Social network strategy (SNS) for HIV testing: a new approach for identifying individuals with undiagnosed HIV infection in Tanzania

Social network strategy (SNS) testing uses network connections to refer individuals at high risk to HIV testing services (HTS). In Tanzania, SNS testing is offered in communities and health facilities. In communities, SNS testing targets key and vulnerable populations (KVP), while in health facilities it complements index testing by reaching unelicited index contacts. Routine data were used to assess performance and trends over time in PEPFAR-supported sites between October 2021 and March 2023. Key indicators included SNS social contacts tested, and new HIV-positives individuals identified. Descriptive and statistical analysis were conducted. Univariable and multivariable analysis were applied, and variables with P-values <0.2 at univariable analysis were considered for multivariable analysis. Overall, 121,739 SNS contacts were tested, and 7731 (6.4%) previously undiagnosed individuals living with HIV were identified. Tested contacts and identified HIV-positives were mostly aged ≥15 years (>99.7%) and females (80.6% of tests, 79.4% of HIV-positives). Most SNS contacts were tested (78,363; 64.7%) and diagnosed (6376; 82.5%) in communities. SNS tests and HIV-positives grew 11.5 and 6.1-fold respectively, from October-December 2021 to January-March 2023, with majority of clients reached in communities vs. facilities (78,763 vs. 42,976). These results indicate that SNS testing is a promising HIV case-finding approach in Tanzania.

Pre-exposure prophylaxis uptake concerns in the Democratic Republic of the Congo: Key population and healthcare workers perspectives

Key populations (KP) in the Democratic Republic of the Congo (DRC), including female sex workers (SW), are disproportionally affected by HIV. Quantitative feedback surveys were conducted at seven health facilities in DRC with 70 KP clients enrolled in pre-exposure prophylaxis (PrEP) services to measure benefits and concerns. The surveys also assessed satisfaction with PrEP services and experiences of stigma at the health facilities. Thirty healthcare workers (HCW) were surveyed to measure attitudes, beliefs, and acceptability of providing services to KP. KP client survey participants were primarily female SW. KP clients reported that the primary concern about taking PrEP was fear of side effects (67%) although few KP reported having experienced side effect (14%). HCW concurred with clients that experienced and anticipated side effects were a primary PrEP uptake concern, along with costs of clinic visits.

Formative assessment to identify perceived benefits and barriers of HIV oral self-testing among female sex workers, service providers, outreach workers, and peer educators to inform scale-up in Kenya

In Kenya, HIV prevalence estimates among female sex workers (FSWs) are almost five times higher than among women in the general population. However, only 68% of infected FSWs are aware of their HIV-positive status. We aimed to identify perceived benefits, opportunities, and barriers of HIV self-testing (HIVST) in improving testing coverage among FSWs. Twenty focus group discussions were conducted with 77 service providers, 42 peer educators (PEs) and outreach workers, and 37 FSWs attending drop-in centers (DiCEs) in four regions of Kenya. An additional 8 FSWs with HIV-negative or unknown status-completed in-depth interviews. Data were analyzed thematically. Acceptability of HIVST was high, with cited benefits including confidentiality, convenience, and ease of use. Barriers included absence of counseling, potential for inaccurate results, fear of partner reaction, possible misuse, and fear that HIVST could lead to further stigmatization. PEs and DiCEs were the preferred models for distributing HIVST kits. FSWs wanted kits made available free or at a nominal cost (100 Kenya Shillings or ∼USD 1). Linkage to confirmatory testing, the efficiency of distributing HIVST kits using peers and DiCEs, and the types and content of effective HIVST messaging require further research.

PrEP for key populations: results from the first PrEP demonstration project in the Democratic Republic of the Congo

Oral pre-exposure prophylaxis (PrEP) is recommended for persons at substantial risk for HIV, including female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), and transgender women (TGW). We report on a PrEP demonstration project at seven clinics in the Democratic Republic of the Congo. Routinely collected data were abstracted to assess PrEP uptake, scheduled visit attendance, and self-reported adherence. Between February and May 2018, 469 eligible clients were offered daily oral PrEP; 75.1% accepted: 78.7% FSW, 20.5% MSM, and 0.9% TGW. Two percent also identified as PWID. Attendance was 64.5% at one-month visits; 82.1% at three-month visits; and among 47.7% of clients who initiated PrEP at least six months before data abstraction, 85.8% at six-month visits. Among 66.3% of clients with at least one adherence assessment, 39% self-reported low adherence. Results demonstrate the acceptability of PrEP delivered in healthcare settings serving FSW, MSM, PWID, and TGW.

