Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston,Jamaica: a qualitative study

Introduction : Young men who have sex with men (MSM) in Jamaica have the highest HIV prevalence in the Caribbean. There is little information about HIV among transgender women in Jamaica, who are also overrepresented in the Caribbean epidemic. HIV‐related stigma is a barrier to HIV testing among Jamaica's general population, yet little is known of MSM and transgender women's HIV testing experiences in Jamaica. We explored perceived barriers and facilitators to HIV testing among young MSM and transgender women in Kingston, Jamaica. Methods : We implemented a community‐based research project in collaboration with HIV and lesbian, gay, bisexual and transgender (LGBT) agencies in Kingston. We held two focus groups, one with young (aged 18–30 years) transgender women (n = 8) and one with young MSM (n = 10). We conducted 53 in‐depth individual semi‐structured interviews focused on HIV testing experiences with young MSM (n = 20), transgender women (n = 20), and community‐based key informants (n = 13). We conducted thematic analysis to identify, analyze, and report themes. Results : Participant narratives revealed social‐ecological barriers and facilitators to HIV testing. Barriers included healthcare provider mistreatment, confidentiality breaches, and HIV‐related stigma: these spanned interpersonal, community and structural levels. Healthcare provider discrimination and judgment in HIV testing provision presented barriers to accessing HIV services (e.g. treatment), and resulted in participants hiding their sexual orientation and/or gender identity. Confidentiality concerns included: clinic physical arrangements that segregated HIV testing from other health services, fear that healthcare providers would publicly disclose their status, and concerns at LGBT‐friendly clinics that peers would discover they were getting tested. HIV‐related stigma contributed to fear of testing HIV‐positive; this intersected with the stigma of HIV as a “gay” disease. Participants also anticipated healthcare provider mistreatment if they tested HIV positive. Participants identified individual (belief in benefits of knowing one's HIV status), social (social support) and structural (accessible testing) factors that can increase HIV testing uptake. Conclusions : Findings suggest the need for policy and practice changes to enhance confidentiality and reduce discrimination in Jamaica. Interventions to challenge HIV‐related and LGBT stigma in community and healthcare settings can enhance access to the HIV prevention cascade among MSM and transgender youth in Jamaica.     

Innovative uses of communication technology for HIV programming for men who have sex with men and transgender persons

Globally, overall rates of HIV are on the decline; however, rates among gay men and other men who have sex with men (MSM) and transgender persons are increasing. Meanwhile, there has been exponential growth in access to communication technology over the last decade. More innovative prevention and care technology-based programmes are needed to help address the growing numbers of MSM and transgender persons living with HIV and those at risk for infection. To address this need, a meeting was hosted by the U.S. Agency for International Development (USAID) through the President''s Emergency Plan for AIDS Relief (PEPFAR) and co-sponsored by amfAR, The Foundation for AIDS Research and the National Institute of Mental Health (NIMH). The meeting brought together researchers, community implementers, advocates and federal partners to discuss the current landscape of technology-based interventions for MSM and transgender persons and to discuss key considerations. Presentations and discussions focused on the research gaps, facilitators and barriers to programme implementation and public–private partnerships. This article summarizes the meeting proceedings and outlines key considerations for future work in this area.     

Factors influencing HIV infection in men who have sex with men in China

To identify risk factors for HIV infection among men who have sex with men (MSM) and to provide a theoretical basis for prevention interventions. Between December 2011 and August 2012, a case–control study was conducted among MSM who underwent voluntary counselling and testing for HIV. Confirmed HIV-positive MSM were included in the case group, and HIV-negative MSM were included in the control group. Information on possible risk factors was collected by a survey questionnaire and a qualitative interview. The results of a conditional logistic regression showed that the following were influencing factors for HIV infection: average monthly income between 2001 and 3000 Yuan (odds ratio (OR)=6.341, 95% CI: 1.714–12.544), only sometimes using condoms when having anal sex with men in the last 6 months (OR=7.601, 95% CI: 1.359–23.083), having HIV-positive sex partners (OR=5.273, 95% CI: 1.572–17.691), rectal trauma with bleeding in the last 6 months (OR=2.947, 95% CI: 1.308–6.638), not using condoms at last sexual encounter (OR=1.278, 95% CI: 1.012–5.595), engaging in commercial sex (OR=5.925, 95% CI: 1.923–13.890) and having more than 16 sex partners in the last 6 months (OR=1.175, 95% CI: 1.021–1.353). These seven factors were the risk factors of HIV infection (OR>1). However, having anal sex less than 10 times in the previous 1 month (OR=0.002, 95% CI: 0.000–0.287) was a protective factor against HIV infection among MSM (OR<1), and insertive (OR=0.116, 95% CI: 0.000–0.236) (OR<1) anal intercourse influenced HIV infection. Interventions should be targeted at MSM whose average monthly income is between 2001 and 3000 Yuan, and who engage in commercial sex. In addition, the importance of using condoms at every sexual encounter should be emphasised in health education, as should the treatment of rectal trauma with bleeding. Finally, MSM should decrease the number of sex partners and frequency of anal sex to decrease the rate of HIV infection.     

