Risk behaviors and reasons for not getting tested for HIV among men who have sex with men: an online survey in Peru

Background

Men who have sex with men (MSM) account for the greatest burden of the HIV epidemic in Peru. Given that MSM are frequent users of the Internet, understanding the risk behaviors and the reasons for not getting tested among MSM who surf the Internet may improve the tailoring of future online behavioral interventions.

Methods

From October 2007 to April 2008, we conducted an online survey among users of seven Peruvian gay websites.

Results

We received 1,481 surveys, 1,301 of which were included in the analysis. The median age of the participants was 22.5 years (range 12 – 71), 67% were homosexual, and the remainder was bisexual. Of survey respondents, 49.4% had never been tested for HIV and only 11.3% were contacted in-person during the last year by peer health educators from the Peruvian Ministry of Health and NGOs. Additionally, 50.8% had unprotected anal or vaginal sex at last intercourse, and a significant percentage reported a condom broken (22.1%), slipped (16.4%) or sexual intercourse initiated without wearing a condom (39.1%). The most common reasons for not getting tested for HIV among high-risk MSM were “I fear the consequences of a positive test result” (n = 55, 34.4%), and “I don''t know where I can get tested” (n = 50, 31.3%).

Conclusions

A small percentage of Peruvian MSM who answered our online survey, were reached by traditional peer-based education programs. Given that among high-risk MSM, fear of a positive test result and lack of awareness of places where to get tested are the most important reasons for not taking an HIV test, Internet interventions aimed at motivating HIV testing should work to reduce fear of testing and increase awareness of places that offer free HIV testing services to MSM.     

Increasing HIV and Decreasing Syphilis Prevalence in a Context of Persistently High Unprotected Anal Intercourse,Six Consecutive Annual Surveys among Men Who Have Sex with Men in Guangzhou,China, 2008 to 2013

Introduction

Previous studies have reported a possibly increasing HIV prevalence among men who have sex with men (MSM) in China. However there have been limited systematic analyses of existing surveillance data to learn the trend of HIV prevalence and factors driving the trend. The aims of this study were to examine the trend of HIV prevalence among MSM in Guangzhou and to explore the role of unprotected anal intercourse (UAI) in the trend.

Methods

Snow-ball sampling was applied in the subject recruitment for the annual serological and behavioral surveys among MSM from 2008 to 2013. Data collected in the behavioral survey include demographic information, HIV related sexual behavior with men and women, access to HIV prevention services, and symptoms of sexually transmitted infections. Chi-square test was used to analyze the trend of HIV prevalence. Multivariate logistic regression was conducted to test the factors associated with HIV infection.

Results

HIV prevalence increased significantly from 5.0% in 2008 to 11.4% in 2013 while syphilis prevalence decreased from 17.4% to 3.3% in the same period. UAI rates were high and stable in every single year, ranging from 54.5% to 62.0%. Those who were having UAI (OR = 1.80, 95% confidence interval (CI): 1.26–2.58), being migrants, having more than 10 partners, and infected with syphilis had higher risk for HIV infection.

Conclusions

HIV epidemic is expanding in Guangzhou. The persistently high UAI may have played a major role in the increasing trend of HIV prevalence. Targeted prevention program should be conducted among MSM who are migrants, low educational level, syphilis infected, or having multiple partners to encourage HIV test and change UAI behavior. The general high UAI calls for tailored intervention program to promote healthy culture and form a safe sex social norm in the MSM community.     

Home-Based HIV Testing for Men Who Have Sex with Men in China: A Novel Community-Based Partnership to Complement Government Programs

Background

The coverage of HIV testing among Chinese men who have sex with men (MSM) remains low after the scale-up of free HIV testing at government-sponsored testing sites. We evaluated the feasibility of home-based HIV self-testing and the willingness to be HIV tested at community-based organizations (CBO).

Methods

We recruited MSM via on-line advertisement, where they completed an on-line informed consent and subsequent questionnaire survey. Eligible MSM received HIV rapid testing kits by mail, performed the test themselves and reported the result remotely.

