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.     

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.     

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).     

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.     

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.     

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.     

Sex in the Era of COVID-19 in a U.S. National Cohort of Cisgender Men,Transgender Women,and Transgender Men Who Have Sex with Men: April–May 2020

Since the emergence of the COVID-19 pandemic, there has been an increasing body of research focused on the effects that measures like stay-at-home orders and social distancing are having on other aspects of health, including mental health and sexual health. Currently, there are limited extant data on the effects of the pandemic on sexual and gender minorities. Between April 15, 2020, and May 15, 2020, we invited participants in an ongoing U.S. national cohort study (Together 5000) to complete a cross-sectional online survey about the pandemic, and its effects on mental and sexual health and well-being (n?=?3991). Nearly all (97.7%) were living in an area where they were told they should only leave their homes for essentials. Most (70.1%) reported reducing their number of sex partners as a result of the pandemic. Among the 789 participants prescribed HIV pre-exposure prophylaxis (PrEP), 29.9% said they stopped taking their PrEP entirely, and 14.2% started selectively skipping doses. For those who had been taking PrEP, discontinuing PrEP was associated with having no new sex partners (β?=?0.90, 95% CI 0.40–1.40). Among the 152 HIV-positive participants, 30.9% said they were unable to maintain an HIV-related medical appointment because of the pandemic and 13.8% said they had been unable to retrieve HIV medications. Additionally, 35.3% of participants were experiencing moderate to severe anxiety because of the pandemic and 36.7% reported symptoms of depression. In a multivariable logistic regression, reporting a new sex partner in the prior 30 days was significantly associated with being aged 30 or older (vs. not, AOR?=?1.21), being Black (AOR?=?1.79) or Latinx (AOR?=?1.40, vs. white), and being unsure if they had been in close contact with someone diagnosed with COVID-19 (AOR?=?1.32, vs. no contact). It was unassociated with COVID-19-induced anxiety, depression, or knowing someone hospitalized with COVID-19. The pandemic has caused disruptions in sexual behavior (partner reduction) as well as difficulties navigating PrEP and HIV care continua. Findings will guide more comprehensive public health responses to optimize HIV prevention and treatment in the era of COVID-19.

     

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.     

Sex,Drugs (Methamphetamines), and the Internet: Increasing Syphilis Among Men Who Have Sex With Men in California, 2004–2008

Objectives. We examined primary and secondary syphilis cases among men who have sex with men (MSM) in California, and the association of methamphetamine use and Internet use to meet sex partners (Internet use) with number of sex partners.Methods. We analyzed California surveillance data for MSM who were diagnosed with syphilis between 2004 and 2008, to assess differences in the mean number of sex partners by methamphetamine use and mutually exclusive groups of patients reporting Internet use (Internet users).Results. Large proportions of patients reported methamphetamine use (19.2%) and Internet use (36.4%). From 2006 through 2008, Adam4Adam was the most frequently reported Web site statewide, despite temporal and regional differences in Web site usage. Methamphetamine users reported more sex partners (mean = 11.7) than nonmethamphetamine users (mean = 5.6; P < .001). Internet users reported more sex partners (mean = 9.8) than non-Internet users (mean = 5.0; P < .001). Multivariable analysis of variance confirmed an independent association of methamphetamine and Internet use with increased numbers of sex partners.Conclusions. Higher numbers of partners among MSM syphilis patients were associated with methamphetamine and Internet use. Collaboration between currently stand-alone interventions targeting methamphetamine users and Internet users may offer potential advances in sexually transmitted disease control efforts.After decades of substantial progress in syphilis control, the number of primary and secondary syphilis cases in California increased each year from 1999 through 2008.1 Prior to 2000, syphilis in California had been primarily among heterosexual populations2,3; however, recent increases have been among men who have sex with men (MSM).1 Similar increases in infectious syphilis cases among MSM have been seen in other metropolitan areas across the United States.4–9Increasing numbers of MSM have reported using the Internet to meet sex partners10–12 (hereafter referred to simply as “Internet use”); a meta-analysis by Liau et al. placed the figure at approximately 40%.13 Early studies examining the association between Internet use and sexual risk behavior found that MSM who reported seeking sex partners online were more likely to report both higher numbers of partners and more anonymous, unlocatable partners than MSM not seeking partners online.14,15 In San Francisco, an outbreak of syphilis among MSM was linked to seeking sex partners through an online chatroom.16 Several studies also found that individuals using the Internet to seek sex partners were at greater risk for sexually transmitted disease (STD) than individuals not seeking sex partners online.17–19 More recent research suggests that such Internet use is a general marker of individuals who already engage in or seek out high-risk sexual behavior; however, its independent contribution to increasing one’s risk of STD infection is unclear.20–23An association between methamphetamine use and risky sexual behavior for STD/HIV transmission among MSM has been well documented. A cross-sectional study in San Francisco found that methamphetamine use, particularly in combination with sildenafil (Viagra), was associated with an increased risk of early syphilis infection among MSM seen at an STD clinic.17 Methamphetamine users are more likely than nonmethamphetamine users to report multiple and anonymous sex partners, STD coinfections, and more frequent unprotected anal intercourse with HIV sero-discordant partners or partners with unknown HIV status.24–27Although methamphetamine use and Internet use have been associated with risky sexual behavior and risk of STD/HIV infection, few studies have examined the effect of these factors together.28,29 We describe the demographics and risk characteristics of MSM primary and secondary syphilis cases diagnosed in California between 2004 and 2008 and, in particular, the relationship of methamphetamine use and Internet use with reported number of sex partners within the year prior to syphilis diagnosis.     

