECTIVES

Sexual networks are known to structure sexually transmitted infection (STI) transmission among men who have sex with men (MSM). We sought to estimate the risks of STI diagnosis for various partnership types within these networks.

METHODS

Our cross-sectional survey analysed data from 1376 MSM screened for a partner management intervention in Lima, Peru. Participants were tested for HIV, syphilis, gonorrhoea (NG) and chlamydia (CT) and completed surveys on their demographics, sexual identity/role, HIV status, partnership types and sexual network from the prior 90 days. χ2 and Wilcoxon rank-sum tests compared participants without an STI to those diagnosed with (1) syphilis, (2) NG and/or CT (NG/CT) and (3) syphilis and NG/CT coinfection (coinfection).

RESULTS

40.8% (n=561/1376) of participants were diagnosed with an STI (syphilis: 14.9%, NG/CT: 16.4%, coinfection: 9.5%). 47.9% of all participants were living with HIV and 8.9% were newly diagnosed. A greater proportion of participants with syphilis and coinfection were living with HIV (73.5%, p<0.001; 71.0%, p<0.001) compared with those with NG/CT (47.8%) or no STI (37.8%). Participants with syphilis more often reported sex-on-premises venues (SOPVs) as the location of their last sexual encounter (51.7%, p=0.038) while those with NG/CT tended to meet their last sexual partner online (72.8%, p=0.031). Respondents with coinfection were the only STI group more likely to report transactional sex than participants without an STI (31.3%, p=0.039).

CONCLUSIONS

Sexual networks and partnership types of Peruvian MSM are associated with differential risks for STIs. Participants diagnosed with syphilis tended to meet single-encounter casual partners at SOPV, while MSM with NG/CT were younger and often contacted casual partners online. Coinfection had higher frequency of transactional sex. These findings suggest the potential importance of public health interventions through combined syphilis/HIV screening at SOPV, syphilis screening at routine clinic appointments for MSM living with HIV and directed advertisements and/or access to NG/CT testing through online platforms.

Substance use and variation in sexual partnership rates among young MSM and young transgender women: Disaggregating between and within-person associations

BACKGROUND

Substance use has been extensively linked to sexual behavior and HIV/STI risk among men who have sex with men (MSM) and transgender women (TW). However, the impact of specific substances and on specific partnership types is not well characterized. The current study seeks to estimate the association between specific substances and partnership rates while carefully disaggregating between and within-person associations to characterize the nature of these associations and inform prevention interventions.

METHODS

Using data from a longitudinal cohort (n = 1159) of young MSM (YMSM) and young TW (YTW), we utilized a series of hybrid mixed effect models to estimate the associations between substance use (i.e., heavy episodic drinking [HED], marijuana, cocaine, ecstasy, methamphetamine, poppers, prescription stimulant, prescription painkiller, and prescription depressants) and partnerships (i.e., one-time, casual, and main).

RESULTS

Results from multivariable models indicated people using substances had higher one-time (HED, poppers) and casual (HED, methamphetamine, poppers) partnership rates. In addition, participants reported higher rates of one-time (HED, ecstasy, methamphetamine, poppers) and casual partners (HED, marijuana, cocaine, methamphetamines, poppers) during periods of substance use.

CONCLUSION

These findings confirm that the highest rates of sexual activity occur among YMSM-YTW using substances during periods of substance use. Yet, these findings should caution researchers against simplistic generalizations as these associations differ across substance and partnership types. Efforts to promote the health of MSM-YTW who use substances should carefully consider this complexity as interventions accounting for the unique cultural context of substance use in these populations are most likely to be successful.

Correlates of condomless anal intercourse with different types of sexual partners among men who have sex with men and transgender women in Lima, Peru

CLINICAL TRIAL REGISTRATION

The Sabes study was registered in March 2013 with the National Institutes of Health at ClinicalTrials.gov (identifier: NCT01815580).

