HIV risk behaviour among gay and bisexual men in Budapest, Hungary

HIV is a growing public health threat in Central and Eastern Europe. In Hungary and a number of other countries, men who have sex with men (MSM) account for a high proportion of HIV infections. However, there has been very little systematic study of the sexual risk practices and characteristics of MSM in this region. This study surveyed 469 MSM recruited in Budapest gay community venues in June 2001. Half the men (50%) engaged in unprotected anal intercourse (UAI) in the past 3 months. Of these, 40% of men's insertive and 50% of their receptive acts were unprotected, and 25% had multiple AI partners in the past 3 months. 17% of MSM exchanged sex for money, 26% had female partners in the past year, and condoms were used in only 23% of their vaginal intercourse occasions. Multivariate analyses showed that high-risk behaviour was predicted by not having condoms available when needed, weak risk reduction intentions, negative attitudes toward safer sex, being in a steady relationship, and having a bisexual orientation. Community-based HIV prevention programmes focused on the needs of gay or bisexual men in Central and Eastern Europe are urgently needed.     

Feasibility and acceptability of pre-exposure prophylaxis use among women in violent relationships

Intimate partner violence (IPV) is associated with a high risk of HIV acquisition. Pre-exposure prophylaxis (PrEP), which does not require partner knowledge or consent, is a promising HIV risk reduction option for women experiencing IPV. Drawing on semi-structured interviews with 26 women experiencing IPV within the last six months, this study explored the feasibility and acceptability of PrEP use in this population. Slightly more than half of the women in this study expressed interest in taking PrEP when in a relationship with an abusive partner. Potential barriers to PrEP, discussed regardless of women's expressed interest in PrEP, included fear of side effects and long-term health concerns, low risk perceptions, potential partner interference, and prioritizing coping with the relationship over HIV prevention. When offering PrEP counseling, providers should inquire about IPV, as women in violent relationships may require tailored counseling to address barriers and concerns specific to their situation.     

Sex work and risk behaviour among HIV-negative gay men

Gay men who engage in sex work may be at increased risk through risk behaviour outside the context of sex work. Among participants in the Health in Men (HIM) cohort of HIV-seronegative gay men in Sydney, 19.7% had ever engaged in sex work. Five percent reported being paid for sex in a six-month period during the study (2001-2006); a minority (18.3%) of these current sex workers reported unprotected anal intercourse (UAI) with clients and 62.0% reported UAI with any casual partners. The practice of sex work itself may not represent increased risk for HIV transmission but sex workers in this study were, nonetheless, at markedly increased risk in other aspects of their lives.     

HIV pre-exposure prophylaxis (PrEP) awareness and acceptability among trans women: a review

ABSTRACT

Transgender (trans) women are disproportionally burdened by the HIV epidemic due to complex structural, psychosocial and biological factors. HIV pre-exposure prophylaxis (PrEP) is a biomedical prevention approach for people at substantial risk of acquiring HIV. This literature review assessed awareness, willingness to use, and barriers and facilitators for PrEP acceptability among trans women. A search was conducted through five databases and included studies with primary data and disaggregate results for trans women. Of 255 retrieved citations, 17 met the inclusion criteria and were included. Low to moderate knowledge about PrEP was observed among studies. However, willingness to use PrEP was predominantly high. Frequent barriers to PrEP acceptability included concerns about side effects, cost, hormone therapy, adherence, PrEP-related stigma and interaction with healthcare workers. Facilitators included perceived reduction of HIV risk, fear of HIV/AIDS and reduced dependence on partners. Findings suggest elevated interest in PrEP and highlight important barriers and facilitators that should be specifically addressed to optimize PrEP uptake and use among this highly vulnerable population.     