Results

Of the 220 men taking a home-based HIV self-testing, 33 MSM (15%) were seropositive. Nearly 65% of the men reported that they were willing to take HIV testing at CBO, while 28% preferred receiving free HIV testing in the government programs at local Centers for Disease Control and Prevention (CDC). Older and lower-income MSM, those who self-reported homosexual orientation, men with no history of sexually transmitted diseases and a lower number of sexual partners in the past six months were associated with preference for taking HIV testing at CBOs. The top three self-reported existing barriers for HIV testing were: no perception of HIV risk (56%), fear of an HIV positive result being reported to the government (41%), and fear of a positive HIV test result (36%).

Conclusion

Home-based HIV self-testing is an alternative approach for increasing the coverage of HIV testing among Chinese MSM. CBO-based HIV testing is a potential alternative, but further studies are needed to evaluate its feasibility.     

A Qualitative Exploration of Sexual Risk and HIV Testing Behaviors among Men Who Have Sex with Men in Beirut,Lebanon

Men who have sex with men (MSM) may account for most new HIV infections in Lebanon, yet little is known about the factors that influence sexual risk behavior and HIV testing in this population. Qualitative interviews were conducted with 31 MSM living in Beirut, and content analysis was used to identify emergent themes. Mean age of the participants was 28.4 years, and all identified as either gay (77%) or bisexual (23%). Half reported not using condoms consistently and one quarter had not been HIV-tested. Many described not using condoms with a regular partner in the context of a meaningful relationship, mutual HIV testing, and a desire to not use condoms, suggesting that trust, commitment and intimacy play a role in condom use decisions. Condoms were more likely to be used with casual partners, partners believed to be HIV-positive, and with partners met online where men found it easier to candidly discuss HIV risk. Fear of infection motivated many to get HIV tested and use condoms, but such affect also led some to avoid HIV testing in fear of disease and social stigma if found to be infected. Respondents who were very comfortable with their sexual orientation and who had disclosed their sexuality to family and parents tended to be more likely to use condoms consistently and be tested for HIV. These findings indicate that similar factors influence the condom use and HIV testing of MSM in Beirut as those observed in studies elsewhere of MSM; hence, prevention efforts in Lebanon can likely benefit from lessons learned and interventions developed in other regions, particularly for younger, gay-identified men. Further research is needed to determine how prevention efforts may need to be tailored to address the needs of men who are less integrated into or do not identify with the gay community.     

The Increased Effectiveness of HIV Preventive Intervention among Men Who Have Sex with Men and of Follow-Up Care for People Living with HIV after ‘Task-Shifting’ to Community-Based Organizations: A ‘Cash on Service Delivery’ Model in China

Background

A large number of men who have sex with men (MSM) and people living with HIV/AIDS (PLHA) are underserved despite increased service availability from government facilities while many community based organizations (CBOs) are not involved. We aimed to assess the feasibility and effectiveness of the task shifting from government facilities to CBOs in China.

Methods

HIV preventive intervention for MSM and follow-up care for PLHA were shifted from government facilities to CBOs. Based on ‘cash on service delivery’ model, 10 USD per MSM tested for HIV with results notified, 82 USD per newly HIV cases diagnosed, and 50 USD per PLHA received a defined package of follow-up care services, were paid to the CBOs. Cash payments were made biannually based on the verified results in the national web-based HIV/AIDS information system.

Findings

After task shifting, CBOs gradually assumed preventive intervention for MSM and follow-up care for PLHA from 2008 to 2012. HIV testing coverage among MSM increased from 4.1% in 2008 to 22.7% in 2012. The baseline median CD4 counts of newly diagnosed HIV positive MSM increased from 309 to 397 cells/µL. HIV tests among MSM by CBOs accounted for less than 1% of the total HIV tests in Nanjing but the share of HIV cases detected by CBOs was 12.4% in 2008 and 43.6% in 2012. Unit cost per HIV case detected by CBOs was 47 times lower than that by government facilities. The coverage of CD4 tests and antiretroviral therapy increased from 71.1% and 78.6% in 2008 to 86.0% and 90.1% in 2012, respectively.

