What is Sexual Health? Articulating a Sexual Health Approach to HIV Prevention for Men Who Have Sex with Men

This article reviews the development of the construct of sexual health as well as how sexual health has become both part of the public health discourse and a key strategy in promoting overall health and human development. There are many lessons learned from international efforts which can be helpful in formulating a broad sexual health approach to HIV prevention among MSM in the United States.     

‘Never Testing for HIV’ Among Men Who Have Sex with Men Recruited from a Sexual Networking Website, United States

HIV testing was assessed online among men accessing a sexual networking website for men who have sex with men. Most of the 8,040 participants reported HIV testing (58.2% ≤ 1 year; 33.1% > 1 year) and 17.1% were HIV-positive. Overall, 8.6% of men including 24% of those 18–24 years of age had never been tested. Among never testers, 25% did not know where to get tested. Predictors of never being tested included younger age (18–24), bisexual or heterosexual orientation, living outside of large metropolitan areas, and not having a healthcare provider. Increasing access to and knowledge of HIV testing sites is needed.     

A Comparison of Men Who Have Sex with Men,People Who Inject Drugs and High-Risk Heterosexuals’ Risk for HIV Infection,San Francisco

HIV in the United States is concentrated in populations such as men who have sex with men (MSM), people who inject drugs (PWID), women of color and people living in poverty. These populations are labeled high-risk for HIV infection because of the higher levels of HIV or HIV risk taking behaviors seen in these groups compared to other sub-populations. It is also possible that a group may engage in behaviors that are “high-risk” for HIV infection but never become infected since HIV is not present or not present to a great extent in their social or sexual networks. We analyzed samples of MSM, PWID and high-risk heterosexuals (HRH) collected through the National HIV Behavioral Surveillance (NHBS) system in San Francisco to examine HIV risk taking and HIV burden to determine if the label “high-risk” is appropriately applied. NHBS samples MSM using time location sampling and PWID and HRH using Respondent Driven Sampling. We sampled 508 MSM in 2011, 570 PWID in 2012 and 267 HRH in 2013. There were, as expected, differences in demographic characteristics across the three groups. HRH had a greater number of high-risk behaviors compared to MSM and PWID but had the lowest HIV prevalence. Focusing on risk behavior alone to label populations without considering the background HIV prevalence in communities, the types of risks engaged in and actual HIV infections may obscure which populations truly merit the label “high-risk” for HIV infection.     

Convergence of HIV Prevalence and Inter-Racial Sexual Mixing Among Men Who Have Sex with Men, San Francisco, 2004–2011

Disparity in HIV prevalence by race/ethnicity has been noted among men who have sex with men for almost 20 years. Research suggests that rather than individual risk behaviors, sexual networks play an important role in HIV prevalence disparity. This analysis uses data from the National HIV Behavioral Surveillance System collected at three time points using time-location sampling in 2004, 2008, 2011. We use Newman’s coefficient to assess racial mixing among 1,207 observations. We found significant differences in HIV status across race groups in 2004 and 2008; yet in 2011, there were no significant differences of HIV status by race. Racial mixing across all races increased from 2004 to 2011; in other words, individuals were increasingly more likely to sexually partner outside their own race/ethnicities. Increased racial mixing may explain this convergence, although full social network studies are necessary in order to fully explain these findings.     

HIV Testing and Awareness of Partner’s HIV Status Among Chinese Men Who Have Sex with Men in Main Partnerships

Many men who have sex with men (MSM) do not use condoms with their main partners, especially if both parties are of the same HIV status. However, significant proportions of MSM have never tested or recently tested and are unaware of their main partners’ HIV status. A cross-sectional survey was conducted among 524 MSM in Jiangsu, China in 2013–2014. Time-location sampling and online convenience sampling were used to recruit participants. We compared awareness of HIV status and recent HIV testing between participants who had main partners versus those who did not, and identified factors associated with recent HIV testing among men in main partnerships. Participants in main partnerships were significantly more likely to report recent HIV testing and being HIV-negative instead of HIV-unknown compared to participants in casual partnerships only. Overall, 74.5 % of participants were aware of their main partners’ HIV status. Among participants in main partnerships, those who had 2–5 male anal sex partners in the past 6 months and those who reported that their partners were HIV-negative had 2.36 (95 % CI 1.12, 4.97) and 4.20 (95 % CI 2.03, 8.70) fold greater odds of being tested in the past year compared to those who had main partners only and those whose partners were HIV-positive/unknown, respectively. Chinese MSM in main partnerships might be practicing serosorting and may be at lower risk for HIV infection due to increased awareness of main partners’ HIV status and higher uptake of recent testing.     

