HIV prevention research for men who have sex with men: a systematic review and meta-analysis

A systematic review of HIV prevention reports published or distributed in the United States as of June 1998 yielded 9 rigorous controlled trials reporting intervention effects on unprotected sex for men who have sex with men. A summary measure of these effects was favorable (odds ratio,.69), statistically significant (95% confidence interval, 0.56-0.86), and very homogeneous. This summary value indicates a 26% reduction in the proportion of men engaging in unprotected anal intercourse. The most clearly favorable effects were observed among interventions that promoted interpersonal skills, were delivered in community-level formats, or focused on younger populations or those at higher behavioral risk. These studies demonstrate that interventions can promote risk reduction among men who have sex with men. Yet given the epidemiology of HIV in the United States, the small number of rigorous controlled intervention trials for this population is striking. Many more rigorous evaluations of HIV prevention efforts with men who have sex with men are needed to ascertain with confidence the effects of specific intervention components, population characteristics, and methodologic features.     

Secondary HIV Prevention: Novel Intervention Approaches to Impact Populations Most at Risk

This paper reviews recent secondary prevention interventions designed to reduce sexual risk behaviors among people living with HIV/AIDS (PLWHA). A summary of findings from previous meta-analyses and narrative reviews of interventions is provided. Next, novel HIV prevention approaches for PLWHA are reviewed. The review reports on the efficacy of interventions delivered in primary care settings or by technology-formats, interventions that also address mental health difficulties, and programs to address particular at-risk populations (eg, men who have sex with men). A critique of recent interventions for people living with HIV/AIDS is provided as well as suggestions for future research.     

Mental health and HIV risk in men who have sex with men

Evidence-based HIV prevention interventions with men who have sex with men (MSM) in the United States have moderate effect sizes in reducing HIV sexual risk behavior. Mental health and psychosocial problems, which both disproportionately affect MSM populations and are implicated in HIV transmission risk behaviors, also likely interfere with the uptake of HIV behavioral interventions. Moreover, given that mental health and psychosocial problems such as depression, substance use, and violence frequently co-occur for many MSM (eg, as syndemic conditions), what is probably needed are combination prevention efforts, or prevention "cocktails," similar to treatment "cocktails," that address the psychological and behavioral mechanisms that interact to produce elevated risk for HIV. Such interventions should incorporate a holistic framework to address the sexual health and overall well being of MSM. Addressing co-occurring psychosocial risk factors is apt to improve effect sizes of current HIV prevention interventions and allow for more effective uptake by MSM.     

HIV knowledge and risk factors among men who have sex with men in Ho Chi Minh City,Vietnam

OBJECTIVES: To describe health risk behavior, knowledge, and attitudes about HIV/AIDS and its prevention in men who have sex with men (MSM) in Ho Chi Minh City (HCMC), Vietnam. METHODS: A cross-sectional survey of 219 MSM using a standardized questionnaire. RESULTS: Men who have sex with men were easy to locate and willing to answer detailed questions about their sexual behavior. Self-identified sexual orientation was 67% homosexual, 31% bisexual, and 1.4% heterosexual. High-risk sexual behavior was common. The mean number of sexual partners was 3.3 in the previous month and 14.8 in the previous year. Only 32% used condoms during their last intercourse, and only 40% used a condom when their last intercourse included anal sex. Eighty-one percent reported sex with nonregular male partners, and 22% also had sex with women in the past year. Drug use other than alcohol was rare. Most correctly identified high-risk sexual behavior and body fluids that could transmit HIV; however, only about half knew that someone who appeared healthy could transmit HIV or that there was no cure for AIDS. Self-rated risk for HIV was very low, and fewer than one third believed that homosexuals in Vietnam are at increased risk for HIV. CONCLUSION: Men who have sex with men in HCMC are at high risk for HIV. Knowledge about HIV transmission and prevention could be improved. Education and interventions specifically aimed at MSM are needed, because education targeted at the general population may not reach MSM or influence their behavior.     