Conclusion

It is feasible to shift essential HIV services from government facilities to CBOs, and to verify independently service results to adopt ‘cash on service delivery’ model. Services provided by CBOs are cost-effective, as compared with that by government facilities.     

HIV and syphilis co-infection increasing among men who have sex with men in China: a systematic review and meta-analysis

Background

This study aims to estimate the magnitude and changing trends of HIV, syphilis and HIV-syphilis co-infections among men who have sex with men (MSM) in China during 2003–2008 through a systematic review of published literature.

Methodology/Principal Findings

Chinese and English literatures were searched for studies reporting HIV and syphilis prevalence among MSM from 2003 to 2008. The prevalence estimates were summarized and analysed by meta-analyses. Meta-regression was used to identify the potential factors that are associated with high heterogeneities in meta-analysis. Seventy-one eligible articles were selected in this review (17 in English and 54 in Chinese). Nationally, HIV prevalence among MSM increased from 1.3% during 2003–2004 to 2.4% during 2005–2006 and to 4.7% during 2007–2008. Syphilis prevalence increased from 6.8% during 2003–2004 to 10.4% during 2005–2006 and to 13.5% during 2007–2008. HIV-syphilis co-infection increased from 1.4% during 2005–2006 to 2.7% during 2007–2008. Study locations and study period are the two major contributors of heterogeneities of both HIV and syphilis prevalence among Chinese MSM.

Conclusions/Significance

There have been significant increases in HIV and syphilis prevalence among MSM in China. Scale-up of HIV and syphilis screening and implementation of effective public health intervention programs should target MSM to prevent further spread of HIV and syphilis infection.     

HIV incidence, risk factors, and motivation for biomedical intervention among gay, bisexual men, and transgender persons in Northern Thailand

Background

HIV prevalence among men who have sex with men (MSM) and transgender (TG) persons is high and increasing in Chiang Mai, northern Thailand.

Objectives

To describe demographic, socioeconomic, sexual behavior and interest in future HIV prevention trials among gay and bisexual MSM and TG presenting for HIV testing (VCT) and pre-screening for the iPrEx pre-exposure chemoprophylaxis trail.

Methods

In 2008–09, MSM/TG participants attending VCT were interviewed and tested for HIV and STI. Univariate and multivariate regression analyses were done to assess associations with HIV infection.

Results

A total of 551 MSM clients (56.1% gay, 25.4% TG, and 18.5% bisexual (BS)) were enrolled. The mean age was 23.9 years. HIV prevalence among MSM overall was 12.9% (71/551); 16.5% among gay men, 9.3% among TG, and 6.9% among BS. Consistent use of condom was low, 33.3% in insertive anal sex and 31.9% in receptive anal sex. Interest in participation was high, 86.3% for PrEP, 69.7% for HIV vaccine trials, but 29.9% for circumcision. HIV was independently associated with being gay identified, aOR 2.8, p = 0.037 and with being aged 25–29, aOR 2.7, p = 0.027. Among repeat testers, HIV incidence was 8.2/100 PY, 95% CI, 3.7/100PY to 18.3/100PY.

Conclusion

HIV risks and rates varied by self-reported sexual orientation and gender identity. HIV was associated with sexual practices, age, and being gay-identified. These are populations are in need of novel prevention strategies and willing to participate in prevention research.     