Do Social Support, Stress, Disclosure and Stigma Influence Retention in HIV Care for Latino and African American Men Who Have Sex with Men and Women?

Limited research has examined the role that social support, stress, stigma and HIV disclosure play in retention in HIV care for African Americans and Latinos. Among 398 Latino and African American men who have sex with men (MSM) and women, the major predictor of retention in HIV care was disclosure of HIV status to more social network members (OR?=?1.5; 95% CI: 1.1, 1.9). Among those who had disclosed (n?=?334), female gender (OR?=?1.8, 95% CI: 1.1, 3.1) and disclosure of HIV status to more network members (OR?=?1.5, 95% CI: 1.1, 1.9) was associated with retention in HIV care. General stress was associated with retention in care (OR?=?1.2; 95% CI: 1.1, 1.3) for African American MSM who had disclosed. More MSM-stigma was associated with poorer retention (OR?=?0.9; 95% CI: 0.8, 0.9) for Latino MSM. Interventions that help patients safely disclose their HIV status to more social network members may improve HIV care retention as would social network counseling for Latino MSM to reduce MSM-stigma.     

Do Safer Sex Self-Efficacy, Attitudes toward Condoms, and HIV Transmission Risk Beliefs Differ among Men who Have Sex with Men, Heterosexual Men, and Women Living with HIV?

To understand sexual decision-making processes among people living with HIV, we compared safer sex self-efficacy, condom attitudes, sexual beliefs, and rates of unprotected anal or vaginal intercourse with at-risk partners (UAVI-AR) in the past 3 months among 476 people living with HIV: 185 men who have sex with men (MSM), 130 heterosexual men, and 161 heterosexual women. Participants were enrolled in SafeTalk, a randomized, controlled trial of a safer sex intervention. We found 15% of MSM, 9% of heterosexual men, and 12% of heterosexual women engaged in UAVI-AR. Groups did not differ in self-efficacy or sexual attitudes/beliefs. However, the associations between these variables and UAVI-AR varied within groups: greater self-efficacy predicted less UAVI-AR for MSM and women, whereas more positive condom attitudes—but not self-efficacy—predicted less UAVI-AR for heterosexual men. These results suggest HIV prevention programs should tailor materials to different subgroups.     

Is Location of Sex Associated with Sexual Risk Behaviour in Men Who Have Sex with Men? Systematic Review of Within-Subjects Studies

To understand associations between location of sex and sexual risk, it is most helpful to compare sexual encounters within persons. We systematically reviewed within-subjects comparisons of sexual encounters reported by men who have sex with men (MSM) with respect to location of sex. Within-subjects comparisons of sexual risk and location of sex were eligible if they collected data post-1996 from samples of MSM. We independently screened results and full-text records in duplicate. Of 6,336 deduplicated records, we assessed 138 full-text studies and included six, most of which compared unprotected anal intercourse against other anal intercourse. This small, but high quality, body of evidence suggests that associations between attendance at sex-on-premises venues and person-level sexual risk may be due to overall propensity towards unprotected sex. However, there may be some location factors that promote or are associated with serononconcordant unprotected anal intercourse. Health promoters may wish to focus on person-level characteristics.     

Young Men Who Have Sex with Men at High Risk for HIV,Bangkok MSM Cohort Study,Thailand 2006–2014

High HIV incidence has been reported in young men who have sex with men (YMSM) in North America and Western Europe, but there are limited data from Southeast Asia suggesting MSM may be the driver of the HIV epidemic in this region. We described HIV incidence and risk factors among 494 YMSM enrolled in a cohort study in Bangkok, Thailand. The HIV incidence was 7.4 per 100 person-years. In multivariable analysis, reporting use of an erectile dysfunction drug in combination with club drugs, having receptive or both insertive and receptive anal intercourse with men, having hepatitis A infection, having rectal Chlamydia trachomatis, having hepatitis B infection prior to HIV seroconversion, and reporting not always using condoms with male steady partners were significantly associated with HIV incidence in YMSM. Reduction in new HIV infections in YMSM are critical to reach targets set by Thailand and the region.     

