Preferences for Injectable PrEP Among Young U.S. Cisgender Men and Transgender Women and Men Who Have Sex with Men

Young men who have sex with men account for approximately 20% of incident HIV infections in the U.S. Antiretroviral pre-exposure prophylaxis (PrEP) administered as a daily pill has been shown to decrease HIV acquisition in at-risk individuals. New modalities for PrEP are being developed and tested, including injectable PrEP; however, acceptability of these emerging modalities has not yet been examined in youth. We conducted six focus groups with 36 young men and transgender men and women who have sex with men in Boston, Chicago, and Los Angeles in 2016 to assess interest in and preference for different PrEP modalities. Youth were purposively recruited based on diversity of age, race/ethnicity, and prior PrEP experience. Data were coded using content coding based on key domains of the interview guide, in particular around the central themes of interest in and barriers and facilitators to injectable PrEP use. Participants were knowledgeable about oral PrEP but suggested barriers to broader uptake, including stigma, marginalization, and access to information. While participants were split on preference for injectable versus oral PrEP, they agreed quarterly injections may be more manageable and better for those who have adherence difficulties and for those who engage in sex more frequently. Concerns specific to injectable PrEP included: severity/duration of side effects, pain, level of protection prior to next injection, distrust of medical system and injections, and cost. Understanding barriers to and preferences for diverse prevention modalities will allow for more HIV prevention options, improved products, and better interventions, thus allowing individuals to make informed HIV prevention choices.     

Receipt and Use of Free Condoms Among U.S. Men Who Have Sex with Men

Objectives

Despite large public investments in condom distribution programs for HIV prevention among men who have sex with men (MSM), few evaluations have documented the reach of condom distribution programs or whether free condoms distributed to MSM are actually used. Among MSM recruited from social networking and dating websites, we examined the proportion who reported acquiring and using free condoms, and associations between select characteristics and reported acquisition and use of free condoms.

Methods

We used baseline data from a prospective, online cohort of U.S. MSM. Participants reported acquiring free condoms in the 12 months before interview and, for those who acquired condoms and had anal intercourse, use of the free condoms they acquired. We used multivariable log binomial regression models to describe factors associated with self-reported acquisition and use of condoms.

Results

Of the 2,893 men in the analytic sample, 1,701 (59%) reported acquiring free condoms in the past year. Acquisition of free condoms was higher for men who were younger, more educated, recently tested for HIV, and had higher numbers of sex partners. Seventy-three percent of men who acquired free condoms reported using them; use was higher for men who were black, had been recently tested for HIV, and reported greater numbers of sex partners.

Conclusions

Most MSM in our online sample reported receiving free condoms, and most who acquired free condoms reported using them. These data suggest that condom distribution programs have reasonable reach and utility as part of a comprehensive package of HIV prevention interventions for U.S. MSM.Men who have sex with men (MSM) are the group at highest risk for HIV infection in the U.S. In 2010, 61% of all new human immunodeficiency virus (HIV) diagnoses in the U.S. were among MSM,¹ who only account for an estimated 2% of the U.S. population.² Further, MSM have been the only risk group in which HIV incidence has been increasing since the early 1990s.³Condoms have been identified as a method to prevent sexual transmission of HIV since the early phases of the HIV epidemic in the U.S. In 1986, the Centers for Disease Control and Prevention issued a recommendation for the use of condoms to prevent sexual transmission of HIV, even prior to definitive findings of the effectiveness of condoms to prevent HIV transmission had been released.⁴ Since that time, condoms have been recognized as the most effective method to prevent the sexual transmission of HIV, aside from abstinence,^5–8 and condom promotion remains a mainstay of HIV prevention strategies, including the National HIV/Acquired Immunodeficiency Syndrome (AIDS) Strategy for the United States.⁹Although the effectiveness of condoms to prevent HIV transmission is well recognized, studies have noted that barriers to obtaining condoms, such as cost¹⁰ and embarrassment associated with purchasing condoms,¹¹ may prevent condom use. Given the demonstrated benefits of condoms coupled with the fact that barriers to purchasing condoms may prevent condom acquisition, many health departments, clinics, community-based organizations, and AIDS service organizations have implemented free condom distribution programs to ensure those individuals most at risk for HIV infection, such as MSM, have access to condoms.^12–14 Regardless of the size of the program, distributing free condoms requires the dedication of significant resources. For example, Louisiana''s statewide condom availability program, which distributed more than 33 million condoms from 1994 to 1996, cost an estimated $3 million during the three-year period.¹⁵ The Free Condom Initiative by the New York City Department of Health and Mental Hygiene (NYC DOHMH) distributed 17.3 million condoms in 2006 at a cost of $1.59 million.¹³Because of the considerable financial and organizational commitment involved in distributing free condoms, understanding the impact of free condom distribution is essential. Although it is important to define key indicators, such as the number of condoms distributed,¹⁶ to measure a program''s success, it is critical to determine the type of individuals receiving free condoms to ensure that those most at risk for HIV infection both have access to and make use of free condoms. To date, few studies have examined factors associated with acquisition and use of free condoms among MSM; those studies that have been conducted have been limited in geographic region to either one state¹⁷ or to urban areas.¹⁸ To address these research gaps, we examined characteristics associated with acquisition and use of free condoms using data from a national online HIV prevention survey.     