Exploring Contextual Differences for Sexual Role Strain Among Transgender Women and Men Who Have Sex with Men in Lima, Peru

Sexual and gender politics inform relational expectations surrounding sexual experiences of Peruvian transgender women (TW) and men who have sex with men (MSM). We used the framework of sexual role strain, or incongruence between preferred sexual role and actual sexual practices, to explore potential conflicts between personally articulated identities and externally defined norms of gender and sexuality and its potential to increase HIV/STI risk. Cross-sectional individual- and dyad-level data from 766 TW and MSM in Lima, Peru were used to assess the partnership contexts within which insertive anal intercourse was practiced despite receptive role preference (receptive role strain), and receptive anal intercourse practiced despite insertive role preference (insertive role strain). Sexual role strain for TW was more common with non-primary partners, while for MSM it occurred more frequently in the context of a primary partnership. Receptive role strain was more prevalent for TW with unknown HIV status (reference: without HIV) or pre-sex drug use (reference: no pre-sex drug use). For homosexual MSM, receptive role strain was more prevalent during condomless anal intercourse (reference: condom-protected) and with receptive or versatile partners (reference: insertive). Among heterosexual or bisexual MSM, insertive role strain was more prevalent with insertive or versatile partners (reference: receptive), and less prevalent with casual partners (reference: primary). Our findings suggest TW and MSM experience different vulnerabilities during sexual role negotiation with different partner-types. Future studies should explore the impact of sexual role strain on condom use agency, HIV/STI risk, and discordances between public and private presentations of gender and sexual orientation.

Let's Talk About Sex: The Impact of Partnership Contexts on Communication About HIV Serostatus and Condom Use Among Men Who Have Sex with Men (MSM) and Transgender Women (TW) in Lima, Peru

Sexual communication with partners informs risk assessment and sexual practices. We evaluated participant, partner, and network factors associated with communication about condom use and HIV serostatus and explored their relationships with condomless anal intercourse (CAI) among 446 men who have sex with men (MSM) and 122 transgender women (TW) in Lima, Peru. Generalized estimating equations assessed contextual influences on communication and practices with recent sexual partners. More frequent HIV communication was reported by MSM who: identified as heterosexual, compared to bisexual or gay; characterized partnerships as stable, compared to casual, anonymous, or commercial; or discussed HIV/STIs with close social contacts (p < 0.05). TW in concurrent partnerships discussed condom use more frequently than those in monogamous relationships (p < 0.05). Condom use discussions and alcohol use among MSM were associated with CAI (p < 0.05). Findings highlight complexity in sexual decision-making and call for further study of conversation content and practices to inform HIV prevention messaging.

Factors related to condomless anal intercourse between men who have sex with men: results from a European bio-behavioural survey

Background

Relationship status is an important factor associated with condomless anal intercourse (CAI) amongst men who have sex with men (MSM).

Methods

A multi-centre bio-behavioural survey with MSM was conducted in 13 European cities (n = 4901) exploring factors associated with CAI via bivariate and multivariate multilevel logistic regression analyses.

Results

Likelihood of CAI with casual partners was associated with being ‘out’ to a majority (AOR = 1.19;95% CI 1,1.42); knowing their HIV status (AOR = 1.86; 95% CI 1.25,2.76); using substances (1–2 AOR = 1.39; 95% CI 1.16,1.63, 2+ AOR = 1.81; 95% CI 1.35,2.42); being older (AOR = 0.98; 95% CI 0.97,0.99); successful sero-communication (AOR = 0.79; 95% CI 0.67,0.94); and, not having a recent HIV test (AOR = 0.78; 95% CI 0.66,0.92). CAI with steady partners was associated with successful sero-communication (AOR = 2.72; 95% CI 2.72,3.66); not having a recent HIV test (AOR = 1.26; 95% CI 1.09,1.46), and; being older (AOR = 0.99; 95% CI 0.98,0.99).

Conclusions

Understandings of partner type and/or relationship status in relation to CAI amongst MSM can potentially play an important role in the development of culturally appropriate HIV/STI prevention and risk-reduction efforts targeting at-risk MSM. Our results speak to the need to consider segmented and tailored public health and health promotion initiatives for MSM with differing CAI behaviours and relationship profiles.

Violence Victimization and Condomless Anal Intercourse Among Transgender Women in China: Mediating Role of Depression

Transgender women (TGW) worldwide report disproportionate violence victimization, depression and condomless anal intercourse (CAI), but the mechanism of the coexistence remains unclear. Using snowball sampling, we recruited 198 self-identified TGW in Shenyang, China between April 2017 and July 2017, and conducted confidential questionnaire survey among them. Positive HIV status was reported by 49 (24.7%) participants. 117 (59.1%) reported at least one type of lifetime violence victimization, with transactional sexual partners being the main violence perpetrators. 108 (54.5%) reported mild to severe depression. 105 (53.0%) reported having CAI with their sexual partners during the last 6 months. Path analysis showed that the association between participants' violence victimization and CAI was fully mediated by their depression (indirect effect: 0.083, p = 0.014; direct effect: 0.137, p = 0.121). We suggest to incorporate violence screening and prevention and mental health services into intervention strategies to prevent CAI among Chinese TGW.

