Individual, social and structural factors influencing PrEP uptake among cisgender women: a theory-informed elicitation study

The underutilization of pre-exposure prophylaxis (PrEP) among cisgender women in the U.S. limits this population's ability to reduce their risk for HIV infection, especially within the unique individual, social and structural systems they navigate. There is a need to identify the relevant multi-level barriers and facilitators to PrEP use among cisgender women to inform theory-guided efforts that address HIV disparities by race/ethnicity among cisgender women. Guided by the Integrated Behavioral Model and the Behavioral Model of Vulnerble Populations we conducted 41 interviews with PrEP eligible cisgender women in New York City and Philadelphia. Directed content analysis identified 11 modal behavioral beliefs crucial to PrEP uptake, including anticipated negative social consequences, 5 normative beliefs centered on available social supports, and 9 control beliefs such as anticipated barriers such as cost. Awareness and knowledge of PrEP as a biobehavioral HIV prevention method is limited for this sample. Through conventional content analysis we identified interpersonal and structural barriers to PrEP uptake including lack of partner support, transportation, mental health challenges, and challenges in accessing PrEP care. Potential solutions to structural barriers were enumerated along with implications for future intervention work and public health programming.

An Event-Level Analysis of Condomless Anal Intercourse with a HIV-Discordant or HIV Status-Unknown Partner Among Black Men Who Have Sex with Men from a Multi-site Study

Despite the high HIV incidence and prevalence among black men who have sex with men (BMSM), little research has examined partner characteristics, partner seeking venue, sexual position, substance use, and sexual risk behavior at the sex event-level among BMSM. Using the baseline data from a multi-site study of 807 BMSM stratified by their HIV status, the goal of this study was to conduct a detailed event-level analysis of 1577 male anal sex events to assess the factors associated with condomless anal intercourse (CLAI) with a HIV-discordant or HIV status-unknown partner. We found CLAI with an HIV-discordant or unknown HIV status partner among HIV-negative BMSM was negatively associated with having sex with a main partner, and was positively associated with taking both receptive and insertive sexual positions during sex. As compared to a sex partner met at bar, night club or dance club, HIV-positive BMSM were less likely to engage in CLAI with HIV-discordant and unknown HIV status partner met at party or friend's house or at community organizations. HIV-positive BMSM had lower odds of engaging in CLAI with HIV-discordant and unknown HIV status partner if they had insertive sexual position or both receptive and insertive sexual positions. These results underscore the importance of delineating unique sex event-level factors associated with sexual risk behavior depending on individuals' HIV status. Our findings suggest event-level partner characteristics, sexual position, and partner seeking venues may contribute to disparities in HIV incidence.

Characteristics and Correlates of Lifetime Suicidal Thoughts and Attempts Among Young Black Men Who Have Sex With Men (MSM) and Transgender Women

This study examined characteristics and correlates of lifetime suicidal thoughts and suicide attempts among HIV-negative young Black men who have sex with men (MSM) and transgender women (transwomen) between 16 and 29 years of age ( N = 161). In our sample, 36.6% of young Black MSM and transwomen reported a history of lifetime suicidal thoughts, while 16.1% reported prior suicide attempts. Using multivariable analysis, a history of intimate partner violence, greater psychological distress, and higher perceived sexuality discrimination were significantly associated with lifetime suicidal thoughts. Childhood sexual abuse history, greater psychological distress, lower score for outness, and higher perceived sexuality discrimination were significantly related to suicide attempts among young Black MSM and transwomen. Efforts to identify and understand factors associated with lifetime suicidal thoughts and attempts are urgently needed to inform the development and implementation of culturally relevant mental health prevention strategies for young Black MSM and transwomen.

Lessons for Patient Education Around Long-Acting Injectable PrEP: Findings from a Mixed-Method Study of Phase II Trial Participants

This study aimed to identify patients' physical and psychosocial experiences of an investigational long-acting injectable PrEP product to aid in the development of patient and provider education materials. Twenty-eight participants of a Phase 2 safety, tolerability, and acceptability study of long-acting integrase inhibitor cabotegravir (CAB-LA) were interviewed on their physical and psychosocial experiences of the injections. Five themes emerged through a framework analysis on these interview transcripts: (1) injection-related pain is highly variable across individuals; (2) pain is more impactful after the injections than during; (3) patient anxiety is critical, but does not determine the experience of injections and decreases over time; (4) intimacy and awkwardness of gluteal injections impacts patients' experiences; (5) patient education and care strategies can mitigate the above factors. These findings can inform further sociobehavioral research within Phase 3 efficacy trials of CAB-LA, as well as patient education and provider guidance for future injectable PrEP products.

Preferences for HIV test characteristics among young, Black Men Who Have Sex With Men (MSM) and transgender women: Implications for consistent HIV testing

BACKGROUND

Promoting consistent HIV testing is critical among young, Black Men Who Have Sex With Men (MSM) and transgender women who are overrepresented among new HIV cases in the United States. New HIV test options are available, including mobile unit testing, one-minute testing, at home or self-testing and couples HIV testing and counseling (CHTC). In the context of these newer options, the objective of this study was to explore whether and how preferences for specific characteristics of the tests acted as barriers to and/or facilitators of testing in general and consistent testing specifically among young Black MSM and transgender women aged 16 to 29.

METHODS

We conducted 30 qualitative, semi-structured, in-depth interviews with young, Black, gay, bisexual or MSM and transgender women in the New York City metropolitan area to identify preferences for specific HIV tests and aspects of HIV testing options. Participants were primarily recruited from online and mobile sites, followed by community-based, face-to-face recruitment strategies to specifically reach younger participants. Thematic coding was utilized to analyze the qualitative data based on a grounded theoretical approach.

RESULTS

We identified how past experiences, perceived test characteristics (e.g., accuracy, cost, etc.) and beliefs about the "fit" between the individual, and the test relate to preferred testing methods and consistent testing. Three major themes emerged as important to preferences for HIV testing methods: the perceived accuracy of the test method, venue characteristics, and lack of knowledge or experience with the newer testing options, including self-testing and CHTC.

CONCLUSIONS

These findings suggest that increasing awareness of and access to newer HIV testing options (e.g., free or reduced price on home or self-tests or CHTC available at all testing venues) is critical if these new options are to facilitate increased levels of consistent testing among young, Black MSM and transgender women. Addressing perceptions of test accuracy and supporting front line staff in creating welcoming and safe testing environments may be key intervention targets. Connecting young Black MSM and transgender women to the best test option, given preferences for specific characteristics, may support more and more consistent HIV testing.

Intervention to Match Young Black Men and Transwomen Who Have Sex With Men or Transwomen to HIV Testing Options (All About Me): Protocol for a Randomized Controlled Trial

Background

HIV testing is a critical component of HIV prevention and care. Interventions to increase HIV testing rates among young black men who have sex with men (MSM) and black transgender women (transwomen) are needed. Personalized recommendations for an individual’s optimal HIV testing approach may increase testing.

Objective

This randomized trial tests the hypothesis that a personalized recommendation of an optimal HIV testing approach will increase HIV testing more than standard HIV testing information.

Methods

A randomized trial among 236 young black men and transwomen who have sex with men or transwomen is being conducted. Participants complete a computerized baseline assessment and are randomized to electronically receive a personalized HIV testing recommendation or standard HIV testing information. Follow-up surveys are conducted online at 3 and 6 months after baseline.

Results

The All About Me randomized trial was launched in June 2016. Enrollment is completed and 3-month retention is 92.4% (218/236) and has exceeded study target goals.

Conclusions

The All About Me intervention is an innovative approach to increase HIV testing by providing a personalized recommendation of a person’s optimal HIV testing approach. If successful, optimizing this intervention for mobile devices will widen access to large numbers of individuals.

