Successes and challenges of HIV prevention in men who have sex with men

Men who have sex with men (MSM) have been substantially affected by HIV epidemics worldwide. Epidemics in MSM are re-emerging in many high-income countries and gaining greater recognition in many low-income and middle-income countries. Better HIV prevention strategies are urgently needed. Our review of HIV prevention strategies for MSM identified several important themes. At the beginning of the epidemic, stand-alone behavioural interventions mostly aimed to reduce unprotected anal intercourse, which, although somewhat efficacious, did not reduce HIV transmission. Biomedical prevention strategies reduce the incidence of HIV infection. Delivery of barrier and biomedical interventions with coordinated behavioural and structural strategies could optimise the effectiveness of prevention. Modelling suggests that, with sufficient coverage, available interventions are sufficient to avert at least a quarter of new HIV infections in MSM in diverse countries. Scale-up of HIV prevention programmes for MSM is difficult because of homophobia and bias, suboptimum access to HIV testing and care, and financial constraints.     

Pre-exposure prophylaxis sorting among men who have sex with men

Factors such as race, masculinity, and sexually transmitted infections have been documented to influence partner selection in men who have sex with men (MSM). Pre-exposure prophylaxis (PrEP) has received mixed evaluations as a responsible step in HIV prevention and as an enabler of risker sexual practices. PrEP may consequently serve as an additional factor in partner choice. We examine the role that PrEP use and “promiscuity” play in affiliation and dating decisions by men who have sex with men with different HIV and PrEP stati. We invited 450 MSM across the United States from a smartphone geo-locating sex application to complete a survey of which 339 successfully finished the task. The survey contained vignettes of fictional men who were promiscuous or monogamous and either taking PrEP or not. Participants provided responses on whether to affiliate with these characters in three social domains: as friends, dates, or sex partners. Neither PrEP nor promiscuity influenced friendship choices. There was a preference for dating monogamous characters. Critically, PrEP influenced sexual affiliations for HIV negative individuals who showed a preference for PrEP-using characters. The pattern of results provides quantitative evidence for PrEP-based sexual sorting aimed at reducing risk of HIV transmission.     

HIV sero disclosure among men who have sex with men and transgender women on HIV pre-exposure prophylaxis

HIV pre-exposure prophyalxis (PrEP) might lead individuals to view serodisclosure as unnecessary. We examined the prevalence of non-disclosure and lack of knowledge of partner status in a global cohort of men who have sex with men (MSM) and transgender women (TW) enrolled in the iPrEx Open Label Extension (OLE). We calculated prevalence ratios by fitting a logistic model and estimating predicted probabilities using marginal standardization. Prevalence of non-disclosure and lack of knowledge of partner status were highest in Thailand (73% and 74%, respectively) and lowest in the USA (23% and 37%, respectively). In adjusted analyses, PrEP use was not significantly associated with non-disclosure or lack of knowledge of partner status (p-values>0.05). We found that relationship characteristics were significantly associated with both outcomes. Non-disclosure was higher among casual (adjusted prevalence ratio [aPR] 1.54, [95% confidence interval 1.24–1.84]) and transactional sex partners (aPR 2.03, [1.44–2.62]), and among partners whom participants have known only minutes or hours before their first sexual encounter (aPR 1.62, [1.33–1.92]). Similarly, participants were less likely to know the HIV status of casual partners (aPR 1.50, [1.30–1.71]), transactional sex partners (aPR 1.62, [1.30–1.95]), and those they have known for only days or weeks (aPR 1.13, [0.99–1.27]) or minutes or hours (aPR 1.27, [1.11–1.42]). Our findings underscore the role of dyadic factors in influencing serodisclosure. Comprehensive risk reduction counseling provided in conjunction with PrEP that address relationship characteristics are needed to help patients navigate discussions around HIV status.     

Space: the new frontier in HIV prevention for young men who have sex with men.

Young men who have sex with men (MSM) in urban areas of the United States continue to be vulnerable to HIV infection. Qualitative data collected with participants in a community level HIV intervention in West Hollywood and Orange County, California, suggest that space -- both actual physical space and the concept of having space -- should be an integral part of an HIV prevention intervention for young MSM. Having such spaces appears to contribute to youth sense of empowerment and efficacy and foster community building, all important components of an effective HIV prevention. Data were drawn from a qualitative research sample of 73. Through narratives, young men describe specific characteristics of the space necessary for effective HIV intervention, including mentoring and supportive staff, tolerant and like-minded peers, information exchange, opportunities for strengthening self-esteem, and a sense of collaborative community invested in social change.     