Amphetamine-type stimulants and HIV infection among men who have sex with men: implications on HIV research and prevention from a systematic review and meta-analysis

Introduction

HIV infections and the use of amphetamine-type stimulants (ATS) among men who have sex with men (MSM) have been increasing internationally, but the role of ATS use as a co-factor for HIV infection remains unclear. We aimed to summarize the association between ATS use and HIV infection among MSM.

Methods

We conducted a systematic search of MEDLINE, EMBASE, GLOBAL HEALTH and PsycINFO for relevant English, peer-reviewed articles of quantitative studies published between 1980 and 25 April 2013. Pooled estimates of the association – prevalence rate ratios (PRR, cross-sectional studies), odds ratio (OR, case-control studies) and hazard ratio (HR, longitudinal studies), with 95% Confidence Intervals (CI) – were calculated using random-effects models stratified by study design and ATS group (meth/amphetamines vs. ecstasy). We assessed the existence of publication bias in funnel plots and checked for sources of heterogeneity using meta-regression and subgroup analysis.

Results

We identified 6710 article titles, screened 1716 abstracts and reviewed 267 full text articles. A total of 35 publications were eligible for data abstraction and meta-analysis, resulting in 56 records of ATS use. Most studies (31/35) were conducted in high-income countries. Published studies used different research designs, samples and measures of ATS use. The pooled association between meth/amphetamine use and HIV infection was statistically significant in all three designs (PRR=1.86; 95% CI: 1.57–2.17; OR=2.73; 95% CI: 2.16–3.46 and HR=3.43; 95% CI: 2.98–3.95, respectively, for cross-sectional, case-control and longitudinal studies). Ecstasy use was not associated with HIV infection in cross-sectional studies (PRR=1.15; 95% CI: 0.88–1.49; OR=3.04; 95% CI: 1.29–7.18 and HR=2.48; 95% CI: 1.42–4.35, respectively, for cross-sectional, case-control and longitudinal studies). Results in cross-sectional studies were highly heterogeneous due to issues with ATS measurement and different sampling frames.

Conclusions

While meth/amphetamine use was significantly associated with HIV infection among MSM in high-income countries in all study designs, evidence of the role of ecstasy in HIV infection was lacking in cross-sectional studies. Cross-sectional study design, measurement approaches and source populations may also be important modifiers of the strength and the direction of associations. Event-specific measure of individual drug is required to establish temporal relationship between ATS use and HIV infection. HIV prevention programmes targeting MSM should consider including interventions designed to address meth/amphetamine use.     

Anogenital HIV RNA in Thai men who have sex with men in Bangkok during acute HIV infection and after randomization to standard vs. intensified antiretroviral regimens

Introduction

HIV transmission risk is highest during acute HIV infection (AHI). We evaluated HIV RNA in the anogenital compartment in men who have sex with men (MSM) during AHI and compared time to undetectable HIV RNA after three-drug versus five-drug antiretroviral therapy (ART) to understand risk for onward HIV transmission.

Methods

MSM with AHI (n=54) had blood, seminal plasma and anal lavage collected for HIV RNA at baseline, days 3 and 7, and weeks 2, 4, 12 and 24. Data were compared between AHI stages: 1 (fourth-generation antigen-antibody combo immunoassay [IA]–, third-generation IA–, n=15), 2 (fourth-generation IA+, third-generation IA–, n=9) and 3 (fourth-generation IA+, third-generation IA+, western blot–/indeterminate, n=30) by randomization to five-drug (tenofovir+emtricitabine+efavirenz+raltegravir+maraviroc, n=18) versus three-drug (tenofovir+emtricitabine+efavirenz, n=18) regimens.