Exploring Unprotected Anal Intercourse among Newly Diagnosed HIV Positive Men Who Have Sex with Men in China: An Ethnographic Study

BackgroundUnprotected anal intercourse (UAI) is a major pathway towards secondary HIV transmission among men who have sex with men (MSM). We explored the socio-cultural environment and individual beliefs and experiences conducive to UAI in the context of Southern China.MethodsWe employed an ethnographic approach utilizing a socio-ecological framework to conduct repeated in-depth interviews with thirty one newly diagnosed HIV positive MSM as well as participant observations in Shenzhen based healthcare settings, MSM venues and NGO offices.ResultsSome men (6/31) reported continuing to practice UAI after an initial diagnosis of being HIV positive. For MSM who had existing lovers or stable partners, the fear of losing partners in a context of non-serostatus disclosure was testified to be a major concern. MSM with casual partners reported that anonymous sexual encounters and moral judgments played a significant role in their sexual risk behaviors. Simultaneously, self-reported negative emotional and psychological status, perception and idiosyncratic risk interpretation, as well as substance abuse informed the intrapersonal context for UAI.ConclusionUAI among these HIV positive MSM was embedded in an intrapersonal context, related to partner type, shaped by anonymous sexual encounters, psychological status, and moral judgments. It is important that prevention and intervention for secondary HIV transmission among newly diagnosed HIV positive MSM in China take into account these contextual factors.     

“How I Wish This Thing Was Initiated 100 Years Ago!” Willingness to Take Daily Oral Pre-Exposure Prophylaxis among Men Who Have Sex with Men in Kenya

BackgroundThe MSM population in Kenya contributes to 15% of HIV incidence. This calls for innovative HIV prevention interventions. Pre-exposure prophylaxis (PrEP) has been efficacious in preventing HIV among MSM in trials. There is limited data on the willingness to take daily oral PrEP in sub-Sahara Africa. PrEP has not been approved for routine use in most countries globally. This study aimed to document the willingness to take PrEP and barriers to uptake and adherence to PrEP in Kenya. The findings will inform the design of a PrEP delivery program as part of the routine HIV combination prevention.MethodsEighty MSM were recruited in 2 Counties in December 2013. Quantitative data on sexual behaviour and willingness to take PrEP were collected using semi-structured interviews and analysed using SPSS. Qualitative data on knowledge of PrEP, motivators and barriers to uptake and adherence to PrEP were collected using in-depth interviews and FGDs and analysed using Nvivo. Analysis of data in willingness to take PrEP was conducted on the HIV negative participants (n = 55).Results83% of MSM were willing to take daily oral HIV PrEP. Willingness to take PrEP was higher among the bi-sexual and younger men. Motivators for taking PrEP were the need to stay HIV negative and to protect their partners. History of poor medication adherence, fear of side effects and HIV stigma were identified as potential barriers to adherence. Participants were willing to buy PrEP at a subsidized price.ConclusionsThere is willingness to take PrEP among MSM in Kenya and there is need to invest in targeted education and messaging on PrEP to enhance adherence, proper use and reduce stigma in the general population and among policy makers.     

Are HIV Epidemics among Men Who Have Sex with Men Emerging in the Middle East and North Africa?: A Systematic Review and Data Synthesis

Background

Men who have sex with men (MSM) bear a disproportionately higher burden of HIV infection than the general population. MSM in the Middle East and North Africa (MENA) are a largely hidden population because of a prevailing stigma towards this type of sexual behavior, thereby limiting the ability to assess infection transmission patterns among them. It is widely perceived that data are virtually nonexistent on MSM and HIV in this region. The objective of this review was to delineate, for the first time, the evidence on the epidemiology of HIV among MSM in MENA.

Methods and Findings

This was a systematic review of all biological, behavioral, and other related data on HIV and MSM in MENA. Sources of data included PubMed (Medline), international organizations'' reports and databases, country-level reports and databases including governmental and nongovernmental organization publications, and various other institutional documents. This review showed that onsiderable data are available on MSM and HIV in MENA. While HIV prevalence continues at low levels among different MSM groups, HIV epidemics appear to be emerging in at least few countries, with a prevalence reaching up to 28% among certain MSM groups. By 2008, the contribution of MSM transmission to the total HIV notified cases increased and exceeded 25% in several countries. The high levels of risk behavior (4–14 partners on average in the last six months among different MSM populations) and of biomarkers of risks (such as herpes simplex virus type 2 at 3%–54%), the overall low rate of consistent condom use (generally below 25%), the relative frequency of male sex work (20%–76%), and the substantial overlap with heterosexual risk behavior and injecting drug use suggest potential for further spread.