Optimizing HIV Services for Key Populations in Public-Sector Clinics in Myanmar

Key populations, ie, female sex workers, men who have sex with men, transgender people, people who inject drugs, and people in prisons and other closed settings, experience stigma, discrimination, and structural barriers when accessing HIV prevention and care. Public health facilities in Myanmar became increasingly involved in HIV service delivery, leading to an urgent need for healthcare workers to provide client-centred, key population-friendly services. Between July 2017-June 2018, the Myanmar Ministry of Health and Sports and National AIDS Programme collaborated with ICAP at Columbia University and the US Centers for Disease Control and Prevention to implement a quasi-experimental, multicomponent intervention including healthcare worker sensitization training with pre- and post- knowledge assessments, healthcare worker and client satisfaction surveys, and structural changes. We observed modest improvements among healthcare workers (n = 50) in knowledge assessments. Classification of clients into key population groups increased and fewer clients were classified as low risk. Key population clients reported favourable perceptions of the quality and confidentiality of care through self-administered surveys. Our findings suggest public health facilities can deliver HIV services that are valued by key population clients.

Modified Antiretroviral Treatment Access Study (MARTAS): A Randomized Controlled Trial of the Efficacy of a Linkage-to-Care Intervention Among HIV-Positive Patients in Ukraine

Between October 2015 and March 2018, we conducted the Modified Antiretroviral Treatment Access Study (MARTAS), a nurse-delivered case management intervention to improve linkage-to-care for persons recently tested HIV positive. Adult participants from nine urban clinics in three regions of Ukraine were randomized to either MARTAS or standard of care (SOC) using individual, parallel, two-arm design. The main study outcome was linkage-to-care (defined as registration at an HIV clinic) within a 3-month period from enrollment in the study. Intention-to-treat analysis of MARTAS (n = 135) versus SOC (n = 139) showed intervention efficacy in linkage to HIV care (84.4% vs. 33.8%; adjusted RR 2.45; 95% CI 1.72, 3.47; p < 0.001). MARTAS is recommended for implementation in Ukraine and may be helpful in other countries with similar gaps in linkage-to-care. Clinicaltrials.gov registration number: NCT02338024.

Addressing Vulnerable Population Needs in the Last Mile to the elimination of mother to child transmission of HIV: (Re)Claiming the HIV Response for Female Sex Workers and Their Children

As countries strive to eliminate mother-to-child transmission of HIV, female sex workers (FSW) and their children still face barriers to accessing these essential services. Data on FSW uptake of HIV and reproductive health services before, during, and after pregnancy reveal inadequate service utilization. Stigma encountered by FSW in healthcare settings may contribute to low uptake of HIV testing, antiretroviral therapy (ART), and other prevention of mother-to-child HIV transmission (PMTCT) services. Coordination between community-based FSW and facility-based PMTCT programs can facilitate successful linkage of pregnant FSW to antenatal services to support PMTCT efforts. We offer a way forward to reach 90-90-90 targets for FSW and their families and eliminate mother-to-child transmission of HIV.

Feasibility and Acceptability of the Modified Antiretroviral Treatment Access Study (MARTAS) Intervention Based on a Pilot Study in Ukraine

We conducted a pilot of the Modified Antiretroviral Treatment Access Study (MARTAS), a linkage to HIV treatment intervention, prior to implementing a multisite randomized controlled trial (RCT) in Ukraine. The objectives of the pilot were to assess the feasibility and acceptability of the MARTAS intervention among a small sample of adults recently diagnosed with HIV at specialty clinics in the Mykolaiv region of Ukraine in 2015. The adapted intervention consisted of up to 6 individual-level sessions with a linkage coordinator (nurse) over a 90-day period. Overall, 22 persons participated in the pilot. On average, participants received 4.2 sessions and 14 participants linked to HIV care within 3 months of study enrollment. All 18 participants who completed the acceptability survey expressed high satisfaction with their interaction with their linkage coordinator. The results of the pilot demonstrated feasibility and acceptability of the MARTAS intervention in advance of a larger scale RCT in Ukraine.

Expansion of HIV Preexposure Prophylaxis to 35 PEPFAR-Supported Early Program Adopters, October 2016-September 2018

The U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the largest bilateral funder of human immunodeficiency virus (HIV) prevention and control programs worldwide, currently supports implementation of preexposure prophylaxis (PrEP) to reduce HIV incidence among persons at substantial risk for infection, including female sex workers, men who have sex with men (MSM), and transgender women (hereafter referred to as key populations). Recent estimates suggest that 54% of all global new HIV infections in 2018 occurred among key populations and their sexual partners (1). In 2016, PEPFAR began tracking initiation of PrEP by key populations and other groups at high risk (2). The implementation and scale-up of PrEP programs across 35 PEPFAR-supported country or regional programs* was assessed by determining the number of programs reporting any new PrEP clients during each quarter from October 2016 to September 2018. As of September 2018, only 15 (43%) PEPFAR-supported country or regional programs had implemented PrEP programs; however, client volume increased by 3,351% over the assessment period in 15 country or regional programs. Scale-up of PrEP among general population clients (5,255%) was nearly three times that of key population clients (1,880%). Among key populations, the largest increase (3,518%) occurred among MSM. Factors that helped drive the success of these PrEP early adopter programs included initiation of national, regional, and multilateral stakeholder meetings; engagement of ministries of health and community advocates; revision of HIV treatment guidelines to include PrEP; training for HIV service providers; and establishment of drug procurement policies. These best practices can help facilitate PrEP implementation, particularly among key populations, in other country or regional programs to reduce global incidence of HIV infection.