Results

Mean age was 29 years and mean duration since HIV exposure was 15.4 days. Mean baseline HIV RNA was 5.5 in blood, 3.9 in seminal plasma and 2.6 log₁₀ copies/ml in anal lavage (p<0.001). Blood and seminal plasma HIV RNA were higher in AHI Stage 3 compared to Stage 1 (p<0.01). Median time from ART initiation to HIV RNA <50 copies/ml was 60 days in blood, 15 days in seminal plasma and three days in anal lavage. Compared with the three-drug ART, the five-drug ART had a shorter time to HIV RNA <1500 copies/ml in blood (15 vs. 29 days, p=0.005) and <50 copies/ml in seminal plasma (13 vs. 24 days, p=0.048).

Conclusions

Among MSM with AHI, HIV RNA was highest in blood, followed by seminal plasma and anal lavage. ART rapidly reduced HIV RNA in all compartments, with regimen intensified by raltegravir and maraviroc showing faster HIV RNA reductions in blood and seminal plasma.     

Willingness to use HIV pre‐exposure prophylaxis among gay men,other men who have sex with men and transgender women in Myanmar

Introduction : HIV pre‐exposure prophylaxis (PrEP) has emerged as a key component of contemporary HIV combination prevention strategies. To explore the local suitability of PrEP, country‐specific acceptability studies are needed to inform potential PrEP implementation. In the context of Myanmar, in addition to resource constraints, HIV service access by gay men, other men who have sex with men, and transgender women (GMT) continues to be constrained by legislative and community stigma and marginalization. We aimed to determine PrEP acceptability among GMT in Myanmar and explore the factors associated with willingness to use PrEP. Methods : GMT were recruited in Yangon and Mandalay through local HIV prevention outreach programmes in November and December 2014. Quantitative surveys were administered by trained peer educators and collected data on demographics, sexual risk, testing history and PrEP acceptability. A modified six‐item PrEP acceptability scale classified self‐reported HIV undiagnosed GMT as willing to use PrEP. Multivariable logistic regression identified factors associated with willingness to use PrEP. Results : Among 434 HIV undiagnosed GMT, PrEP awareness was low (5%). PrEP acceptability was high, with 270 (62%) GMT classified as willing to use PrEP. GMT recruited in Mandalay (adjusted odds ratio (aOR) = 1.79; 95%CI = 1.05–3.03), who perceived themselves as likely to become HIV positive (aOR = 1.82; 95%CI = 1.10–3.02), who had more than one recent regular partner (aOR = 2.94; 95%CI = 1.41–6.14), no regular partners (aOR = 2.05; 95%CI = 1.10–3.67), more than five casual partners (aOR = 2.05; 95%CI = 1.06–3.99) or no casual partners (aOR = 2.25; 95%CI = 1.23–4.11) were more likely to be willing to use PrEP. The association between never or only occasionally using condoms with casual partners and willingness to use PrEP was marginally significant (aOR = 2.02; 95%CI = 1.00–4.10). GMT who reported concern about side effects and long‐term use of PrEP were less likely (aOR = 0.35; 95%CI = 0.21–0.59) to be willing to use PrEP. Conclusions : This is the first study to assess PrEP acceptability in Myanmar. Findings suggest PrEP is an acceptable prevention option among GMT in Myanmar, providing they are not required to pay for it. Implementation/demonstration projects are needed to explore the feasibility and cost‐effectiveness of PrEP as a prevention option for GMT in Myanmar.     

Prevalence and correlates of HIV among men who have sex with men in Tijuana,Mexico

Introduction

Men who have sex with men (MSM) in developing countries such as Mexico have received relatively little research attention. In Tijuana, Mexico, a border city experiencing a dynamic HIV epidemic, data on MSM are over a decade old. Our aims were to estimate the prevalence and examine correlates of HIV infection among MSM in this city.

Methods

We conducted a cross-sectional study of 191 MSM recruited through respondent-driven sampling (RDS) in 2012. Biological males over the age of 18 who resided in Tijuana and reported sex with a male in the past year were included. Participants underwent interviewer-administered surveys and rapid tests for HIV and syphilis with confirmation.