Trial Registration

ClinicalTrial.gov NCT02834572; https://clinicaltrials.gov/ct2/show/NCT02834572 (Archived by WebCite at http://www.webcitation.org/6vLJWOS1B)

Sexual Risk Behaviors Among Black Men Who Have Sex With Men Who Also Report Having Sex With Transgender Partners: Analysis of HIV Prevention Trials Network (HPTN) 061 Study

HIV Prevention Trials Network (HPTN 061) study data of Black MSM were analyzed to determine characteristics associated with having transgender sexual partners (TGP) and the association of having TGP with sexual risk. Of 1,449 cisgender MSM, 343(24%) reported also having TGP. MSM with TGP were more likely to be older, have a sexual orientation other than homosexual, have a history of incarceration, or have insufficient funds for necessities, but less likely to be HIV positive or report sex with men to health care providers. MSM with TGP were 3.67 times more likely to recently have 5+ new partners and 2.02 times more likely to report 6+ condomless sexual acts. Since MSM with TGP reported not disclosing sex with men to health care providers, these men may need tailored HIV prevention and care. Future studies should examine differing sexual risks MSM take with sexual partners with different gender identities.

Barriers and facilitators of HIV vaccine and prevention study participation among Young Black MSM and transwomen in New York City

Background

Black men who have sex with men (MSM), and Transwomen (TW) shoulder disproportionate burden of HIV. However, they are unrepresented in HIV vaccine trials. We investigated the perceptions of that factors associated with HIV vaccine trials participation among Black MSM and TW in New York.

Methods

Self-administered online questionnaires were administered to 18–29 years of NYC residents who identified as Black MSM and TW, assessing demographics, awareness and willingness to participate in HIV vaccine trials, barriers and facilitators associated with willingness, and sexual behaviors. Frequency summation was performed to determine barriers and facilitators, and logistic regression analysis was performed to determine factors association with expressed willingness.

Results

Black MSM and TW who reported engaging in risk behaviors had a 61% lower likelihood of participating in HIV vaccine trials when compared to those who did not report engaging in any risk behavior. Facilitators associated with trial participation were: cash compensation, confidentiality regarding participation, public transportation vouchers, gift cards, and food or grocery vouchers as potential facilitators for trial participation. Conversely, fear of side effects from the vaccine, concerns about testing positive on routine HIV testing due to an HIV vaccine, limited knowledge of research trials, and fear of being judged as HIV-positive were perceived as barriers.

Conclusions

These findings provided insights into the considerations and perceptions of Black MSM and TW towards HIV vaccine trials. However, further studies are needed to delineate the complex mechanisms underlying the decision-making process and establish approaches to increase study participation in this population.

Neighborhood determinants of mood and anxiety disorders among men who have sex with men in New York City

PURPOSE

We examined the relationship between economic, physical, and social characteristics of neighborhoods, where men who have sex with men (MSM) lived and socialized, and symptom scores of depression and generalized anxiety disorder (GAD).

METHODS

Participants came from a cross-sectional study of a population-based sample of New York City MSM recruited in 2010-2012 (n = 1126). Archival and survey-based data were obtained on neighborhoods, where the men lived and where they socialized most often.

RESULTS

MSM who socialized in neighborhoods with more economic deprivation and greater general neighborhood attachment experienced higher GAD symptoms. The relationship between general attachment to neighborhoods where MSM socialized and mental health depended on the level of gay community attachment: in neighborhoods characterized by greater gay community attachment, general neighborhood attachment was negatively associated with GAD symptoms, while in low gay community attachment neighborhoods, general neighborhood attachment had a positive association with GAD symptoms.

CONCLUSIONS

This study illustrates the downsides of having deep ties to social neighborhoods when they occur in the absence of broader access to ties with the community of one's sexual identity. Interventions that help MSM cross the spatial boundaries of their social neighborhoods and promote integration of MSM into the broader gay community may contribute to the reduction of elevated rates of depression and anxiety in this population.

Higher T-Cell Responses Induced by DNA/rAd5 HIV-1 Preventive Vaccine Are Associated With Lower HIV-1 Infection Risk in an Efficacy Trial

Background

It is important to identify vaccine-induced immune responses that predict the preventative efficacy of a human immunodeficiency virus (HIV)-1 vaccine. We assessed T-cell response markers as correlates of risk in the HIV Vaccine Trials Network (HVTN) 505 HIV-1 vaccine efficacy trial.

Methods

2504 participants were randomized to DNA/rAd5 vaccine or placebo, administered at weeks 0, 4, 8, and 24. Peripheral blood mononuclear cells were obtained at week 26 from all 25 primary endpoint vaccine cases and 125 matched vaccine controls, and stimulated with vaccine-insert-matched peptides. Primary variables were total HIV-1-specific CD4+ T-cell magnitude and Env-specific CD4+ polyfunctionality. Four secondary variables were also assessed. Immune responses were evaluated as predictors of HIV-1 infection among vaccinees using Cox proportional hazards models. Machine learning analyses identified immune response combinations best predicting HIV-1 infection.

Results

We observed an unexpectedly strong inverse correlation between Env-specific CD8+ immune response magnitude and HIV-1 infection risk (hazard ratio [HR] = 0.18 per SD increment; P = .04) and between Env-specific CD8+ polyfunctionality and infection risk (HR = 0.34 per SD increment; P < .01).

Conclusions

Further research is needed to determine if these immune responses are predictors of vaccine efficacy or markers of natural resistance to HIV-1 infection.

Associations Among Neighborhood Characteristics and Sexual Risk Behavior Among Black and White MSM Living in a Major Urban Area

Identifying neighborhood characteristics associated with sexual HIV risk behavior among gay, bisexual and other men who have sex with men (MSM) living in urban areas may inform the development of policies and programs to reduce risk and subsequently HIV prevalence in urban areas. New York City M2M was a cross-sectional study designed to identify neighborhood-level characteristics associated with sexual risk behaviors among MSM living in New York City. This paper presents results of an analysis of neighborhood-level indicators of three distinct social theories of influence of the neighborhood environment on human behavior: physical disorder, social disorganization and social norms theories. Using multilevel modeling on a sample of 766 MSM stratified by race/ethnicity, we found little support for the role of social disorganization on the sexual risk behavior of MSM, whereas different indicators of physical disorder exerted negative effects across race groups. Our results suggest that the beneficial effects of housing stock maintenance and general neighborhood physical orderliness and cleanliness may have positive effects beyond those traditionally studied for African American MSM and that the field needs novel theorizing regarding whether and how neighborhood or virtual community-level factors relate to sexual behavior among MSM.

Gradients in Depressive Symptoms by Socioeconomic Position Among Men Who Have Sex With Men in the EXPLORE Study

This study examines gradients in depressive symptoms by socioeconomic position (SEP; i.e., income, education, employment) in a sample of men who have sex with men (MSM). Data were used from EXPLORE, a randomized, controlled behavioral HIV prevention trial for HIV-uninfected MSM in six U.S. cities (n = 4,277). Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression scale (short form). Multiple linear regressions were fitted with interaction terms to assess additive and multiplicative relationships between SEP and depressive symptoms. Depressive symptoms were more prevalent among MSM with lower income, lower educational attainment, and those in the unemployed/other employment category. Income, education, and employment made significant contributions in additive models after adjustment. The employment-income interaction was statistically significant, indicating a multiplicative effect. This study revealed gradients in depressive symptoms across SEP of MSM, pointing to income and employment status and, to a lesser extent, education as key factors for understanding heterogeneity of depressive symptoms.