Brief Report: Seroadaptive Behaviors Varied Among Geographically Diverse iPrEx Participants

BACKGROUND

Seroadaptive behaviors refer to a wide range of harm reduction practices to decrease HIV transmission risk. Effective implementation of seroadaptive behaviors is dependent on knowledge of one's own serostatus and that of one's sexual partners. Partner-level and environmental-level attributes may affect seroadaptation practices. We assessed factors associated with seroadaptive behaviors.

METHODS

Men who have sex with men and transgender women were recruited from an HIV pre-exposure prophylaxis clinical trial (iPrEx) with study sites in the US, Peru, Ecuador, Brazil, Thailand, and South Africa. Partnership-level data were collected at the baseline visit for the 3 most recent partners. Participants were considered to have practiced seroadaptive behaviors if: (1) they believed their partner to be HIV-negative, that is, serosorting; or (2) no condomless receptive sex occurred with an HIV-positive or unknown status partner, that is, seropositioning.

RESULTS

Of 2331 participants, 41% always practiced seroadaptive behaviors, 36% sometimes did, and 23% never did. Participants enrolled at study sites in the US (P < 0.001) and Peru/Ecuador (P < 0.001) were more likely to practice seroadaptive behaviors, whereas transgender women were less likely to do so (P < 0.001). Seroadaptive behaviors were more likely to occur in relationships with steady partners (P = 0.005) and emotionally close relationships (P = 0.013).

CONCLUSIONS

Seroadaptive behaviors were more frequently observed among iPrEx participants from the US, Peru, and Ecuador study sites and among participants in relationships with partners who they were more committed to and felt emotionally close to. Our findings suggest that seroadaptive behaviors may be influenced by social norms that vary geographically and culturally.

Intimate Partner Violence Against Transgender Women: Prevalence and Correlates in Lima, Peru (2016-2018)

Limited data exists on intimate partner violence (IPV) among transgender women (TW), though global trends suggest IPV is associated with HIV risk in this population. We describe the prevalence of verbal, physical, and/or sexual violence as well as participant- and partner-level correlates of IPV among TW in Lima, Peru. Among 389 respondents, 15.2% reported IPV with one or more of their last three sexual partners: 9.2% verbal, 8.2% physical, and 2.3% sexual violence. Physical and verbal violence were more common with stable partners (aPR 3.46, 95% CI 1.17-10.25, aPR 2.46, 95% CI 1.14-5.28, respectively). Physical violence was associated with condomless receptive anal intercourse (cRAI) (aPR 2.22, 95% CI 1.19-4.13) and partner alcohol use (aPR 4.38, 95% CI 1.56-12.33) while verbal violence correlated with participant inebriation (aPR 4.86, 95% CI 1.63-14.46). Our results link IPV with stable partnerships, alcohol use, and cRAI, suggesting TW in Peru may benefit from multidimensional IPV prevention strategies to foster supportive relationships and reduce HIV transmission.

Information-Motivation-Behavioral Skills model of consistent condom use among transgender women in Shenyang, China

BACKGROUND

The Information-Motivation-Behavioral Skills (IMB) model has received consistent empirical support in the context of HIV prevention among various key populations, but not yet among transgender women (TGW). None effective interventions has been carried out among TGW so far to control their high prevalence of unprotected anal intercourse. The intent of the current study is to examine the application of the IMB model to clarifying the association between condom use correlates and condom use frequency among TGW in China.

METHODS

Using snowball sampling, we recruited 198 self-identified TGW in Shenyang, China from April 2017 to July 2017. Participants were required to complete a questionnaire assessing their background characteristics and IMB model constructs. Structural equation modeling (SEM) was conducted to demonstrate the utility of the IMB model.

RESULTS

The consistent condom use (CCU) rate was 47.0%. Results of SEM indicated that HIV-preventive motivation (comprising condom use attitude and subjective norms; β = 0.823, P <  0.001) and behavioral skills (including condom use skills and self-efficacy; β = 0.979, P = 0.004) were related to more frequent condom use, whereas HIV knowledge was unrelated to condom use (β = 0.052, P = 0.540).

