Assessing HIV Stigma on Prevention Strategies for Black Men Who Have Sex with Men in the United States

The deleterious effects of HIV stigma on HIV+ Black MSM care continuum outcomes have been well-documented. How HIV stigma shapes HIV prevention for HIV? persons in this community is poorly understood. We sought to test the relationship of HIV stigma with HIV? Black MSM on HIV testing, pre-exposure prophylaxis (PrEP) awareness, and PrEP use. We recruited 772 participants at Black Pride events across five US cities in 2016. Multivariable logistic regression models assessed the association of external HIV stigma on prevention outcomes adjusting for sociodemographic variables. Stigma was positively associated with PrEP awareness (AOR?=?1.34; 95% CI?=?1.09, 1.66; p value?=?0.005), and not associated with PrEP use or HIV testing in our sample. These findings highlight the complex nature of HIV stigma among BMSM and include results for PrEP, which can affect uptake other prevention methods. We support anti-HIV stigma efforts and advise further exploration on HIV stigma among BMSM and prevention outcomes.     

HIV Testing Behaviors Among Female Sex Workers in Southwest China

Despite the recognized importance of HIV testing in prevention, care and treatment, HIV testing remains low in China. Millions of female sex workers (FSW) play a critical role in China’s escalating HIV epidemic. Limited data are available regarding HIV testing behavior among this at-risk population. This study, based on a cross-sectional survey of 1,022 FSW recruited from communities in Southwest China, attempted to address the literature gap. Our data revealed that 48% of FSW ever took HIV testing; older age, less education, working in higher-income commercial sex venues and better HIV knowledge were associated with HIV testing. Those who never took HIV testing were more likely to engage in high-risk behaviors including inconsistent condom use with clients and stable partners. A number of psychological and structural barriers to testing were also reported. We call for culturally appropriate interventions to reduce HIV risks and promote HIV testing for vulnerable FSW in China.     

Depression,sexual behavior,and HIV treatment outcomes among transgender women,cisgender women and men who have sex with men living with HIV in Brazil and Thailand: a short report

ABSTRACT

One in five transgender women (TW) are living with HIV, yet little has been published about their health outcomes. We analyzed data from TW (n?=?37), cisgender women (CW, n?=?165), and cisgender men who have sex with men (MSM, n?=?151) in Thailand and Brazil. We hypothesized: (1) TW will have higher odds of depressive symptoms, lower odds of condom use and greater odds of a detectable viral load compared to MSM and CW; and (2) TW will have lower odds of condom use and higher odds of detectable viral load. We found that TW had higher odds of depression (OR 2.2, 95%CI: 1.0, 4.8, p?=?0.04) and were less likely than MSM (22% v. 42%, p?=?0.01) to use condoms with partners of unknown serostatus. In multivariable models, TW had lower odds than MSM of using condoms with partners with unknown serostatus (OR 0.38, 95%CI: 0.15, 0.90) and CW had lower odds than MSM of using condoms with HIV-negative partners (0.60 [0.38, 0.95], p?=?0.029). We found no significant differences in detectable viral load. Disaggregating data by gender is important to understand factors that contribute to viral suppression and HIV transmission risk among people living with HIV.     

Repeat Use of Post-exposure Prophylaxis for HIV Among Nairobi-Based Female Sex Workers Following Sexual Exposure

As ART-based prevention becomes available, effectively targeting these interventions to key populations such as female sex workers (FSW) will be critical. In this study we analyze patterns of repeated post-exposure prophylaxis (PEP) access in the context of a large FSW program in Nairobi. During close to 6000 person-years of follow-up, 20 % of participants (n = 1119) requested PEP at least once and 3.7 % requested PEP more than once. Repeat PEP users were younger, had a higher casual partner volume, and were more likely to use condoms with casual and regular partners, have a regular partner, and test for HIV prior to enrolment. Barriers to PEP included stigma, side effects, and lack of knowledge, suggesting repeated promotion may be required for higher rates of uptake. A small subset of FSW, potentially those with heightened risk perception, showed a higher frequency of PEP use; these individuals may be most amenable to rollout of pre-exposure prophylaxis.     

Predictors of HIV Testing and Their Influence on PrEP Acceptance in Men Who Have Sex with Men: A Cross-Sectional Study

HIV testing is the gateway to biomedical means of prevention and treatment. Identifying predictors of HIV testing is important to inform future preventive interventions. Of 444 men who have sex with men without known HIV infection enrolled in a study in Hong Kong, 64% had ever been HIV-tested. Testers were generally older, better educated, had a higher monthly income, and more likely self-identified as gay. Testers often used Internet and frequented saunas for sex networking, compared with non-testers attending bars, massage centres and public toilets. HIV testing habit also varied with the profile of body image type and preferred type in sex networking. Higher acceptance of pre-exposure prophylaxis (PrEP) was observed among testers. Overall, socioeconomic status played an important role in both HIV testing and access to PrEP. Interventions targeting sex networking venues and alternative means of testing provision are needed to increase coverage of HIV testing.     