Conclusions

This systematic review and data synthesis indicate that HIV epidemics appear to be emerging among MSM in at least a few MENA countries and could already be in a concentrated state among several MSM groups. There is an urgent need to expand HIV surveillance and access to HIV 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. Please see later in the article for the Editors'' Summary     

The origin and evolutionary history of HIV-1 subtype C in Senegal

Background

The classification of HIV-1 strains in subtypes and Circulating Recombinant Forms (CRFs) has helped in tracking the course of the HIV pandemic. In Senegal, which is located at the tip of West Africa, CRF02_AG predominates in the general population and Female Sex Workers (FSWs). In contrast, 40% of Men having Sex with Men (MSM) in Senegal are infected with subtype C. In this study we analyzed the geographical origins and introduction dates of HIV-1 C in Senegal in order to better understand the evolutionary history of this subtype, which predominates today in the MSM population

Methodology/Principal Findings

We used a combination of phylogenetic analyses and a Bayesian coalescent-based approach, to study the phylogenetic relationships in pol of 56 subtype C isolates from Senegal with 3,025 subtype C strains that were sampled worldwide. Our analysis shows a significantly well supported cluster which contains all subtype C strains that circulate among MSM in Senegal. The MSM cluster and other strains from Senegal are widely dispersed among the different subclusters of African HIV-1 C strains, suggesting multiple introductions of subtype C in Senegal from many different southern and east African countries. More detailed analyses show that HIV-1 C strains from MSM are more closely related to those from southern Africa. The estimated date of the MRCA of subtype C in the MSM population in Senegal is estimated to be in the early 80''s.

Conclusions/Significance

Our evolutionary reconstructions suggest that multiple subtype C viruses with a common ancestor originating in the early 1970s entered Senegal. There was only one efficient spread in the MSM population, which most likely resulted from a single introduction, underlining the importance of high-risk behavior in spread of viruses.     

Motivating Men Who Have Sex with Men to Get Tested for HIV through the Internet and Mobile Phones: A Qualitative Study

Background

Men who have sex with men (MSM) have the highest HIV prevalence in Peru, yet they are underserved by traditional preventive programs. In Peru, the Internet and mobile phones have emerged as an effective and convenient tool to reach this population.

Methods and Findings

From October 2010 to February 2011, we conducted eight focus groups with gay identified MSM (closeted and out-of-the-closet) and with self-identified heterosexual MSM in order to identify key features and preferences to be used to tailor culturally-appropriate messages that could be delivered through Internet and mobile phones to motivate MSM to get tested for HIV. Participants reported that in order to motivate HIV testing among MSM, interventions need to be based on motivational messages that encourage participants to overcome the fear of getting tested. Messages should increase the HIV risk perception (of participants who do not consider themselves at risk) by eliciting risky situations experienced by MSM. Messages should emphasize confidentiality, respect and the professionalism of the personnel conducting the counseling and testing. A thorough explanation of the process of HIV testing and the steps to follow after receiving the results should be provided. Messages should also contain information about the venue where the test will be conducted in terms of client characteristics, location, hours of operation and personnel. Finally, stigmatizing and stereotyping messages or images about “being gay” should not be included, as they act as deterrents for getting tested.

Conclusions

Interventions aimed at motivating HIV testing among MSM should include motivational messages that reduce the fear of getting tested and increase the risk perception of participants. They should also market the venue where the testing will be conducted, the professionals who will perform the tests, and the type of tests available. Stigmatizing messages or images should be avoided.     

Access to Healthcare,HIV/STI Testing,and Preferred Pre-Exposure Prophylaxis Providers among Men Who Have Sex with Men and Men Who Engage in Street-Based Sex Work in the US

Background

Pre-exposure prophylaxis (PrEP) is a promising strategy for HIV prevention among men who have sex with men (MSM) and men who engage in sex work. But access will require routine HIV testing and contacts with healthcare providers. This study investigated men’s healthcare and HIV testing experiences to inform PrEP implementation.