CONCLUSIONS

The low CCU rate suggested that TGW in China were at high risk of HIV infection and transmission and a key intervention population. HIV-preventive interventions for this population should focus on enhancing motivation and strengthening behavioral skills to increase condom use frequency and reduce HIV infection.

Characterizing Men Who Have Sex with Transgender Women in Lima, Peru: Sexual Behavior and Partnership Profiles

HIV prevalence is high among transgender women (TW), but how HIV is transmitted to this population is not well understood. This analysis aims to characterize sexual partners of TW (PTW) to understand how their behavior contributes to HIV risk among TW. We examined baseline data from TW, PTW, and men who have sex with men (MSM) from a treatment-as-prevention study in Lima, Peru. Individual and partnership characteristics were compared across groups, and Poisson regression was used to calculate prevalence ratios for associations between sexual concurrency and potential correlates. We found that 81% of PTW had no cisgender male partners. Prevalence of alcohol dependency, concurrency, and condomless anal intercourse was high and HIV testing was low compared to the other groups. Our results suggest that PTW are a distinct population from MSM and TW, engage in behavior associated with HIV transmission, and are likely not well reached by HIV prevention interventions.

Transactional Sex, Substance Use, and Sexual Risk: Comparing Pay Direction for an Internet-Based U.S. Sample of Men Who Have Sex with Men

Demographic, behavioral, and structural factors among four mutually exclusive transactional sex categories were assessed in an online sample of 7217 sexually active US men who have sex with men (MSM): (1) No Trade Sex group (87%); (2) Sellers, accepting money or drugs for sex (5%); (3) Buyers, giving money or drugs for sex (6%); and (4) Sellers and Buyers, accepting and giving money or drugs for sex (2%). Separate multivariable logistic regressions compared men who did not report past 60-day transactional sex with men in the three transactional sex groups. Sellers were more likely to report being black or Asian (versus white), low income, a recent STI diagnosis, six or more recent male anal sex partners, and polydrug use. Buyers were more likely to report being older, higher income, urban residence, incarceration history, a recent STI diagnosis, and having non-main sex partners. Sellers and Buyers were more likely to report a higher income, incarceration history, six or more recent male anal sex partners, and polydrug use. Findings suggest that public health policy and HIV prevention harm reduction strategies should address the distinct sexual and behavioral risk patterns among MSM who engage in transactional sex based on payment direction.

Homophobia and heteronormativity as dimensions of stigma that influence sexual risk behaviors among men who have sex with men (MSM) and women (MSMW) in Lima, Peru: a mixed-methods analysis

BACKGROUND

Stigma differentially influences HIV and STI care among MSM, especially regarding partner notification practices. Recognizing the heterogeneous behaviors/identities within the category "MSM," we used mixed-methods to assess sexual risk behaviors among men who have sex with men only (MSMO) and behaviorally bisexual MSM (MSMW) with HIV and/or other STIs.

METHODS

MSMO/MSMW recently diagnosed (< 30 days) with HIV, syphilis, urethritis, or proctitis completed a cross-sectional survey assessing sexual risk behaviors, anticipated disclosure, and sexual partnership characteristics (n = 332). Multivariable generalized estimating equation models assessed characteristics associated with female compared to male partners in the last three partnerships. Follow-up qualitative interviews (n = 30) probed partner-specific experiences (e.g., acts and disclosure).

RESULTS

Among all participants, 13.9% (n = 46) described at least one of their last three sex partners as female (MSMW). MSMW (mean age of 31.8) reported a mean of 3.5 partners (SD = 4.5) in the past 3 months and MSMO (mean age 30.6) reported a mean of 4.6 partners (SD = 9.7) in the past 3 months. MSMW were more likely to report unprotected insertive anal sex (77.9%) than MSMO (43.1%; p < 0.01). Cisgender female partners were associated with condomless insertive sex in the last 3 months (aPR: 3.97, 95%CI: 1.98-8.00) and classification as a "primary" partnership (2.10, 1.34-3.31), and with lower prevalence of recent HIV diagnosis (0.26, 0.11-0.61). Planned notification of HIV/STI diagnoses was less common for female than for male partners (0.52, 0.31-0.85). Narratives illustrate internal (e.g., women as 'true' partners) and community-level processes (e.g., discrimination due to exposure of same-sex behavior) that position homosexual behavior and bisexual identity as divergent processes of deviance and generate vulnerability within sexual networks.