Complex routes into HIV care for migrant workers: a qualitative study from north India

Migrant workers are designated a bridge population in the spread of HIV and therefore if infected, should be diagnosed and treated early. This study examined pathways to HIV diagnosis and access to care for rural-to-urban circular migrant workers and partners of migrants in northern India, identifying structural, social and individual level factors that shaped their journeys into care. We conducted a qualitative study using in-depth interviews with HIV-positive men (n?=?20) and women (n?=?13) with a history of circular migration, recruited from an antiretroviral therapy centre in one district of Uttar Pradesh, north India. Migrants and partners of migrants faced a complex series of obstacles to accessing HIV testing and care. Employment insecurity, lack of entitlement to sick pay or subsidised healthcare at destination and the household's economic reliance on their migration-based livelihood led many men to continue working until they became incapacitated by HIV-related morbidity. During periods of deteriorating health they often exhausted their savings on private treatments focused on symptom management, and sought HIV testing and treatment at a public hospital only following a medical or financial emergency. Wives of migrants had generally been diagnosed following their husbands' diagnosis or death, with access to testing and treatment mediated via family members. For some, a delay in disclosure of husband's HIV status led to delays in their own testing. Diagnosing and treating HIV infection early is important in slowing down the spread of the epidemic and targeting those at greatest risk should be a priority. However, despite targeted campaigns, circumstances associated with migration may prevent migrant workers and their partners from accessing testing and treatment until they become sick. The insecurity of migrant work, the dominance of private healthcare and gender differences in health-seeking behaviour delay early diagnosis and treatment initiation.     

Fertility desires and preferences for safer conception strategies among people receiving care for HIV at a publicly-funded clinic in Seattle,WA

Understanding fertility desires and preferences for HIV prevention among individuals living with HIV, including the potential use of pre-exposure prophylaxis (PrEP) by HIV uninfected partners, can inform the delivery of safer conception counseling to reduce the risk of HIV transmission during pregnancy attempts. Men and women, predominantly heterosexual, engaged in HIV care in Seattle, WA, self-administered a questionnaire and we abstracted antiretroviral therapy (ART) status and HIV viral levels from medical records. We summarized participants’ sexual behavior, fertility desires, and preferences for safer conception strategies and used log-binomial regression to identify demographic, sexual, and behavioral factors associated with perceived acceptability of PrEP for HIV uninfected partners during pregnancy attempts. 52% of the 150 participants were female and the mean age was 48 years (range 23–74). 94.7% of participants were using ART and 79.3% had HIV viral load < 40 copies/mL. 22.2% of men and 34.6% of women reported that a healthcare provider had initiated discussion about fertility desires. 28.7% of participants were reproductive-age and desired children. Among sexually active reproductive-age participants with fertility desires, 56.3% reported inconsistent condom use and 62.5% did not report using effective birth control. 74.4% of reproductive age participants with fertility desires perceived that PrEP would be acceptable to an HIV uninfected partner and there were no significant predictors of PrEP acceptability. Nearly one third of reproductive-aged individuals living with HIV expressed fertility desires, highlighting a need for safer conception counseling in this setting. PrEP and ART were favored safer conception strategies.     

Factors associated with unprotected sexual intercourse with steady male, casual male, and female partners among men who have sex with men in Barcelona, Spain.

To increase understanding of the HIV epidemic among MSM in Barcelona, anonymous questionnaires were completed by 640 MSM recruited in the city in 2002. The prevalence of unprotected anal intercourse (UAI) with casual male partners in the prior 12 months was higher among self-reported HIV-positive men (confirmed through saliva testing) than among men who were HIV-negative or of unknown serostatus (35% vs. 20%, p < .01). The prevalence of UAI with steady male partners was substantially lower among HIV-positive men than other men (28% vs. 60%, p < .01). In multivariate analyses, UAI with casual partners was more likely among HIV-positive individuals; those who used drugs before sex; perceived less acceptance of their sexual orientation by family, friends, or coworkers; and were less concerned about HIV prevention because of antiretroviral therapy (ART). UAI with steady partners was more likely among HIV-negative men with seroconcordant partners, those living with a partner, and men less concerned about HIV prevention because of ART. Findings indicate a need for prevention programs targeting HIV-positive MSM in Barcelona. Attention to substance use and attitudes about HIV prevention are needed for MSM in general.     