An Internet-Based HIV Self-Testing Program to Increase HIV Testing Uptake Among Men Who Have Sex With Men in Brazil: Descriptive Cross-Sectional Analysis

Background

Approximately 30% of people living with HIV worldwide are estimated to be unaware of their infection. HIV self-testing (HIVST) is a strategy recommended by the World Health Organization to increase access to and uptake of testing among key populations who are at high risk for HIV infection.

Objective

This study aimed to describe the development and feasibility of a free, anonymous, internet-based HIVST strategy designed for men who have sex with men in Curitiba, Brazil (electronic testing [e-testing]).

Methods

The project was developed under the scope of the “A Hora é Agora” (The Time is Now) program. Individuals aiming to request an HIVST package (two tests each) answered an anonymous 5-minute questionnaire regarding inclusion criteria and sexual risk behavior. Eligible individuals could receive one package every 6 months for free. Website analytics, response to online questionnaires, package distribution, and return of test results were monitored via a platform-integrated system.

Results

Between February 2015 and January 2016, the website documented 17,786 unique visitors and 3218 completed online questionnaires. Most individuals self-reported being white (77.0%), young (median age: 25 years, interquartile range: 22-31 years), educated (87.3% completed secondary education or more), and previously tested for HIV (62.5%). Overall, 2526 HIVST packages were delivered; of those, 542 (21.4%) reported a result online or by mail (23 reactive and 11 invalid). During the study period, 37 individuals who reported using e-testing visited the prespecified health facility for confirmatory testing (30 positive, 7 negative).

Conclusions

E-testing proved highly feasible and acceptable in this study, thus supporting scale-up to additional centers for men who have sex with men in Brazil.

Respondent-Driven Sampling in a Multi-Site Study of Black and Latino Men Who Have Sex with Men

PURPOSE

Respondent-driven sampling (RDS) was used to recruit four samples of Black and Latino men who have sex with men (MSM) in three metropolitan areas to measure HIV prevalence and sexual and drug use behaviors. We compared demographic and behavioral risk characteristics of participants across sites, assessed the extent to which the RDS statistical adjustment procedure provides estimates that differ from the crude results, and summarized our experiences using RDS.

METHODS

From June 2005 to March 2006 a total of 2,235 MSM were recruited and interviewed: 614 Black MSM and 516 Latino MSM in New York City, 540 Black MSM in Philadelphia, and 565 Latino MSM in Los Angeles County. Crude point estimates for demographic characteristics, behavioral risk factors and HIV prevalence were calculated for each of the four samples. RDS Analysis Tool was used to obtain population-based estimates of each sampled population's characteristics.

RESULTS

RDS adjusted estimates were similar to the crude estimates for each study sample on demographic characteristics such as age, income, education and employment status. Adjusted estimates of the prevalence of risk behaviors were lower than the crude estimates, and for three of the study samples, the adjusted HIV prevalence estimates were lower than the crude estimates. However, even the adjusted HIV prevalence estimates were higher than what has been previously estimated for these groups of MSM in these cities. Each site faced unique circumstances in implementing RDS.

CONCLUSIONS

Our experience in using RDS among Black and Latino MSM resulted in diverse recruitment patterns and uncertainties in the estimated HIV prevalence and risk behaviors by study site.

Factors associated with concurrent heroin use among patients on methadone maintenance treatment in Vietnam: A 24-month retrospective analysis of a nationally representative sample

BACKGROUND

Methadone maintenance treatment (MMT) is highly effective for reducing heroin use and HIV transmission among people who inject opioids. We sought to measure and understand factors associated with continued heroin use, a critical factor affecting treatment outcome among MMT patients in Vietnam.

METHOD

We collected data from medical charts of a nationally representative sample of patients who were on MMT from May 2008 to December 2013. We selected 10 MMT clinics using probability proportional to size and 50 patients/clinic by systematic random sampling. Concurrent heroin use was defined by self-report/positive urine test recorded in patient charts during month 3, 6, 12, and 24 after MMT initiation. We used multivariable logistic regression to identify factors associated with concurrent heroin use over the first 24 months in treatment.

FINDINGS

All clients used heroin at baseline; concurrent heroin use was 55% at month 3; 19%, 14.6% and 15.2% at month 6, 12, and 24, respectively. Having no family emotional/financial support at baseline versus having this support (AOR = 2.03; 95% confidence interval [CI] = 1.17-3.53); using heroin for <15 years versus ≥15 years at baseline (AOR = 1.55; 95% CI = 1.01-2.38); being HIV-infected/not on antiretroviral treatment (ART; AOR = 1.79; 95% CI = 1.07-2.98) or being HIV infected/on ART (AOR = 2.39; 95% CI = 1.61-3.55), versus not being HIV infected; baseline methamphetamine use versus non-use (AOR = 2.68; 95% CI = 1.08-6.65), were associated with increased odds of concurrent heroin use among patients.