Economic, Legal, and Social Hardships Associated with HIV Risk among Black Men who have Sex with Men in Six US Cities

We assessed whether economic, legal, and social hardships were associated with human immunodeficiency virus (HIV) risk among a sample of Black men who have sex with men (MSM) and whether associations were moderated by city of residence. The study analyzed baseline and follow-up data from HIV Prevention Trials Network 061 (N = 1553). Binary logistic regression assessed associations between hardships and HIV risk indicators. Multivariate regressions were used to test if city of residence had a moderating effect for hardships and HIV risks. Adjusted analyses showed that Black MSM with recent job loss were more likely to engage in condomless insertive anal intercourse (adjusted odds ratios (AOR) = 1.37, 95% CI 1.01-1.87) and that those with recent financial crisis were more likely to have had two or more male sexual partners in the past 6 months (AOR = 1.65; 95% CI 1.18-2.29). Black MSM with recent convictions were more likely to have a sexually transmitted infection at 6 months (AOR = 3.97; 95% CI 1.58-9.94), while those who were unstably housed were more likely to have a sexually transmitted infection at 12 months (AOR = 1.71; 95%CI 1.02 = 2.86). There were no city of residence and hardship interaction effects on HIV risks. Hardships are important factors that influence HIV risk for Black MSM. Integrating strategies that address structural factors that influence HIV risk may enhance HIV prevention interventions implementation efforts.

Correlates of Seroadaptation Strategies Among Black Men Who have Sex with Men (MSM) in 4 US Cities

We assessed associations of demographic, psychosocial, and substance use factors with seroadaptation strategies among 835 BMSM in four US cities. Seroadaptation strategies were practiced by 59.8 % of men, with 10.5 % practicing 100 % condom use, 26.5 % serosorting, 7.2 % condom serosorting, and 15.6 % seropositioning. In multivariable analyses, compared to men who used no seroadaptation strategies, serosorters were older, were less likely to be HIV infected, had fewer male sex partners, and had higher levels of social support and sexual self-efficacy. Condom serosorters had less psychological distress, were more likely to use methamphetamine, and had higher levels of sexual self-efficacy. Seropositioners were older, were less likely to be HIV infected, to have a main partner, and report alcohol/drug use with sex, while having higher levels of sexual self-efficacy. Seroadaptation practices among BMSM need to be considered to address perceived safer sex strategies and strengthen access to a broader reach of culturally-relevant prevention efforts.

"Just Because It's Out There, People Aren't Going to Use It." HIV Self-Testing Among Young, Black MSM, and Transgender Women

HIV disproportionately affects young black MSM and transgender women in the US. Increasing HIV testing rates among these populations is a critical public health goal. Although HIV self-tests are commercially available, there is a need to better understand access to and uptake of HIV self-testing among this population. Here, we report results of a qualitative study of 30 young black MSM and transgender women residing in the New York City area to understand facilitators of and barriers to a range of HIV testing approaches, including self-testing. Mean age was 23.7 years (SD = 3.4). Over half (54%) had some college or an associate's degree, yet 37% had an annual personal income of less than $10,000 per year. Most (64%) participants had tested in the past 6 months; venues included community health/free clinics, medical offices, mobile testing units, hospitals, emergency departments, and research sites. Just one participant reported ever using a commercially available HIV self-test. Facilitators of self-testing included convenience, control, and privacy, particularly as compared to venue-based testing. Barriers to self-testing included the cost of the test, anxiety regarding accessing the test, concerns around correct test operation, and lack of support if a test result is positive. Participants indicated that instruction in correct test operation and social support in the event of a positive test result may increase the likelihood that they would use the self-test. Alongside developing new approaches to HIV prevention, developing ways to increase HIV self-testing is a public health priority for young, black MSM, and transgender women.

Sexual Networks and HIV Risk among Black Men Who Have Sex with Men in 6 U.S. Cities

BACKGROUND

Sexual networks may place U.S. Black men who have sex with men (MSM) at increased HIV risk.

METHODS

Self-reported egocentric sexual network data from the prior six months were collected from 1,349 community-recruited Black MSM in HPTN 061, a multi-component HIV prevention intervention feasibility study. Sexual network composition, size, and density (extent to which members are having sex with one another) were compared by self-reported HIV serostatus and age of the men. GEE models assessed network and other factors associated with having a Black sex partner, having a partner with at least two age category difference (age difference between participant and partner of at least two age group categories), and having serodiscordant/serostatus unknown unprotected anal/vaginal intercourse (SDUI) in the last six months.

RESULTS

Over half had exclusively Black partners in the last six months, 46% had a partner of at least two age category difference, 87% had ≤5 partners. Nearly 90% had sex partners who were also part of their social networks. Among HIV-negative men, not having anonymous/exchange/ trade partners and lower density were associated with having a Black partner; larger sexual network size and having non-primary partners were associated with having a partner with at least two age category difference; and having anonymous/exchange/ trade partners was associated with SDUI. Among HIV-positive men, not having non-primary partners was associated with having a Black partner; no sexual network characteristics were associated with having a partner with at least two age category difference and SDUI.

CONCLUSIONS

Black MSM sexual networks were relatively small and often overlapped with the social networks. Sexual risk was associated with having non-primary partners and larger network size. Network interventions that engage the social networks of Black MSM, such as interventions utilizing peer influence, should be developed to address stable partnerships, number of partners, and serostatus disclosure.

Ties that bind: community attachment and the experience of discrimination among Black men who have sex with men

In the USA, the impact of psychological distress may be greater for Black men who have sex with men given that they may experience both racial discrimination in society at large and discrimination due to sexual orientation within Black communities. Attachments to community members may play a role in addressing psychological distress for members of this vulnerable population. This analysis is based on 312 Black men who have sex with men recruited for a behavioural intervention trial in New York City. Analyses were conducted using bivariate and multivariable logistic regression to examine the relationship of discrimination and community attachment to psychological distress. Most participants (63%) reported exposure to both discrimination due to race and sexual orientation. However, a majority of participants (89%) also reported racial and/or sexual orientation community attachment. Psychological distress was significant and negatively associated with older age (40 years and above), being a high school graduate and having racial and/or sexual orientation community attachments. Psychological distress was significantly and positively associated with being HIV-positive and experiencing both racial and sexual orientation discrimination. Similar results were found in the multivariable model. Susceptibility to disparate psychological distress outcomes must be understood in relation to social membership, including its particular norms, structures and ecological milieu.

Types of female partners reported by black men who have sex with men and women (MSMW) and associations with intercourse frequency, unprotected sex and HIV and STI prevalence

We used baseline data from a study of Black MSM/MSMW in 6 US cities to examine the association of female partnership types with disease prevalence and sexual behaviors among the 555 MSMW participants. MSMW reported more than three times as many total and unprotected sex acts with each primary as they did with each non-primary female partner. We compared MSMW whose recent female partners were: (1) all primary ("PF only", n = 156), (2) both primary and non-primary ("PF & NPF", n = 186), and (3) all non-primary ("NPF only", n = 213). HIV/STI prevalence did not differ significantly across groups but sexual behaviors did. The PF only group had the fewest male partners and was the most likely to have only primary male partners; the PF & NPF group was the most likely to have transgender partners. PF & NPF men reported the most sex acts (total and unprotected) with females; NPF only men reported the fewest. Implications for HIV risk and prevention are discussed.