First Anal Intercourse and Condom Use Among Men Who Have Sex with Men in Switzerland

The aim of this study was to analyze the circumstances of first anal intercourse (FAI) among men who have sex with men (MSM) and to identify factors associated with condom use at this event. We conducted a cross-sectional survey among a convenience sample of MSM living in Switzerland (N = 2,200). Anonymous questionnaires were distributed using Swiss gay communication channels (newspapers, associations, websites) and gay bathhouses. We gathered data on age at FAI, age of the partner, degree of familiarity with him, place of first meeting, and sociodemographic indicators. We did not ask whether FAI was insertive, receptive, or both. Data were stratified by birth year classes (birth cohorts). The median age at FAI fell from 24.5 years among men born before 1965 to 20.0 years among those born between 1975 and 1984 (p < .001). In each birth cohort, between 20 and 30% reported a partner 10 years older or more. Of eight variables examined in multivariate analysis, two were positively associated with condom use: age of participants at FAI and low degree of familiarity between partners. Conversely, large age discrepancy between partners was negatively associated with condom use. In conclusion, our data showed that early initiation of anal intercourse and large age discrepancy were associated with risk taking: a pattern of initiation that may facilitate HIV transmission from older to younger cohorts of MSM. Since age at FAI is on the decrease, there is an urgent need to heighten awareness of prevention actions regarding sexual debut of MSM.     

Safer Sex Communication and Unsafe Sexual Behavior Among Young Men Who Have Sex with Men in California

Our objective was to investigate sexualcommunication and risk-taking behaviors among young menwho have sex with men (MSM). MSM aged 17 to 25 yearswere recruited from four areas throughout California. The construct Safer Sex Communication, assessedthrough principal-components analysis, was defined asperceived efficacy or experience in minimizing the riskof sexual HIV infection through communication with partners. In the 6 months prior to thesurvey, 35.6% of the MSM had participated in unprotectedanal intercourse (UAI). Adjusted logistic regressionanalyses found low Safer Sex Communication to be predictive of UAI. In addition, negativeattitudes toward safe sex, high perceived risk of HIVinfection, 10 or more male sex partners during theprevious 6 months, and use of cocaine in the past 6months were also independently related to UAI. SaferSex Communication skills should be an outcome ofinterventions designed to prevent HIV transmission amongyoung MSM.     

Compulsive Sexual Behavior and Risk for Unsafe Sex Among Internet Using Men Who Have Sex with Men

The present study explored the relationship between compulsive sexual behavior (CSB) and unprotected anal intercourse (UAI) for men who have sex with men (MSM) across a number of ethnic/racial groups and who used the Internet to seek sexual partners. A sample of 2,716 MSM (512 Asian, 445 Black, 683 Latino, 348 Other, 728 White) completed on online survey that collected information about their sexual behaviors with partners met online and offline. The survey also included the Compulsive Sexual Behavior Inventory (CSBI). Consistent with the notion that CSB is a stable trait, higher scores on the CSBI were associated with greater odds for engaging in UAI, regardless of the context in which sex partners were met (online or offline). Differences in median CSB scores were generally similar across racial and ethnic groups. The median CSB score was significantly higher for HIV-positive participants than for HIV-negative participants. HIV-prevention interventions are needed among MSM, but should take into account that some may be resistant to risk reduction strategies because of CSB.     

Syndemic Health Disparities and Sexually Transmitted Infection Burden Among Black Men Who Have Sex with Men Engaged in Sex Work in the U.S.

Archives of Sexual Behavior - Black men who have sex with men (MSM) engaged in sex work (BMSM-SW) experience elevated HIV and sexually transmitted infection (STI) prevalence. Further, BMSM-SW have...     