CONCLUSIONS

MSMW recently diagnosed with HIV/STI in Peru report varying partnership characteristics, with different partner-specific risk contexts and prevention needs. Descriptions highlight how behaviorally bisexual partnerships cut across traditional risk group boundaries and suggest that HIV/STI prevention strategies must address diverse, partnership-specific risks.

Characterizing HIV risk among cisgender men in Latin America who report transgender women as sexual partners: HIV risk in Latin America men

Cisgender men (CM) who report transgender women (TW) as sexual partners are an understudied population in the HIV epidemic in Latin America. The current study sought to characterize this group in a 2012 cross-sectional online survey of Latin American CM who were members of a sexual networking website for men who have sex with men (N = 11,847). Multivariable logistic regression models were fit to estimate demographic, behavioral, and psychosocial correlates of having a TW sexual partner and engaging in condomless sex. Overall, 0.9% (n = 106) reported a TW sexual partner in the last 12 months; of these, 76.4% (n = 81) reported condomless sex in the last three months. Identifying as bisexual or heterosexual compared to gay, and specifying a versatile sexual role preference compared to insertive were associated with reporting a recent TW sex partner (all p < 0.05). HIV-negative serostatus, lifetime STI history, and alcohol dependence were associated with recent condomless sex (all p < 0.05). CM with TW sexual partners have distinct HIV-related vulnerabilities. Future research is needed to understand CM who report TW sexual partners, including their sexual preferences and practices, sexual networks, exposure to stigma, biomedical prevention interest and uptake, and acceptability of integrating alcohol abuse screening into sexual health services.

Correlates of Rectal Douching Practices Among Men Who Have Sex With Men in Kenya

BACKGROUND

Among men who have sex with men (MSM), rectal douching (RD) has been associated with increased prevalence of human immunodeficiency virus and other sexually transmitted infections. Substances commonly used for RD, especially water-based solutions, could disrupt the rectal epithelium and increase susceptibility to infection. The few existing reports on RD among MSM are primarily in middle- and high-income settings, and to date, no study has focused on RD among MSM in Africa.

METHODS

We conducted a secondary data analysis of programmatic data from key population service centers in western Kenya. Data were extracted from records of clients who identified as MSM and accessed services between January 1, 2014, and September 1, 2016. We compared demographic and behavioral characteristics of men who did and did not practice RD. Logistic regression assessed associations with RD.

RESULTS

Of the 202 MSM in this analysis, 63% engaged in RD. All who engaged in RD used water-based substances. Those who engaged in receptive anal intercourse in the last 3 months were more likely to report RD (odds ratio, 3.19; 95% confidence interval, 1.67-6.07). Among MSM who engaged in sex work, those who practiced RD reported more regular clients per week (2.8 clients vs. 1.3 clients, P = 0.01). Rectal douching practices did not vary by other sexual risk practices.

CONCLUSIONS

Rectal douching is common in this population of Kenyan MSM, especially among those who have recently engaged in receptive anal intercourse, suggesting that a rectal douche that delivers microbicides could be a potential intervention to reduce human immunodeficiency virus/sexually transmitted infection within this population.

Perceived Barriers and Facilitators to Integrating HIV Prevention and Treatment with Cross-Sex Hormone Therapy for Transgender Women in Lima, Peru

Transgender women (TW) represent a vulnerable population at increased risk for HIV infection in Peru. A mixed-methods study with 48 TW and 19 healthcare professionals was conducted between January and February 2015 to explore barriers and facilitators to implementing a model of care that integrates HIV services with gender-affirmative medical care (i.e., hormone therapy) in Lima, Peru. Perceived acceptability of the integrated care model was high among TW and healthcare professionals alike. Barriers included stigma, lack of provider training or Peruvian guidelines regarding optimal TW care, and service delivery obstacles (e.g., legal documents, spatial placement of clinics, hours of operation). The hiring of TW staff was identified as a key facilitator for engagement in health care. Working in partnership with local TW and healthcare provider organizations is critical to overcoming existing barriers to successful implementation of an integrated HIV services and gender-affirmative medical care model for this key population in Peru.

