Overcoming HIV Stigma? A Qualitative Analysis of HIV Cure Research and Stigma Among Men Who Have Sex with Men Living with HIV

Despite global progress in HIV stigma reduction, persistent HIV stigma thwarts effective HIV service delivery. Advances in HIV biomedical research toward a cure may shift perceptions of people living with HIV and HIV stigma. The purpose of this study was to examine how men who have sex with men (MSM) living with HIV in Guangzhou, China perceive HIV cure research and its potential impact on MSM and HIV stigma. We conducted in-depth interviews with 26 MSM living with HIV about their perceptions of HIV cure research and the potential impact of an HIV cure on their lives. Thematic coding was used to identify themes and structure the analysis. Two overarching themes emerged. First, participants stated that an HIV cure may have a limited impact on MSM-related stigma. Men noted that most stigma toward MSM was linked to stereotypes of promiscuity and high rates of sexual transmitted diseases in the MSM community and might persist even after a cure. Second, participants believed that an HIV cure could substantially reduce enacted, anticipated, and internalized stigma associated with HIV. These findings suggest that a biomedical cure alone would not remove the layered stigma facing MSM living with HIV. Comprehensive measures to reduce stigma are needed.     

Why the Wait? Delayed HIV Diagnosis among Men Who Have Sex with Men

We sought to identify factors associated with delayed diagnosis of human immunodeficiency virus (HIV; testing HIV-seropositive 6 months or more after HIV seroconversion), by comparing delayed testers to non-delayed testers (persons who were diagnosed within 6 months of HIV seroconversion), in King County, Washington among men who have sex with men (MSM). Participants were recruited from HIV testing sites in the Seattle area. Delayed testing status was determined by the Serologic Testing Algorithm for Recent HIV Seroconversion or a self-reported previous HIV-negative test. Quantitative data on sociodemographic characteristics, health history, and drug-use and sexual behaviors were collected via computer-assisted self-interviews. Qualitative semi-structured interviews regarding testing and risk behaviors were also conducted. Multivariate analysis was used to identify factors associated with delayed diagnosis. Content analysis was used to establish themes in the qualitative data. Out of the 77 HIV-seropositive MSM in this sample, 39 (51%) had evidence of delayed diagnosis. Factors associated with delayed testing included being African-American, homeless, “out” to 50% or less people about male-male sex, and having only one sex partner in the past 6 months. Delayed testers often cited HIV-related sickness as their reason for testing and fear and wanting to be in denial of their HIV status as reasons for not testing. Delayed testers frequently did not identify as part of the MSM community, did not recognize that they were at risk for HIV acquisition, and did not feel a responsibility to themselves or others to disclose their HIV status. This study illustrates the need to further explore circumstances around delayed diagnosis in MSM and develop outreach methods and prevention messages targeted specifically to this potentially highly marginalized population in order to detect HIV infections earlier, provide HIV care, and prevent new infections.     

Are HIV-Negative Men Who Have Sex with Men and Who Bareback Concerned About HIV Infection? Implications for HIV Risk Reduction Interventions

The emergence of barebacking (intentional unprotected anal intercourse in situations where there is risk of HIV infection) among men who have sex with men (MSM) has been partially attributed to a decrease in HIV-related concerns due to improved anti-retroviral treatment. It is important to understand the level of concern these men have regarding HIV infection because it can affect their interest in risk reduction behaviors as well as their possible engagement in risk reduction interventions. As part of a study on MSM who use the Internet to seek sexual partners, 89 ethnic and racially diverse men who reported never having an HIV-positive test result completed an in-depth qualitative interview and a computer-based quantitative assessment. Of the 82 men who were asked about concerns of HIV infection during the qualitative interviews, 30 expressed “significant concern” about acquiring HIV, 42 expressed “moderate concern,” and 10 expressed “minimal concern.” Themes that emerged across the different levels of concern were their perceptions of the severity of HIV infection, having friends who were HIV positive, and their own vulnerability to HIV infection. However, these themes differed depending on the level of concern. Among the most frequently mentioned approaches to decrease risk of HIV infection, participants mentioned avoiding HIV-positive sex partners, limiting the number of partners with whom they barebacked, and not allowing partners to ejaculate inside their rectum. Findings suggest that many MSM who bareback would be amenable to HIV prevention efforts that do not depend solely on condom use.     