CONCLUSION

The association between concurrent heroin use among MMT patients and lack of family emotional/financial support, highlights the critical importance of these types of support for successful treatment. Association with shorter heroin use history suggests motivational enhancement may reduce concurrent heroin use. Living with HIV, whether on ART or not, is associated with increased concurrent heroin use and suggests safe injection commodities and education, and drug-drug interaction management, are needed for this subgroup. Though few MMT clients reported baseline methamphetamine use, its association with later heroin use suggests the need for effective methamphetamine use interventions.

Patient and provider perspectives inform an intervention to improve linkage to care for HIV patients in Ukraine

BACKGROUND

Engagement with HIV medical care is critical to successful HIV treatment and prevention efforts. However, in Ukraine, delays in the timely initiation of HIV treatment hamper viral suppression. By January 01, 2016, only 126,604 (57.5%) of the estimated 220,000 people living with HIV (PLWH) had registered for HIV care, and most (55.1%) of those who registered for HIV care in 2015 did that at a late stage of infection. In the US, Anti-Retroviral Treatment and Access to Services (ARTAS) intervention successfully linked newly diagnosed PLWH to HIV services using strengths-based case management with a linkage coordinator. To tailor the ARTAS intervention for Ukraine, we conducted a qualitative study with patients and providers to understand barriers and facilitators that influence linkage to HIV care.

METHODS

During September-October 2014, we conducted 20 in-depth interviews with HIV-positive patients and two focus groups with physicians in infectious disease, sexually transmitted infection (STI), and addiction clinics in Dnipropetrovsk Region of Ukraine. Interviews and focus groups were audio-recorded and transcribed verbatim. We translated illustrative quotes into English. We used thematic analysis for the data analysis.

RESULTS

Participants (20 patients and 14 physicians) identified multiple, mostly individual-level factors influencing HIV care initiation. Key barriers included lack of HIV knowledge, non-acceptance of HIV diagnosis, fear of HIV disclosure, lack of psychological support from health providers, and HIV stigma in community. Responsibility for one's health, health deterioration, and supportive provider communication were reported as facilitators to linkage to care. Expected benefits from the case management intervention included psychological support, HIV education, and help with navigating the segmented health system.

CONCLUSIONS

The findings from the study will be used to optimize the ARTAS for the Ukrainian context. Our findings can also support future linkage-to-care strategies in other countries of Eastern Europe and Central Asia.

Early HIV Infections Among Men Who Have Sex with Men in Five Cities in the United States

We tested blood samples from men who have sex with men (MSM) to detect early HIV infection. Early HIV included both acute (infected past 30 days) and recent (estimated recency past 240 days). Acute infections were defined as screen immunoassay (IA) negative/NAAT-positive or IA-positive/Multispot-negative/NAAT-positive. Recent infections were defined as avidity index cutoff <30 % on an avidity-based IA and, (1) not reporting antiretroviral therapy use or, (2) HIV RNA >150 copies/mL. Of 937 samples, 26 % (244) were HIV-infected and of these 5 % (12) were early. Of early infections, 2 were acute and 10 recent; most (8/12) were among black MSM. Early infection was associated with last partner of black race [adjusted relative risk (ARR) = 4.6, confidence intervals (CI) 1.2-17.3], receptive anal sex at last sex (ARR = 4.3, CI 1.2-15.0), and daily Internet use to meet partners/friends (ARR = 3.3, CI 1.1-9.7). Expanding prevention and treatment for black MSM will be necessary for reducing incidence in the United States.

Engagement in HIV care among HIV-positive men who have sex with men from 21 cities in the United States

We assessed factors associated with HIV care among HIV-infected men who have sex with men (MSM). We used 2008 data on MSM from the National HIV Behavioral Surveillance System (NHBS). Venue-based, time-space sampling was used to recruit and interview men in 21 U.S. cities with high AIDS prevalence. Among self-reported HIV-positive MSM, we used generalized estimating equations (clustered on city of interview) to evaluate factors associated with delayed linkage to care (care entry >3 months after diagnosis), not currently receiving care (no visit for HIV care during the 6 months before the study interview), and not being on antiretroviral therapy (ART). Among 8,153 MSM, 882 (11 %) were self-reported HIV-positive. 25 % had delayed linkage, 12 % were not currently receiving care and among those with at least one heath care visit 30 % were not on ART. In multivariate analysis, lower income and testing positive at their first HIV test were associated with delayed linkage. Age 18-29 years, and not having health insurance were associated with not currently receiving care. Among those with at least one health care visit, being age 18-39 years, having private or no health insurance, and stimulant use were associated with not being on ART. These findings can inform efforts to improve engagement in care.

Estimated HIV Incidence in California, 2006-2009

Introduction

Accurate estimates of HIV incidence are crucial for prioritizing, targeting, and evaluating HIV prevention efforts. Using the methodology the CDC used to estimate national HIV incidence, we estimated HIV incidence in Los Angeles County (LAC), San Francisco (SF), and California’s remaining counties.