Partner-Level Factors Associated with Insertive and Receptive Condomless Anal Intercourse Among Transgender Women in Lima, Peru

Condomless anal intercourse among transgender women (TW) in Peru has been shown to vary by the type of partner involved (e.g. primary vs. casual vs. transactional sex partner), but no previous studies have explored variations in partner-level patterns of condom use according to type of anal intercourse. We evaluated the relationship between partnership characteristics and condom use during insertive (IAI) versus receptive anal intercourse (RAI) among TW with recent, non-female partners. Condomless IAI was more common with transactional and casual sex partners and by TW who self-reported HIV-uninfected serostatus (p < 0.05), alcohol use disorders, or substance use before sex. Condomless RAI was more common with primary partners and by TW who described their HIV serostatus as unknown (p < 0.05). Examining partner-level differences between condomless IAI and RAI reveals distinct patterns of HIV/STI risk among TW, suggesting a need for HIV prevention strategies tailored to the specific contexts of partners, practices, and networks.

Sex with older partners, condomless anal sex and unrecognized HIV infection among Chinese men who have sex with men

We examined the prevalence of sex with older male partner (SWOMP) and its association with condomless anal intercourse (CAI) with male partners and unrecognized HIV infection among young men who have sex with men (MSM) in Shanghai, China. The analytic sample included 243 MSM who were 18-45 years and HIV negative or of unknown HIV serostatus. Older male partner refers to male sex partner who was at least 10 years older than themselves. Overall, 99 (43.0%) and 50 (20.7%) reported having SWOMP in lifetime and in the last 3 months, respectively. Having any CAI with male partners in the last 3 months was independently associated with SWOMP and sex with stable male partners in the last 3 months. Unrecognized HIV infection was independently associated with being HSV-2 positive and having any CAI with male partners as well as SWOMP in last 3 months. Sex with stable male partner in the last 3 months was also marginally significantly associated with unrecognized infection (p = 0.084). Older partner selection is common among young MSM in China. Prevention programs should incorporate education messages about the HIV risk associated with SWOMP. MSM should be informed that having condomless sex with stable partners may place them at HIV risk.

Expedited Partner Therapy (EPT) increases the frequency of partner notification among MSM in Lima, Peru: a pilot randomized controlled trial

BACKGROUND

Expedited Partner Therapy (EPT) has been shown to improve treatment outcomes among heterosexual partners of individuals with curable sexually transmitted infections (STIs). Although the use of EPT with men who have sex with men (MSM) has been debated, due to the potential for missed opportunities to diagnose unidentified cases of HIV and syphilis infection in symptomatic partners, increases in partner notification (PN) resulting from use of EPT may promote testing and treatment of otherwise unidentified partners. We assessed the impact of EPT on self-reported PN among MSM in Peru with gonorrheal (GC) and/or chlamydial (CT) infection.

METHODS

We enrolled 173 MSM in Lima, Peru with symptomatic or asymptomatic GC and/or CT infection between 2012 and 2014. We enrolled 44 MSM with symptomatic urethritis/proctitis and 129 MSM with asymptomatic GC/CT infection, diagnosed based on nucleic acid testing (Aptima Combo 2 Transcription-Mediated Amplification [TMA]) from urethral, pharyngeal, and rectal sites. Eligible participants were randomly assigned to receive either standard PN counseling (n = 84) or counseling plus EPT (cefixime 400 mg/azithromycin 1 g) for up to five recent partners (n = 89). Self-reported notification was assessed by computer-assisted self-administered survey among 155 participants who returned for 14-day follow-up.

RESULTS

The median age of participants was 26 (interquartile range [IQR]: 23-31) with a median of 3 sexual partners (IQR: 2-4) in the previous 30-day period. Among all participants, 111/155 (71.6%) notified at least one partner at 14-day follow-up with a median of 1 partner notified per participant (IQR: 0-2). For participants randomized to receive EPT, 69/83 (83.1%) reported notifying at least one partner, compared with 42/72 (58.3%) of participants in the control arm (odds ratio = 3.52; 95% confidence interval [CI]: 1.68-7.39). The proportion of all recent partners notified was significantly greater in the EPT than in the control arm (53.5%, 95% CI: 45.0-62.0% versus 36.4%, 95% CI: 27.0-47.4%).

CONCLUSIONS

Provision of EPT led to significant increases in notification among Peruvian MSM diagnosed with GC/CT infection. Additional research is needed to assess the impact of EPT on biological outcomes, including persistent or recurrent infection, antimicrobial resistance, and HIV/STI transmission, in MSM sexual networks.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01720654 . Registered on 10/29/2012.