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.     

Sexual Identity,Stigma, and Depression: the Role of the “Anti-gay Propaganda Law” in Mental Health among Men Who Have Sex with Men in Moscow,Russia

Depression is a major public health problem in the Russian Federation and is particularly of concern for men who have sex with men (MSM). MSM living in Moscow City were recruited via respondent-driven sampling and participated in a cross-sectional survey from October 2010 to April 2013. Multiple logistic regression models compared the relationship between sexual identity, recent stigma, and probable depression, defined as a score of ≥23 on the Center for Epidemiological Studies Depression scale. We investigated the interactive effect of stigma and participation in the study after the passage of multiple “anti-gay propaganda laws” in Russian provinces, municipalities, and in neighboring Ukraine on depression among MSM. Among 1367 MSM, 36.7% (n?=?505) qualified as probably depressed. Fifty-five percent identified as homosexual (n?=?741) and 42.9% identified as bisexual (n?=?578). Bisexual identity had a protective association against probable depression (reference: homosexual identity AOR 0.71; 95%CI 0.52–0.97; p?<?0.01). Those who experienced recent stigma (last 12 months) were more likely to report probable depression (reference: no stigma; AOR 1.75; 95%CI 1.20–2.56; p?<?0.01). The interaction between stigma and the propaganda laws was significant. Among participants with stigma, probable depression increased 1.67-fold after the passage of the anti-gay laws AOR 1.67; 95%CI 1.04–2.68; p?<?0.01). Depressive symptoms are common among MSM in Russia and exacerbated by stigma and laws that deny homosexual identities. Repeal of Russia’s federal anti-gay propaganda law is urgent but other social interventions may address depression and stigma in the current context.     

What Makes a Respondent-Driven Sampling “Seed” Productive? Example of Finding At-Risk Massachusetts Men Who Have Sex with Men

Several recent studies have sought to elaborate upon the applicability and validity of respondent-driven sampling (RDS) to find hard-to-reach samples in general and men who have sex with men (MSM) in particular. Few published studies have elucidated the characteristics associated with initial RDS participants (“seeds”) who successfully recruited others into a study. A total of 74 original seeds were analyzed from four Massachusetts studies conducted between 2006 and 2008 that used RDS to reach high-risk MSM. Seeds were considered “generative” if they recruited two or more subsequent participants and “non-generative” if they recruited zero or one participant. Overall, 34% of seeds were generative. In separate multivariable logistic regression models controlling for age, race, health insurance, HIV status, and the study for which the seed was enrolled, unprotected anal sex in the past 12 months [adjusted odds ratio (AOR) = 6.68; 95% confidence interval (95% CI) = 1.27–35.12; p = 0.03], cocaine use during sex at least monthly during the past 12 months (AOR = 8.81; 95% CI = 1.68–46.27; p = 0.01), and meeting sex partners at social gatherings (AOR = 7.42; 95% CI = 1.58–34.76; p = 0.01) and public cruising areas (AOR = 4.92; 95% CI = 1.27–19.01; p = 0.02) were each significantly associated with increased odds of being a generative seed. These findings have methodological and practical implications for the recruitment of MSM via RDS. Finding ways to identify RDS seeds that are consistently generative may facilitate collecting a sample that is closer to reflecting the MSM who live in all of the communities in a given location or study sample.