Methods

We estimated new HIV infections in 2006–2009 among adults and adolescents in LAC, SF and the remaining California counties using the Serologic Testing Algorithm for Recent Seroconversion (STARHS). STARHS methodology uses the BED HIV-1 capture enzyme immunoassay to determine recent HIV infections by testing remnant serum from persons newly diagnosed with HIV. A population-based incidence estimate is calculated using HIV testing data from newly diagnosed cases and imputing for persons unaware of their HIV infection.

Results

For years 2007–2009, respectively, we estimated new infections in LAC to be 2426 (95% CI 1871–2982), 1669 (CI 1309–2029) and 1898 (CI 1452–2344) (p<0.01); in SF for 2006–2009, 492 (CI 327–657), 490 (CI 335–646), 458 (CI 342–574) and 367 (CI 261–473) (p = 0.14); and in the remaining California counties in 2008–2009, 2526 (CI 1688–3364) and 2993 (CI 2141–3846) respectively. HIV infection rates among men who have sex with men (MSM) in LAC were 100 times higher than other risk populations; the SF MSM rate was 3 to 18 times higher than other demographic groups. In LAC, incidence rates among African-Americans were twice those of whites and Latinos; persons 40 years or older had lower rates of infection than younger persons.

Discussion

We report the first HIV incidence estimates for California, highlighting geographic disparities in HIV incidence and confirming national findings that MSM and African-Americans are disproportionately impacted by HIV. HIV incidence estimates can and should be used to target prevention efforts towards populations at highest risk of acquiring new HIV infections, focusing on geographic, racial and risk group disparities.

Using laboratory surveillance data to estimate engagement in care among persons living with HIV in Los Angeles County, 2009

Poor engagement in HIV care has been associated with delayed access to antiretroviral treatment and increased HIV transmission. Using viral load (VL) results from HIV laboratory surveillance data to conduct longitudinal and cross-sectional analyses, we examined linkage to care, retention in care, and their associated factors in 37,325 persons living with HIV (PLWH) in Los Angeles County (LAC). Linkage to care was considered timely if a VL test result was present ≤3 months of diagnosis. Successful retention in care was defined as having two or more VL test results ≥90 days apart during 2009. Of 6841 persons newly diagnosed with HIV in 2007-2009, 67% were linked to care within 3 months of diagnosis. Factors associated with delayed linkage to care included being African American, Latino, and Asian/Pacific Islander (adjusted hazard ratio [AHR]=0.81; 95% CI=0.75-0.87, AHR=0.83; 95% CI=0.77-0.89, AHR=0.82; 95% CI=0.71-0.94, respectively). Of the 37,325 PLWH, 52% were retained in care during 2009. Factors associated with lack of retention in care included injection drug use (adjusted prevalence ratio [APR]=0.88; 95% CI=0.84-0.93), incarceration at diagnosis (APR=0.56; 95% CI=0.51-0.61), being diagnosed in pre-highly active antiretroviral therapy (HAART) era (APR=0.94; 95% CI=0.92-0.96) or at a public facility (APR=0.97; 95% CI=0.95-1.00), age <45 years (APR=0.87; 95% CI=0.86-0.89), and having concurrent HIV/AIDS diagnoses (APR=0.94; 95% CI=0.92-0.96). This study demonstrates the value of using VL surveillance data to monitor engagement in care among PLWH, and its potential to improve linkage and retention efforts where disparities in care are observed.

Homophobia and racism experienced by Latino men who have sex with men in the United States: correlates of exposure and associations with HIV risk behaviors

Using cross-sectional data collected from 1081 Latino men who have sex with men (MSM) recruited with respondent-driven sampling (RDS) techniques from Los Angeles and New York, we examined the extent to which Latino MSM reported exposure to social discrimination (i.e., experienced both homophobia and racism, homophobia only, racism only, or neither homophobia nor racism). More than 40% of respondents experienced both homophobia and racism in the past 12 months. Los Angeles participants, those with lower income, and those who reported being HIV-positive were more likely to report experiencing both types of social discrimination. Adjusting for potential confounders, men exposed to both homophobia and racism were more likely than men exposed to neither form of discrimination to report unprotected receptive anal intercourse with a casual sex partner (AOR = 1.92, 95% CI, 1.18-3.24) and binge drinking (AOR = 1.42, 95% CI, 1.02-1.98). Our findings suggest the presence of a syndemic of adverse social experiences and call for more intervention research to address both homophobia and racism experienced among Latino MSM in the United States.

Having supportive social relationships is associated with reduced risk of unrecognized HIV infection among black and Latino men who have sex with men

We examined the hypothesis that black and Latino men who have sex with men (MSM) who have supportive social relationships with other people are less likely to have unrecognized HIV infection compared with MSM of color who report lower levels of social support. We interviewed 1286 black and Latino MSM without known HIV infection in three metropolitan areas who were recruited using respondent driven sampling. Participants completed a computer-administered questionnaire and were tested for HIV. Unrecognized HIV infection was found in 118 men (9.2%). MSM who scored higher on the supportive relationship index had significantly lower odds of testing HIV-positive in the study. The mediation analysis identified two possible behavioral pathways that may partially explain this association: men who had strong supportive relationships were more likely to have had a test for HIV infection in the past 2 years and less likely to have recently engaged in high-risk sexual behavior. The findings illuminate the protective role of social relationships among MSM of color in our sample.