The association between substance use and sub-optimal HIV treatment engagement among HIV-infected female sex workers in Lilongwe,Malawi

Female sex workers (FSW) have a high prevalence of substance use and HIV, but the impact of substance use on HIV treatment engagement is not well established. We evaluated the association between alcohol and marijuana use and sub-optimal HIV treatment engagement outcomes among HIV-infected FSW in Lilongwe, Malawi. We enroled FSW using venue-based recruitment into a cross-sectional evaluation assessing substance use and HIV treatment engagement. Seropositive FSW, identified through HIV rapid testing, received rapid CD4 count and viral load testing. We used Poisson regression with robust variance estimates to ascertain associations of alcohol and marijuana use with sub-optimal HIV treatment outcomes: (1) lack of ART use among previously diagnosed, ART-eligible FSW and (2) viral nonsuppression among FSW on ART. Of previously diagnosed, ART-eligible FSW (n?=?96), 29% were not using ART. Patterns of hazardous drinking were identified in 30%, harmful drinking in 10%, and alcohol dependence in 12%. ART-eligible FSW with harmful drinking or alcohol dependency were 1.9 (95% CI: 1.0, 3.8) times as likely to not use ART compared to FSW without harmful or dependent drinking. Among those on ART, 14% were virally nonsuppressed. The prevalence ratio for viral nonsuppression was 2.0 (95% CI: 0.6, 6.5) for harmful drinkers and alcohol-dependent FSW. Over 30% of ART-eligible FSW reported using marijuana. Marijuana-using FSW were 1.9 (95% CI: 0.8, 4.6) times as likely to not use ART compared to FSW who were not using marijuana. Given the high prevalence of alcohol use and its association with lack of ART use, ART uptake and alcohol reduction strategies should be tailored for alcohol-using FSW in Malawi.     

HIV care and treatment experiences among female sex workers living with HIV in sub-Saharan Africa: A systematic review

Female sex workers (FSW) living with HIV in sub-Saharan Africa have poor engagement to HIV care and treatment. Understanding the HIV care and treatment engagement experiences of FSW has important implications for interventions to enhance care and treatment outcomes. We conducted a systematic review to examine the HIV care experiences and determinants of linkage and retention in care, antiretroviral therapy (ART) initiation, and ART adherence and viral suppression among FSW living with HIV in sub-Saharan Africa. The databases PubMed, Embase, Web of Science, SCOPUS, CINAHL, Global Health, Psycinfo, Sociological Abstracts, and Popline were searched for variations of search terms related to sex work and HIV care and treatment among sub-Saharan African populations. Ten peer-reviewed articles published between January 2000 and August 2015 met inclusion criteria and were included in this review. Despite expanded ART access, FSW in sub-Saharan Africa have sub-optimal HIV care and treatment engagement outcomes. Stigma, discrimination, poor nutrition, food insecurity, and substance use were commonly reported and associated with poor linkage to care, retention in care, and ART initiation. Included studies suggest that interventions with FSW should focus on multilevel barriers to engagement in HIV care and treatment and explore the involvement of social support from intimate male partners. Our results emphasise several critical points of intervention for FSW living with HIV, which are urgently needed to enhance linkage to HIV care, retention in care, and treatment initiation, particularly where the HIV prevalence among FSW is greatest.     

HIV/AIDS prevention practices among military personnel in Northwest Ethiopia

ABSTRACT

The spread of HIV/AIDS is a major public health problem in military personnel in Africa. However, the epidemiological evidence regarding HIV/AIDS prevention practices among military personnel in Ethiopia remains unclear. The aim of this study was to investigate HIV/AIDS prevention practices among military personnel in Northwest Ethiopia. A cross-sectional study among military personnel (n?=?410) was conducted in Northwest Ethiopia in 2015. Data were collected using a pre-tested questionnaire. Multivariable logistic regression model was fitted to ascertain factors influencing participation in HIV/AIDS prevention programs. About one-fourth (24.6%) of the military personnel had multiple sexual partners, of whom 24.7% failed to use condoms regularly when having sex with non-regular sexual partners. Majority of the sample (n?=?355, 86.6%) participated in HIV/AIDS prevention programs. Military personnel who had multiple sexual partners were 6.3 times more likely to report history of non-participation in HIV/AIDS prevention programs (AOR?=?6.3, CI₉₅?=?3.5–11.54). A considerable proportion of military personnel had multiple sexual partners with lower levels of condom utilization with non-regular sexual partners. The study further demonstrated misconceptions about HIV/AIDS in Ethiopian military personnel, which reduce their likelihood of participation in HIV/AIDS prevention programs. Health authorities need to strengthen and accelerate HIV/AIDS prevention programs focusing towards military personnel.     

