What HIV-Positive MSM Want from Sexual Risk Reduction Interventions: Findings from a Qualitative Study

via pubmed.gov, by Vanable PA, Carey MP, Brown JL, Littlewood RA, Bostwick R, Blair D

Abstract

To facilitate the development of a tailored intervention that meets the needs of HIV-positive men who have sex with men (HIV-positive MSM), we conducted formative research with 52 HIV-positive MSM. We sought to (a) identify major barriers to consistent condom use, (b) characterize their interest in sexual risk reduction interventions, and (c) elicit feedback regarding optimal intervention format. Men identified several key barriers to consistent condom use, including treatment optimism, lessened support for safer sex in the broader gay community, challenges communicating with partners, and concerns about stigmatization following serostatus disclosure. Many men expressed an interest in health promotion programming, but did not want to participate in an intervention focusing exclusively on safer sex. Instead, they preferred a supportive group intervention that addresses other coping challenges as well as sexual risk reduction. Study results reveal important considerations for the development of appealing and efficacious risk reduction interventions for HIV-positive MSM.



[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

Criminalizing HIV Transmission Will Only Spread the Problem

Via the Vancouver Sun, by Peter McKnight.

It sounds like the synopsis of a B-movie: Thanks to the long arm of the law, the world is once again safe from The Attack of the Killer HIV-people.

Safe from Johnson Aziga, the Ontario man who had sex with more than a dozen women without informing them of his HIV-positive status. Several of the women contracted HIV, including two who subsequently died, which led to Aziga being declared a dangerous offender and handed an indeterminate sentence earlier this week.

And safe from the 17-year-old Edmonton girl who was charged this week with two counts of aggravated sexual assault after allegedly having sex with two men without informing them of her HIV-positive status. The girl had been the subject of an urgent police bulletin, which led to the worldwide publication of her name, picture and health status. Aside from painting a rather ghoulish picture of people living with HIV, such unusual cases inevitably send the message that the best way to handle HIV-non-disclosure is through the criminal law.

Police forces across the country seem to have got the message, given the increase in the number and severity of charges laid for HIV-non-disclosure in recent years. Well over 100 HIV-positive people across Canada - and at least 14 in B.C. - have now been charged with offences ranging from assault to first-degree murder.

Courts, too, have been enthusiastic in prosecuting cases of non-disclosure, with defendants receiving everything from suspended sentences to, in Aziga's case, an indeterminate and potentially lifelong sentence of imprisonment.

This enthusiasm for criminal prosecution exists despite - or perhaps because of - uncertainty about the disclosure obligations of HIV-positive people. The Supreme Court of Canada has held that individuals are under a legal duty to reveal their HIV-positive status before engaging in sex that poses a "significant risk" of HIV transmission, but what constitutes a significant risk remains unclear.

Read the rest here.

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

Gay Men: PrEP Acceptable and Unlikely to Change Risk Behaviour

Via AIDSMap, by Michael Carter.

Approximately 50% of gay men said they were likely to use pre-exposure prophylaxis (PrEP), but few reported that it would lead to a change in their risk behaviour, according to data presented to the International AIDS Society conference in Rome.

Nevertheless, the investigators were concerned that even minor increases in rates of unprotected anal sex could offset the benefits of pre-exposure prophylaxis.

The IPrEX study showed that PrEP significantly reduced the risk of infection with HIV for gay and bisexual men. Overall, men who took PrEP had their risk of HIV reduced by 44%. If adherence was high, the risk was reduced by 73%.

“PrEP offers much promise as the first biomedical intervention to have success in at-risk men who have sex with men,” comment the researchers.

They therefore undertook further analysis to see how likely the men who participated in the study were to use PrEP and if its availability would change their HIV risk behaviour.

They undertook a survey in December 2010, immediately following the release of the IPrEX results, using Facebook and Black Gay Chat to recruit participants. A total of 1155 gay and other men who have sex with men were recruited to the study.