Modeling the impact of social discrimination and financial hardship on the sexual risk of HIV among Latino and Black men who have sex with men

OBJECTIVES

We examined the impact of social discrimination and financial hardship on unprotected anal intercourse with a male sex partner of serodiscordant or unknown HIV status in the past 3 months among 1081 Latino and 1154 Black men who have sex with men (MSM; n = 2235) residing in Los Angeles County, California; New York, New York; and Philadelphia, Pennsylvania.

METHODS

We administered HIV testing and a questionnaire assessing 6 explanatory variables. We combined traditional mediation analysis with the results of a path analysis to simultaneously examine the direct, indirect, and total effects of these variables on the outcome variable.

RESULTS

Bivariate analysis showed that homophobia, racism, financial hardship, and lack of social support were associated with unprotected anal intercourse with a serodiscordant or sero-unknown partner. Path analysis determined that these relations were mediated by participation in risky sexual situations and lack of social support. However, paths between the explanatory variable and 2 mediating variables varied by participants' serostatus.

CONCLUSIONS

Future prevention research and program designs should specifically address the differential impact of social discrimination and financial hardship on lack of social support and risky sexual situations among Latino and Black MSM.

Sex drugs, peer connections, and HIV: Use and risk among African American, Latino, and Multiracial young men who have sex with men (YMSM) in Los Angeles and New York

African American and Latino young men who have sex with men are at high risk for HIV infection. We administered brief intercept surveys (N=416) at 18 Black and Latino gay pride events in Los Angeles and New York in 2006 and 2007. Ordinal logistic regressions were used to model the effects of substance use during sex, peer connectedness, relationship status, and homelessness on condom use. Alcohol use, crystal use, homelessness, and having a primary relationship partner were negatively associated with condom use, while peer connectedness and marijuana use during sex were positively associated with condom use. Implications for service providers and future research are discussed.

Drug use, high-risk sex behaviors, and increased risk for recent HIV infection among men who have sex with men in Chicago and Los Angeles

We examined how drugs, high-risk sexual behaviors, and socio-demographic variables are associated with recent HIV infection among men who have sex with men (MSM) in a case-control study. Interviewers collected risk factor data among 111 cases with recent HIV infection, and 333 HIV-negative controls from Chicago and Los Angeles. Compared with controls, cases had more unprotected anal intercourse (UAI) with both HIV-positive and HIV-negative partners. MSM with lower income or prior sexually transmitted infections (STI) were more likely to be recently HIV infected. Substances associated with UAI included amyl nitrate ("poppers"), methamphetamine, Viagra (or similar PDE-5 inhibitors), ketamine, and gamma hydroxybutyrate (GHB). Cases more frequently used Viagra, poppers, and methamphetamine during UAI compared with controls. In multivariate analysis, income, UAI with HIV-positive partners, Viagra, and poppers remained associated with recent HIV seroconversion. Better methods are needed to prevent HIV among MSM who engage in high-risk sex with concurrent drug use.

Understanding differences in HIV sexual transmission among Latino and black men who have sex with men: The Brothers y Hermanos Study

HIV sexual transmission risk behaviors were examined among 1,065 Latino and 1,140 black men who have sex with men (MSM). Participants completed a computer-administered questionnaire and were tested for HIV infection. Of men who reported that their last HIV test was negative or that they had never been tested or did not get the result of their last test, 17% of black and 5% of Latino MSM tested HIV-positive in our study. In both ethnic groups, the three-month prevalence of unprotected anal intercourse (UAI) with HIV-negative or unknown serostatus partners was twice as high among men unaware of their HIV infection than men who knew they were HIV seropositive at the time of enrollment. UAI exclusively with HIV-positive partners was more prevalent among HIV-positive/aware than HIV-positive/unaware men. The findings advance understanding of the high incidence of HIV infection among black MSM in the U.S.

Locating unrecognized HIV infections among men who have sex with men: San Francisco and Los Angeles

Unrecognized HIV infections, where the individual is unaware of his or her HIV serostatus, may play the most important role in the continued spread of HIV. Using venue-level data from the National HIV Behavioral Surveillance System, we conducted preliminary bivariate analyses to identify variables associated with unrecognized HIV infection and subsequently entered those variables into multiple logistic regression models to then characterize unrecognized HIV infections in Los Angeles and San Francisco. In Los Angeles, public sex environments have the highest likelihood of having men who have sex with men (MSM) with unrecognized HIV infection (adjusted odds ratio (AOR) 3.2, 95% confidence interval (CI) = 1.3-7.9). For San Francisco, MSM with unrecognized HIV infection are most likely found in adult bookstores (AOR = 8.0, 95% CI = 2.8-39). We identified opportunities to promote HIV testing through specific locations where unrecognized infections among MSM are found in highest concentrations.