HIV risk differences between African-American and white men who have sex with men

African-American men who have sex with men remain at disproportionately greater risk for contracting human immunodeficiency virus (HIV) infection. While high HIV seroincidence has been documented among homosexual African-American men, behavioral research has rarely studied the HIV risk issues confronting these men. This study assessed a sample of 253 men who have sex with men to determine if African-American (n = 79) and white (n = 174) men report different rates of HIV risk behaviors and differ in characteristics indicative of risk. African-American men who have sex with men were more likely to be HIV-seropositive, to report past treatment for gonorrhea and syphilis, and to have a recent unprotected sex partner known or believed to be HIV-seropositive. Multivariate analyses of covariance, controlling for group differences in age, education, and income, revealed that African-American men who have sex with men were less open about their sexual orientation, scored lower in HIV risk behavior knowledge, had more female sexual partners, and more frequently used cocaine in association with sex relative to white men who have sex with men. Human immunodeficiency virus prevention programs tailored to the needs and risk issues of African-American men who have sex with men are needed.     

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

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

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

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

Elevated syringe borrowing among men who have sex with men: a prospective study

OBJECTIVE: Despite efforts to scale up HIV prevention services for drug users, high rates of HIV risk behavior persist among some subpopulations. Given that few prospective studies have considered the relationship between sexual activity and syringe sharing, we sought to evaluate syringe sharing among male injection drug users (IDUs) who have sex with men (MSM) in Vancouver. METHODS: We performed a longitudinal analysis of factors associated with syringe borrowing among male participants enrolled in the Vancouver Injection Drug Users Study during the years 1996 to 2005 using generalized estimating equations (GEE). RESULTS: Among the 1019 male participants included in this analysis, 553 (54.3%) reported borrowing syringes during the study period. In multivariate GEE analysis, MSM were at an elevated risk for syringe borrowing (adjusted odds ratio [AOR] = 1.50, 95% confidence interval [CI]: 1.10 to 2.04) after extensive adjustment for other known risk factors. CONCLUSIONS: Among male participants, having sex with men was found to be strongly and independently associated with syringe borrowing. Our findings may aid policy makers in their efforts to identify IDUs who should be targeted with education and prevention efforts, and indicate the need for ongoing development of prevention interventions that address sexual orientation.     

Progress, challenges, and new opportunities for the prevention of mother-to-child transmission of HIV under the US President's Emergency Plan for AIDS Relief

In June 2011, the Joint United Nations Programme on HIV/AIDS, the US President's Emergency Plan for AIDS Relief (PEPFAR), and other collaborators outlined a transformative plan to virtually eliminate pediatric AIDS worldwide. The ambitious targets of this initiative included a 90% reduction in new pediatric HIV infections and a 50% reduction in HIV-related maternal mortality--all by 2015. PEPFAR has made an unprecedented commitment to the expansion and improvement of prevention of mother-to-child HIV transmission (PMTCT) services globally and is expected to play a critical role in reaching the virtual elimination target. To date, PEPFAR has been instrumental in the success of many national programs, including expanded coverage of PMTCT services, an enhanced continuum of care between PMTCT and HIV care and treatment, provision of more efficacious regimens for antiretroviral prophylaxis, design of innovative but simplified PMTCT approaches, and development of new strategies to evaluate program effectiveness. These accomplishments have been made through collaborative efforts with host governments, United Nations agencies, other donors (eg, the Global Fund for AIDS, Tuberculosis, and Malaria), nongovernmental organizations, and private sector partners. To successfully meet the ambitious global targets to prevent new infant HIV infections, PEPFAR must continue to leverage the existing PMTCT platform, while developing innovative approaches to rapidly expand quality HIV services. PEPFAR must also carefully integrate PMTCT into the broader combination prevention agenda for HIV, so that real progress can be made toward an "AIDS-free generation" worldwide.     

Men who have sex with men: estimated population sizes and mortality rates by race/ethnicity, Miami-Dade County, Florida