Methods

We conducted 8 focus groups (n = 38) in 2012 and 56 in-depth qualitative interviews in 2013–14 with male sex workers (MSWs) (n = 31) and other MSM (n = 25) in Providence, RI. MSWs primarily met clients in street-based sex work venues. Facilitators asked participants about access to healthcare and HIV/STI testing, healthcare needs, and preferred PrEP providers.

Results

MSWs primarily accessed care in emergency rooms (ERs), substance use clinics, correctional institutions, and walk-in clinics. Rates of HIV testing were high, but MSWs reported low access to other STI testing, low insurance coverage, and unmet healthcare needs including primary care, substance use treatment, and mental health services. MSM not engaging in sex work were more likely to report access to primary and specialist care. Rates of HIV testing among these MSM were slightly lower, but they reported more STI testing, more insurance coverage, and fewer unmet needs. Preferred PrEP providers for both groups included primary care physicians, infectious disease specialists, and psychiatrists. MSWs were also willing to access PrEP in substance use treatment and ER settings.

Conclusions

PrEP outreach efforts for MSWs and other MSM should engage diverse providers in many settings, including mental health and substance use treatment, ERs, needle exchanges, correctional institutions, and HIV testing centers. Access to PrEP will require financial assistance, but can build on existing healthcare contacts for both populations.     

Increased HIV Testing among Men Who Have Sex with Men from 2008 to 2012, Nanjing,China

BackgroundHIV testing is the first point of HIV treatment entry for HIV-infected individuals and an avenue to engage persons at risk in prevention. In China, where the prevalence of HIV among men who have sex with men (MSM) has been rising over the last decade, uptake of HIV testing has been low.MethodsWe examined changes in HIV testing in the preceding 12 months through two cross-sectional surveys conducted among MSM in Nanjing, Jiangsu province, China in 2008 and 2012. Respondent-driven sampling (RDS) was used to recruit participants. Questionnaire interviews and venous blood were collected to measure HIV testing, risk behaviors, and prevalence of HIV, syphilis, and HSV-2.ResultsA total of 430 and 589 MSM were surveyed in 2008 and 2012, respectively, with comparable samples in each round with respect to demographic characteristics. HIV testing in the past 12 months increased significantly from 20.1% (95% CI 13.3–26.8) in 2008 to 46.0% (95% CI 39.3–51.4, p < 0.001) in 2012. HIV prevalence was stable, at 6.6% (95% CI 2.5–11.3) in 2008 and 10.1% (95% CI 6.6–13.9, p = 0.240) in 2012, as was syphilis (14.3% in 2008 vs. 9.9% in 2012, p = 0.240). HSV-2 prevalence (18.6% in 2008 vs. 10.2% in 2012, p = 0.040) and self-reported STI in the last year (24.3% in 2008 vs. 14.3% in 2012, p = 0.020) significantly decreased. Changes in reported sexual behaviors were mixed and the profiles of who did and did not test varied between 2008 and 2012.ConclusionsHIV testing uptake more than doubled among MSM in Nanjing from 2008 to 2012 –a period of massive promotion and scale up of testing programs for MSM. However, additional efforts are still needed to further increase the proportion of men being not only tested but also undergoing repeat testing if they engage in continued risk taking behavior.     

“If You Tell People That You Had Sex with a Fellow Man,It Is Hard to Be Helped and Treated”: Barriers and Opportunities for Increasing Access to HIV Services among Men Who Have Sex with Men in Uganda

Background

Despite the high HIV prevalence among men who have sex with men (MSM) in sub-Saharan Africa, little is known about their access to HIV services. This study assessed barriers and opportunities for expanding access to HIV services among MSM in Uganda.