Locating unrecognized HIV infections among men who have sex with men: San Francisco and Los Angeles

Unrecognized HIV infections, where the individual is unaware of his or her HIV serostatus, may play the most important role in the continued spread of HIV. Using venue-level data from the National HIV Behavioral Surveillance System, we conducted preliminary bivariate analyses to identify variables associated with unrecognized HIV infection and subsequently entered those variables into multiple logistic regression models to then characterize unrecognized HIV infections in Los Angeles and San Francisco. In Los Angeles, public sex environments have the highest likelihood of having men who have sex with men (MSM) with unrecognized HIV infection (adjusted odds ratio (AOR) 3.2, 95% confidence interval (CI) = 1.3-7.9). For San Francisco, MSM with unrecognized HIV infection are most likely found in adult bookstores (AOR = 8.0, 95% CI = 2.8-39). We identified opportunities to promote HIV testing through specific locations where unrecognized infections among MSM are found in highest concentrations.

The Young Men's Survey phase II: hepatitis B immunization and infection among young men who have sex with men

OBJECTIVES

We measured the prevalence of hepatitis B virus (HBV) immunization and HBV infection among men aged 23 to 29 years who have sex with men.

METHODS

We analyzed data from 2834 men who have sex with men in 6 US metropolitan areas. Participants were interviewed and tested for serologic markers of immunization and HBV infection in 1998 through 2000.

RESULTS

Immunization prevalence was 17.2%; coverage was 21.0% among participants with private physicians or health maintenance organizations and 12.6% among those with no source of health care. Overall, 20.6% had markers of HBV infection, ranging from 13.7% among the youngest to 31.0% among the oldest participants. Among those susceptible to HBV, 93.5% had regular sources of health care, had been tested for HIV, or had been treated for a sexually transmitted disease.

CONCLUSIONS

Although many young men who have sex with men have access to health care, most are not immunized against HBV. To reduce morbidity from HBV in this population, providers of health care, including sexually transmitted disease and HIV prevention services, should provide vaccinations or referrals for vaccination.

Research needed to more effectively combat HIV among African-American men who have sex with men

It is estimated that nearly half of all African-American men who have sex with men (AAMSM) living in major U.S. cities are already infected with HIV. Without a substantial and committed investment in research in HIV prevention among AAMSM and subsequent evidence-based policies and community programs, it is unlikely that we will ever be able to curtail the HIV epidemic among African Americans in general, regardless of gender, age or sexual orientation. In this paper, we briefly review what is known and what research questions remain in order to curtail the epidemic among AAMSM. Finally, we provide recommendations for future research that include the: 1) development of a national cohort of young AAMSM to prospectively study biological, behavioral, social and contextual factors that place AAMSM at risk for infection with HIV and other STDs; 2) adapting existing interventions in HIV prevention to the unique characteristics of AAMSM and evaluating their effectiveness; 3) evaluating factors such as intracommunity and familial discrimination against AAMSM that may lead to lack of disclosure; and 4) enhancing our understanding of how cultural and social factors can be used in a positive and self-affirming way to strengthen HIV prevention and care for AAMSM.

Perceptions of lifetime risk and actual risk for acquiring HIV among young men who have sex with men

Among young men who have sex with men (MSM) surveyed in six US cities, we evaluated the magnitude and correlates of perceived lifetime risk for acquiring HIV, and missed opportunities to increase risk perception by providers of health-care and HIV-testing services. Overall, approximately one quarter of young MSM perceived themselves at moderate/high risk for acquiring HIV. Adjusting for demographic, prior testing, and behavioral characteristics, moderate/high perceived risk had the strongest association with unrecognized HIV infection. However, half of the 267 young MSM with unrecognized infection perceived themselves at low lifetime risk for acquiring HIV, and many young MSM with low-risk perception reported considerable risk behaviors. Providers of health-care and HIV-testing services missed opportunities to assess risks and recommend testing for young MSM. To increase HIV testing, prevention providers should intensify efforts to assess, and to increase when needed, perceptions of lifetime risks for acquiring HIV among young MSM.

Unintentional HIV exposures from young men who have sex with men who disclose being HIV-negative

OBJECTIVE

To evaluate the proportion of new sexual partners potentially exposed to HIV from young MSM who disclosed being HIV-negative.

DESIGN

Cross-sectional, observational study of men aged 23-29 years recruited from randomly sampled MSM-identified venues in six US cities.

METHODS

Participants were interviewed and tested for HIV. Analyses were restricted to MSM who reported last testing HIV-negative and having one or more new partners in the prior 6 months.

RESULTS

Of 1701 MSM who reported a total of 11 793 new partners, 1075 (63%) disclosed being HIV-negative to 4253 (36%) new partners before having sex with them for the first time. Of disclosers, 352 (33%) reported last testing HIV-negative > 1 year before their interview and 80 (7%) tested HIV-positive (HIV-infected unaware). By race, 24% of black, 5% of Hispanic, and 3% of white disclosers tested HIV-positive. Of the 4253 new partners, 296 (7%) were partners of the 80 HIV-infected unaware MSM. By race, 22% of new partners of black, 3% of new partners of Hispanic, and 4% of new partners of white MSM, were partners of HIV-infected unaware MSM who disclosed being HIV-negative.