Sexual sensation seeking, reduced concern about HIV and sexual risk behaviour among gay men in primary relationships

Gay and bisexual men who indicated they were currently in a primary relationship with another man (N = 230) completed measures of HIV treatment attitudes, sexual risk behaviour and sexual sensation seeking. Results indicate non-primary partner sexual activity is common in many gay relationships and men in non-exclusive relationships possessed greater levels of sexual sensation seeking and treatment-related reduced concern about the dangerousness of HIV than men in exclusive relationships. Results also suggest that individuals who were members of HIV-seroconcordant relationships were more likely to engage in unprotected sexual activity with their primary sexual partners than gay men who were members of HIV-discordant couples. A series of regression analyses revealed that reduced concern about HIV mediated the relationship between sexual sensation seeking and sexual risk behaviour. The next generation of HIV prevention interventions must address the attitudinal shifts that have occurred among some gay men regarding the seriousness of HIV and should be sensitive to the dynamics of gay relationships.     

HIV risk and communication between regular partners in a cohort of HIV-negative gay men

This paper reports on the breaking of agreements between regular partners among HIV-negative gay men in Sydney. Data were from the 1333 men completing face-to-face interviews through December 2003 for the Health in Men (HIM) open cohort of HIV-negative gay men in Sydney.822 men had a primary regular partner during the six month period before their 2003 interview. Most of these men had entered into agreements with their partners about sex either with each other or with other partners (87.2%). They most commonly agreed not to use condoms with each other (50.6%). Regarding casual sex, they most commonly agreed to always use condoms (34.2%) or to have no sex with men outside their relationships (28.6%). 48.8% reported some discomfort discussing with their partner their sex outside the relationship. Among those with agreements with their partners, 27.7% reported ever breaking those agreements. Those who found it more difficult to discuss issues of HIV serostatus and sexuality were more likely to report having broken their agreements (p<.001; p=.021 at one-year follow-up) and were more likely to have engaged in unprotected anal intercourse with casual partners (p<.001). A third of those men who broke their agreements did not inform their partner. A substantial proportion of gay men with agreements with their regular partners report some discomfort discussing sexuality and HIV serostatus with their partners. Difficulty discussing these issues may place these men at increased risk of breaking their agreements and may place both themselves and their partners at increased risk of infection.     

Stigma and suicide among gay and bisexual men living with HIV

HIV positive gay and bisexual men (GBM) continue to struggle with the pervasiveness of HIV stigma, but little is known about the health effects of stigma. In this article, suicidal ideation and attempts are measured among GBM living with HIV, evaluating the extent to which these experiences are associated with stigma and suicide. Drawing from an online national survey of Canadian GBM completed by 7995 respondents, a sub-set of data provided by respondents self-reporting HIV-positive status was used for the current study. The associations between suicidal ideation (SI) and attempts (SA) and four measures of HIV stigma were measured: social exclusion, sexual rejection, verbal abuse and physical abuse. A total of 673 HIV-positive men completed the survey (8% of total sample). Among this group, 22% (n?=?150) reported SI and 5% (n?=?33) SA in the last 12 months. After adjusting for sociodemographic factors, SI and SA were associated with each of the four measures of HIV stigma: being excluded socially for being HIV positive (SI adjusted odds ratio, AOR 2.0 95% CI 1.4–3.1; SA AOR 3.8 95% CI 1.9–7.9), rejected as a sexual partner (SI AOR 1.6 95% CI 1.1–2.4; SA AOR 2.6 95% CI 1.1–6.0), verbally abused (SI AOR 2.9 95% CI 1.9–4.5; SA AOR 2.4 95% CI 1.1–5.1), and physically abused (SI AOR 4.5 95% CI 1.8–11.7; SA AOR 6.4 95% CI 2.0–20.1). Furthermore, experiencing multiple forms of stigma was associated with significantly increased risk of SI and SA. The authors conclude that HIV positive GBM experience significant levels of stigma that are associated with heightened risk for suicide. The findings affirm the need for targeted interventions to prevent suicide amid public health efforts to de-stigmatize HIV and mental illness.     