Where are the Young Men in HIV Prevention Efforts? Comments on HIV Prevention Programs and Research from Young Men Who Sex with Men in Los Angeles County

Despite increasing rates of HIV infection among young men who have sex with men (YMSM), only a minority participate in formal HIV prevention efforts. Semi-structured mixed-methods interviews were conducted with a diverse sample of YMSM (N?=?100, M _age?=?25.0?years) in Los Angeles, California, to identify facilitators and barriers to participation in HIV prevention programs. Summative content analyses were used to evaluate transcribed field notes from these interviews. Results showed that 28.0?% of all participants had previously attended an HIV prevention program, and that 21.3?% of those who were also asked if they had ever participated in any research pertaining to HIV prevention had done so. A significantly higher percentage of those who had participated in HIV prevention programs had been tested for HIV in the past 6?months compared to those who had not (p?<?.05). The most frequently mentioned barriers to participation in such a program were being too busy to attend (12.0?%), not perceiving themselves to be at risk for HIV infection (14.0?%), and believing that they already knew everything they needed to know about HIV transmission (23.0?%). YMSM suggested that future interventions should use technology (e.g., the Internet, mobile devices), engage their social networks, and highlight HIV prevention as a means for community connection. Collectively, these results provide some explanations for why YMSM account for a minority of HIV prevention program participants and offer possible directions for future HIV prevention efforts that target YMSM.     

Are Partner Race and Intimate Partner Violence Associated with Incident and Newly Diagnosed HIV Infection in African-American Men Who Have Sex with Men?

Black gay, bisexual, and other men who have sex with men (BMSM) experience a disparate rate of HIV infections among MSM. Previous analyses have determined that STI coinfection and undiagnosed HIV infection partly explain the disparity. However, few studies have analyzed the impact of partner-level variables on HIV incidence among BMSM. Data were analyzed for BMSM who attended the Los Angeles LGBT Center from August 2011 to July 2015 (n = 1974) to identify risk factors for HIV infection. A multivariable logistic regression was used to analyze predictors for HIV prevalence among all individuals at first test (n = 1974; entire sample). A multivariable survival analysis was used to analyze predictors for HIV incidence (n = 936; repeat tester subset). Condomless receptive anal intercourse at last sex, number of sexual partners in the last 30 days, and intimate partner violence (IPV) were significant partner-level predictors of HIV prevalence and incidence. Individuals who reported IPV had 2.39 times higher odds (CI 1.35–4.23) and 3.33 times higher hazard (CI 1.47–7.55) of seroconverting in the prevalence and incidence models, respectively. Reporting Black partners only was associated with increased HIV prevalence, but a statistically significant association was not found with incidence. IPV is an important correlate of both HIV prevalence and incidence in BMSM. Further studies should explore how IPV affects HIV risk trajectories among BMSM. Given that individuals with IPV history may struggle to negotiate safer sex, IPV also warrants consideration as a qualifying criterion among BMSM for pre-exposure prophylaxis (PrEP).     

Viewing Pornography Depicting Unprotected Anal Intercourse: Are There Implications for HIV Prevention Among Men Who Have Sex with Men?

We used an Internet-based questionnaire to investigate whether viewing pornography depicting unprotected anal intercourse (UAI) was associated with engaging in UAI in a sample of 821 non-monogamous men who have sex with men (MSM). In the 3 months prior to interview, 77.2% viewed pornography depicting UAI, 42.6% engaged in insertive UAI, and 38.9% engaged in receptive UAI. Polytomous logistic regression of the 751 subjects who provided data on pornography viewing showed significantly elevated odds ratios for having engaged in receptive UAI, insertive UAI, and both receptive and insertive UAI associated with increasing percentage of pornography viewed that depicted UAI. We also found independently significant associations of engaging in UAI with age, use of inhalant nitrites, and HIV status. Although the data cannot establish causality, our findings indicate that viewing pornography depicting UAI and engaging in UAI are correlated. Further research is needed to determine if this observation may have utility for HIV prevention.     