Preference for and Maintenance of Anal Sex Roles Among Men Who Have Sex with Men: Sociodemographic and Behavioral Correlates

Self-labeling of, and preference for, anal sex roles is an important aspect of identities and cultures among men who have sex with men (MSM) populations. In this article, we examined sociodemographic and behavioral correlates of preference for and maintenance of anal sex roles, and risk for HIV infection. Using time-location sampling, we conducted a cross-sectional survey of racially diverse MSM in San Francisco. Of the 386 men who reported an anal sex role preference, 41% preferred being “versatile” while 21 and 37% preferred being “bottom” and “top” only. Lower educated men, Asian/Pacific Islander men, and men born in Asia/Philippines were more likely to prefer being “bottom.” Among all racial/ethnic groups, men in general did not maintain their preferences 100% of the time in their reported sexual behavior, and none of the racial/ethnic groups maintained their preference at greater or lesser levels than any other group. There were no significant differences in all the behavioral risks between men who maintained their preferences and those who did not. Yet, prevalence of HIV infection was two times higher among men who were strictly “bottom.” Linguistically and/or culturally appropriate HIV prevention information/interventions at an appropriate educational level should be provided to those from the developing world and those of lower socioeconomic status, who may lack the knowledge of differential risks associated with anal sex activities.     

HIV Acquisition and Transmission Potential Among African American Men Who Have Sex with Men and Women in Three U.S. Cities

Black men who have sex with men and women (BMSMW) are at increased HIV risk, but few efficacious interventions meet their unique needs. Three HIV prevention interventions were evaluated with a common protocol. Baseline data were pooled to describe sexual behavior involving transmission risk with male, female, and male-to-female transgender partners and identify factors associated with transmission risk. BMSMW from Los Angeles, Philadelphia, and Chicago who reported sexual risk and bisexual behavior in the past year were recruited via modified chain referral sampling and community recruitment. Baseline assessments were conducted via audio computer-assisted interview and sexual behaviors assessed over the past 3 months. From December 2010 to November 2012, 584 BMSMW were enrolled across the three cities. More than half (55%) were recruited by other participants. Overall, the mean age was 43 years. Seventy-five percent reported an annual income <$10,000 and selling sex was prevalent (31%). Three-quarters identified as bisexual. Thirty-nine percent were HIV-positive. Among HIV-positive participants, 46% reported sex without condoms with HIV-negative or unknown male partners and 45% with HIV-negative or unknown female partners. Overall, factors associated with sex without condoms included network size, education, income, sexual orientation identification, HIV status, exchange sex, homonegativity, and social support. Findings support the need for enhanced HIV prevention efforts for this population. Future studies should examine contextual factors in addition to individual risk behaviors to inform the development and implementation of promising strategies to prevent HIV and promote the overall health and wellness of BMSMW and their sexual partners.     

Anal Sex Role, Circumcision Status, and HIV Infection Among Men Who Have Sex with Men in Chongqing, China

Men who have sex with men (MSM) in China face a rapidly expanding HIV epidemic. Anal sex role plays a significant role in HIV infection. Research has already begun in China investigating the potential for circumcision-based interventions to slow the rise of HIV among Chinese MSM. Using peer referral recruitment, we sampled 491 men who reported anal sex role preference. We analyzed preferred anal sex role, enacted sex role during recent sexual behavior, and circumcision status and HIV infection among MSM in one Chinese city. Men reported on their anal sex role preference and reported on up to three male sexual partners. Men were asked to report on whether they were “top” or “bottom” with each of the partners. Those that preferred being bottom and versatile were significantly younger than those who preferred being top. Men who preferred bottoming and those that preferred the versatile role were significantly more likely to be HIV-infected than those who preferred to be tops. There was no significant association between circumcision and HIV infection among men who maintained their preferred top role. In terms of anal sex role behavior, prevalence was not statistically different across anal sex roles. Circumcision conferred no additional protection to men who preferred and who engaged the top role during anal sex. HIV interventions will need to address anal sex roles in more sophisticated ways than perhaps originally thought. Simplistic assumptions that anal sex role is a fixed behavior undermines interventions such as circumcision among MSM.     