Participants completed a questionnaire about their knowledge and willingness to use PrEP; perceptions of the risk of HIV infection from unprotected anal sex with or without PrEP; perceptions of sexual pleasure; and perception of likelihood to experience sexual pleasure with or without a condom and with or without PrEP.

The men had an average age of 33 years, 75% were white, and 51% reported unprotected anal sex at least once in the last twelve months.

Only a third of men had heard of PrEP before the release of the study results. Just under half of individuals reported that they were “very” or “extremely” likely to use PrEP.

Unprotected anal sex without a condom was widely considered to involve a high risk of HIV.

The availability of PrEP did not alter the perception of the risk associated with HIV in the majority of men, regardless of whether they were the insertive (75%) or receptive (60%) partner in anal sex.

Three-quarters of men stated that the 44% efficacy of PrEP in the IPrEX study would not affect their use of condoms. However, 7% reported that they would use condoms less frequently.

Read the rest here.

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

Narrow Window To Avert HIV Epidemics Among MSM in Middle East and North Africa

Via AIDSMap, by Michael Carter.

HIV epidemics are emerging among men who have sex with men (MSM) in a number of Middle Eastern and North African countries, an international team of investigators report in the online journal PLoSMedicine.

Prevalence of HIV was as high as 28% among some populations of MSM in Pakistan, and in 2008 over 50% of new HIV infections in Lebanon were in men who reported anal sex with another man.

High levels of risk behaviour in many countries suggested that there was the potential for further spread of HIV.

Alarmed by their findings, the investigatorssuggest “there is an urgent need to expand HIV surveillance and access to testing, prevention, and treatment services in a rapidly narrowing window of opportunity to prevent the worst of HIV transmission among MSM in the Middle East and North Africa.”

Worldwide, MSM are one of the groups most affected by HIV. The epidemic in most industrialised countries is focused on MSM, and research conducted in sub-Saharan Africa has found evidence of large but generally hidden MSM epidemics. Moreover, epidemics in MSM are well established and growing in Latin America and South East Asia.

In contrast, little is known about the MSM HIV epidemic in Middle Eastern and North African countries. Sex between men is often highly stigmatised in this setting, and in five countries homosexuality is punishable by death.

Given this lack in knowledge, a team of investigators lead by Dr Ghina Mumtaz undertook a systematic literature review to gain a better understanding of the HIV prevalence in MSM, their risk behaviour and knowledge of HIV in 23 North African and Middle Eastern Countries.

The authors believe their study “provides an integrated analysis and synthesis of the evidence to address the gap in our knowledge of what could potentially materialise as the key risk group for HIV sexual transmission in this region in the next decade.”

A total of 26 studies were included in the investigators’ analysis. They defined MSM as men who had insertive or receptive anal sex. However, the researchers emphasised that there was a huge diversity in MSM self-identity, role and behaviour in the region.

Overall, the prevalence of MSM behaviour was consistently between 2-3%. However, in some populations such as truck drivers (9%-49%) or street children (15%-77%) it was considerably higher.

Read the rest here.

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

If you're HIV positive, safe sex isn't just about condoms

Via The Guardian, by Deborah Jack.

As the HIV epidemic has evolved over three decades, the "just use a condom" message has remained the cornerstone of prevention. But stubbornly high levels of new HIV infections in the UK show we've struggled to always translate this simple message into real life.

Most monogamous couples will decide to stop using condoms at some point, but what if one half of the couple is HIV positive? Until recently, it has been assumed there is no safe option other than condoms for life. But new research into the preventive benefits of HIV treatment (antiretroviral therapy) is set to change this, and could potentially revolutionise the way we think about HIV prevention and safer sex advice.

HIV treatment works by reducing the level of HIV in the body (the viral load) to such an extent that a person's infectiousness is almost zero (clinically referred to as "undetectable"). A big effect of this – in addition to keeping the person healthy – is that the risk of transmitting HIV to another person is dramatically reduced.