Men Sex Workers and Other Men Who Have Sex With Men: How Do Their HIV Risks Compare in New Zealand?

Sex workers have their perspective on HIV transmission, claiming that in general they are more similar than different from other people in HIV status and the practice of safe sex. Such an assertion of similarity goes against public and professional opinion that prostitution is a major vector in the spread of AIDS. Taking the sex workers' similarity claim seriously, this paper considers the conditions under which it would be valid. We focus on those factors that make a population more or less vulnerable to HIV and how they affect its spread into the sex work population. Data from New Zealand comparing men sex workers and other men who have sex with men is used to evaluate these ideas. Data partially support the hypothesis in that these two groups of men are similar with regard to their HIV status. We do find the sex workers to be different, however, in their being less likely to engage in safe sex practices. We provide an explanation for why this has not lead to their having a higher rate of seropositivity.     

Sex Work Among Men Who Have Sex with Men and Transgender Women in Bogotá

This qualitative study examined sex work among internally displaced male and transgender female sex workers in Bogotá, Colombia. Internal displacement has occurred in Colombia as a result of decades of conflict among armed groups and has created large-scale migration from rural to urban areas. Informed by the polymorphous model of sex work, which posits that contextual conditions shape the experience of sex work, we examined three main research questions. The first dealt with how internal displacement was related to the initiation of sex work; the second concerned the effect of agency on sex worker satisfaction; and the third examined how sex work in this context was related to HIV and other risks. Life history interviews were conducted with 26 displaced individuals who had done sex work: 14 were men who have sex with men and 12 were transgender women (natal males). Findings revealed that many participants began doing sex work in the period immediately after displacement, because of a lack of money, housing, and social support. HIV risk was greater during this time due to limited knowledge of HIV and inexperience negotiating safer sex with clients. Other findings indicated that sex workers who exerted more control and choice in the circumstances of their work reported greater satisfaction. In addition, we found that although many sex workers insisted on condom use with clients, several noted that they would sometimes have unprotected sex for additional money. Specific characteristics affecting the experience of sex work among the transgender women were also discussed.     

Should Men who have sex with Men be allowed to donate blood in Israel?

Background

The present permanent deferral policy in Israel for MSM was established in 1977 and was based on the previous (now outdated) USA Food and Drug Administration standards. This study analyses epidemiological data regarding blood donations among MSM, in order to estimate the risk for HIV transfusion transmitted infection (TTI) if the policy is changed to allow at-risk MSM to donate blood.

Methods

An Excel based spreadsheet model integrated demographic, epidemiological data from the HIV National Register, laboratory, blood donation and testing data in order to calculate TTI due to false-negatives in known HIV+ donors, windows period donations, asymptomatic carriers and laboratory misclassification errors. A sensitivity analysis of our estimated TTIs for deferral periods for MSM was performed based on a literature review regarding this overall policy issue worldwide.

Results

MSM in Israel have a considerably higher relative risk (RR) of both prevalence (115) and incidence (143) of being HIV+ than persons without a risk factor. Allowing MSM to donate blood, without any deferral period, will add an additional five HIV TTI cases over the next decade. Imposition of a 1 or 5 years deferral of abstinence will increase the number of HIV TTI cases only by 0.10 and 0.05 cases, respectively.

Conclusion

A 1 year deferral period for blood donations from MSM in Israel is recommended.

     

Latino Men’s Sexual Behavior with Transgender Persons

Male-to-female transgender persons are thought to be “vectors” for HIV/STI transmission, yet little quantitative information exists about the risk behavior of their male sexual partners who may serve as a “bridge” for HIV transmission into the general population. As part of an online survey examining the sexual risk behavior of Latino men who have sex with men (N = 1,026), we identified 44 (4%) participants who reported having had sex with a transgender partner. Compared with a randomly selected sub-sample of 200 men who did not report sex with a transgender person, sexual partners of transgender persons were almost three times more likely to have had unprotected sexual intercourse in the last three months. In addition, men who had sex with transgender persons were more likely to be HIV-positive; married, separated, or divorced; identify as bisexual or straight; have sex with women; and live in rural or small town communities. Regression analysis revealed that community size, sexual compulsivity, and having had a transgender partner were independent predictors of unprotected sex. Among Latino men who have sex with men, men with a history of sex with a transgender person appear more likely to be sexually compulsive and at greater risk for HIV and other sexually transmitted infections. These men may, therefore, also serve as a “bridge” for HIV transmission to (as opposed to from) the transgender population.     

