The Annual American Men's Internet Survey of Behaviors of Men Who Have Sex With Men in the United States: Key Indicators Report 2018

Behavior Change Among HIV-Negative Men Who Have Sex with Men Not Using PrEP in the United States

This study measures changes in condomless anal sex (CAS) among HIV-negative men who have sex with men (MSM) who are not taking pre-exposure prophylaxis (PrEP). It considers the 2014-2019 cycles of the American Men's Internet Survey, a serial, cross-sectional web-based survey of US cisgender MSM aged ≥ 15 years, in which ~ 10% of each year's sample is drawn from the previous year. Among those surveyed for 2 years who remained HIV-negative and off PrEP, reports of having any CAS and of CAS partner number were compared across years. We disaggregated by partner HIV status, and considered demographic predictors. The overall population saw a significant 2.2 percentage-point (pp) increase in reports of any CAS year-over-year. Sub-populations with the largest year-on-year increases were 15-24-year-olds (5.0-pp) and Hispanic respondents (5.1-pp), with interaction (young Hispanic respondents = 12.8-pp). On the relative scale, these numbers correspond to 3.2%, 7.2%, 7.3% and 18.7%, respectively. Absolute increases were concentrated among partners reported as HIV-negative. Multivariable analyses for CAS initiation found effects concentrated among Hispanic and White youth and residents of fringe counties of large metropolitan areas. CAS partner number increases were similarly predicted by Hispanic identity and young age. Although condom use remains more common than PrEP use, increasing CAS among MSM not on PrEP suggests potential new HIV transmission pathways. Concentration of increases among 18-24-year-old MSM portends future increases in the proportion of newly diagnosed HIV that occur among youth. Concentration among young Hispanic MSM will likely expand existing disparities. Although reducing barriers to PrEP remains vital, condom promotion for MSM remains a key public health practice and appears to be missing key audiences. LGBTQ+-inclusive sex education is one avenue for enhancing these efforts.

Predicting salivary cortisol and sexual behavior stigma among MSM in the American Men's Internet Survey 2019

Physiological stress levels in response to sexual behavior stigma among men who have sex with men (MSM) in the United States (US) are understudied. The current study aims to explore the relationship between sexual behavior stigma and salivary cortisol both overall and stratified by race/ethnicity. If such an association exists, it may suggest that sexual behavior stigma can be physiologically measured or indicated by the presence of heightened salivary cortisol. A subsample of 667 MSM participants from the 2019 American Men's Internet Survey (AMIS; N = 10,129) submitted morning (AM) and evening (PM) saliva cortisol samples using at-home mail-in collection kits. Average daily cortisol and daily cortisol change were calculated; simple linear regressions estimated associations between cortisol measures and sexual behavior stigma characterized in four different ways (ever and recent experience of individual stigma items; average ever and recent experience of three stigma scales: stigma from family and friends, anticipated healthcare stigma, general social stigma). Participants reported a mean age of 36.0 years (SD = 14.9), with most being non-Hispanic white (n = 480, 72.0%), Hispanic (n = 164, 12.3%), or Black/African American (n = 146, 10.9%), and identified as homosexual/gay (n = 562, 84.3%). Reporting ever experiencing healthcare providers gossiping was significantly associated with higher PM cortisol (β = 0.12, p = 0.001) and higher average daily cortisol (β = 0.11, p = 0.004), while reporting ever experiencing police refusing to protect was associated with higher AM cortisol (β = 0.08, p = 0.03) and higher average daily cortisol (β = 0.09, p = 0.02). Recent experiences of stigma were not significant predictors of any measure of cortisol. Measures of salivary cortisol may be used to characterize sexual behavior stigma among MSM populations, however more insight is needed to determine its exact relationship and strength.

Effects of mode of transportation on PrEP persistence among urban men who have sex with men

Little is known about the effect of travel-related factors, such as mode of transportation, on retention in PrEP care, or PrEP persistence. We used data from the 2020 American Men's Internet Survey and conducted multilevel logistic regression to estimate the association between mode of transportation used for healthcare access and PrEP persistence among urban gay, bisexual, and other men who have sex with men (MSM) in the U.S. MSM using public transportation were less likely to report PrEP persistence (aOR: 0.51; 95% CI: 0.28-0.95) than MSM using private transportation. There were no significant associations between PrEP persistence and using active transportation (aOR: 0.67; 95% CI: 0.35-1.29) or multimodal transportation (aOR: 0.85; 95% CI: 0.51-1.43) compared to using private transportation. Transportation-related interventions and policies are needed to address structural barriers to accessing PrEP services and to improve PrEP persistence in urban areas.

