HIV treatment as prevention in men who have sex with men: examining the evidence

The Dimensions of Desire Among Gay, Bisexual, and Other Men Who Have Sex With Men (gbMSM): An Evolutionary Concept Analysis

Background and Purpose: Within nursing discourses, the concept of desire among gay, bisexual, and other men who have sex with men (gbMSM) is not well understood. Among nurses, this concept is often constructed as being synonymous with sexual and other risk-taking behaviors, which can influence the type of care nurses provide to gbMSM and affect how this group engages with nurses - and their health. This misinterpretation of what desire represents has resulted in gbMSM becoming the target of public health campaigns and nursing interventions aimed at curbing their deviant behaviors. Such an approach by nurses, however, overlooks the meaning of desire among gbMSM. Methods: To enhance nursing knowledge about, and improve nursing practice for, gbMSM, a concept analysis of desire specific to this group was undertaken using Rodger's evolutionary model. For this analysis, 90 articles reviewed from the disciplines of nursing and allied health, medicine, and psychology. Results: Findings from this analysis revealed a complexity to desire among gbMSM that extended well beyond engagement in radical sexual practices and into dimensions of desire for connection, freedom, and acceptance. These revelations were applied to demonstrate how nurses' beliefs about desire and subsequent regulations for "good health" can inhibit the ways in which desire is produced among gbMSM. Implications for Practice: Such findings demonstrate a need to develop future approaches for nursing practice that recognize the innate value and individual perspectives about desire held by this group, which can be uniquely tailored to meet their health needs.

Public health counselling following an HIV diagnosis among men who have sex with men: tensions between individual needs and health protection mandates

Background

In Ontario, provincial regulations stipulate that public health units must complete post-test counselling with all persons newly diagnosed with human immunodeficiency virus. Public health nurses conduct this follow-up and are responsible for ensuring appropriate surveillance and management of human immunodeficiency virus with the primary objective of reducing ongoing human immunodeficiency virus transmission in their health jurisdiction. To date, little research has explored the effectiveness of this mandatory public health counselling from the perspective of patients - the majority of whom are men who have sex with men.

Aims

To address gaps in public health nursing practice, a pilot study was conducted with men who have sex with men in Ottawa to explore their attitudes and experiences of receiving mandatory human immunodeficiency virus follow-up after their diagnosis.

Methods

Qualitative interviews were conducted and interpreted using thematic analysis.

Results

This analysis revealed a contrariety between the needs of individuals and of public health units, with patients' perceiving their personal wishes to be secondary to public health mandates - and led patients to simultaneously want to evade, and be assisted by, public health nurses.

Conclusions

Public health units and nurses should consider adopting a more patient-centered approach to HIV case management, which incorporates patients' experiences of receiving an HIV diagnosis.

Avoiding missed opportunities to screen for HIV

HIV transmission is ongoing, primarily among men who have sex with men, injection drug users, and persons from HIV endemic regions. One prevention strategy has been prompt HIV diagnosis. Undermining these efforts is that some persons are diagnosed with HIV late in their infection because practitioners missed the diagnosis. In this article, the authors review the epidemiology and pathophysiology of HIV/AIDS, and provide a recommended clinical approach: (1) continue to screen persons who belong to the groups that are at-risk for HIV, and (2) appropriately rule out HIV infection in persons who present with HIV and AIDS-like symptoms.

The Evolution of HIV Prevention: From Discipline to Control

HIV prevention has changed since the identification of AIDS in 1981, the discovery of HIV in 1983, and the rollout of HIV antibody testing in 1985. Since this time, HIV prevention changed from behavior modification to testing to treatment as prevention to chemoprophylaxis using HIV medications among HIV-negative persons. While these modifications have been heralded as public health successes, critical evaluations are needed. In this article, we present one such review in which we argue that HIV prevention, while previously disciplinary in the Foucauldian sense, has become controlling in the Deleuzian sense. In this way, the parameters of context are targeted and behavior change is less relevant. This highlights the importance of questioning public health "advancements" and using novel theoretical lens to do so.

Considerations for Research on Sexually Transmitted Infections (STIs): Reflections of an STI Clinician-Researcher

Sexually transmitted infections (STIs) have been explored in various sexual subgroups. While excellent, these analyses have primarily occurred from uniquely biologic, epidemiologic, or sociologic perspectives. Missing from these discussions has been in-depth presentations of the dynamics of STI transmission from all three viewpoints simultaneously. In this paper, I present information about STI transmission for each STI, including considerations of prevalence, and then review the STI research and of the concept of risk. I then apply these three considerations to a fictitious case study to show their importance and utility. I close by arguing that this information could strengthen future sociologic reviews of STIs and sexual health by helping such researchers include more nuanced understandings about STIs.