Methods

In October-December 2013, a cross-sectional qualitative study was conducted in 12 districts of Uganda. Semi-structured in-depth interviews were conducted with 85 self-identified MSM by snowball sampling and 61 key informants including HIV service providers and policy makers. Data were analysed using manifest content analysis and Atlas.ti software.

Results

Three quarters of the MSM (n = 62, 72.9%) were not comfortable disclosing their sexual orientation to providers and 69 (81.1%) felt providers did not respect MSM. Half (n = 44, 51.8%) experienced difficulties in accessing health services. Nine major barriers to access were identified, including: (i) unwelcoming provider behaviours; (ii) limited provider skills and knowledge; (iii) negative community perceptions towards MSM; (iv) fear of being exposed as MSM; (v) limited access to MSM-specific services; (vi) high mobility of MSM, (vii) lack of guidelines on MSM health services; viii) a harsh legal environment; and ix) HIV related stigma. Two-thirds (n = 56, 66%) participated in MSM social networks and 86% of these (48) received support from the networks to overcome barriers to accessing services.

Conclusions

Negative perceptions among providers and the community present barriers to service access among MSM. Guidelines, provider skills building and use of social networks for mobilization and service delivery could expand access to HIV services among MSM in Uganda.     

Psychosocial Health Problems Associated with Increased HIV Risk Behavior among Men Who Have Sex with Men in Nepal: A Cross-Sectional Survey

Background

Men who have sex with men (MSM) are marginalized, hidden, underserved and at high risk for HIV in Nepal. We examined the association between MSM sub-populations, psychosocial health problems and support, access to prevention and non-use of condoms.

Methods

Between September-November of 2010, a cross-sectional survey on HIV-related risk behavior was performed across Nepal through snowball sampling facilitated by non-governmental organizations, recruiting 339 MSM, age 15 or older. The primary outcomes were: (a) non-use of condoms at least once in last three anal sex encounters with men and (b) non-use of condoms with women in the last encounter. The secondary outcome was participation in HIV prevention interventions in the past year.

Results

Among the 339 MSM interviewed, 78% did not use condoms at their last anal sex with another man, 35% did not use condoms in their last sex with a woman, 70% had experienced violence in the last 12 months, 61% were experiencing depression and 47% had thought of committing suicide. After adjustment for age, religion, marital status, and MSM subpopulations (bisexual, ta, meti, gay), non-use of condoms at last anal sex with a man was significantly associated with non-participation in HIV interventions, experience of physical and sexual violence, depression, repeated suicidal thoughts, small social support network and being dissatisfied with social support. Depression was marginally associated with non-use of condoms with women. The findings suggest that among MSM who reported non-use of condoms at last anal sex, the ta subgroup and those lacking family acceptance were the least likely to have participated in any preventive interventions.

Conclusions

MSM in Nepal have a prevalence of psychosocial health problems in turn associated with high risk behavior for HIV. Future HIV prevention efforts targeting MSM in Nepal should cover all MSM subpopulations and prioritize psychosocial health interventions.     

HIV-1 Genetic Characteristics and Transmitted Drug Resistance among Men Who Have Sex with Men in Kunming,China

Background

Yunnan has been severely affected by HIV/AIDS in China. Recently, the reported prevalence of HIV-1 among men who have sex with men (MSM) in Yunnan was high in China. To monitor dynamic HIV-1 epidemic among Yunnan MSM, HIV-1 genetic characteristics and transmitted drug resistance (TDR) were investigated.

Methods

Blood samples from 131 newly HIV-1 diagnosed MSM were continuously collected at fixed sites from January 2010 to December 2012 in Kunming City, Yunnan Province. Partial gag, pol and env genes were sequenced. Phylogenetic, evolutionary and genotypic drug resistance analyses were performed.