HIV risk and prevention among men who have sex with men in rural South Africa

Rural South African men who have sex with men (MSM) are likely to be underserved in terms of access to relevant healthcare and HIV prevention services. While research in urban and peri-urban MSM populations has identified a range of factors affecting HIV risk in South African MSM, very little research is available that examines HIV risk and prevention in rural MSM populations. This exploratory study begins to address this lack by assessing perceptions of HIV risk among MSM in rural Limpopo province. Using thematic analysis of interview and discussion data, two overarching global themes that encapsulated participants’ understandings of HIV risk and the HIV risk environment in their communities were developed. In the first theme, “community experience and the rural social environment”, factors affecting HIV risk within the broad risk environment were discussed. These included perceptions of traditional value systems and communities as homophobic; jealousy and competition between MSM; and the role of social media as a means of meeting other MSM. The second global theme, “HIV/AIDS knowledge, risk and experience”, focused on factors more immediately affecting HIV transmission risk. These included: high levels of knowledge of heterosexual HIV risk, but limited knowledge of MSM-specific risk; inconsistent condom and lubricant use; difficulties in negotiating condom and lubricant use due to uneven power dynamics in relationships; competition for sexual partners; multiple concurrent sexual partnerships; and transactional sex. These exploratory results suggest that rural South African MSM, like their urban and peri-urban counterparts, are at high risk of contracting HIV, and that there is a need for more in-depth research into the interactions between the rural context and the specific HIV risk knowledge and behaviours that affect HIV risk in this population.     

Risk of HIV infection attributable to oral sex among men who have sex with men and in the population of men who have sex with men

We examined HIV infection and estimated the population-attributable risk percentage (PAR%) for HIV associated fellatio among men who have sex with other men (MSM). Among 239 MSM who practised exclusively fellatio in the past 6 months, 50% had three partners, 98% unprotected; and 28% had an HIV-positive partner; no HIV was detected. PAR%, based on the number of fellatio partners, ranges from 0.10% for one partner to 0.31% for three partners. The risk of HIV attributable to fellatio is extremely low.     

Implementation of HIV non-occupational post-exposure prophylaxis for men who have sex with men in 2 cities of Southwestern China

Non-occupational post-exposure prophylaxis (nPEP) has often relied on the joint work of emergency physicians and infectious disease specialists in busy emergency departments and human immunodeficiency virus (HIV)/sexually transmitted infections clinics abroad, where adherence education and follow-up are invariably reactive. In our pilot study, community-based organizations (CBOs) were invited to together implement the nPEP tailored to men who have sex with men (MSM) in 2 cities of Guangxi in Southwestern China, of which experiences and lessons drawn from would be provided to the promotion of nPEP in China.The study population enrolled MSM individuals prescribed nPEP from September 2017 to December 2019. One-to-one follow-ups by CBOs were applied through the treatment. Predictors of treatment completion were assessed by logistic regression.Of 271 individuals presented for nPEP, 266 MSM with documented treatment completion or non-completion, 93.6% completed the 28-day course of medication. Completion was associated with reporting side effects (aOR = .10; 95% CI: 0.02–0.38; P = .001). The follow-up rate of 91.9% was achieved based on the definition of loss to follow-up. No documented nPEP failures were found, although 1 MSM subsequently seroconverted to HIV due to ongoing high-risk behavior.CBOs’ engagement in HIV nPEP, especially the “one-to-one” follow-up supports by peer educators partly ensure adherence and retention to nPEP. Tailored interventions are needed to address the subsequent high-risk behaviors among the MSM population.     

Risk factors for HIV infection among men who have sex with men

OBJECTIVES: Risk factors for HIV acquisition were examined in a recent cohort of men who have sex with men (MSM). DESIGN: A longitudinal analysis of 4295 HIV-negative MSM enrolled in a randomized behavioral intervention trial conducted in six US cities. METHODS: MSM were enrolled and assessed for HIV infection and risk behaviors semi-annually, up to 48 months. RESULTS: In multivariate analysis, men reporting four or more male sex partners, unprotected receptive anal intercourse with any HIV serostatus partners and unprotected insertive anal intercourse with HIV-positive partners were at increased risk of HIV infection, as were those reporting amphetamine or heavy alcohol use and alcohol or drug use before sex. Some depression symptoms and occurrence of gonorrhea also were independently associated with HIV infection. The attributable fractions of high number of male partners, use of alcohol or drugs before sex, and unprotected receptive anal intercourse with unknown status partners and the same with presumed negative partners accounted for 32.3, 29.0, 28.4 and 21.6% of infections, respectively. CONCLUSIONS: The challenge is to develop strategies to identify men in need. Interventions are needed to help men reduce their number of sexual partners, occurrences of unprotected anal intercourse, alcohol or drug use before sex and address other mental health issues.