Motivators, concerns, and barriers to adoption of preexposure prophylaxis for HIV prevention among gay and bisexual men in HIV-serodiscordant male relationships

The purpose of this study was to identify factors that may facilitate or impede future adoption of preexposure prophylaxis (PrEP) for HIV prevention among gay and bisexual men in HIV-serodiscordant relationships. This qualitative study utilized semistructured interviews conducted with a multiracial/-ethnic sample of 25 gay and bisexual HIV-serodiscordant male couples (n=50 individuals) recruited from community settings in Los Angeles, CA. A modified grounded theory approach was employed to identify major themes relating to future adoption of PrEP for HIV prevention. Motivators for adoption included protection against HIV infection, less concern and fear regarding HIV transmission, the opportunity to engage in unprotected sex, and endorsements of PrEP's effectiveness. Concerns and barriers to adoption included the cost of PrEP, short- and long-term side effects, adverse effects of intermittent use or discontinuing PrEP, and accessibility of PrEP. The findings suggest the need for a carefully planned implementation program along with educational and counseling interventions in the dissemination of an effective PrEP agent.     

Institutional distrust among gay,bisexual, and other men who have sex with men as a barrier to accessing pre-exposure prophylaxis (PrEP)

Populations at highest risk for acquiring HIV are more likely to pass through criminal justice (CJ) settings, and CJ-involved individuals are often at the intersection of multiple overlapping risk factors. The present study explored interest in, knowledge of, and barriers to PrEP uptake among gay, bisexual, and other men who have sex with men involved in the criminal justice system. Using semi-structured interviews, 26 participants who identified as MSM were asked about PrEP knowledge and interest, HIV risk, and incarceration experience. One theme that emerged across interviews was how institutional distrust in CJ settings may instill lack of trust in medical care after perceived mistreatment. Participants explained how lack of privacy fostered feelings that medical care was not confidential, care received was tied to status as an incarcerated person, and feelings of dehumanization led to distrust. Findings explore how distrust may hinder PrEP uptake and other HIV prevention efforts in CJ settings as well as after release. They highlight the need for greater privacy efforts and cultural humility, and explore how medical settings may function as spaces for people who are incarcerated to disclose HIV risk status. Few studies to our knowledge have examined the role of institutional distrust on men who have sex with men (MSM) in the context of pre-exposure prophylaxis (PrEP) interventions. The present study has implications for creating best practices to structure HIV prevention interventions in CJ settings.     

Sexual risk behaviour among gay men in a relationship.

OBJECTIVE: To examine whether gay men in a relationship have adopted negotiated safety as an HIV risk reduction strategy. METHODS: A confidential, anonymous questionnaire was completed by 1004 gay men attending gyms in central London in September-October 1997. Information was sought on sociodemographic characteristics, HIV testing and sexual risk behaviour. Men reporting unprotected anal intercourse (UAI) in the previous 3 months were classified as 'status-unknown' if they did not know their own HIV status, that of their UAI partner(s) or both. Men who knew their own and their UAI partner's HIV status were classified as 'status-known'. RESULTS: Of the 1004 men surveyed, 986 provided complete information on relationship, personal HIV test history and HIV status of UAI partner. Over half (539) said they were currently in a relationship with another man, of whom 173 reported UAI in the previous 3 months; 140 (80.9%) with their main partner only, 18 (10.4%) with a casual partner only and 15 (8.7%) with both their main and casual partners. Of the 140 men reporting UAI only with their main partner, 62 (44.3%) did not know their own HIV status or that of their partner. Overall, a quarter (26.0%) of the men in a relationship reported UAI only with their main partner in the previous 3 months; 11.5% status-unknown UAI, 14.5% status-known UAI. In a multivariate logistic model, both age and being in a relationship were significantly associated with UAI (status-unknown and status-known). CONCLUSION: Gay men in a relationship, surveyed in central London gyms, have for the most part adopted the first principle of negotiated safety: only to have UAI with their main partner. However, not all have embraced the second principle: to establish HIV seroconcordance. Nearly half the men reporting UAI only with their main partner were unaware of their own HIV status, their partner's or both. As a consequence, more than one in 10 men in a relationship reported high-risk (i.e. status-unknown) UAI with their main partner. Because the study population, from central London gyms, was not randomly selected, these findings may not be generalizable to all gay men in London. Nonetheless, HIV prevention programmes should continue to encourage gay men in a relationship to seek an HIV test and establish seroconcordance if they wish to have UAI with each other.     