Genotypic and functional impact of HIV-1 adaptation to its host population during the North American epidemic

HLA-restricted immune escape mutations that persist following HIV transmission could gradually spread through the viral population, thereby compromising host antiviral immunity as the epidemic progresses. To assess the extent and phenotypic impact of this phenomenon in an immunogenetically diverse population, we genotypically and functionally compared linked HLA and HIV (Gag/Nef) sequences from 358 historic (1979–1989) and 382 modern (2000–2011) specimens from four key cities in the North American epidemic (New York, Boston, San Francisco, Vancouver). Inferred HIV phylogenies were star-like, with approximately two-fold greater mean pairwise distances in modern versus historic sequences. The reconstructed epidemic ancestral (founder) HIV sequence was essentially identical to the North American subtype B consensus. Consistent with gradual diversification of a “consensus-like” founder virus, the median “background” frequencies of individual HLA-associated polymorphisms in HIV (in individuals lacking the restricting HLA[s]) were ∼2-fold higher in modern versus historic HIV sequences, though these remained notably low overall (e.g. in Gag, medians were 3.7% in the 2000s versus 2.0% in the 1980s). HIV polymorphisms exhibiting the greatest relative spread were those restricted by protective HLAs. Despite these increases, when HIV sequences were analyzed as a whole, their total average burden of polymorphisms that were “pre-adapted” to the average host HLA profile was only ∼2% greater in modern versus historic eras. Furthermore, HLA-associated polymorphisms identified in historic HIV sequences were consistent with those detectable today, with none identified that could explain the few HIV codons where the inferred epidemic ancestor differed from the modern consensus. Results are therefore consistent with slow HIV adaptation to HLA, but at a rate unlikely to yield imminent negative implications for cellular immunity, at least in North America. Intriguingly, temporal changes in protein activity of patient-derived Nef (though not Gag) sequences were observed, suggesting functional implications of population-level HIV evolution on certain viral proteins.

Upon HIV transmission, many – though not all – immune escape mutations selected in the previous host will revert to the consensus residue. The persistence of certain escape mutations following transmission has led to concerns that these could gradually accumulate in circulating HIV sequences over time, thereby undermining host antiviral immune potential as the epidemic progresses. As certain immune-driven mutations reduce viral fitness, their spread through the population could also have consequences for the average replication capacity and/or protein function of circulating HIV sequences. Here, we characterized HIV sequences, linked to host immunogenetic information, from patients enrolled in historic (1979–1989) and modern (2000–2011) HIV cohorts from four key cities in the North American epidemic. We reconstructed the epidemic's ancestral (founder) HIV sequence and assessed the subsequent extent to which known HIV immune escape mutations have spread in the population. Our data support the gradual spread of many - though not all - immune escape mutations in HIV sequences over time, but to an extent that is unlikely to have major immediate immunologic consequences for the North American epidemic. Notably, in vitro assessments of ancestral and patient-derived HIV sequences suggested functional implications of ongoing HIV evolution for certain viral proteins.

Concomitant socioeconomic, behavioral, and biological factors associated with the disproportionate HIV infection burden among Black men who have sex with men in 6 U.S. cities

BACKGROUND

American Black men who have sex with men (MSM) are disproportionately affected by HIV, but the factors associated with this concentrated epidemic are not fully understood.

METHODS

Black MSM were enrolled in 6 US cities to evaluate a multi-component prevention intervention, with the current analysis focusing on the correlates of being newly diagnosed with HIV compared to being HIV-uninfected or previously diagnosed with HIV.

RESULTS

HPTN 061 enrolled 1553 Black MSM whose median age was 40; 30% self-identified exclusively as gay or homosexual, 29% exclusively as bisexual, and 3% as transgender. About 1/6(th) (16.2%) were previously diagnosed with HIV (PD); of 1263 participants without a prior HIV diagnosis 7.6% were newly diagnosed (ND). Compared to PD, ND Black MSM were younger (p<0.001); less likely to be living with a primary partner (p<0.001); more likely to be diagnosed with syphilis (p<0.001), rectal gonorrhea (p = 0.011) or chlamydia (p = 0.020). Compared to HIV-uninfected Black MSM, ND were more likely to report unprotected receptive anal intercourse (URAI) with a male partner in the last 6 months (p<0.001); and to be diagnosed with syphilis (p<0.001), rectal gonorrhea (p = 0.004), and urethral (p = 0.025) or rectal chlamydia (p<0.001). They were less likely to report female (p = 0.002) or transgender partners (p = 0.018). Multivariate logistic regression analyses found that ND Black MSM were significantly more likely than HIV-uninfected peers to be unemployed; have STIs, and engage in URAI. Almost half the men in each group were poor, had depressive symptoms, and expressed internalized homophobia.

CONCLUSIONS

ND HIV-infected Black MSM were more likely to be unemployed, have bacterial STIs and engage in URAI than other Black MSM. Culturally-tailored programs that address economic disenfranchisement, increase engagement in care, screen for STIs, in conjunction with safer sex prevention interventions, may help to decrease further transmission in this heavily affected community.

Safety and comparative immunogenicity of an HIV-1 DNA vaccine in combination with plasmid interleukin 12 and impact of intramuscular electroporation for delivery

BACKGROUND

DNA vaccines have been very poorly immunogenic in humans but have been an effective priming modality in prime-boost regimens. Methods to increase the immunogenicity of DNA vaccines are needed.

METHODS

HIV Vaccine Trials Network (HVTN) studies 070 and 080 were multicenter, randomized, clinical trials. The human immunodeficiency virus type 1 (HIV-1) PENNVAX®-B DNA vaccine (PV) is a mixture of 3 expression plasmids encoding HIV-1 Clade B Env, Gag, and Pol. The interleukin 12 (IL-12) DNA plasmid expresses human IL-12 proteins p35 and p40. Study subjects were healthy HIV-1-uninfected adults 18-50 years old. Four intramuscular vaccinations were given in HVTN 070, and 3 intramuscular vaccinations were followed by electroporation in HVTN 080. Cellular immune responses were measured by intracellular cytokine staining after stimulation with HIV-1 peptide pools.

RESULTS

Vaccination was safe and well tolerated. Administration of PV plus IL-12 with electroporation had a significant dose-sparing effect and provided immunogenicity superior to that observed in the trial without electroporation, despite fewer vaccinations. A total of 71.4% of individuals vaccinated with PV plus IL-12 plasmid with electroporation developed either a CD4(+) or CD8(+) T-cell response after the second vaccination, and 88.9% developed a CD4(+) or CD8(+) T-cell response after the third vaccination.

CONCLUSIONS

Use of electroporation after PV administration provided superior immunogenicity than delivery without electroporation. This study illustrates the power of combined DNA approaches to generate impressive immune responses in humans.

Recruitment of urban US women at risk for HIV infection and willingness to participate in future HIV vaccine trials

Enrollment of US women with sufficient risk of HIV infection into HIV vaccine efficacy trials has proved challenging. A cohort of 799 HIV-negative women, aged 18-45, recruited from three US cities was enrolled to assess recruitment strategies based on geographic risk pockets, social and sexual networks and occurrence of sexual concurrency and to assess HIV seroincidence during follow-up (to be reported later). Among enrolled women, 90 % lived or engaged in risk behaviors within a local risk pocket, 64 % had a male partner who had concurrent partners and 50 % had a male partner who had been recently incarcerated. Nearly half (46 %) were recruited through peer referral. At enrollment, 86 % of women said they were willing to participate in a vaccine efficacy trial. Results indicate that participant and partner risk behaviors combined with a peer referral recruitment strategy may best identify an at-risk cohort willing to participate in future trials.

Use of a high resolution melting (HRM) assay to compare gag, pol, and env diversity in adults with different stages of HIV infection

BACKGROUND

Cross-sectional assessment of HIV incidence relies on laboratory methods to discriminate between recent and non-recent HIV infection. Because HIV diversifies over time in infected individuals, HIV diversity may serve as a biomarker for assessing HIV incidence. We used a high resolution melting (HRM) diversity assay to compare HIV diversity in adults with different stages of HIV infection. This assay provides a single numeric HRM score that reflects the level of genetic diversity of HIV in a sample from an infected individual.