Results

Multiple genotypes were identified among MSM in Kunming, including CRF01_AE (64.9%), CRF07_BC (25.2%), unique recombinant forms (URFs, 5.3%), subtype B (3.1%) and CRF08_BC (1.5%). CRF01_AE and CRF07_BC were the predominant strains. The mean of genetic distance within CRF01_AE were larger than that within CRF07_BC. The estimated introducing time of CRF01_AE in Yunnan MSM (1996.9) is earlier than that of CRF07_BC (2002.8). In this study, subtype B was first identified in Yunnan MSM. CRF08_BC seems to be the distinctive strain in Yunnan MSM, which was seldom found among MSM outside Yunnan. The proportion of URFs increased, which further contributed to genetic diversity among MSM. Strikingly, genetic relatedness was found among these strains with MSM isolates from multiple provinces, which suggested that a nationwide transmission network may exist. TDR-associated mutations were identified in 4.6% individuals. The multivariate analysis revealed that non-native MSM and divorced/widowed MSM were independently associated with a higher TDR rate.

Conclusion

This work revealed diverse HIV-1 genetics, national transmission networks and a baseline level of TDR in MSM. These findings enhance our understanding of the distribution and evolution of HIV-1 in MSM, and are valuable for developing HIV prevention strategies for MSM.     

Client and Provider Perspectives on New HIV Prevention Tools for MSM in the Americas

Men who have sex with men (MSM) in the Americas require targeted, combination HIV prevention approaches. We solicited client and provider perspectives on emerging prevention interventions including HIV pre-exposure prophylaxis (PrEP) and HIV self-tests through focus groups and in-depth interviews with 130 MSM and 41 providers across four sites: New York, San Francisco, Lima, and Rio de Janeiro. Among the MSM participants, we identified three prevention typologies: non-condom users, inconsistent condom users, and consistent condom users. Northern and Southern MSM differed in the variety of harm reduction strategies utilized: where U.S. MSM relied on condom use as well as disclosure and seroadaptive behaviors for prevention, condom use without disclosure or serostatus discussions was the norm in South America. Interest in new prevention technologies was shaped by the social context. U.S. MSM preferences differed by typology, such that non-condom users were interested in taking PrEP and using home HIV tests. MSM in Brazil, regardless of typology, were interested in exploring new prevention options. MSM in Peru demonstrated moderate interest but were less comfortable with adopting new strategies. MSM and providers’ opinions differed substantially with respect to new prevention options. Across sites, most providers were reticent to engage with new prevention options, though some NGO-based providers were more supportive of exploring new prevention tools. Both clients and providers will need to be engaged in developing integrated prevention strategies for MSM.     

Factors Associated with Loss-to-Follow-Up during Behavioral Interventions and HIV Testing Cohort among Men Who Have Sex with Men in Nanjing,China

Background

Behavioral interventions (BIs) remained the cornerstone of HIV prevention in resource-limited settings. One of the major concerns for such efforts is the loss-to-follow-up (LTFU) that threatens almost every HIV control program involving high-risk population groups.

Methods

To evaluate the factors associated with LTFU during BIs and HIV testing among men who have sex with men (MSM), 410 HIV sero-negatives MSM were recruited using respondent driven sampling (RDS) in Nanjing, China during 2008, they were further followed for 18 months. At baseline and each follow-up visits, each participant was counseled about various HIV risk-reductions BIs at a designated sexually transmitted infection (STI) clinic.

Results

Among 410 participants recruited at baseline, altogether 221 (53.9%) were LTFU at the 18-month follow-up visit. Overall, 46 participants were found to be positive for syphilis infection at baseline while 13 participants were HIV sero-converted during the follow-up period. Increasing age was less (Adjusted Odds Ratio(aOR) of 0.90, 95% confidence Interval (CI) 0.86–0.94) and official residency of provinces other than Nanjing (AOR of 2.49, 95%CI 1.32–4.71), lower level of education (AOR of 2.01, 95%CI 1.10–3.66) and small social network size (AOR of 1.75, 95%CI 1.09–2.80) were more likely to be associated with higher odds of LTFU.

Conclusion

To improve retention in the programs for HIV control, counseling and testing among MSM in Nanjing, focused intensified intervention targeting those who were more likely to be LTFU, especially the young, less educated, unofficial residents of Nanjing who had smaller social network size, might be helpful.