Leveraging social capital: multilevel stigma, associated HIV vulnerabilities, and social resilience strategies among transgender women in Lima, Peru

INTRODUCTION

In Peru, transgender women (TW) experience unique vulnerabilities for HIV infection due to factors that limit access to, and quality of, HIV prevention, treatment and care services. Yet, despite recent advances in understanding factors associated with HIV vulnerability among TW globally, limited scholarship has examined how Peruvian TW cope with this reality and how existing community-level resilience strategies are enacted despite pervasive social and economic exclusion facing the community. Addressing this need, our study applies the understanding of social capital as a social determinant of health and examines its relationship to HIV vulnerabilities to TW in Peru.

METHODS

Using qualitative methodology to provide an in-depth portrait, we assessed (1) intersections between social marginalization, social capital and HIV vulnerabilities; and (2) community-level resilience strategies employed by TW to buffer against social marginalization and to link to needed HIV-related services in Peru. Between January and February 2015, 48 TW participated (mean age = 29, range = 18-44) in this study that included focus group discussions and demographic surveys. Analyses were guided by an immersion crystallization approach and all coding was conducted using Dedoose Version 6.1.18.

RESULTS

Themes associated with HIV vulnerability included experiences of multilevel stigma and limited occupational opportunities that placed TW at risk for, and limited their engagement with, existing HIV services. Emergent resiliency-based strategies included peer-to-peer and intergenerational knowledge sharing, supportive clinical services (e.g. group-based clinic attendance) and emotional support through social cohesion (i.e. feeling part of a community).

CONCLUSION

This study highlights the importance of TW communities as support structures that create and deploy social resiliency-based strategies aimed at deterring and mitigating the impact of social vulnerabilities to discrimination, marginalization and HIV risk for individual TW in Peru. Public health strategies seeking to provide HIV prevention, treatment and care for this population will benefit from recognizing existing social capital within TW communities and incorporating its strengths within HIV prevention interventions. At the intersection of HIV vulnerabilities and collective agency, dimensions of bridging and bonding social capital emerged as resiliency strategies used by TW to access needed healthcare services in Peru. Fostering TW solidarity and peer support are key components to ensure acceptability and sustainability of HIV prevention and promotion efforts.

Sexual Orientation, Gender Identity and Perceived Source of Infection Among Men Who Have Sex with Men (MSM) and Transgender Women (TW) Recently Diagnosed with HIV and/or STI in Lima, Peru

Risk perception and health behaviors result from individual-level factors influenced by specific partnership contexts. We explored individual- and partner-level factors associated with partner-specific perceptions of HIV/STI risk among 372 HIV/STI-positive MSM and transgender women (TW) in Lima, Peru. Generalized estimating equations explored participants' perception of their three most recent partner(s) as a likely source of their HIV/STI diagnosis. Homosexual/gay (PR = 2.07; 95 % CI 1.19-3.61) or transgender (PR = 2.84; 95 % CI 1.48-5.44) partners were more likely to be considered a source of infection than heterosexual partners. Compared to heterosexual respondents, gay and TW respondents were less likely to associate their partner with HIV/STI infection, suggesting a cultural link between gay or TW identity and perceived HIV/STI risk. Our findings demonstrate a need for health promotion messages tailored to high-risk MSM partnerships addressing how perceived HIV/STI risk aligns or conflicts with actual transmission risks in sexual partnerships and networks.

Anticipated Notification of Sexual Partners following STD Diagnosis among Men Who Have Sex with Men and Transgender Women in Lima, Peru: A Mixed Methods Analysis

BACKGROUND

New strategies to support partner notification (PN) are critical for STD control and require detailed understanding of how specific individual and partnership characteristics guide notification decisions.

METHODS

From 2011 to 2012, 397 MSM and TW recently diagnosed with HIV, syphilis, or another STD completed a survey on anticipated notification of recent sexual partners and associated factors. Qualitative interviews were conducted with a subset of participants to provide further depth to quantitative findings. Prevalence ratios and generalized estimating equation (GEE) models were used to analyze participant- and partner-level factors associated with anticipated PN.