BACKGROUND: Estimated numbers of men who have sex with men (MSM) by race/ethnicity and mortality rates among such MSM with HIV/AIDS are unavailable. This hampers efficient targeting of HIV/AIDS prevention and care resources. METHODS: An existing estimation methodology was adapted to develop MSM population estimates by race/ethnicity for Miami-Dade County, Florida. We ascertained and characterized deaths that occurred during 2003 to 2005 among MSM HIV/AIDS cases, matching HIV/AIDS surveillance and vital statistics registries. We calculated estimated average annual racial/ethnic-specific mortality rates and rate ratios (RRs) among MSM HIV/AIDS cases. RESULTS: An estimated 63,020 men aged > or =18 years in the county are MSM (7.5% of all men aged > or =18 years; point estimate). Among 754 MSM HIV/AIDS deaths, point-estimate mortality rates per 100,000 MSM were higher for blacks (733.5) than for whites (229.2) (P < 0.01) and Hispanics (360.5) (P < 0.01). The best estimate of the black/white MSM mortality RR among HIV/AIDS cases was 3.20:1 (P < 0.01); for Hispanic/white MSM, it was 1.57:1 (P < 0.01). Sensitivity analyses suggested the estimates were reasonably robust to biases that we examined. CONCLUSIONS: Black and Hispanic MSM were more likely to die with HIV/AIDS than white MSM. Plausible racial/ethnic-specific MSM population and mortality rate estimates can inform effective HIV/AIDS prevention efforts and program planning.     

HIV检测对MSM人群艾滋病感染风险的影响

目的分析艾滋病检测对MSM人群知识、行为与感染HIV风险的影响,为调整MSM人群艾滋病防治策略提供依据。方法以过去一年接受过艾滋病检测的MSM人群为干预组,未接受过艾滋病检测的为对照组,比较两组的人口学特征、知识、行为以及梅毒与HIV感染率。结果干预组和对照组分别有423人和528人,平均年龄分别为（26.8±8.0）岁和（26.3±6.2）岁。干预组艾滋病防治知识知晓率高于对照组（χ2=28.9,P〈0.001）,最近6个月与男性发生无保护性性行为的比例低于对照组（χ2=14.7,P〈0.001）,HIV感染率明显低于对照组（χ2=15.0,P〈0.001）。结论艾滋病检测可以有效提高MSM人群安全套使用率,降低感染艾滋病的风险,应在MSM人群中倡导主动咨询检测,扩大咨询检测覆盖面。     

Expanding the space: inclusion of most-at-risk populations in HIV prevention, treatment, and care services

The provision of appropriate HIV prevention, treatment, and care services for most-at-risk populations (MARP) will challenge many health care systems. For people who sell sex or inject drugs and for men who have sex with men, stigma, discrimination, and criminalization can limit access to care, inhibit service uptake, and reduce the disclosure of risks. Several models for provision of HIV services to MARP may address these issues. We discuss integrated models, stand-alone services, and hybrid models, which may be appropriate for some MARP in some settings. Both public health and human rights frameworks concur that those at greatest risk should have expanded access to services.     

Voluntary medical male circumcision: an HIV prevention priority for PEPFAR

As the science demonstrating strong evidence for voluntary medical male circumcision (VMMC) for HIV prevention has evolved, the President's Emergency Plan for AIDS Relief (PEPFAR) has collaborated with international agencies, donors, and partner country governments supporting VMMC programming. Mathematical models forecast that quickly reaching a large number of uncircumcised men with VMMC in strategically chosen populations may dramatically reduce community-level HIV incidence and save billions of dollars in HIV care and treatment costs. Because VMMC is a 1-time procedure that confers life-long partial protection against HIV, programs for adult men are vital short-term investments with long-term benefits. VMMC also provides a unique opportunity to reach boys and men with HIV testing and counseling services and referrals for other HIV services, including treatment. After formal recommendations by WHO in 2007, priority countries have pursued expansion of VMMC. More than 1 million males have received VMMC thus far, with the most notable successes coming from Kenya's Nyanza Province. However, a myriad of necessary cultural, political, and ethical considerations have moderated the pace of overall success. Because many millions more uncircumcised men would benefit from VMMC services now, US President Barack Obama committed PEPFAR to provide 4.7 million males with VMMC by 2014. Innovative circumcision methods-such as medical devices that remove the foreskin without injected anesthesia and/or sutures-are being rigorously evaluated. Incorporation of safe innovations into surgical VMMC programs may provide the opportunity to reach more men more quickly with services and dramatically reduce HIV incidence for all.     