CONCLUSIONS

Many new sex partners may be unintentionally exposed to HIV from young MSM, particularly those who are black and who disclose being HIV-negative based on an earlier test. Young MSM should test for HIV more frequently and consistently use condoms with all partners unless they are in a mutually monogamous relationship in which both partners have tested HIV-negative at least 3 months since their last potential HIV exposure.

Recent HIV Testing Among Young Men Who Have Sex With Men: Correlates, Contexts, and HIV Seroconversion

OBJECTIVES

We evaluated the correlates and contexts of HIV testing within the past year, subsequent risk reduction, and HIV seroconversion among young men who have sex with men (MSM).

METHODS

Young men aged 23 to 29 years were approached, interviewed, counseled, and tested for HIV at 181 randomly sampled MSM-identified venues in six U.S. cities from 1998 through 2000. Analyses were restricted to 2,797 MSM who reported never testing HIV-positive.

RESULTS

Of the 2,797 MSM, 1,281 (46%) either never previously tested or had not tested in the past year (never/remote testers); 1,516 (54%) had tested in the past year (recent testers); and 271 (10%) tested HIV-positive as part of the study. Of 1,885 recent sex partners reported by HIV-infected participants, 68% were partners of never/remote testers. Of recent testers, 50% tested anonymously, 51% tested because of specific risks, 59% were counseled, 47% reported reducing their risks after testing, and 8% tested HIV-positive (percent HIV-infected by race: blacks, 24%; Hispanics, 6%; whites, 4%; Asians, 1%).

CONCLUSION

Nearly half of young MSM participants had not tested in the past year and HIV-infected never/remote testers accounted for approximately two thirds of recent partners potentially exposed to HIV. Of those who had tested recently, many MSM, especially those who are black, had already acquired HIV. To reduce HIV transmission and facilitate early diagnosis and entry into care, increased HIV testing among young at-risk MSM in the United States, especially those who are black, is needed.

Unrecognized HIV infection, risk behaviors, and perceptions of risk among young men who have sex with men: opportunities for advancing HIV prevention in the third decade of HIV/AIDS

This study evaluated the magnitude and distribution of unrecognized HIV infection among young men who have sex with men (MSM) and of those with unrecognized infection, the prevalence and correlates of unprotected anal intercourse (UAI), perceived low risk for infection, and delayed HIV testing. MSM aged 15-29 years were approached, interviewed, counseled, and tested for HIV at 263 randomly sampled venues in 6 US cities from 1994-2000. Of 5649 MSM participants, 573 (10%) tested positive for HIV. Of these, 91% of black, 69% of Hispanic, and 60% of white MSM (77% overall) were unaware of their infection. The 439 MSM with unrecognized infection reported a total of 2253 male sex partners in the previous 6 months; 51% had UAI; 59% perceived that they were at low risk for being infected; and 55% had not tested in the previous year. The HIV epidemic among MSM in the United States continues unabated, in part, because many young HIV-infected MSM are unaware of their infection and unknowingly expose their partners to HIV. To advance HIV prevention in the third decade of HIV/AIDS, prevention programs must reduce unrecognized infection among young MSM by increasing the demand for and availability of HIV testing services.

Comparing sexual behavioral patterns between two bathhouses: implications for HIV prevention intervention policy

There is a glaring lack of data to inform culturally appropriate HIV prevention interventions targeting environments such as bathhouses where men who have sex with men (MSM) practice sexual risk behaviors. This study compares sexual behavioral patterns across two bathhouse sites in order to identify important themes to address when tailoring HIV prevention interventions to bathhouse environments. We analyzed semi-structured interviews with workers and patrons at two bathhouses to explore similarities and differences. A coding scheme was established and data were organized according to conceptual themes. We found that differences between the two sites emerged in six key areas: bathhouse clientele, attraction to particular sites, sexual practices and condom use, communication about sex and HIV status, bathhouse rules, and substance use. Implications for HIV prevention intervention policy are discussed.

Effects of pool-fencing ordinances and other factors on childhood drowning in Los Angeles County, 1990-1995

OBJECTIVES

This study estimated the effects of local pool-fencing ordinances and other factors on the rate of childhood drowning in Los Angeles County, California.

METHODS

Stage 1 was a retrospective dynamic cohort study of all drownings among children younger than 10 years that occurred in residential swimming pools in Los Angeles County between 1990 and 1995. Stage 2 was a matched case-control study that compared pools in which childhood drownings occurred (cases) with randomly selected pools in which drownings did not occur (controls).

RESULTS

The drowning rate was relatively high among toddlers (aged 1-4 years), boys, and African Americans and in areas with a high density of residential swimming pools. Pool-fencing ordinances were not associated with a reduced overall rate of childhood drowning.

CONCLUSIONS

Local ordinances enacted in Los Angeles County before 1996 do not appear to have been effective in reducing the rate of childhood drowning in residential pools. Possible reasons for this ineffectiveness are insufficient building codes for isolating pools from homes, inadequate enforcement of the ordinances, and inadequate operation or maintenance of fencing equipment by pool owners.