Last month we heard the conclusive results of the first global study into HIV "treatment as prevention" – a 96% reduction in transmission risk when the HIV-positive partner received treatment and responded effectively. When put into practice, this means people living with HIV who are on treatment can, like everyone else, consider giving up condoms when their relationship is committed and monogamous.

But before we get carried away, it is not time to throw away our condoms altogether. They are still the best protection against other sexually transmitted infections, so any couple wanting to rely on treatment rather than condoms to prevent HIV transmission must be confident they are both STI free and monogamous. Other STIs in the body can make HIV levels spike upwards, which seriously compromises the effects of treatment as prevention and significantly increases risk of transmission.

Read the rest here.

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

HIV Risk of Anal Sex Misunderstood Among Heterosexuals

This news article features our very own Zoe Duby, an IRMA advocate and valued member of our community! Congratulations to Zoe, and thank you for working so hard as an advocate for rectal microbicides and HIV prevention in South Africa and worldwide.

Via PlusNews.

Vaginal sex, thigh sex, even armpit sex - people have sex in lots of ways, but in heterosexual anal sex, HIV prevention programming is silent about the high risk of infection that goes with it, and people may have mistaken this silence for safety.

The risk of contracting HIV through unprotected receptive anal sex is almost 20 times greater than the HIV risk associated with vaginal intercourse.

While this fact is often a focus in HIV prevention programming aimed at men-who-have-sex-with-men (MSM), it has been largely left out of programmes for heterosexuals, according to Zoe Duby of the University of Cape Town, South Africa, and the Desmond Tutu HIV Foundation.

Duby presented the findings of her study, which interviewed almost 400 people in Tanzania, Uganda and Kenya, at the 1st HIV Social Sciences and Humanities Conference held recently in Durban, South Africa.

“Safer sex programming has, in my opinion, failed to take into account varying definitions of sex. The omission of anal sex in safe sex messaging has been interpreted as meaning that anal sex is safe,” she told IRIN/PlusNews.

“What people preach out there, it’s just vaginal sex - not information on anal [sex],” said a young woman from Salgaa, Kenya, who was quoted in the research. “So somebody thinks, ‘if I do [sex] this other way, then I will not get HIV.’”

Even more worrying was that research showed healthcare workers often held similar views, and some incorrectly believed HIV was only present in vaginal fluid. The virus is, in fact, also present in male sperm and blood.

“Me, I do not want to practice vaginal sex because that is the highest [risk] sex that transmits HIV, so it is a belief… that non-vaginal sex does not transmit HIV,” one Kenyan healthcare worker reported.

A nurse in Malaba, Uganda, said: “As you go and have sex vaginally you can get HIV, but these other methods, they do not expose you [to HIV].”

Read the rest here.

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

Self-Perceived Risk of HIV Infection and Attitudes About PrEP Among STD Clinic Attendees

Via Liebert Online, by Y. Omar Whiteside, Tammy Harris, Christopher Scanlon, Stephen Clarkson, and Wayne Duffus

Background

Despite the advances in the prevention of and treatment for HIV infection, the estimated rates of HIV infections remained constant from 2005 to 2008. More importantly, during this period the estimated number of newly diagnosed HIV/AIDS cases increased 8%. In 2008, blacks accounted for more than half (52%) of all new HIV cases diagnosed. The South, where the majority of black/African Americans live, continues to suffer disproportionately from the HIV/AIDS epidemic. The Centers for Disease Control and Prevention's (CDC) 2008 HIV Surveillance Report documented that the death rate among persons with AIDS increased in both the South and the Midwest and that the South has the highest number of AIDS diagnoses of any region in the country. Because of this region's epidemiology, the need to prevent new HIV infections is of paramount importance.

South Carolina, a southern state, has one of the highest AIDS rates in the United States (2008 AIDS rate: 15.5 per 100,000 population in South Carolina; 12.2 per 100,000 population in the United States) In 2008, Columbia, South Carolina, ranked seventh in its AIDS case rate (25.6 per 100,000 population) among metropolitan statistical areas. Of increasing concern to South Carolina public health officials is the high prevalence of HIV-infected residents and the potential for unabated transmission.