Homonegativity and Associated Factors Among Men Who Have Sex with Men in Estonia

Men who have sex with men (MSM) continue to be at higher risk for negative health outcomes including HIV, STIs, depression, substance use, suicidality, and anxiety. Associative relationships between homonegativity (internal and external) and these outcomes are used to explain the observed disproportionate impact. The current study assessed associations between internalized homonegativity and high-risk behaviours, markers of substance use and symptoms of mental illness as well as openness and level of same sex attraction. A 2013 Internet-based survey was conducted among MSM, collecting data on socio-demographics, sexuality, drug and alcohol use, mental health, suicidality, and internalized homonegativity. The sample (n = 265) had a median age of 31 years, with 85 % employed at least part-time; at least a college-level education in 43 %; and 87 % lived in an urban setting. Sexual orientation was reported as: gay, 72 %; bisexual 23 %; other 5 %. Almost all men (97 %) reported ever having sex with a man, with more than one-third (36 %) having a steady male partner. Statistically significant higher homonegativity scores were detected among men reporting any level of opposite sex attraction compared to men attracted to only men; mostly men (p = 0.001), men and women equally (p = 0.002), and mostly women (p = 0.004), as well as less openness of same sex attraction to family and friends; >50 % family (p = 0.032), no family knowing (p = 0.042), and few friends knowing (p = 0.011). Anxiety risk and increased homonegativity also had a statistically significant increasing relationship. The identified associations between homonegativity and opposite sex attraction among MSM warrants further exploration as well as the relationship with increased anxiety risk.     

HIV Prevalence and Demographic Determinants of Unprotected Anal Sex and HIV Testing Among Men Who Have Sex with Men in Beirut,Lebanon

The limited epidemiological data in Lebanon suggest that HIV incident cases are predominantly among men who have sex with men (MSM). We assessed the prevalence of HIV and demographic correlates of condom use and HIV testing among MSM in Beirut. Respondent-driven sampling was used to recruit 213 participants for completion of a behavioral survey and an optional free rapid HIV test. Multivariate regression analysis was used to examine demographic correlates of unprotected anal sex and any history of HIV testing. Nearly half (47 %) were under age 25 years and 67 % self-identified as gay. Nearly two-thirds (64 %) reported any unprotected anal intercourse (UAI) with men in the prior 3 months, including 23 % who had unprotected anal intercourse with men whose HIV status was positive or unknown (UAIPU) to the participant. Three men (1.5 % of 198 participants tested) were HIV-positive; 62 % had any history of HIV testing prior to the study and testing was less common among those engaging in UAIPU compared to others (33 % vs. 71 %). In regression analysis, men in a relationship had higher odds of having UAI but lower odds of UAIPU and any university education was associated with having UAI; those with any prior history of HIV testing were more likely to be in a relationship and have any university education. HIV prevention efforts for MSM need to account for the influence of relationship dynamics and promotion of testing needs to target high-risk MSM.     

南宁市男男性接触者艾滋病相关知识及危险行为调查

目的 了解男男性接触者人群艾滋病相关知识知晓率和高危险行为,为制定有效的干预措施提供科学依据.方法 采用滚雪球抽样法和方便抽样法选择对象,用自行设计的问卷采用匿名问卷形式进行调查,共调查230名MSM.结果 MSM人群艾滋病传播途径相关知识的知晓率达85.24%.93.48%有过肛交,92.17%有过口交,83.49%有过互相手淫,首次性行为年龄最小11岁,平均年龄20.88岁.首次性行为对象为男性占73.5%,女性占26.5%,目前完全同性为51.3%,双性为47.4%.过去1年平均男性伴数6.56个,最近1个月平均男性伴数1.58个.最近1次肛交和口交时安全套使用率分别为72.44%、13.47%,最近6个月肛交、口交安全套使用率分别为42.86%、3.62%,肛交、口交从不使用安全套率分别为11.22%、62.18%.结论 南宁市MSM人群普遍存在多性伴和安全套使用率低危险性行为,应加强对MSM人群的健康教育、行为干预.     

Correlates of Forced Sex Among Populations of Men Who Have Sex with Men in Thailand

Although forced sex is a correlate of HIV infection, its prevalence and associated risks are not well described among men who have sex with men (MSM) in developing-country settings. Between March and October 2005, we assessed the prevalence of forced sex and correlates among populations of MSM (this includes general MSM, male sex workers, and male-to-female transgender persons) in Thailand using a community-based sample. Participants were enrolled from venues around Bangkok, Chiangmai, and Phuket using venue day-time sampling. Handheld computer-assisted self-interviewing was used to collect demographic and behavioral data and logistic regression evaluated factors associated with forced sex, defined as ever being forced to have sexual intercourse against one’s will. Of the 2,049 participants (M age, 24.8 years), a history of forced sex was reported by 376 (18.4%) men and, of these, most were forced by someone they knew (83.8%), forced more than once (67.3%), and had first occurrence during adolescence (55.1%). In multivariate analysis, having a history of forced sex was significantly associated with being recruited in Phuket, classification as general MSM or transgender (versus classification as male sex worker), drug use, increased number of male sexual partners, and buying sex. The findings in our assessment were consistent with assessments from Western countries. Longitudinal studies are needed to understand the mechanisms of the relationships between forced sex correlates found in our assessment and HIV acquisition and transmission risks.     