METHODS

HIV diversity was measured in 203 adults: 20 with acute HIV infection (RNA positive, antibody negative), 116 with recent HIV infection (tested a median of 189 days after a previous negative HIV test, range 14-540 days), and 67 with non-recent HIV infection (HIV infected >2 years). HRM scores were generated for two regions in gag, one region in pol, and three regions in env.

RESULTS

Median HRM scores were higher in non-recent infection than in recent infection for all six regions tested. In multivariate models, higher HRM scores in three of the six regions were independently associated with non-recent HIV infection.

CONCLUSIONS

The HRM diversity assay provides a simple, scalable method for measuring HIV diversity. HRM scores, which reflect the genetic diversity in a viral population, may be useful biomarkers for evaluation of HIV incidence, particularly if multiple regions of the HIV genome are examined.

A post-trial assessment of factors influencing study drug adherence in a randomized biomedical HIV-1 prevention trial

High adherence and maintenance of blinding are critical for placebo-controlled efficacy trials of HIV-1 biomedical prevention strategies. We assessed adherence to study drug and factors affecting adherence, including perceived randomization group, in a post-trial questionnaire of participants who completed HPTN 039, a randomized, placebo-controlled trial of HSV-2 suppression with twice-daily acyclovir to reduce HIV-1 acquisition. Of the 3172 trial participants, 2003 (63%) completed the post-trial questionnaire. Of these 2003, 72% reported missing a dose of study drug less than twice a week. Study drug adherence was not compromised by perceived randomization or genital ulcer symptoms during the study. Alcohol use was cited as an adherence barrier in some populations. Assessment of study drug adherence during and at the end of trials can evaluate perceptions of randomization and adherence by randomization arm, help to better understand barriers to and motivations for adherence, and develop interventions to increase adherence for future trials.

Neighborhood-level correlates of consistent condom use among men who have sex with men: a multi-level analysis

There is growing evidence that the neighborhood environment influences sexual behavior and related outcomes, but little work has focused specifically on men who have sex with men (MSM). Using interview data from a probability sample of 385 young MSM living in New York City, recruited at public venues in 1999 and 2000 as part of the Young Men's Survey-New York City, and data on neighborhood characteristics obtained from the U.S. Census 2000, we conducted multi-level analyses of the associations between neighborhood-level characteristics and consistent condom use during anal intercourse, while controlling for individual-level sociodemographic and other factors. After adjusting for individual-level factors, neighborhood-level gay presence remained significantly and positively associated with consistent condom use during anal intercourse. This finding suggests that neighborhoods with a significant gay presence may have norms that act to discourage high risk sexual activity.

Recruitment of men who have sex with men for large HIV intervention trials: analysis of the EXPLORE Study recruitment effort

Testing HIV prevention strategies requires that researchers recruit participants at high risk of HIV infection. Data from the EXPLORE Study, a behavioral intervention trial involving men who have sex with men (MSM), were used to examine the relationship between recruitment strategies and participant characteristics, sexual risk behaviors and HIV incidence. The EXPLORE Study used a wide variety of recruitment strategies; no one strategy accounted for more than 20% of enrolled men. Younger men and men of color were more likely to be recruited through club and bar outreach, friend referral, and street outreach. Men reporting 10 or more sexual partners were more likely to be recruited through advertising and street outreach. Men reporting unprotected sex were more likely to be recruited through clinic referrals. HIV incidence did not significantly differ by recruitment strategy. Our findings support the need for a wide range of recruitment strategies in attracting MSM at high risk for HIV into clinical studies.

Analysis of HIV type 1 gp41 and enfuvirtide susceptibility among men in the United States who were HIV infected prior to availability of HIV entry inhibitors

We analyzed HIV gp41 from 195 men in the United States who were HIV-1 infected between 1999 and 2002, before enfuvirtide (ENF) was approved for clinical use in the United States. gp41 genotyping results were obtained for 175 samples. None of the samples had major ENF resistance mutations. Six (3.4%) samples had minor ENF resistance mutations in the HR1 region (V38G, N43K, L44M, L45M). Twenty-eight (16%) samples had the N42S polymorphism, which is associated with ENF hypersusceptibility. Accessory mutations in the HR2 region were identified in some samples (E137K, S138A). Five of the six samples with HR1 resistance mutations were analyzed with a phenotypic assay; one sample had reduced ENF susceptibility (a sample with N42S +L44M + E137K). Prior to the availability of ENF, some men in the United States were infected with HIV that contained mutations associated with ENF resistance or hypersusceptibility. However, most of the mutations were not associated with phenotypic ENF resistance.

Alcohol and drug use in the context of anal sex and other factors associated with sexually transmitted infections: results from a multi-city study of high-risk men who have sex with men in the USA

Men who have sex with men (MSM) who use alcohol and drugs are at especially high risk for sexually transmitted infections (STIs); more information is needed about associated factors to improve risk reduction. We assessed reported STIs and demographic and event-level alcohol and drug use characteristics associated with STIs in a diverse, multi-city study in the USA of MSM who use substances. Improved risk reduction efforts are needed for this group as well as some initiatives tailored to men who are HIV positive, younger and use drugs (not alcohol) in the context of anal sex.

Associations of Sexual Victimization, Depression, and Sexual Assertiveness with Unprotected Sex: A Test of the Multifaceted Model of HIV Risk Across Gender

This study examined whether the Multifaceted Model of HIV Risk (MMOHR) would predict unprotected sex based on predictors including gender, childhood sexual abuse (CSA), sexual victimization (SV), depression, and sexual assertiveness for condom use. A community-based sample of 473 heterosexually active men and women, aged 18-46 years completed survey measures of model variables. Gender predicted several variables significantly. A separate model for women demonstrated excellent fit, while the model for men demonstrated reasonable fit. Multiple sample model testing supported the use of MMOHR in both men and women, while simultaneously highlighting areas of gender difference. Prevention interventions should focus on sexual assertiveness, especially for CSA and SV survivors, as well as targeting depression, especially among men.

Same-sex attraction disclosure to health care providers among New York City men who have sex with men: implications for HIV testing approaches

BACKGROUND

While the Centers for Disease Control and Prevention recommends at least annual human immunodeficiency virus (HIV) screening for men who have sex with men (MSM), a large number of HIV infections among this population go unrecognized. We examined the association between disclosing to their medical providers (eg, physicians, nurses, physician assistants) same-sex attraction and self-reported HIV testing among MSM in New York City, New York.

METHODS

All men recruited from the New York City National HIV Behavioral Surveillance (NHBS) project who reported at least 1 male sex partner in the past year and self-reported as HIV seronegative were included in the analysis. The primary outcome of interest was a participant having told his health care provider that he is attracted to or has sex with other men. Sociodemographic and behavioral factors were examined in relation to disclosure of same-sex attraction.

RESULTS

Among the 452 MSM respondents, 175 (39%) did not disclose to their health care providers. Black and Hispanic MSM (adjusted odds ratios, 0.28 [95% confidence interval, 0.14-0.53] and 0.46 [95% confidence interval, 0.24-0.85], respectively) were less likely than white MSM to have disclosed to their health care providers. No MSM who identified themselves as bisexual had disclosed to their health care providers. Those who had ever been tested for HIV were more likely to have disclosed to their health care providers (adjusted odds ratio, 2.10; 95% confidence interval, 1.01-4.38).

CONCLUSIONS

These data suggest that risk-based HIV testing, which is contingent on health care providers being aware of their patients' risks, could miss these high-risk persons.