Methods

This was an exploratory study on self-perceived risk of HIV infection and attitudes about using PrEP among sexually transmitted diseases (STD) clinic attendees. It was designed as a cross-sectional study and was conducted from January 2009 to May 2009 and October 2010 to December 2010 in an STD clinic in South Carolina. An STD clinic was chosen as the location from which to draw participants because individuals with an STD have an increased risk for both HIV infection and transmission. The inclusion criteria were that participants be at least 16 years of age; have had oral, anal, or vaginal sex within the past 6 months; be seeking STD clinic services, self-report being HIV-negative, and not have previously completed the survey. Participants were given a 20-min, self-administered, paper-based, anonymous survey that measured demographic information; sexual exposure history; self-perceived risk perception for HIV infection; and attitudes about PrEP.

Results

Compared to heterosexual participants, homosexual participants were significantly more likely to have knowledge of PrEP (odds ratio [OR]=6.7, 95% confidence interval [CI]: 1.70–26.1). Compared to those participants who had 1 sexual partner in the past 3 months, individuals who had 2 to 4 sexual partners in the past 3 months were approximately 2.35 times as likely to have a lower level of agreement with the statement “I believe I am at risk of getting HIV” (p=0.0003). Compared to female participants, respondents who were male were approximately 2.8 times as likely to have a lower level of agreement with the statement “If I had to it would be very difficult for me (or my partner) to both use condoms and take daily pills to prevent HIV infection” (p<0.0001). These results suggest the need for the creation of PrEP implementation programs that are tailored to self-perceived risk perception, age, and gender.

Read the full study here.



[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

Expanded access to ART has the potential to avert millions of AIDS orphans in Africa

Via aidsmap, by Michael Carter

Universal adult access to antiretroviral therapy compared to current roll-out could prevent over 4 million more children being orphaned because of HIV in the sub-Saharan African countries hardest hit by AIDS, according to published in the online journal AIDS Research and Therapy.


“Results from this study highlight the positive impact that expanded ART [antiretroviral therapy] may have in sub-Saharan countries already burdened with high numbers of AIDS orphans,” comment the investigators. They add, “we found that achieving universal ART uptake among adults may avert over 4 million maternal, paternal and double AIDS orphans over the next 10 years.”

It is estimated that 11.6 million children in sub-Saharan Africa have already lost one or both parents because of HIV. Orphans have greater material, physical, health-related and psychological need, and there is also evidence that they have higher levels of HIV-related risk behaviour. Moreover, HIV-infected orphans often delay accessing essential care and have poor rates of adherence to HIV therapy.

Antiretroviral therapy has significantly reduced rates of HIV-related illness and death. At the end of 2008, it was estimated that 44% of eligible patients in sub-Saharan Africa were receiving HIV therapy.

Read the rest

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

Changing HIV Risk Behaviors

Via The Forum for Collaborative HIV Research

Background: Previous studies have suggested that initial reductions in risk behavior after HIV diagnosis are not sustained. We investigated how seroadaptive tactics, including fewer total partners, serodiscordant partners, and “risk partnerships” (defined as insertive unprotected anal intercourse with an HIV– or partners unknown status), adopted by HIV+ men who have sex with men (MSM) influence HIV transmission risk over time.

Methods: MSM with acute/recent (<6 months) HIV infection were enrolled from 1998 to 2010 into the OPTIONS cohort. During 2009 to 2010, at every 3-month interval, subjects completed computer-assisted self-interviews detailing risk behavior in the prior 3 months.

To assess the relationship between transmission risk and time, we categorized individuals as being in the pre-diagnosis, post-diagnosis (as long as 6 months post-diagnosis), or later follow-up period based on their first interview. We calculated the mean number of partnerships for each category. Trends over time were assessed in subsets of individuals with data at multiple time points using linear regression.