A Relationship-Focused HIV Prevention Intervention for Young Sexual Minority Men in the United States: A Pilot Randomized Controlled Trial of the We Prevent Intervention

We Prevent is a virtual counseling intervention designed to improve communication as a mechanism for reducing HIV risk among young sexual minority men (SMM) in relationships. We evaluated the feasibility, acceptability, and preliminary efficacy of We Prevent in comparison to standard Counseling, Testing, and Referral among a national sample of 318 SMM ages 15-24 in a pilot randomized control trial. We found significant differences in condomless sex with outside partners; however, there were no differences in other sexual behaviors, sexual agreements, intimate partner violence (IPV), or communication between the conditions across the 9-month follow-ups. Stratified analyses found non-significant trends suggestive that We Prevent may reduce condomless sex for those ages 15-17 and for relationships over 1-year and may reduce IPV in relationships over 1-year. Though study retention was adequate, session attendance was low. Exit interviews participants reported benefits of We Prevent and provided insights into how to increase uptake.

Brief Report: Challenges in Obtaining the Informed Perspectives of Stakeholders Regarding HIV Molecular Epidemiology

BACKGROUND

HIV molecular epidemiology (HIV-ME) is now being used in a variety of ways, including molecular HIV surveillance to help identify and respond to emerging HIV transmission clusters as specified in the Ending the HIV Epidemic in the U.S. initiative. However, HIV-ME in general, and its use for cluster detection and response, in particular, raises significant ethical and social concerns, which have spurred vigorous debates. Nevertheless, there is a paucity of information regarding how these potential benefits and concerns are perceived among people living with HIV and people without HIV at an increased risk.

SETTING

Virtual engagement with US participants.

METHODS

We rigorously developed a brief informational video about HIV-ME and conducted a series of in-depth interviews with people living with HIV and people without HIV at an increased risk.

RESULTS

Through extensive stakeholder engagement during the video development process and subsequent in-depth interviews (N = 24), several preliminary findings surfaced. In contrast to the high level of concern raised by some critics of HIV-ME, our data appear to show broad support for it. In addition, we observed conflation of perspectives about HIV-ME with concerns about HIV public health surveillance more generally.

CONCLUSION

Our experiences reveal substantial communication challenges related to the nature of HIV-ME that need to be overcome to ensure that it is properly understood, which is necessary for meaningfully engaging stakeholders in discussions about its use. Moreover, ongoing, responsive, engagement efforts are critical. Additional systematic data are needed to help inform policy making and practice regarding HIV-ME.

Geospatial Prioritization to Reach Hispanic or Latino and Other Priority Populations Through HIV Home Testing Services

CONTEXT

Hispanic or Latino men who have sex with men (HLMSM) are disproportionately affected by the HIV/AIDS epidemic in New York State (NYS) and nationally. In 2019, HLMSM comprised 13% of all new diagnoses and 21% of new diagnoses among men who have sex with men (MSM) in NYS excluding New York City. HIV home testing programs are effective methods for increasing HIV testing.

OBJECTIVE

This pilot sought to determine whether the NYS HIV Home Test Giveaway (HHTG) can effectively reach priority populations, specifically HLMSM/transgender/gender nonconforming persons who have sex with men, to increase uptake of HIV home testing services and identify new HIV infections.

DESIGN/SETTING

We recruited participants using media campaigns linked to a brief self-administered eligibility survey. Eligible participants provided their e-mail address to receive a code for a free HIV home test and were sent a self-administered follow-up survey 4 to 11 weeks after eligibility survey completion.

PARTICIPANTS

The 2018 and 2019 NYS HHTG reached 1214 and 1340 participants, respectively. A total of 606 participants in 2018 and 736 participants in 2019 were eligible to receive the HHTG home test kit.

MAIN OUTCOME MEASURES

HHTG utilization and test results.

RESULTS

Hispanic or Latino persons participated at higher rates (34.8% and 25.4% in 2018 and 2019, respectively) than the percentage of Hispanic men in prioritized zip codes (15.7% and 15.6% in 2018 and 2019, respectively). The majority of participants who received HHTG test kits used them to test themselves (87.5% in 2018 and 90.6% in 2019). Across both rounds, 4 participants reported new HIV-positive results, for a seropositivity rate of approximately 1%.

CONCLUSION

Geospatial prioritization was successful in reaching Hispanic or Latino priority populations for HIV testing. HIV self-testing programs such as the HHTG are beneficial methods to reach priority populations for state and national Ending the HIV Epidemic initiatives.

Substance use disparities by age, race, sex, and sexual orientation among persons living with HIV in the Southern U.S

BACKGROUND

Alcohol and drug use is overrepresented among individuals living with Human Immunodeficiency Virus (HIV) and is associated with poor health outcomes. Determining the extent to which substance use differs between demographic profiles of people living with HIV (PLWH) would determine at-risk groups that would benefit from intervention.