Sexual dysfunction in gay and bisexual men with HIV infection: evaluation, treatment and implications

Sexual dysfunction problems are common in people with HIV infection, but their relevance has been recently highlighted in response to the increased survival shown by many individuals with HIV, and the publicity surrounding the development of new treatments for male sexual dysfunction. Thirty-four gay/bisexual men with HIV infection presenting with sexual dysfunction were assessed. Antiretroviral combination therapy including protease inhibitors was taken by 44%, other combinations not including protease inhibitors by 24%, while 32% were not taking any antiretrovirals. Primarily psychogenic sexual dysfunction was thought to be present in 44%, primarily organic dysfunction in 22% and a mixed aetiology in 34%. Treatments offered included psychological interventions and physical methods of treatment, alone or in combination. Treatment was effective, with 76% reporting resolution of the problems, 14% reporting improvement and only 10% reporting no change. Practical and ethical issues raised by the findings are discussed.     

Mobilizing young gay and bisexual men for HIV prevention: a two-community study.

BACKGROUND: To develop, implement and evaluate a community-level HIV prevention program (the Mpowerment Project) for young gay men in two US communities. DESIGN: Using a multiple baseline design, a cohort of young gay men was recruited independently of the intervention in each community and surveyed twice (1 year apart) regarding sexual risk behavior and psychosexual variables. The intervention was then implemented sequentially in each community. The cohorts were resurveyed immediately post- and 1-year post-intervention. Since there were few differences between the two communities, data were pooled to increase statistical power. INTERVENTION: The program had four components: peer outreach, whereby young gay men encouraged other men to engage in safer sex; peer-led small groups; a publicity campaign; and a young men's center. RESULTS: Baseline rates of unprotected anal intercourse were stable. Following intervention, the proportion of men who engaged in unprotected anal intercourse decreased from 38.3 to 30.9% (-19.3% relative reduction), with a reduction from 19.2 to 13.6% (-29.2% relative reduction) with non-primary partners, and a reduction from 57.7 to 41.8% (-27.6% relative reduction) with boyfriends. Reductions were sustained 1 year later with non-primary partners, but mixed results were found regarding sex with boyfriends. CONCLUSIONS: Mobilizing young gay men to support each other about safer sex is an effective approach to HIV prevention, but programs must be sustained. To reach young gay men, HIV prevention activities must be embedded into the satisfaction of needs for social and community belonging.     

HIV transmission risk behaviours among HIV-positive persons in serodiscordant relationships

As many as one in three persons living with HIV-AIDS continue to practise unprotected sexual intercourse and these practices often occur with HIV-negative or unknown HIV serostatus (serodiscordant) partners. The current study examined the rates of HIV transmission risk behaviours in non-regular (e.g. casual) and regular (e.g. steady) serodiscordant relationships. HIV positive men (n = 269) and women (n = 114) responded to measures of demographic characteristics, health and mental health status, and sexual behaviours assessed in partner-by-partner interviews. 257 (67%) participants were sexually active in the preceding three months and 182 (71%) of the sexually active persons had engaged in vaginal or anal intercourse with serodiscordant partners. Comparisons of persons with non-regular (n = 97) and regular (n = 85) serodiscordant partners showed that overall rates of unprotected and protected intercourse were greater with regular partners than non-regular partners. Disclosure of HIV status to regular and non-regular serodiscordant partners did not appear to influence the pattern of results. Mathematical modelling showed that HIV transmission estimates over a one-year horizon were significantly greater for male regular partners of HIV-positive men than non-regular partners and there was a trend toward greater HIV transmission rates from HIV-positive men to their regular serodiscordant female partners compared to non-regular partners. Results suggest an urgent need for HIV transmission risk reduction interventions for HIV serodiscordant couples, particularly for couples in established, regular relationships.     