Characterizing the HIV Prevention and Care Continua in a Sample of Transgender Youth in the U.S.

In the U.S., transgender and other gender minority (TG) youth are an at-risk group understudied in HIV prevention and treatment. This study sought to characterize the HIV prevention and care continua in a diverse sample of 181 sexually-active TG ages 16–24 years (mean age = 20.7 years; 76.8% trans feminine; 69.1% youth of color) recruited July–December 2015 in 14 U.S. cities. Overall, 30.9% reported living with HIV, of which 71.4% were on antiretroviral therapy (ART) and 55.0% were medication adherent; 65.6% were known to be virally suppressed. In multivariable models, medical gender affirmation was associated with lower odds of viral suppression. Medical gender affirmation and stigma in HIV care were each independently associated with elevated odds of having missed HIV care appointments. Among at-risk TG youth not living with HIV, only 8.2% had accessed pre-exposure prophylaxis (PrEP). Early biobehavioral prevention and treatment interventions are needed for TG youth.     

San Franciscan MSM have similar types and numbers of partnerships with men inside San Francisco and outside San Francisco, 2011

Sexual networks among men who have sex with men (MSM) across health jurisdictions may play a role in HIV transmission and acquisition. Levels of HIV prevention activities may be different across health jurisdictions leading to differential risk for HIV transmission with partners in and outside of San Francisco (SF). We examined MSM sexual partnerships within and outside SF. Data were collected during the 2011 National HIV Behavioral Surveillance MSM data collection cycle. Participants were asked to report characteristics of and sexual behaviors with up to five most recent sexual partners. Restricting our analysis to sexually active San Franciscans (n?=?329 MSM reporting 927 partnerships), we found that SF MSM have similar numbers of partnerships (SF mean?=?1.3, non-SF mean?=?1.2) and levels of risk behavior with men within and outside SF. With the current intensity of HIV prevention occurring in SF additional strategies may be needed to address the fact that SF MSM have many sexual connections to men in other health jurisdictions where HIV prevention may not be similar to those in SF.     

Obligations of motherhood in shaping sex work,condom use,and HIV care among Swazi female sex workers living with HIV

Parental obligations influence sexual behaviour among female sex workers (FSW) and may serve as a risk or protective factor for HIV acquisition. How these obligations affect behaviours beyond HIV prevention, including HIV care, is understudied. We analysed 25 interviews conducted with 11 mothers who sell sex and are living with HIV, and 4 key informants as part of a larger study examining the positive health, dignity, and prevention needs of FSW in eSwatini. Despite awareness of HIV reinfection, FSW initiated sex work and engaged in condomless sex due to financial pressures of providing for children. While women attributed having condomless sex to their obligations as a provider, motherhood also served as motivation to engage in HIV care. Further, FSW described children as a source of support in HIV care. Children reminded mothers to take their medications, prepared food to take with medications, and assisted with travel to the clinic.     

Low uptake of HIV testing and no HIV positivity in stable serodiscordant heterosexual partners of long-term treated HIV-infected Thais

The objective of this study was to characterize HIV-serodiscordant heterosexual couples and to evaluate acceptance for HIV testing and HIV prevalence in nonindex partners. We conducted a cross-sectional study with quantitative and qualitative components. Two cohorts of 1767 HIV-positive people were screened to identify heterosexual HIV-serodiscordant couples. HIV-positive partners (index) were administered a questionnaire; CD4, viral load (VL), and antiretroviral therapy (ART) history were gathered from clinical records. HIV-negative/unknown status partners (nonindex) were invited for a similar questionnaire and HIV testing. In-depth interviews with three HIV-serodiscordant couples were conducted. Two hundred and ninety-seven index partners agreed to enroll in this study. The median duration of the relationship was 10 years, and 81% were sexually active. All but two index partners were on ART, and 98% had VL < 1000 copies/mL. Only 111 (37%) nonindex partners came for HIV testing, and all of them tested HIV-negative. In addition, only 41% of nonindex partners had HIV testing in the last one year. The main reasons for the nonindex partners not to come for HIV testing were “no interest” (n = 117, 63%) and “nondisclosure of HIV status” (n = 46, 25%). The latter was substantiated and explained by the qualitative outcome of this study, suggesting relation to stigma against HIV-positive people. Our results support the WHO recommendation for starting ART for treatment and prevention in HIV-serodiscordant couples at any CD4 count. Furthermore, we recommend the dissemination of data showing that no HIV transmission in heterosexual couples through sex practice has been observed provided VL is suppressed. This could be a powerful tool for effective fight against stigma and self-stigma in people living with HIV.     