Effect of aciclovir on HIV-1 acquisition in herpes simplex virus 2 seropositive women and men who have sex with men: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Across many observational studies, herpes simplex virus type 2 (HSV-2) infection is associated with two-fold to three-fold increased risk for HIV-1 infection. We investigated whether HSV-2 suppression with aciclovir would reduce the risk of HIV-1 acquisition.

METHODS

We undertook a double-blind, randomised, placebo-controlled phase III trial in HIV-negative, HSV-2 seropositive women in Africa and men who have sex with men (MSM) from sites in Peru and the USA. Participants were randomly assigned by block randomisation to twice daily aciclovir 400 mg (n=1637) or matching placebo (n=1640) for 12-18 months, and were seen monthly for dispensation of study drug, adherence counselling and measurement by pill count and self-reporting, and risk reduction counselling, and every 3 months for genital examination and HIV testing. The primary outcome was HIV-1 acquisition and secondary was incidence of genital ulcers. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00076232.

FINDINGS

3172 participants (1358 women, 1814 MSM) were included in the primary dataset (1581 in aciclovir group, 1591 in control group). The incidence of HIV-1 was 3.9 per 100 person-years in the aciclovir group (75 events in 1935 person-years of follow-up) and 3.3 per 100 person-years in the placebo group (64 events in 1969 person-years of follow-up; hazard ratio 1.16 [95% CI 0.83-1.62]). Incidence of genital ulcers on examination was reduced by 47% (relative risk 0.53 [0.46-0.62]) and HSV-2 positive genital ulcers by 63% (0.37 [0.31-0.45]) in the aciclovir group. Adherence to dispensed study drug was 94% in the aciclovir group and 94% in the placebo group, and 85% of expected doses in the aciclovir group and 86% in the placebo group. Retention was 85% at 18 months in both groups (1028 of 1212 in aciclovir group, 1030 of 1208 in placebo group). We recorded no serious events related to the study drug.

INTERPRETATION

Our results show that suppressive therapy with standard doses of aciclovir is not effective in reduction of HIV-1 acquisition in HSV-2 seropositive women and MSM. Novel strategies are needed to interrupt interactions between HSV-2 and HIV-1.

Antiretroviral drug resistance, HIV-1 tropism, and HIV-1 subtype among men who have sex with men with recent HIV-1 infection

OBJECTIVE

Antiretroviral drug treatment may be complicated in individuals infected with antiretroviral drug-resistant or non-subtype B HIV-1 strains. HIV-1 tropism may also affect disease progression. We analyzed antiretroviral drug resistance, HIV-1 subtype, and HIV-1 tropism among 195 men who have sex with men from six major cities in the United States, using samples collected within 6 months of HIV-1 seroconversion (1999-2003).

METHODS

HIV-1 genotyping was performed using the ViroSeq HIV-1 Genotyping System. HIV-1 tropism was determined using a commercial assay. HIV-1 subtyping was performed by phylogenetic analysis of pol region sequences.

RESULTS

Thirty-one (15.9%) of the men had evidence of antiretroviral drug resistance. Seven (3.6%) men had multi-class resistance, including three (1.5%) with resistance to all three antiretroviral drug classes. We found no statistically significant association of antiretroviral drug resistance with demographic factors, sexual practices, self-reported sexually transmitted infections, use of recreational drugs, or use of antiretroviral drug post-exposure prophylaxis. All samples were HIV-1 subtype B. Four men had CXCR4-using HIV-1 strains. One man with a CXCR4-using strain also had antiretroviral drug resistance.

CONCLUSIONS

Antiretroviral drug resistance is relatively common among recently infected men who have sex with men in the United States. CXCR4-using strains were detected in a small number of these infections, which were all subtype B HIV-1.

Prevalence and Incidence of Pharyngeal Gonorrhea in a Longitudinal Sample of Men Who Have Sex with Men: The EXPLORE Study

BACKGROUND

The prevalence of gonorrhea of the pharynx among select samples of men who have sex with men (MSM) ranges from 9% to 15%. To our knowledge, there have been no longitudinal studies in a prospective MSM cohort to estimate pharyngeal gonorrhea incidence or predictors of infection. We examined the prevalence, incidence, and sociodemographic and behavioral predictors of pharyngeal gonorrhea in a cohort of sexually active, human immunodeficiency virus-negative MSM.

METHODS

We conducted a prospective study of pharyngeal gonorrhea among MSM who were enrolled in a behavioral intervention study to prevent human immunodeficiency virus infection (Project EXPLORE). Participants were enrolled in this ancillary study from March 2001 through July 2003. At baseline and every 6 months thereafter until 31 July 2003, participants were tested for pharyngeal gonorrhea and were administered a questionnaire regarding their oral sex practices. Rectal and urethral gonorrhea testing were also performed.

RESULTS

Prevalence of pharyngeal gonorrhea was 5.5% (136 cases diagnosed from 2475 tests). The incidence rate was 11.2 cases per 100 person-years. Pharyngeal gonorrhea was positively associated with younger age and the number of insertive oral sex partners in the past 3 months. Ejaculation did not increase the risk of pharyngeal gonorrhea. Gonorrhea of the pharynx was asymptomatic in 92% of cases.

CONCLUSIONS

The pharynx is a common, asymptomatic reservoir for gonorrhea in sexually active MSM.

Gender differences in sexual behaviors, sexual partnerships, and HIV among drug users in New York City

We compared sexual behaviors/partnerships and determined sexual risk correlates associated with HIV by gender among street-recruited drug users using chi-square tests and logistic regression. Men reported higher risk sexual behaviors, yet fewer high-risk sexual partners than women. After adjustment, HIV seropositive men were more likely than seronegatives to be older, MSM, use condoms, and have an HIV-infected partner. HIV seropositive women were more likely to be older, have an HIV-infected partner, and not use non-injected heroin. IDU was not associated with HIV. Prospective studies are needed to determine how gender-specific sexual behaviors/partnerships among drug users affect HIV acquisition.

High risk of human immunodeficiency virus in men who have sex with men with herpes simplex virus type 2 in the EXPLORE study

The relation between herpes simplex virus type 2 (HSV-2) and human immunodeficiency virus (HIV) acquisition was evaluated among 4,295 high-risk, HIV-negative men who have sex with men in an intensive behavioral intervention (colloquially referred to as "EXPLORE") study in the United States from 1999 to 2003. Sexual behavior data were obtained by computer-assisted self-interview, and sera were collected semiannually for HIV and HSV-2 serology. HSV-2 infection was classified as "recent incident" (at the first HSV-2 seropositive visit), "remote incident" (within 24 months of the first positive visit), and "prevalent" (for visits >24 months after the first HSV-2 positive visit). Baseline HSV-2 prevalence was 20.3%. HSV-2 incidence was 1.9 (95% confidence interval (CI): 1.6, 2.2) per 100 person-years; significant risk factors were African-American race, unprotected receptive anal intercourse, an HIV-positive male sex partner, and six or more male partners in the prior 6 months. The behavioral intervention did not reduce HSV-2 acquisition (adjusted hazard ratio (HR) = 1.2, 95% CI: 0.9, 1.6). Overall HIV incidence was 1.9 (95% CI: 1.7, 2.2) per 100 person-years. HIV risk was elevated among men who have sex with men with recent incident HSV-2 (adjusted HR = 3.6, 95% CI: 1.7, 7.8), remote incident HSV-2 (adjusted HR = 1.7, 95% CI: 0.8, 3.3), and prevalent HSV-2 (adjusted HR = 1.5, 95% CI: 1.1, 2.1) infection compared with HSV-2 seronegative participants. HIV intervention strategies targeting HSV-2 prevention and suppression among men who have sex with men should be evaluated.