Prevention of sexually transmitted HIV infections through the President's Emergency Plan for AIDS Relief: a history of achievements and lessons learned

HIV prevention in the President's Emergency Plan for AIDS Relief (PEPFAR) began when both data on HIV prevalence and the toolbox of interventions for prevention of sexual transmission were relatively limited. PEPFAR's early focus was on scaling-up information, education, and communication programs that included messaging on abstinence for youth and faithfulness primarily through nongovernmental organizations, including faith-based organizations. Additional activities included condom promotion, distribution, and social marketing. In epidemics concentrated within key populations, PEPFAR's prevention efforts focused on a minimum package of services including outreach, information, education, and communication programs, STI treatment (where appropriate), and condom promotion and distribution. As more epidemiological data became available and with experience gleaned in these early efforts, the need for tailored and flexible approaches became evident. The next iteration of prevention efforts still emphasized behavioral interventions, but incorporated a sharper focus on key epidemic drivers, especially multiple partners; a data-driven emphasis on high transmission areas and populations, including prevention with people living with HIV; and a more strategic and coordinated approach at the national level. Recently, the paradigm for prevention efforts has shifted yet again. Evidence that biomedical interventions such as male circumcision, treatment for prevention of vertical and horizontal transmission, and treatment itself could lead to declines in incidence has refocused PEPFAR's prevention portfolio. New guidance on sexually transmitted HIV focuses on combination prevention, emphasizing biomedical, behavioral and structural approaches. Landmark speeches by the President and the Secretary of State and new ambitious targets for PEPFAR point toward a new goal: an AIDS-free generation.     

Trends in AIDS incidence and survival among racial/ethnic minority men who have sex with men,United States, 1990-1999

OBJECTIVES: We describe trends in AIDS incidence, survival, and deaths among racial/ethnic minority men who have sex with men (MSM). METHODS: We examined AIDS surveillance data for men diagnosed with AIDS from 1990 through 1999, survival trends from 1993 through 1997, and trends in AIDS incidence and deaths from 1996 to 1999, when highly active antiretroviral therapy (HAART) was introduced. RESULTS: The percentage of racial/ethnic minority MSM with AIDS increased from 33% of 26,930 men in 1990 to 54% of 17,162 men in 1999. From 1996 through 1998, declines in AIDS incidence were smallest among black MSM (25%, from 66.2 to 49.5 per 100,000) and Hispanic MSM (29%, from 39.3 to 27.8), compared with white MSM (41%, from 17.9 to 10.5). Declines in deaths of MSM with AIDS were also smallest among black MSM (53%, from 39.7 to 18.6 deaths per 100,000) and Hispanic MSM (61%, 21.6 to 8.4), compared with white MSM (63%, 12.3 to 4.5). Survival improved each year for all racial/ethnic groups but was poorest for black MSM in all years. CONCLUSIONS: Since the introduction of HAART, a combination of factors that include relatively higher infection rates in more recent years and differences in survival following AIDS diagnosis contribute to observed differences in trends in AIDS incidence and deaths among racial/ethnic minority MSM. Increased development of culturally sensitive HIV prevention services, and improved access to testing and care early in the course of disease are needed to further reduce HIV-related morbidity in racial/ethnic minority MSM.     

A conceptual model of HIV disclosure in casual sexual encounters among men who have sex with men

HIV/AIDS continues to disproportionately impact men who have sex with men (MSM). Advances in highly active antiretroviral therapies (HAART) have successfully helped HIV-infected individuals lead longer, healthier, and presumably more sexually active lives. Consequently, secondary prevention approaches aimed at reducing the rate of HIV transmission have raised important questions about the role of sexual communication, namely HIV disclosure, as a primary target for intervention. This paper proposes a conceptual model of HIV disclosure in casual sexual encounters among MSM informed by Goffman's work on stigma and based on existing empirical research. The article concludes with an agenda for research based in this integrative model.     