CDC-funded HIV testing,HIV positivity,and linkage to HIV medical care in non-health care settings among young men who have sex with men (YMSM) in the United States

In the United States, HIV infection disproportionately affects young gay, bisexual, and other men who have sex with men, aged 13–24 years (collectively referred to as YMSM), specifically black YMSM. Knowledge of HIV status is the first step for timely and essential prevention and treatment services. Because YMSM are disproportionately affected by HIV, the number of CDC-funded HIV testing events, overall and newly diagnosed HIV positivity, and linkage to HIV medical care among YMSM in non-health care settings were examined from 61 health department jurisdictions. Differences by age and race/ethnicity were analyzed. Additionally, trends in number of HIV testing events and newly diagnosed HIV positivity were examined from 2011 to 2015. In 2015, 42,184 testing events were conducted among YMSM in non-health care settings; this represents only 6% of tests in non-health care settings. Overall and newly diagnosed HIV positivity was 2.8% and 2.1%, respectively, with black/African–American YMSM being disproportionately affected (5.6% for overall; 4% for newly diagnosed); 71% of YMSM were linked within 90 days. The newly diagnosed HIV positivity among YMSM decreased from 2.8% in 2011 to 2.4% in 2015, and the number of newly diagnosed YMSM also decreased. Further targeted testing efforts among YMSM are needed to identify undiagnosed YMSM, specifically black YMSM.     

Differences in testing,stigma, and perceived consequences of stigmatization among heterosexual men and women living with HIV in Bengaluru,India

Approximately 2.4 million people in India are living with HIV. Gender inequality affects HIV prevention, detection, and management. The purpose of this paper was to describe gender differences in the experience of living with HIV in Bengaluru, India. A subsample of n = 313 (159 men and 154 women) from a larger cohort was used for these analyses. Participants were recruited through AIDS service organizations. They completed an interviewer-administered survey assessing HIV testing experience, types of stigma, and perceived consequences of stigmatization. The majority of men (67%) reported getting HIV tested because of illness, while women were more likely to be tested after learning their spouse's HIV-positive status (42%). More men (59%) than women (45%, p<0.05) were tested in private care settings. Men reported significantly higher mean levels of internalized stigma (men: M=0.71, SD = 0.63; women: M=0.46, SD = 0.55; p<0.001), whereas the women reported significantly higher scores for enacted stigma (men: M=1.30, SD = 1.69; women: M=2.10, SD = 2.17; p<0.001). These differences remained significant after controlling for potential socio-demographic covariates. Following their diagnosis, more women reported moving out of their homes (men: 16%; women: 26%; p<0.05). More men (89%) than women (66%; p<0.001) reported to have modified their sexual behavior after being diagnosed. These findings suggest that the experience of living with HIV and HIV stigma varies by gender in this population. Suggestions for a gender-based approach to HIV prevention and stigma reduction are provided.     

Choice in HIV testing: the acceptability and anticipated use of a self-administered at-home oral HIV test among South Africans

Combination HIV prevention is being widely promoted by funders. This strategy aims to offer HIV prevention choices that can be selected and combined to decrease HIV risk in ways that fit with each individual’s situation. Treatment as prevention and pre-exposure prophylaxis are two new evidence-based strategies to decrease HIV incidence, both of which require high HIV testing rates to be effective, and the Joint United Nations Programme on HIV/AIDS (UNAIDS) has set a goal of 90% of HIV-positive individuals knowing their status by 2030. However, HIV testing rates in many countries remain suboptimal. Just as no single HIV prevention method is ideal for all people in all situations, no single HIV testing modality is likely to be acceptable to everyone. By offering HIV testing choices, we may be able to increase testing rates. However, many low-resourced countries have been slow to take up new HIV testing options such as the self-administered at-home oral HIV test that is currently available in the United States. In this paper, we present findings from 20 in-depth interviews, conducted in 2010, documenting opinions about self-administered at-home oral HIV testing, a testing modality still largely unavailable in Africa. Participants were clients of three primary healthcare clinics in South Africa. Self-testing was seen as enabling confidentiality/privacy, saving time, and facilitating testing together with partners. However, concerns were raised about psychological distress when testing at home without a counsellor. Some suggested this concern could be minimised by having experienced clinic-based HIV testing and counselling before getting self-testing kits for home use. Thus, self-administered HIV testing could be an option added to the current testing modalities to address some important barriers to testing.