The urban environment and sexual risk behavior among men who have sex with men

Increasingly, studies show that characteristics of the urban environment influence a wide variety of health behaviors and disease outcomes, yet few studies have focused on the sexual risk behaviors of men who have sex with men (MSM). This focus is important as many gay men reside in or move to urban areas, and sexual risk behaviors and associated outcomes have increased among some urban MSM in recent years. As interventions aimed at changing individual-level risk behaviors have shown mainly short-term effects, consideration of broader environmental influences is needed. Previous efforts to assess the influence of environmental characteristics on sexual behaviors and related health outcomes among the general population have generally applied three theories as explanatory models: physical disorder, social disorganization and social norms theories. In these models, the intervening mechanisms specified to link environmental characteristics to individual-level outcomes include stress, collective efficacy, and social influence processes, respectively. Whether these models can be empirically supported in generating inferences about the sexual behavior of urban MSM is underdeveloped. Conceptualizing sexual risk among MSM to include social and physical environmental characteristics provides a basis for generating novel and holistic disease prevention and health promotion interventions.

Recruitment and baseline epidemiologic profile of participants in the first phase 3 HIV vaccine efficacy trial

OBJECTIVE

To describe recruitment and baseline epidemiologic characteristics of volunteers in the first phase 3 placebo-controlled trial of a recombinant gp120 HIV vaccine (AIDSVAX B/B).

METHODS

Volunteers were gay/bisexual men or women at risk for sexually transmitted HIV infection. Recruitment strategies, demographics, and risk factors were assessed. HIV status was determined by standard HIV-1 antibody assays. Seronegative/viremic HIV infection at enrollment was determined using the HIV-1 nucleic acid test.

RESULTS

From June 1998 through October 1999, 5417 of 7185 volunteers screened were enrolled at 61 sites in the United States, Canada, and The Netherlands. Successful recruitment methods included distribution of study information at gay venues, advertising and media coverage, and referrals from volunteers. Most volunteers were altruistically motivated, men (98%), young (median, 36 years), white (83%), well educated (61% college education or more), and at high risk for HIV during the 6 months before enrollment. At baseline, 14 were HIV infected (12 were seronegative but viremic; 2 were seropositive and viremic).

CONCLUSION

Men and women at high risk for sexually transmitted HIV infection were successfully recruited for the first phase 3 HIV vaccine efficacy trial. Knowledge of recruitment and baseline epidemiologic characteristics of participants in this trial will provide valuable guidance for designing and conducting future trials.

Association of sex, hygiene and drug equipment sharing with hepatitis C virus infection among non-injecting drug users in New York City

BACKGROUND

Hepatitis C virus (HCV) rates are higher in non-injecting drug users (NIDUs) than general population estimates. Whether this elevated HCV rate is due to drug use or other putative risk behaviors remains unclear.

METHODS

Recent non-injection drug users of heroin, crack and/or cocaine were street-recruited from 2000 to 2003 and underwent an interview and venipuncture for HCV antibody assays. Multiple logistic regression analyses were used to assess correlates for HCV infection.

RESULTS

Of 740 enrollees, 3.9% were HCV positive. The median age (intraquartile range) was 30 (35-24) years, 70% were male and 90% were Black or Hispanic. After adjustment, HCV seropositives were significantly more likely than seronegatives to be older than 30 [adjusted odds ratio (AOR)=5.71], tattooed by a friend/relative/acquaintance [AOR=3.61] and know someone with HCV [AOR=4.29], but were less likely to have shared nail or hair clippers, razors or a toothbrush [AOR=0.32].

CONCLUSIONS

Non-commercial tattooing may be a mode of HCV transmission among NIDUs and education on the potential risk in using non-sterile tattooing equipment should be targeted toward this population. While no evidence was found for HCV transmission through NIDU equipment sharing or sexual risk behavior, further research is still warranted.

Age-related prevalence of anal cancer precursors in homosexual men: the EXPLORE study

BACKGROUND

Infection with human papillomavirus (HPV) is causally linked to the development of anal and cervical cancer. In the United States, the incidence of anal cancer among men who have sex with men (MSM) is higher than the incidence of cervical cancer among women. Anal squamous intraepithelial lesions (ASILs) are anal cancer precursors comprising low-grade squamous intraepithelial lesions (LSILs) and high-grade squamous intraepithelial lesions (HSILs). The prevalence of cervical cancer precursor lesions peaks at around 30 years of age. The age-related prevalence of ASILs in HIV-negative MSM is unknown.

METHODS

We conducted a cross-sectional analysis of the prevalence and determinants of ASILs in 1262 HIV-negative MSM aged 18-89 years recruited from four U.S. cities. Anal cytology and behavioral data were obtained. Anal HPV infection status was assessed by polymerase chain reaction. Independent predictors of ASILs were identified using logistic regression. All statistical tests were two-sided.

RESULTS

The prevalences of LSILs and HSILs were 15% and 5%, respectively, and did not change with age. In a multivariable analysis, the risk of LSILs was associated with having more than five male receptive anal sex partners (P = .03), any use of poppers (alkyl nitrites) in the previous 6 months [odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.1 to 2.5; P = .03] or use of injection drugs two or more times per month during the previous 6 months [OR = 19, 95% CI = 1.3 to 277; P = .03], older age at first receptive anal intercourse (P = .004), and infection with a greater number of HPV types (P < .001 for linear trend). The risk of HSILs was associated with any anal HPV infection (OR = 3.2, 95% CI = 1.1 to 9.4; P = .039) and infection with an increasing number of HPV types (P < .001 for linear trend).

CONCLUSIONS

Sexually active HIV-negative MSM in all age groups have a high prevalence of ASILs, possibly reflecting their ongoing sexual exposure to HPV.

Motivations for Participating in an HIV Vaccine Efficacy Trial

Understanding why people join HIV vaccine efficacy trials is critical for trial recruitment and education efforts. We assessed participants' motivations for joining the VaxGen VAX004 study, a randomized, double-blind, placebo-controlled, phase 3 multicenter trial. Of 5417 participants, 94% were men who have sex with men (MSM) and 6% were women at risk for heterosexual transmission of HIV. Most participants gave altruistic reasons for trial participation: 99% reported having joined to help find an HIV vaccine, and 98% reported having joined to help their community. Some gave more personal reasons: 56% joined to reduce risk behavior and 46% joined to get protection from HIV. Additional reasons related to receiving services or compensation included to obtain information about HIV (75%), to receive free HIV testing (34%), and for financial reimbursement (14%). Multivariate logistic regression analysis showed that female participants were significantly more motivated than male participants to join the trial for protection and to receive services or compensation (all P<0.05). Participants with 13 or more sex partners in the 6 months before enrollment were more likely than those with fewer sex partners to report having joined the trial for protection but less likely to have joined to reduce risk behavior (both P<0.05). Because many participants reported personal protection from HIV as their reason for joining, vaccine trial risk-reduction counseling should continue to emphasize the placebo-controlled trial design and unknown efficacy of the test product, particularly for women and persons with large numbers of sex partners. Because a significant minority of participants reported joining to receive HIV information, HIV testing, and financial reimbursement, a need is indicated for provision of HIV prevention services outside research trials and for monitoring to ensure that participants are not motivated to join trials for financial gain.