Results: In 504 interviews, 237 MSM contributed data: 52 (10.3%) interviews assessed behavior pre-diagnosis, 65 (12.9%) post-diagnosis, and 387 (76.8%) in follow-up. The mean number of sexual partners per 3 months was significantly higher pre-diagnosis (12.2) than post-diagnosis (3.8) and follow-up (7.5) periods.

The proportion of reported partners who were HIV– or of unknown status was 0.80 pre-diagnosis, 0.24 post-diagnosis, and 0.62 in follow-up. Mean “risk partnerships” per 3 months was 2.80 pre-diagnosis, but was significantly lower in both post-diagnosis (0.09) and follow-up (0.20) groups.

Read the rest

[If an item is not written by an IRMA member, it should not be construed that IRMA has taken a position on the article's content, whether in support or in opposition.]

MSM and Condom Use: Factors Associated With Not Using A Condom

From PLoS One, by Larmarange et al.

Men who have sex with other men (MSM) are a vulnerable population in Africa that has been insufficiently explored. Given the high rate of bisexuality among MSM (73% in the past year), it is important to understand their risk-taking behaviors regarding both men and women.

This socio-behavioral survey was carried out in 2007 and recruited 501 MSM. The study explored why a condom was not used during last sexual intercourse with men and with women, and considered risk factors including having sex in a public place, participation in an MSM prevention program, age, employment and education.

The study concludes that participation in a prevention program specifically targeting MSM is a major factor in prevention, but that these programs must also address heterosexual practices and the associated risks.

Read the article

Elevated HIV Prevalence Despite Lower Rates of Sexual Risk Behaviors

from AIDS Patient Care and STDs, by Magnus et al.

The District of Columbia (DC) has among the highest HIV/AIDS rates in the United States, with 3.2% of the population and 7.1% of black men living with HIV/AIDS. The purpose of this study was to examine HIV risk behaviors in a community-based sample of men who have sex with men (MSM) in DC.

Data were from the National HIV Behavioral Surveillance system. MSM who were 18 years were recruited via venue-based sampling between July 2008 and December 2008. Behavioral surveys and rapid oral HIV screening with Western blot confirmation on positives were collected. Factors associated with HIV positivity and unprotected anal intercourse were identified. Of 500 MSM, 35.6% were black. Of all men, 14.1% were confirmed HIV positive; 41.8% of these were newly identified HIV positive. Black men (26.0%) were more likely to be HIV positive than white (7.9%) or Latino/Asian/other (6.5%) men. Black men had fewer male sex partners than non-black, fewer had ever engaged in intentional unprotected anal sex, and more used condoms at last anal sex. Black men were less likely to have health insurance, have been tested for HIV, and disclose MSM status to health care providers. Despite significantly higher HIV/AIDS rates, black MSM in DC reported fewer sexual risks than non-black.

These findings suggest that among black MSM, the primary risk of HIV infection results from nontraditional sexual risk factors, and may include barriers to disclosing MSM status and HIV testing. There remains a critical need for more information regarding reasons for elevated HIV among black MSM in order to inform prevention programming.

Read more.

HIV, transmitted drug resistance, and the paradox of preexposure prophylaxis

Proceedings of the National Academy of Sciences of the United States of America
by Virginie Supervie, J. Gerardo García-Lermb, Walid Heneine, and Sally Blower

Excerpt:

If the results from the phase III trials ending in 2010 show moderate to high efficacy, then PrEP interventions could be implemented in the near future in resource-rich countries. We have shown PrEP could significantly reduce transmission in the MSM community in San Francisco even if efficacy is only moderate, provided coverage is high and risk compensation does not occur. High coverage may be attainable: recent surveys indicate ~70% of MSM in California and in Massachusetts have stated they would be willing to take PrEP on a daily basis if it were proven safe and effective (41, 42); furthermore, MSM reporting risky behaviors were more likely to anticipate using PrEP (42). Although our quantitative results are specific to the MSM community in San Francisco, the qualitative insights we have gained are applicable to any high-risk community where treatment has been readily available for many years and current levels of transmitted resistance are already high.

Read the entire article.