The Social Geography of Partner Selection in Toronto, Canada: A Qualitative Description of "Convection Mixing"

The geographic distribution of sexually transmitted infections reflects the underlying social process of sexual partner selection. This qualitative study explored the social geography of partner selection among sexual minority men and used the results to develop a mid-range theory of STI transmission. In-depth interviews with 31 sexual minority men who lived, worked, or socialized in Toronto, Canada, occurred in June and July 2016. Participants were asked how they found sexual partners and reconstructed their egocentric sexual networks for the previous 3 months. Participants described an iterative process of partner selection involving intention (sex versus dating), connecting with community, and selecting a partner based on intersecting partner characteristics (external, internal, and emergent feelings when interacting with potential partners) and personal preferences. Geography influenced partner selection three ways: (1) participant search patterns maximized the number of potential partners in the shortest distance possible; (2) the density of sexual minority men in a participant's community directly impacted participant's social and sexual isolations; and (3) geosexual isolation influenced sexual mixing patterns. Participants described "convection mixing," where assortative urban mixing nested within disassortative suburban mixing resulted in movement from the suburbs to downtown and back to the suburbs. We theorize that convection mixing may be contributing to the persistence of STI epidemics in core and outbreak areas by creating STI reservoirs outside of, and connected to, core and outbreak areas.

'I don't care if you think I'm gay … that won't make me either promiscuous or HIV positive': HIV, stigma, and the paradox of the gay men's sexual health clinic - An exploratory study

Young gay men are affected by HIV. Due to a lack of studies on these males, and that previous research notes youth's minimal healthcare seeking, we recruited young gay men at a gay men's STI testing clinic to explore their perceptions of care. Eight men participated in semi-structured interviews. Our results identified that, while our participants experienced stigma in some interactions, particularly when healthcare workers emphasized the probability of contracting HIV for gay men, overall they reported positive experiences with healthcare providers, particularly at the gay men's STI clinic. The gay men's STI clinic diminishes stigma and promotes HIV testing among a group of gay male youth who are affected by HIV, while its very existence propagates the association between gay males and HIV that most of the participants found stigmatizing. The association between sexuality and HIV was reported as stigmatizing in some situations, while the construction of a clinic on the premise that gay men require such testing was not. This reinforces the idea that stigma is a personal experience independent of action and locale.

Quality of HIV Websites With Information About Pre-Exposure Prophylaxis or Treatment as Prevention for Men Who Have Sex With Men: Systematic Evaluation

Background

Knowledge and uptake of high-efficacy HIV prevention strategies such as pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP) remain low among men who have sex with men (MSM) who are at the highest risk for HIV infection in the United States. Electronic health (eHealth) interventions are promising tools for disseminating information about these critical yet underutilized strategies and addressing key barriers to uptake among target populations. However, existing HIV prevention websites are understudied and unevaluated.

Objective

This study aimed to systematically review and evaluate existing HIV websites that include information about PrEP or TasP for MSM.

Methods

From March 2018 to May 2018, 2 trained research assistants (RAs) entered relevant key words and phrases into 3 commonly used search engines and applied exclusion criteria to all returned results to identify 31 websites included in this review. RAs independently scored each website for authority, usability, interactivity, and PrEP/TasP-related content based on a standardized rating scale and then averaged the results.

Results

No website received a perfect score in any of the 4 categories, and the average website score was 62% (37/60). Less than a quarter of the websites (23%, 7/31) received a score of more than 75% (7.5/10) for content. Approximately two-thirds of the websites (65%, 20/31) received a score of 50% (5/10) or lower for interactivity. The average score in usability was 68% (6.8/10) and in authority was 69% (6.9/10). Other deficiencies observed included difficulty locating relevant content and lack of information targeting audiences with the highest likelihood of HIV infection.

Conclusions

Existing HIV prevention websites with information about PrEP or TasP for MSM fail to provide adequate content as well as present that content to users in an interactive and audience-conscious way. Future eHealth interventions should attempt to rectify these deficiencies to successfully engage and educate MSM at high risk for HIV regarding prevention strategies.

Community-based, nurse-led post-exposure prophylaxis: results and implications

HIV medications can be used as post-exposure prophylaxis to efficaciously prevent an HIV-negative person who has come into contact with HIV from becoming HIV-positive. Traditionally, these medications have been available in emergency departments, which have constituted a barrier for the members of many minority groups who are greatly affected by HIV transmission (i.e. gay, bisexual and other men who have sex with men, and persons who use injection drugs). From 5 September 2013 through 4 September 2015, we sought to increase the use of HIV post-exposure prophylaxis by having registered nurses provide these medications, when indicated, in community clinics in Ottawa, Canada. We undertook a chart review of patients who accessed services for HIV post-exposure prophylaxis in this period. Over the two years of data collection, 112 persons requested HIV post-exposure prophylaxis and 64% (n = 72) initiated these medications. Most (93%, or n = 67, of the 72 initiations) were among men, with 88% (n = 59) of these men reporting same sex sexual partners. Among these 58 men, 31% (n = 18) had sexual contact with other men known to be HIV-positive. Among women (n = 8), five initiated post-exposure prophylaxis: three after needle-sharing contact or sexual contact with a male partner who reportedly shared needles, and two after unprotected vaginal sex with a male partner known to be HIV-positive. Overall, no one was diagnosed with HIV at the four-month HIV testing follow-up, although six persons were diagnosed with HIV from the baseline HIV testing, and an additional four were diagnosed with HIV during routine HIV testing one year after completing post-exposure prophylaxis. In total, nine persons in our sample were thus diagnosed with HIV during the study period, which accounted for 9.4% (n = 10 of 106) of all reported HIV diagnoses in Ottawa during this time. We conclude that nurse-initiated HIV post-exposure prophylaxis can be an effective way to provide HIV prevention services to persons who are at high-risk for HIV.