HIV sexual risk behavior over 36 months of follow-up in the world's first HIV vaccine efficacy trial

Increased risk behavior among participants in HIV vaccine efficacy trials has been a concern. This study evaluated HIV sexual risk behavior among 5095 HIV-negative men who have sex with men (MSM) and 308 women enrolled in a randomized, double-blind, placebo-controlled efficacy trial of a bivalent rgp120 vaccine at 61 sites, primarily in North America. Sexual risk behavior data were collected at baseline and semiannually for 36 months. Overall, sexual risk behavior did not exceed baseline levels during the trial. Among MSM, younger age (< or =30 years), perceived assignment to vaccine, and nonblack race were associated with an increased probability of unprotected anal sex. Among women, unprotected vaginal sex initially decreased but was statistically equivalent to baseline by 24 months, whereas unprotected vaginal sex with HIV-infected partners decreased from baseline, where it remained throughout the trial. HIV sexual risk behavior did not increase among trial participants; however, it was substantial throughout the trial. Consistently high levels of risk behavior and the association of these behaviors to perceived assignment and demographic variables underscore the need for vigilant HIV risk reduction counseling, informed consent, and educational processes in the context of HIV vaccine efficacy trials.

Longitudinal patterns of methamphetamine, popper (amyl nitrite), and cocaine use and high-risk sexual behavior among a cohort of san francisco men who have sex with men

Most prior studies examining drug use among men who have sex with men (MSM) have been cross-sectional or retrospective and have not determined whether periods of increased drug use are associated with high-risk sexual behavior at the individual level. In this article, we describe patterns of use of methamphetamines, poppers, and sniffed cocaine and sexual risk behavior among 736 San Francisco MSM enrolled in the EXPLORE study and followed for up to 48 months. In longitudinal analysis, use of methamphetamines, poppers, and sniffed cocaine declined during follow-up. However, compared with older participants, younger participants were more likely to increase their drug use over time. Results of conditional logistic regression demonstrated that high-risk sexual behavior was more common during reporting periods characterized by increased methamphetamine, poppers, or sniffed cocaine use. This within-person analysis found that compared with periods of no drug use, periods of both light drug use (less than weekly use of drugs) and heavier drug use (at least weekly use of at least one drug) were significantly associated with increased risk of engaging in unprotected anal sex with an HIV-positive or unknown-status partner. These results suggest that even intermittent, recreational use of these drugs may lead to high-risk sexual behavior, and that, to reduce and prevent risks of HIV, no level of use of these drugs should be considered "safe." HIV prevention interventions should target MSM who report either light or heavy use of methamphetamines, poppers, and sniffed cocaine.

A comparison of HIV seropositive and seronegative young adult heroin- and cocaine-using men who have sex with men in New York City, 2000-2003

The purpose of this analysis was to determine the prevalence and correlates of HIV infection among a street-recruited sample of heroin- and cocaine-using men who have sex with men (MSM). Injection (injecting <or=3 years) and non-injection drug users (heroin, crack, and/or cocaine use <10 years) between 18 and 40 years of age were simultaneously street-recruited into two cohort studies in New York City, 2000-2003, by using identical recruitment techniques. Baseline data collected among young adult men who either identified as gay/bisexual or reported ever having sex with a man were used for this analysis. Nonparametric statistics guided interpretation. Of 95 heroin/ cocaine-using MSM, 25.3% tested HIV seropositive with 75% reporting a previous HIV diagnosis. The majority was black (46%) or Hispanic (44%), and the median age was 28 years (range 18-40). HIV-seropositive MSM were more likely than seronegatives to be older and to have an HIV-seropositive partner but less likely to report current homelessness, illegal income, heterosexual identity, multiple sex partners, female partners, and sex for money/drug partners than seronegatives. These data indicate high HIV prevalence among street-recruited, drug-using MSM compared with other injection drug use (IDU) subgroups and drug-using MSM; however, lower risk behaviors were found among HIV seropositives compared with seronegatives. Large-scale studies among illicit drug-using MSM from more marginalized neighborhoods are warranted.

Age‐Specific Prevalence of Anal Human Papillomavirus Infection in HIV‐Negative Sexually Active Men Who Have Sex with Men: The EXPLORE Study

BACKGROUND

In the United States, anal cancer in men who have sex with men (MSM) is more common than cervical cancer in women. Human papillomavirus (HPV) is causally linked to the development of anal and cervical cancer. In women, cervical HPV infection peaks early and decreases after the age of 30. Little is known about the age-specific prevalence of anal HPV infection in human immunodeficiency virus (HIV)-negative MSM.

METHODS

We studied the prevalence and determinants of anal HPV infection in 1218 HIV-negative MSM, 18-89 years old, who were recruited from 4 US cities. We assessed anal HPV infection status by polymerase chain reaction.

RESULTS

HPV DNA was found in the anal canal of 57% of study participants. The prevalence of anal HPV infection did not change with age or geographic location. Anal HPV infection was independently associated with receptive anal intercourse (odds ratio [OR], 2.0; P<.0001) during the preceding 6 months and with >5 sex partners during the preceding 6 months (OR, 1.5; P<.0001).

CONCLUSIONS

Urban, HIV-negative MSM have a stable, high prevalence of anal HPV infection across all age groups. These results differ substantially from the epidemiologic profile of cervical HPV infection in women. This may reflect differences between these populations with respect to the number of new sex partners after the age of 30 and may explain the high incidence of anal cancer in MSM.

Acceptance and completion of hepatitis B vaccination among drug users in New York City

Hepatitis B (HBV) vaccination rates remain low among drug users. We examined correlates of vaccine acceptance and completion in two ongoing prospective studies of young injecting and non-injecting drug users in New York City. Street recruited drug users were enrolled at one of two neighbourhood locations (Harlem and the Bronx) between 2000 and 2004 and completed risk behaviour questionnaires and HBV testing. Free HBV vaccination was offered. Among 1117 participants, 26.1% (275) had a previous HBV infection, 57.9% (610) were susceptible to HBV, and 16.0% (169) had serological evidence of previous vaccination. Of the 610 participants susceptible to HBV, 466 (76.4%) returned for their results and were offered vaccination; 53.9% (251) received at least one dose of the vaccine (acceptors). Correlates of vaccine acceptance included older age, public assistance as main income source, and being recruited in the Bronx. Daily crack users were significantly less likely to initiate the vaccine series. Among 240 vaccine acceptors, 98 (40.8%) completed all three doses. Daily injectors, Hispanics, and those recruited in Harlem were less likely to complete the vaccination series. HBV vaccination acceptance among drug users seems likely in programmes that are convenient and offer remuneration; however, extended efforts are needed to improve series completion.

Effects of a behavioural intervention to reduce acquisition of HIV infection among men who have sex with men: the EXPLORE randomised controlled study

BACKGROUND

Effective interventions are needed to prevent acquisition of HIV infection in men who have sex with men. To date, no behavioural interventions specifically for this risk group have been tested with HIV infection as the primary outcome.

METHODS

This multisite two-group randomised controlled phase IIb trial tested the efficacy of a behavioural intervention in preventing HIV infection among 4295 men who have sex with men. The experimental intervention consisted of ten one-on-one counselling sessions followed by maintenance sessions every 3 months. The standard condition was twice-yearly Project RESPECT individual counselling. Twice-yearly follow-up visits included testing for HIV antibody and assessment of behavioural outcomes.

FINDINGS

The rate of acquisition of HIV infection was 18.2% (95% CI -4.7 to 36.0) lower in the intervention group than the standard group. Adjustment for baseline covariates attenuated the intervention effect to 15.7% (-8.4 to 34.4). The effect was more favourable in the first 12-18 months of follow-up. The occurrence of unprotected receptive anal intercourse with HIV-positive and unknown-status partners was 20.5% (10.9 to 29.0) lower in the intervention than in the standard group.

INTERPRETATION

The results from the primary analyses allow us to rule out that the experimental intervention is associated with a 35% lower rate of HIV acquisition than in the standard group. The overall estimate of a difference of 18.2%, more favourable estimates of effect in the first 12-18 months, and similar effects on risk behaviours suggest that prevention of HIV infection among men who have sex with men by a behavioural intervention is feasible. Further work should be done to develop more effective interventions.