Results

A total of 33 MSM tested positive for HIV, yielding an RDS-adjusted estimated 20% prevalence. Of those who tested positive, 89% were previously unaware of their HIV status. An estimated 36% (95% CI: 26.4–46.5) had been tested for HIV in the past year, and 30% (95% CI: 19.0–40.0) were estimated to have ever used methamphetamine. Independent correlates of being infected with HIV were methamphetamine use (odds ratio [OR]=2.24, p=0.045, 95% CI: 1.02, 4.92) and active syphilis infection (OR=4.33, p=0.01, 95% CI: 1.42, 13.19).

Conclusions

Our data indicate that MSM are a key sub-population in Tijuana at higher risk for HIV. Tijuana would also appear to have the highest proportion among upper-middle-income countries of HIV-positive MSM who are unknowingly infected. More HIV prevention research on MSM is urgently needed in Tijuana.     

Willingness to use pre‐exposure prophylaxis (PrEP) for HIV prevention among men who have sex with men (MSM) in Malaysia: findings from a qualitative study

Background : Men who have sex with men (MSM) continue to be disproportionately affected by HIV in Malaysia. Recent success has been observed within demonstration projects examining the efficacy of HIV pre‐exposure prophylaxis (PrEP), an antiretroviral ‐based medication taken by HIV‐negative men to prevent sero‐conversion. In order for such promising findings to be translated in real‐world settings, it is important to understand the acceptability of PrEP, including perceived barriers to access or uptake. Methods : As part of a larger mixed‐methods study exploring acceptability and willingness to use PrEP among MSM in Malaysia, 19 men took part in audio‐recorded focus group discussions hosted by a community‐based HIV organization and facilitated by a trained researcher. Discussions focussed on awareness and potential information management, general perceptions of PrEP and potential motivations or barriers to the use of PrEP, including those at the personal, social, health system or structural level. Data were transcribed verbatim and underwent a detailed thematic analysis. Results : Rather than perceiving PrEP as a replacement for condoms in terms of having safer sex, many participants viewed it as an additional layer protection, serving as a crucial barrier to infection on occasions where condom use was intended, but did not occur. It was also perceived as more valuable to “at‐risk” men, such as those in HIV sero‐discordant relationships or those with a higher number of sexual partners. Elements of discussion tended to suggest that some men taking PrEP may be subject to stigma from others, on the assumption they may be promiscuous or engage in high‐risk sexual behaviours. Conclusions : This qualitative study indicates that, broadly speaking, PrEP may be acceptable to MSM in Malaysia. However, in order for its potential to be realized, and uptake achieved, educative interventions are required to inform the target population as to the efficacy and potential, positive impact of PrEP. Given concerns for how those taking it may be stigmatized, it is crucial that the use of PrEP is presented as a responsible course of action, and one of a range of strategies that men can use to keep themselves safe from HIV.     

New HIV testing technologies in the context of a concentrated epidemic and evolving HIV prevention: qualitative research on HIV self‐testing among men who have sex with men and transgender women in Yangon,Myanmar

Introduction : Global effort to increase early diagnosis and engagement in HIV care emphasize the importance of developing novel approaches to reaching those missed by traditional methods. Such needs are particularly great for men who have sex with men (MSM), transgender women (TW), and other populations who face stigma. Myanmar's HIV epidemic is concentrated among key populations and the revised National Strategy aims to reduce late diagnosis and barriers to care to curb HIV incidence among these groups. HIV self‐testing (HIVST) may be one method to improve testing and diagnosis among key populations, by placing HIV testing and disclosure within the individual's control. Methods : Formative, qualitative research including in‐depth interviews with adult MSM (N = 12) and TW (N = 13) and focus group discussions with MSM, TW, and community key informants (N = 35) were conducted in June‐September 2015 in Yangon, Myanmar. To inform a subsequent HIV care continuum intervention, including HIVST, participants’ opinions and perceptions about HIVST were elicited. Results : The confidentiality and privacy of HIVST, particularly as it related to disclosure of HIV status and sexual behaviour, was widely recognized among participants. These major advantages were further supported by the opportunity to avoid stigma, convenience of self‐testing (reduced need for transportation and time to go to clinics), and the availability of a pain‐free testing option. Participants weighed these benefits against perceived disadvantages of HIVST, the majority of which centred on the perception that HIVST does not include counselling. Participants were concerned that potential lack of counselling would result in poor mental health outcomes, inadequate linkage to HIV care and surveillance, and reductions in disclosure of HIV status. Participants did not view these disadvantages as an impediment, but provided suggestions for future implementation of HIVST in Myanmar. Conclusions : MSM and TW are optimistic about the confidentiality and privacy afforded by HIVST but wanted HIV counselling and linkage to appropriate services. The domestic reprioritization of HIV and opening of the country to international support has substantially increased the availability of HIV treatment and provides new opportunities, like HIVST, to potentially improve the HIV response for key populations who are at risk for HIV acquisition.     