The Impact of Urban US Policing Practices on Black Men Who Have Sex with Men’s HIV Vulnerability: Ethnographic Findings and a Conceptual Model for Future Research

This paper advances research on racism and health by presenting a conceptual model that delineates pathways linking policing practices to HIV vulnerability among Black men who have sex with men in the urban USA. Pathways include perceived discrimination based on race, sexuality and gender performance, mental health, and condom-carrying behaviors. The model, intended to stimulate future empirical work, is based on a review of the literature and on ethnographic data collected in 2014 in New York City. This paper contributes to a growing body of work that examines policing practices as drivers of racial health disparities extending far beyond violence-related deaths.     

Is Contact with Children Related to Legitimizing Beliefs Toward Sex with Children Among Men with Pedophilia?

Among pedophilic men, social contact with children has been discussed as creating a risk situation for sexual abuse. Also, pedophilic men searching for such contact are seen as harboring more beliefs legitimizing sexual contact with children. However, social contact may also decrease false beliefs. We tested these competing views in an anonymous Internet survey with a non-forensic, non-clinical sample of 104 self-classified pedophilic men. Results showed that both increased social and physical contact were significantly linked to fewer legitimizing beliefs toward sex with children, even when controlling for past psychotherapy, educational level, social desirability, and age. Controlling for previous conviction for child sexual offenses reduced the effect for physical contact, but not for social contact. Exploratory analyses showed that either type of contact had no significant effect on total self-perceived risk of offending. However, pedophilic men with physical contact with children perceived a higher risk of more direct (i.e., child abuse) than indirect offenses (i.e., child pornography offenses) compared to pedophilic men without physical contact. Despite limitations of the correlational design and the only small to moderate effects, the results challenge the assumption that complete avoidance of contact with children is necessary for persons with pedophilia to reduce the risk of abusive behavior.     

A Qualitative Analysis of Father–Son Relationships among HIV-Positive Young Black Men Who Have Sex with Men

Young black men who have sex with men (YBMSM) are experiencing high and rising rates of HIV infection, more than any other age-risk group category in the USA. Contributors to HIV risk in this group remain incompletely elucidated. We conducted exploratory qualitative interviews with 20 HIV-positive YBMSM aged 17–24 and found that father–son relationships were perceived to be important sociocontextual influences in participants’ lives. Participants discussed the degree of their fathers’ involvement in their lives, emotional qualities of the father–son relationship, communication about sex, and masculine socialization. Participants also described pathways linking father–son relationships to HIV risk, which were mediated by psychological and situational risk scenarios. Our thematic analysis suggests that father–son relationships are important to the psychosocial development of YBMSM, with the potential to either exacerbate or attenuate sexual risk for HIV. Interventions designed to strengthen father–son relationships may provide a promising direction for future health promotion efforts in this population.     

‘Men who use the Internet to seek sex with men’: Rethinking sexuality in the transnational context of HIV prevention

ABSTRACT

MISM (i.e. men who use the Internet to seek sex with men) has emerged in public health literature as a population in need of HIV prevention. In this paper, we argue for the importance of rethinking the dominant notions of the MISM category to uncover its ethnocentric and heteronormative bias. To accomplish this, we conducted a historical, epistemological and transnational analysis of social sciences and health research literature (n?=?146) published on MISM between 2000 and 2014. We critically unravel the normative underpinnings of ‘westernised’ knowledge upon which the MISM category is based. We argue that the essentialist approach of Western scholarship can homogenise MISM by narrowly referring to behavioural aspects of sexuality, thereby rendering multiple sexualities/desires invisible. Furthermore, we argue that a Eurocentric bias, which underlies the MISM category, may hinder our awareness of the transnational dynamics of sexual minority communities, identities, histories and cultures. We propose the conceptualisation of MISM as hybrid cultural subjects that go beyond transnational and social boundaries, and generate conclusions about the future of the MISM category for HIV prevention and health promotion.     