Are Information, Motivation, and Behavioral Skills Linked with HIV-Related Sexual Risk among Young Men Who Have Sex with Men?

Young men who have sex with men are disproportionately affected by HIV/AIDS, yet relatively little is known about the most effective theoretical frameworks for preventive interventions with this population. This study investigated the fit of the Information-Motivation-Behavioral Skills (IMB) model for predicting sexual risk among a sample of ethnically diverse young men who have sex with men aged 14-21. Path analysis results indicated that the IMB model predicted a moderate amount of variance in primary and secondary sexual risk for young men who have sex with men (r(2) = .26 and .21, respectively). Fit of this model was acceptable on most indicators of model fit for primary and secondary risk.     

Parental Monitoring,Parent–Adolescent Communication About Sex,and Sexual Risk Among Young Men Who Have Sex with Men

Parental monitoring and parent–adolescent communication about sex protect against HIV-related sexual risk behaviors among heterosexual adolescents, but it is unknown if these findings generalize to young men who have sex with men (YMSM). Sexual orientation-specific stressors, including “coming out” to parents, complicate the family context of YMSM. We examined associations between parental monitoring, communication about sex, outness to cohabitating parents, and sexual behaviors. Ethnically diverse YMSM ages 14–19 provided cross-sectional data (n = 257). Monitoring and outness to parents interacted to predict recent same-sex unprotected anal intercourse (UAI). For YMSM who reported mixed or uncertain outness to parents, higher levels of perceived parental monitoring were associated with greater risk of UAI. Higher levels of communication about sex were associated with greater risk of UAI for YMSM out to parents. Parental monitoring and communication about sex might not protect YMSM against sexual risk in the same way they protect heterosexual youth. Future research should examine whether adapted forms of family factors could protect YMSM, and family-based HIV risk-reduction interventions for YMSM should be attuned to the unique ways family factors function within this group.     

Rural Men Who Have Sex with Men’s (MSM) Experiences and Preferences for Outreach Health Programming

Rural men who have sex with men (MSM) are particularly vulnerable to HIV/STI infections, though most outreach efforts to reach MSM have been focused on urban populations. More attention is needed to study effective ways of reaching/recruiting rural MSM, yet little is known about their preferences; particularly as studies show significant differences in the behaviors and perceptions of rural versus urban MSM. Our study uses a qualitative instrument to gauge what outreach methods are most effective from the perspective of 40, rural MSM. Outreach facilitators included online marketing, emphasizing rural areas, while outreach barriers included traditional forms of print media/advertising, or anything that may jeopardize anonymity. Implications for future outreach in rural areas and limitations are also discussed.     

Virtual Versus Physical Spaces: Which Facilitates Greater HIV Risk Taking Among Men Who Have Sex with Men in East and South-East Asia?

Increasing use of the Internet to seek sex partners is accompanied by rising HIV infections among men who have sex with men (MSM) in East and South-East Asia. We examined whether the Internet facilitates greater HIV risk taking among MSM in the region. A cross-sectional sample of 9,367 MSM was recruited via the Internet in 2010. We compared socio-demographic and HIV-related behavioral characteristics among MSM who met sex partners on the Internet only, who met sex partners offline only, and who met sex partners through both. Multinomial logistic regression was used to identify independent correlates that were associated with differences in where participants met their male sex partners. Compared to MSM who met partners offline only, those who met partners online only were less likely to have multiple male sex partners, have paid for sex, have consumed recreational drugs, and have used alcohol before sex. MSM who met partners both online and offline appeared to be the riskiest group that they were more likely to have multiple male sex partners, have engaged in UIAI, and have consumed alcohol before sex. These findings suggest that social networking websites alone do not facilitate greater HIV risk taking among MSM. Rather, they provide additional venues for MSM who already engage in HIV-related high risk behaviors to seek sex partners. The Internet offers incredible opportunities to reach large numbers of MSM in East and South-East Asia for HIV prevention and research. Web-based outreach and prevention activities are needed to reach these men. In addition, mobile and application-based interventions should also be developed and disseminated.