Uptake and Predictors of Anal Cancer Screening in Men Who Have Sex With Men

Objectives. We investigated attitudes about and acceptance of anal Papanicolaou (Pap) screening among men who have sex with men (MSM).Methods. Free anal Pap screening (cytology) was offered to 1742 MSM in the Multicenter AIDS Cohort Study, who reported history of, attitudes about, and experience with screening. We explored predictors of declining screening with multivariate logistic regression.Results. A history of anal Pap screening was uncommon among non–HIV-infected MSM, but more common among HIV-infected MSM (10% vs 39%; P < .001). Most participants expressed moderate or strong interest in screening (86%), no anxiety about screening (66%), and a strong belief in the utility of screening (65%). Acceptance of screening during this study was high (85%) across all 4 US sites. Among those screened, most reported it was “not a big deal” or “not as bad as expected,” and 3% reported that it was “scary.” Declining to have screening was associated with Black race, anxiety about screening, and low interest, but not age or HIV status.Conclusions. This study demonstrated high acceptance of anal Pap screening among both HIV-infected and non–HIV-infected MSM across 4 US sites.In the past 3 decades, anal cancer incidence has increased 39% in women and 96% in men in the United States.1–3 In the general US population, anal cancer incidence remains higher among women than men (1.8 vs 1.4 cases per 100 000 annually), but the incidence is especially high among men who have sex with men (MSM; 35 per 100 000).4–6 Indeed, data suggest that anal cancer incidence among MSM may be similar to or higher than incidence of cervical cancer among US women before the introduction of cervical cytology screening in the mid-1950s.1,7–13 Incidence estimates for HIV-infected MSM are even higher and vary from 45.9 per 100 000 person-years14 in meta-analyses to 78.2 per 100 000 person-years15 for US AIDS Surveillance Epidemiology and End Results data.Human papillomavirus (HPV) infection is the major cause of anal cancer.4,14,16,17 Consistent with the increased anal cancer incidence among MSM, anal HPV prevalence and incidence are elevated among MSM compared with the general population.18,19 HIV-infected MSM have even higher anal HPV prevalence, compared with non–HIV-infected MSM (98% vs 57%).20,21 As effective antiretroviral therapy (ART, also referred to as HAART) helps HIV-infected individuals live longer, more may now develop anal cancer.6,22,23 On the basis of initial studies, it is unclear whether ART use reduces risk of anal intraepithelial neoplasia (AIN2/3, precancer)24 or anal cancer,25,26 although low CD4-cell count does appear to increase risk of anal cancer.27Recent research suggests that anal Papanicolaou (Pap) screening may have utility in preventing anal cancer9,28–30 and is a cost-effective screening method for anal cancer prevention among MSM.31,32 Like cervical dysplasia, anal dysplasia is slow-growing and treatable, and studies suggest that anal Pap tests can detect dysplasia with similar sensitivity and specificity to cervical Pap tests.33–35 On the basis of these data and the success of cervical Pap screening in reducing cervical cancer incidence, some have proposed routine anal Pap cytology (referred to as anal Pap screening hereafter) among MSM.9,36 However, these guidelines remain preliminary as researchers have not yet conducted a randomized trial to establish whether anal Pap screening reduces anal cancer deaths. Furthermore, recent studies have suggested that anal precancers (AIN2+) are relatively common among unscreened non–HIV-infected (∼4%) and HIV-infected (15%–30%) MSM, much higher than anal cancer rates, so other researchers have suggested that closer examination of the relative harms and benefits of treating all AIN 2/3 in MSM is first needed.24,35,37–40Despite the high incidence of anal cancer among MSM and recommendations, by some, for screening, MSM currently have low awareness of, access to, and use of anal Pap screening.41,42 Indeed, in our previous research, we observed a low reported prevalence of ever having anal Pap screening among MSM.43 We have expanded on these previous findings by examining acceptance of screening when offered for free. We also examined attitudes about anal Pap screening, experience with screening, and reasons for declining to have an anal Pap test.