Awareness and Acceptability of pre-exposure prophylaxis (PrEP) among gay,bisexual and other men who have sex with men (GBMSM) in Kenya

ABSTRACT

Kenyan gay, bisexual, and other men who have sex with men (GBMSM) are significantly affected by HIV. Pre-exposure prophylaxis (PrEP) is an effective biomedical approach to HIV prevention. We conducted a cross-sectional survey of 459 HIV-negative Kenyan GBMSM to assess individual and interpersonal correlates of PrEP awareness/acceptability using univariate and hierarchical logistic regression modeling. We found that 64.3% of participants had heard of PrEP and 44.9% were willing to use PrEP. In hierarchical logistic regression models for PrEP awareness, condom use with regular partners, higher condom use self-efficacy, higher perceived ability to use PrEP, history of STI, and membership in LGBT organization were significantly associated with being aware of PrEP (χ^2?=^?69.6, p?<?.001). In hierarchical logistic regression models for PrEP acceptability, higher self-esteem, higher condom use self-efficacy, depression/anxiety, higher perceived ability to use PrEP, willingness to engage in PrEP follow-up visits, coercion at sexual debut, and family exclusion were significantly associated with being acceptable to PrEP (χ^2?=^?231.8, p?<?.001). Individual and interpersonal factors were significantly associated with PrEP awareness and acceptability. Our findings underscore the need to promote awareness and understanding of PrEP as an effective HIV prevention tool in combination with other safer-sex methods that are appropriate given an individual’s personal circumstances.     

Methamphetamine abuse as a barrier to HIV medication adherence among gay and bisexual men

Medication adherence among persons with HIV infection is important not only because of the effect of non-adherence on an individual's health but also because non-adherence can lead to medication-resistant viral strains. However, adherence to HIV medications is difficult due to complex dosing regimens and side effects. This paper is a qualitative analysis of HIV medication adherence among gay and bisexual methamphetamine-abusing men enrolled in an outpatient drug treatment research project. As part of an open-ended, semi-structured interview, 23 HIV-infected men discussed the effects of their methamphetamine use on their medication adherence. Substance-use barriers to adherence were coded into two main themes: (1) planned non-adherence and (2) unplanned non-adherence. Planned non-adherence was a strategy for coping with demanding HIV medication schedules, or was linked to sexual behaviours while using methamphetamine or to fears of interaction effects from mixing methamphetamine with HIV medications. Participants did not define their medication regimen adjustments as non-adherence but as a way to achieve a sense of control over their lives. Unplanned non-adherence was linked to methamphetamine-related disruptions in food and sleep schedules. Findings are helpful in designing culturally specific HIV medication adherence interventions for this population.     

Partner type and sexual risk behavior among HIV positive gay and bisexual men: social cognitive correlates.

This study used elements of social cognitive theory to examine the relationship between partner type and sexual risk behavior in a sample of HIV positive gay and bisexual men. Self-efficacy captures one's perceived ability to perform a behavior; outcome expectancies are estimations that a behavior will result in a given outcome. An examination of sexual risk behavior revealed that men with steady partners and men with anonymous partners had the most unprotected anal intercourse (UAI), while men with casual partners had the least. Men with anonymous partners had the lowest scores on self-efficacy and outcome expectancies for condom use, negotiation, and disclosure. Outcome expectancies for negotiation of safer sex were inversely related to UAI for men with steady partners. Self-efficacy for condom use and negotiation were inversely related to UAI for men with casual partners. These findings suggest the need to consider partner type in the development of sexual risk reduction interventions.     

Disclosure of HIV status and psychological well-being among Latino gay and bisexual men

This study examined disclosure of HIV-positive serostatus by 301 Latino gay and bisexual men to members of their social networks and the mental health consequences of such disclosure. The sample was recruited from clinics, hospitals, and community agencies in New York City, Washington, DC, and Boston. Proportions disclosing differed depending on the target, with 85% having disclosed to closest friend, 78% to male main partner, 37% to mother, and 23% to father. Although there were differences depending on the target, disclosure was related to greater quality of social support, greater self-esteem, and lower levels of depression. Moreover, findings indicated that social support mediated the relationship between disclosure of serostatus and both self-esteem and depression. Thus, disclosure resulted in greater social support, which in turn had positive effects on psychological well-being. Findings demonstrate that generally Latino gay men are selective in choosing people to whom they disclose their serostatus and that disclosure tends to be associated with positive outcomes.