RESULTS

Among all partners reported, 52.5% were described as "Very Likely" or "Somewhat Likely" to be notified. Anticipated notification was more likely for main partners than casual (adjusted Prevalence Ratio [aPR], 95% CI: 0.63, 0.54-0.75) or commercial (aPR, 95% CI: 0.44, 0.31-0.62) partners. Other factors associated with likely notification included perception of the partner as an STD source (aPR, 95% CI: 1.27, 1.10-1.48) and anticipated future sexual contact with the partner (aPR, 95% CI: 1.30, 1.11-1.52). An HIV diagnosis was associated with a lower likelihood of notification than non-HIV STDs (aPR: 0.68, 0.55-0.86). Qualitative discussion of the barriers and incentives to PN reflected a similar differentiation of anticipated notification according to partnership type and type of HIV/STD diagnosis.

DISCUSSION

Detailed attention to how partnership characteristics guide notification outcomes is essential to the development of new PN strategies. By accurately and thoroughly assessing the diversity of partnership interactions among individuals with HIV/STD, new notification techniques can be tailored to partner-specific circumstances.

Sexual health and socioeconomic-related factors among HIV-positive men who have sex with men in Puerto Rico

Most of the research among HIV-positive populations has been approached from behavioral risk models. This is particularly true for those otherwise socially vulnerable groups like men who have sex with men (MSM). As a response to this pattern, we examined data from an ongoing health promotion research being conducted in Puerto Rico (PR). The study is limited to HIV-positive MSM and consists of the participation in a survey interview that includes domains used to assess indicators of socio-economic-related factors (age, educational level, employment, religion, and partnership status) and sexual health (sexual satisfaction, condom use, and sexual health knowledge(SHK)). Participants reported a relatively high level (75 %) of sexual satisfaction and inconsistent condom use (50.9 % reported always using a condom). A deficient (61 %) SHK was also reported. In multivariate analyses, a higher educational level was associated with higher sexual satisfaction (aβ = 3.223; 95 % CI 0.291-6.156) and higher levels of SHK (aβ = 1.328; 95 % CI 0.358-2.297), while unemployment was associated with less condom use (aOR 0.314; 95 % CI 0.122-0.810). Not having a primary sexual partner was associated with less sexual satisfaction (aβ = -3.871; 95 % CI -7.534-0.208) and more condom use (aOR 4.292; 95 % CI 1.310-14.068). Findings support the notion that men of a disadvantaged socioeconomic position may have a poorer sexual health status; with a lower level of education and unemployment leading this disparity. Findings also evidence that partnership status may have a role in the sexual health of HIV-positive MSM. To our knowledge, this is the first comprehensive analysis of sexual health and socioeconomic indicators among Hispanic/Latino HIV-positive MSM in PR and in the Caribbean. Findings provide valuable information to address the sexual health needs of an underserved population.

Sexually transmitted infections associated with alcohol use and HIV infection among men who have sex with men in Kampala, Uganda

OBJECTIVES

Few studies have been conducted in Africa to assess prevalence of sexually transmitted infections (STIs) and risk factors among men who have sex with men (MSM). We report findings from the first behavioural survey to include STI testing among MSM in Kampala, Uganda.

METHODS

Respondent-driven sampling (RDS) was used to recruit MSM for a biobehavioural survey. Eligible participants were men who reported anal sex with another man in the previous 3 months, were 18 years or older, and resided in Kampala. Information was collected on demographics, sexual behaviour, alcohol and drug use, and STI symptoms. Blood, urine and rectal specimens were tested for syphilis, HIV, rectal and urethral gonorrhoea, and chlamydia. Analyses weighted for RDS were conducted to assess associations with STI diagnosis.

RESULTS

A total of 295 MSM participated in the survey. Almost half (weighted percentage: 47.3%) reported STI symptoms in the last 6 months and 12.9% tested HIV-positive. Prevalence of non-HIV STI was 13.5%; syphilis prevalence was 9.0%. Adjusting for age and education, STI was associated with HIV (adjusted OR (AOR)=3.46, 95% CI 1.03 to 11.64), alcohol use before sex (AOR=4.99, 95% CI 1.86 to 13.38) and having sold sex in the last 3 months (AOR=3.17, 95% CI 1.25 to 8.07), and inversely associated with having anonymous sex partners (AOR=0.20, 95% CI 0.07 to 0.61).

CONCLUSIONS

We observed high levels of self-reported STI symptoms and STI prevalence associated with alcohol use and HIV among MSM in Kampala. Public health interventions supporting MSM are needed to address STI risk and facilitate access to diagnosis and treatment services.