METHODS

Cross-sectional screening data (N = 1307, M_age = 42.7 years, 66% male, 86% African American, 39% sexual minority) was examined from an HIV clinic in the southern U.S. largely treating underserved and low-income patients. Age, gender, race/ethnicity, sexual orientation, and their interactions were entered as predictors of substance use and related impairment in a series of zero-inflated negative binomial regressions.

RESULTS

African Americans reported more drug use (p = 0.004) and drug-related negative consequences (p = 0.003). Notably, alcohol-related negative consequences of African American heterosexuals were much higher at younger ages, compared to sexual minorities (regardless of race) and White heterosexuals of all age groups (p = 0.04).

CONCLUSIONS

Among PLWH in the U.S. South, African Americans may be uniquely at-risk with for problems related to drug-related functional impairment. Specifically, young heterosexual African Americans are at high risk for alcohol-related impairment. Implications are discussed.

Examining pharmacies' ability to increase pre-exposure prophylaxis access for black men who have sex with men in the United States

BACKGROUND

Pre-exposure prophylaxis (PrEP) has not effectively reached black men who have sex with men (BMSM). Using innovative, nontraditional health care settings-such as community pharmacies-may improve PrEP uptake among BMSM.

OBJECTIVE

To examine correlates of patient willingness to be screened for PrEP (via human immunodeficiency virus [HIV] testing and risk assessment) in pharmacies among BMSM in the United States.

METHODS

Data from the 2020 American Men's Internet Survey were analyzed. Using a modified Poisson regression method with robust variance estimates, we examined differences in willingness to screen for PrEP in pharmacies among BMSM. A 95% confidence interval (95% CI) was calculated for each estimated prevalence ratio (PR).

RESULTS

Of 826 respondents, 637 (77%) were willing to be screened for PrEP in pharmacies. Having a high school degree (PR 0.76 [95% CI 0.62-0.95]), willingness to use PrEP (1.70 [1.41-2.05]), and comfort speaking with pharmacy staff about PrEP (2.5 [1.86-3.51]) were significantly associated with willingness to screen for PrEP in a pharmacy setting. Importantly, there were no observed differences in willingness by age, employment status, annual household income, or insurance status.

CONCLUSION

Pharmacy-based PrEP access may be an effective strategy to end inequities in HIV, given that our results indicate that most BMSM are willing to be screened for PrEP in pharmacies. Future studies should examine whether willingness to use pharmacy-based HIV prevention services is associated with subsequent uptake of these services among BMSM.

Frequency and Combination of Sequential Sexual Acts That May Lead to Sexually Transmitted Infections at Different Anatomic Sites Within the Same Person

Modeling studies suggest that transmission of gonorrhea and chlamydia to multiple anatomic sites within the same person is necessary to reproduce observed high rates of extragenital gonorrhea/chlamydia. Limited empiric behavioral data support this idea. In this cross-sectional study, we enrolled individuals assigned male at birth who reported sex with men (MSM) and denied receptive anal sex (RAS) in the past 2 years. Participants enrolled in-person at the Sexual Health Clinic in Seattle, Washington (December 2019-September 2021) or online (July 2021-September 2021), and completed a sexual history questionnaire that asked about specific sexual acts and sequence of those acts during their last sexual encounter. We enrolled 210 MSM during the 16-month recruiting period. The median number of sex acts reported at last sexual encounter was 4 (interquartile range 3-5). The most commonly reported acts at last sex were: kissing (83%), receiving oral sex (82%), and insertive anal sex (65%). There was substantial variability in the sequence of acts reported; no unique sequence of sex acts was reported by more than 12% of the population. Ninety percent of participants reported sequences of behaviors that could lead to gonorrhea or chlamydia transmission within the same person (respondent or partner); the most common of these combinations was kissing followed by receiving oral sex (64% reporting). Engaging in multiple sex acts within a single sexual encounter is common and may lead to gonorrhea/chlamydia transmission within the same person. This complicates empiric measurements of transmission probabilities needed to estimate population-level transmission.

Engaging Black or African American and Hispanic or Latino Men Who Have Sex With Men for HIV Testing and Prevention Services Through Technology: Protocol for the iSTAMP Comparative Effectiveness Trial

BACKGROUND

Gay, bisexual, and other men who have sex with men (MSM), particularly Black or African American MSM (BMSM) and Hispanic or Latino MSM (HLMSM), continue to be disproportionately affected by the HIV epidemic in the United States. Previous HIV self-testing programs have yielded high testing rates, although these studies predominantly enrolled White, non-Hispanic MSM. Mobile health tools can support HIV prevention, testing, and treatment. This protocol details an implementation study of mailing free HIV self-tests (HIVSTs) nested within a randomized controlled trial designed to assess the benefit of a mobile phone app for increasing the uptake of HIV prevention and other social services.