Importance of sex partner HIV status in HIV risk assessment among men who have sex with men

Clinical HIV risk assessments have not typically integrated questions about sex partners' HIV status with questions about condom use and type of sex. Since 2001, we have asked all men who have sex with men (MSM) evaluated in an urban sexually transmitted disease (STD) clinic how often in the preceding 12 months they used condoms for anal sex with partners who were HIV-positive, HIV-negative, and of unknown HIV status. Overall, MSM displayed a pattern of assortative mixing by HIV status, particularly for unprotected anal intercourse (UAI). Nevertheless, 433 (27%) of 1580 MSM who denied knowing they were HIV-positive and 93 (43%) of 217 HIV-positive MSM reported having UAI with a partner of opposite or unknown HIV status. Among men who denied previously knowing they were HIV-positive, 24 (9.6%) of 251 MSM who reported having UAI with an HIV-positive partner or partner of unknown HIV status compared with 11 (1.7%) of 620 MSM who denied such exposure tested HIV-positive (odds ratio=5.8, 95% confidence interval: 2.8-12.1). UAI with an HIV-positive partner or partner with unknown HIV status was 69% sensitive and 73% specific in identifying men with previously undiagnosed HIV infection; UAI regardless of partner HIV status was 80% sensitive but only 45% specific. The positive predictive value was highest for risk assessments that included partner HIV status. Integrating questions about anal sex partner HIV status and condom use identifies MSM at greatest risk for HIV acquisition and transmission. These risk criteria might be effectively used to triage MSM into more intensive prevention interventions.     

Scale-up of HIV treatment through PEPFAR: a historic public health achievement

Since its inception in 2003, the US President's Emergency Plan for AIDS Relief (PEPFAR) has been an important driving force behind the global scale-up of HIV care and treatment services, particularly in expansion of access to antiretroviral therapy. Despite initial concerns about cost and feasibility, PEPFAR overcame challenges by leveraging and coordinating with other funders, by working in partnership with the most affected countries, by supporting local ownership, by using a public health approach, by supporting task-shifting strategies, and by paying attention to health systems strengthening. As of September 2011, PEPFAR directly supported initiation of antiretroviral therapy for 3.9 million people and provided care and support for nearly 13 million people. Benefits in terms of prevention of morbidity and mortality have been reaped by those receiving the services, with evidence of societal benefits beyond the anticipated clinical benefits. However, much remains to be accomplished to achieve universal access, to enhance the quality of programs, to ensure retention of patients in care, and to continue to strengthen health systems.     

Misperceptions about HIV transmission among heterosexual African-American and Latino men and women

This research was conducted to identify myths and misperceptions about HIV/AIDS and barriers to risk reduction among heterosexual African-American and Latino-American men and women in Houston, Texas. Sixty four Latino-American and 69 African-American men and women, aged 13 to 59 years, participated in 10 and 11 focus groups, respectively. Each group was audiotaped, transcribed, and analyzed using theme and domain analysis. The data confirmed the existence of myths and misperceptions among both groups about HIV/AIDS, specifically that HIV is an agent of genocide, suspicion of government information, belief that one can identify risky partners by odor and appearance, that partners' reported histories are accurate, significant misperceptions as to the meaning of "safe sex" (particularly in women), and belief that specific classes of people (not including oneself) are at risk for HIV. These data strongly suggest that concentration on narrow targeting of misinformation common in particular minority populations is important in the development of HIV/AIDS prevention programs.     

The HIV epidemic among older men who have sex with men

The authors present HIV prevalence and risk behavior data for urban men who have sex with men (MSM) aged 50 years or older. Data are based on a probability sample of MSM conducted in 1997 (n = 2881 total; 507 older MSM) in New York, Los Angeles, Chicago, and San Francisco. The authors determined HIV status through self-report and biologic measures. Risk behavior was assessed through self-report. The authors found that HIV prevalence was 19% (95% CI: 14, 25) for men in their 50s and 3% (95% CI: 1, 10) for men in their 60s. No men in their 70s were HIV-positive. Prevalence was at high levels for older blacks (30%), MSM who are injection drug users (21%), moderately heavy drug users (35%), and less closeted men (21%). High-risk sex between serodiscordant partners was relatively constant (4%-5%) across age groups older than 30 years of age and decreased among MSM in their 70s. Current levels of HIV among older urban MSM in the United States are very high, particularly among those in their 50s. High mortality rates among MSM with AIDS up to 1996 (before highly active antiretroviral therapy [HAART]) would account for the lower levels among men in their 60s and 70s. Because of HAART, we would expect HIV levels to increase in these age groups. Given high levels of risk behavior among MSM through the sixth decade of life, the authors would expect an older MSM epidemic of substantially larger proportion than that observed in the 1980s and 1990s.