Sexuality in Young Adult Men Aged 18–24 with Epilepsy

The aim of this study was to determine the extent of sexual dysfunction in young male patients (18–24 years) with epilepsy. Forty-five male patients with epilepsy aged between 18 and 24, and forty-four age- matched healthy male volunteers were included in the study. Participants completed a battery of self-reported tests (ASEX: Arizona Sexual Experiences Scale, HADS: Hospital Anxiety and Depression Scale). Demographic and clinical variables were recorded. Serum total testosterone was measured between 8:00 and 10:00 a.m. in patients with epilepsy. Sexual function scores (sexual drive and penile erection) were higher in patients with epilepsy than those of the control group (p < 0.001 and p = 0.008, respectively). The difference between the mean total ASEX scores, which were 13.9 and 11.4 in patients with epilepsy and controls, respectively, was significant (p = 0.009). HAD anxiety scores were significantly higher in patients with epilepsy than controls (p = 0.01) (Table 2). HAD-depression scores of both groups were similar (p = 0.09). This study demonstrates that young male patients with epilepsy have lower levels of sexual activity and drive and more erectile problems. Impaired sexual function is associated with anxiety scores.     

HIV Diagnoses Among Men Who Have Sex With Men and Women—United States and 6 Dependent Areas, 2008-2011

Objectives. We sought to describe HIV diagnoses among men who have sex with men and women (MSMW), who have the potential to bridge HIV transmission risk from men who have sex with men (MSM) to women.Methods. Applying National HIV Surveillance System data for persons aged 13 years and older, we examined estimated numbers and percentages of HIV diagnoses among MSMW and MSM only (MSMO) from 2008 to 2011, and estimated the annual percentage change and 95% confidence intervals, by age and race/ethnicity.Results. In 2011, 26.4% of 30 896 MSM diagnosed with HIV infection also had had sex with women. A larger percentage of MSMW were Black/African American (44.5%) compared with MSMO (36.0%), and fewer MSMW were White (26.4%) compared with MSMO (36.2%); similar percentages were classified as either MWMW or MSMO among other racial/ethnic groups. Among MSMW, HIV diagnoses were relatively stable and MSMO increased more than 6% annually among those aged 13 to 29 years.Conclusions. Many MSM diagnosed with HIV infection had also had sex with women. Intensified interventions are needed to decrease HIV infections overall for MSMW and reverse the increasing trends among young MSMO.Men who have sex with men (MSM) constitute the majority of persons diagnosed with HIV in the United States. In 2011, 61.8% of HIV diagnoses were attributed to male-to-male sexual contact.1 Data from the Center for Disease Control and Prevention’s (CDC) National HIV Surveillance System indicate that MSM are the only risk group with significant increases in HIV incidence in recent years,2 and reducing HIV incidence is one of the 3 primary goals in the National HIV/AIDS Strategy.3 Some MSM also have sex with women (MSMW). Scant information compared to MSM exists on the epidemiology of MSMW, who have the potential to bridge HIV transmission risk from MSM to women. Some studies have reported bisexual compared to heterosexual men are more likely to exchange sex, use substances, experience forced sex, and have more sexual partners.4,5 A meta-analysis estimated that MSMW are more than 5 times as likely to be HIV-positive as men who have sex with women exclusively.6 In a previous analysis of National HIV Surveillance System (NHSS) data derived from AIDS cases reported nationally from June 1981 through June 1990, MSMW constituted 26% of all males diagnosed with AIDS, increasing from 23% in 1983 to 26% in 1989. Racial/ethnic distributions for MSMW included 41% Black/African American, 31% Hispanic/Latino and 21% White.7 Because of the unique attributes and behaviors of MSMW, it is important to characterize this population to guide tailored prevention efforts. We described HIV diagnoses among MSMW using NHSS data from 2008 through 2011. In particular, we estimated numbers, percentages, and trends of HIV diagnoses among MSMW.     