OBJECTIVE

This study was a comparative effectiveness trial of innovative recruitment and testing promotion strategies intended to effectively reach cisgender BMSM and HLMSM. We evaluated the use of a mobile app for increasing access to care.

METHODS

Study development began with individual and group consultations that elicited feedback from 3 core groups: HIV care practitioners and researchers, HIV service organization leaders from study states, and BMSM and HLMSM living in the study states. Upon completion of the formative qualitative work, participants from 11 states, based on the observed areas of highest rate of new HIV diagnoses among Black and Hispanic MSM, were recruited through social networking websites and smartphone apps. After eligibility was verified, participants consented and were randomized to the intervention arm (access to the Know@Home mobile app) or the control arm (referral to web resources). We provided all participants with HIVSTs. The evaluation of the efficacy of a mobile phone app to support linkage to posttest prevention services that included sexually transmitted infection testing, pre-exposure prophylaxis initiation, antiretroviral treatment, and acquisition of condoms and compatible lubricants has been planned. Data on these outcomes were obtained from several sources, including HIVST-reporting surveys, the 4-month follow-up survey, laboratory analyses of dried blood spot cards returned by the participant, and data obtained from the state health department surveillance systems. Where possible, relevant subgroup analyses were performed.

RESULTS

During the formative development phase, 9 consultations were conducted: 6 in-depth individual discussions and 3 group consultations. From February 2020 through February 2021, we enrolled 2093 MSM in the randomized controlled trial from 11 states, 1149 BMSM and 944 HLMSM.

CONCLUSIONS

This study was designed and implemented to evaluate the effectiveness of recruitment strategies to reach BMSM and HMSM and of a mobile app with regard to linkage to HIV prevention or treatment services. Data were also obtained to allow for the analyses of cost and cost-effectiveness related to study enrollment, HIV testing uptake, identification of previously undiagnosed HIV, sexually transmitted infection testing and treatment, and linkage to HIV prevention or treatment services.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04219878); https://clinicaltrials.gov/ct2/show/NCT04219878.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43414.

Sexually transmitted infection prevention behaviours: health impact, prevalence, correlates, and interventions

Sexually transmitted infections (STIs) remain a major public health threat, disproportionately affecting young people, and men who have sex with men. In this narrative review of the current state of behavioural science research on STI prevention, we consider the definition, health impacts, correlates and determinants, and interventions to promote STI prevention behaviour. Research on STI prevention behaviour has extended from a focus on abstinence, partner reduction and condom use, to also include novel preventive behaviours, notably treatment-as-prevention, pre-exposure prophylaxis (i.e., the preventive use of medicines by uninfected people), and vaccination for some STIs. Social-cognitive factors specified by, for instance the theory of planned behaviour, are critical proximal determinants of STI prevention behaviours, and related interventions can effectively promote STI prevention behaviours. Social-ecological perspectives highlight that individual-level determinants are embedded in more distal environmental influences, with social stigma especially affecting STI prevention behaviours and requiring effective intervention. Further to providing a major domain of application, STI prevention also poses critical challenges and opportunities for health psychology theory and research. We identify a need for health behaviour theory that addresses the processes linking multiple levels of influence on behaviour and provides practical guidance for multi-level behaviour change interventions adapted to specific contexts.

Gay Dating App Users Support and Utilize Sexual Health Features on Apps

Men who have sex with men (MSM) frequently meet sex partners through dating apps. Research has demonstrated an association between app use and greater number of sex partners and STIs, but dating apps also pose an opportunity for intervention. By advocating for sexual health features on dating apps, Building Healthy Online Communities (BHOC) aims to increase communication about sexual health among app users. In partnership with Emory University, BHOC added questions to an annual survey of MSM. The questions assessed awareness and uptake of profile fields and sexual health features on the dating apps. Among survey participants, 67% (6737/10,129) reported using dating apps to meet a partner in the past year. Among this group, 77% (4993/6525) reported awareness of sexual health features. 61% of app users (2866/4721) who were aware of them reported using one or more sexual health features. BHOC continues to advocate for increased uptake of these features.

Perceptions of Relationship Quality Before and During COVID-19 Pandemic Among Young Sexual Minority Men in Romantic Relationships

The COVID-19 pandemic has impacted the well-being of people worldwide; however, there has been limited research examining ways in which the pandemic has created changes in relationship quality among young sexual minority men. We analyzed data from a sample of 150 young sexual minority men, aged 15-24 years. In total, 25% reported their relationship quality decreased during the pandemic, 47% reported no change, and 28% reported increased relationship quality due to COVID-19. In multinomial models, intimate partner violence, lower commitment, and spending less time with a partner due to COVID-19 were associated with decreased relationship quality during the pandemic compared to those who reported no change or increased relationship quality due to the pandemic. More efforts are needed to understand and address the impact of COVID-19 on the romantic relationships of young sexual minority men.