Preference for using a variety of future HIV pre‐exposure prophylaxis products among men who have sex with men in three US cities

BackgroundDaily oral pre‐exposure prophylaxis (PrEP) is available and recommended for men who have sex with men (MSM) at risk for HIV infection. Other HIV prevention products are being developed, including long‐acting injectable (LAI) and event‐based oral and topical formulations. Understanding preferences for potential products by MSM can help direct further development of prevention messaging.MethodsWe present baseline data from HIV‐negative participants enrolled in the US Mobile Messaging for Men (M‐cubed) Study. Participants were asked their likelihood of and rank order preference for using daily oral PrEP and various potential prevention products (one‐ to ‐three‐month injections, 2‐1‐1 sexual event oral dosing, anal or penile gel, or anal suppository), and their sociodemographic characteristics. Bivariate and multivariable logistics regression assessed demographic associations with likelihood of use and rank order preference.ResultsOverall, most MSM reported a likelihood of using LAI (74%), sexual event‐based pills (67%) and penile gel (64%). Men who reported recent unprotected (condomless and PrEPless) anal sex most preferred a penile gel formulation (74%), followed closely by LAI and event‐based pills (73% each). Current PrEP users (vs. non‐users) had greater odds of reporting likelihood to use LAI (AOR = 3.29, 95% CI = 2.12 to 5.11), whereas men reporting recent unprotected anal sex had a greater odds of likelihood to use a penile gel (AOR = 1.79, 95% CI = 1.27 to 2.52) and an anal suppository (AOR = 1.48, 95% CI = 1.08 to 2.02). Hispanic/Latino (vs. White) MSM (AOR = 2.29, 95% CI = 1.40 to 3.73) and, marginally, Black MSM (AOR = 1.54, 95% CI = 1.00 to 2.38) had greater odds of reporting likelihood to use penile gel. Similar patterns were found for rank ordering preference of products, including condoms.ConclusionsMost MSM were interested in using various potential future HIV prevention products, especially LAI. However, two typologies of potential users emerged: men who prefer sexual event‐based methods (condoms, event‐based pill, sexual gels and suppositories) and men who prefer non‐sexual event‐based methods (daily pill, LAI). Men who reported recent unprotected anal sex preferred a penile gel product most, followed closely by sexual event‐based pills and LAI. Racial/ethnic differences were noted as well. These findings on product preferences can help in formulation development and messaging.     

长沙市男男性行为者异性性行为特征及影响因素分析

目的了解长沙市男男性行为者(MSM)异性性行为的特征、影响因素及其HIV/梅毒感染状况,为制定阻断HIV/性传播疾病向妇女传播的干预措施提供参考。方法采取滚雪球和同伴推动抽样方法,对参加自愿咨询检测服务的MSM进行匿名问卷调查,同时抽取静脉血进行HIV和梅毒血清学检测。结果共调查MSM 604例,15.2%在最近6个月内与女性发生过性行为,其中28.0%发生异性性行为从未使用安全套,坚持每次使用安全套仅31.7%。84.8%MSM最近6个月也发生了同性性行为,6.4%从不使用安全套,56.4%有时使用安全套。最近6个月发生过异性性行为的MSM在异性性行为中安全套使用率低于同性性行为中的使用率(P0.05)。MSM的HIV和梅毒感染率分别为12.9%和7.3%。多因素Logistic回归分析显示,婚姻状况、月收入、性取向、首次性交对象是MSM异性性行为的影响因素(P0.05,P0.01)。结论 MSM有异性性行为者比例较高,且发生异性性行为时安全套使用率较低。应重点加强对已婚、月收入高、性取向为双性恋或异性恋或不确定、首次性交对象为女性的MSM安全性行为干预,以降低HIV/性传播疾病向妇女传播的风险。