HIV Prevalence and Awareness of Positive Serostatus Among Men Who Have Sex With Men and Transgender Women in Bogotá, Colombia

Objectives. We estimated HIV prevalence among men who have sex with men (MSM) and transgender women in Bogotá, Colombia, and explored differences between HIV-positive individuals who are aware and unaware of their serostatus.Methods. In this cross-sectional 2011 study, we used respondent-driven sampling (RDS) to recruit 1000 MSM and transgender women, who completed a computerized questionnaire and received an HIV test.Results. The RDS-adjusted prevalence was 12.1% (95% confidence interval [CI] = 8.7, 15.8), comparable to a previous RDS-derived estimate. Among HIV-positive participants, 39.7% (95% CI = 25.0, 54.8) were aware of their serostatus and 60.3% (95% CI = 45.2, 75.5) were unaware before this study. HIV-positive–unaware individuals were more likely to report inadequate insurance coverage, exchange sex (i.e., sexual intercourse in exchange for money, goods, or services), and substance use than other participants. HIV-positive–aware participants were least likely to have had condomless anal intercourse in the previous 3 months. Regardless of awareness, HIV-positive participants reported more violence and forced relocation experiences than HIV-negative participants.Conclusions. There is an urgent need to increase HIV detection among MSM and transgender women in Bogotá. HIV-positive–unaware group characteristics suggest an important role for structural, social, and individual interventions.Colombia ranks second among countries in Latin America in HIV prevalence, with estimates ranging from 0.7% to 1.1% of the adult population.1 Men who have sex with men (MSM) represent the group most strongly affected, with prevalence of 18% to 20% based on venue-based convenience samples2,3 and 15% based on respondent-driven sampling (RDS).4 Colombia has a long history of armed conflict, and the pervasive conditions of violence, internal displacement, and poverty can be relevant to HIV transmission.5 “Social cleansing” by armed groups has been aimed at MSM and transgender women, as well as people living with HIV,5 and the stigma associated with homosexuality and HIV is widespread and inherent in structural inequalities in Colombia.6,7 Social epidemiological models posit that HIV is influenced by such structural (e.g., civil unrest, migration) and social factors (e.g., social networks, community attitudes), as well as individual characteristics (e.g., psychological characteristics, behavior).8Public health efforts emphasize the importance of detecting and treating undiagnosed HIV as a means of reducing HIV incidence.9–11 In the United States, approximately 20% of HIV-positive individuals are thought to be unaware of their infection, but this group is estimated to be responsible for nearly half of new transmissions.12 There is limited research concerning awareness of serostatus in Latin America. Undiagnosed infection was found to be 89% among HIV-positive MSM sampled in Peru in 2011,13 and rates are likely to be high in Colombia because of low levels of testing,6 including among MSM.4,14 Recent studies of MSM in France, Peru, and the United States have found associations between undiagnosed infection and demographic characteristics such as age, income, and education13,15,16; risk behaviors14,17,18; family or intimate partner violence19; and health insurance coverage.20 We also examined awareness in relation to violence and forced relocation, conditions specific to the Colombian context.Respondent-driven sampling was developed as a means of obtaining unbiased estimates from hidden populations,21–23 and it has been shown to capture a more diverse24,25 and hidden26 group of MSM than time–location or snowball sampling. Research has suggested, however, that biases can occur.27–29Our current study and a study conducted by the United Nations Population Fund and the Colombian Ministry of Health and Social Protection (UNFPA/MSPS) were independently funded at approximately the same time to address the limited information about behavioral risk and HIV prevalence among Colombian MSM. Comparison of findings from the 2 studies provides evidence concerning reliability of the RDS-derived prevalence estimates. We estimated HIV prevalence among MSM and transgender women in Bogotá, Colombia, examined reliability of RDS-derived estimates in relation to the UNFPA/MSPS study,4 and investigated the role of the social and structural context of Colombia in both prevalence and awareness of positive serostatus.