Global Burden of HIV among Men Who Engage in Transactional Sex: A Systematic Review and Meta-Analysis

Background

Men who engage in transactional sex, the exchange of sex for money, goods, or other items of value, are thought to be at increased risk of HIV, but there have been no systematic attempts to characterize HIV burden in this population. We undertook a systematic review and meta-analysis to quantify the burden in this population compared with that of men in the general population to better inform future HIV prevention efforts.

Methods

We searched seven electronic databases, national surveillance reports, and conference abstracts for studies of men who engage in transactional sex published between 2004–2013. Random effects meta-analysis was used to determine pooled HIV prevalence and prevalence ratios (PR) for the difference in HIV prevalence among men who engage in transactional sex as compared to general population men.

Findings

Of 66 studies included representing 31,924 men who had engaged in transactional sex in 28 countries, pooled biological assay-confirmed HIV prevalence was 10.5% (95% CI = 9.4 to 11.5%). The highest pooled HIV prevalence was in Sub-Saharan Africa (31.5%, 95% CI = 21.6 to 41.5%), followed by Latin America (19.3%, 95% CI = 15.5 to 23.1%), North America (16.6%, 95% CI = 3.7 to 29.5%), and Europe (12.2%, 95% CI = 6.0 to 17.2%). Men who engaged in transactional sex had an elevated burden of HIV compared to the general male population (PR = 20.7, 95% CI = 16.8 to 25.5).

Conclusions

The global burden of HIV is disproportionately high among men who engage in transactional sex compared with the general male population. There is an urgent need to include this population in systematic surveillance as well as to scale-up access to quality HIV prevention programs.     

Prevalence of Consensual Male–Male Sex and Sexual Violence,and Associations with HIV in South Africa: A Population-Based Cross-Sectional Study

Background

In sub-Saharan Africa the population prevalence of men who have sex with men (MSM) is unknown, as is the population prevalence of male-on-male sexual violence, and whether male-on-male sexual violence may relate to HIV risk. This paper describes lifetime prevalence of consensual male–male sexual behavior and male-on-male sexual violence (victimization and perpetration) in two South African provinces, socio-demographic factors associated with these experiences, and associations with HIV serostatus.

Methods and Findings

In a cross-sectional study conducted in 2008, men aged 18–49 y from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces provided anonymous survey data and dried blood spots for HIV serostatus assessment. Interviews were completed in 1,737 of 2,298 (75.6%) of enumerated and eligible households. From these households, 1,705 men (97.1%) provided data on lifetime history of same-sex experiences, and 1,220 (70.2%) also provided dried blood spots for HIV testing. 5.4% (n = 92) of participants reported a lifetime history of any consensual sexual activity with another man; 9.6% (n = 164) reported any sexual victimization by a man, and 3.0% (n = 51) reported perpetrating sexual violence against another man. 85.0% (n = 79) of men with a history of consensual sex with men reported having a current female partner, and 27.7% (n = 26) reported having a current male partner. Of the latter, 80.6% (n = 21/26) also reported having a female partner. Men reporting a history of consensual male–male sexual behavior are more likely to have been a victim of male-on-male sexual violence (adjusted odds ratio [aOR] = 7.24; 95% CI 4.26–12.3), and to have perpetrated sexual violence against another man (aOR = 3.10; 95% CI 1.22–7.90). Men reporting consensual oral/anal sex with a man were more likely to be HIV+ than men with no such history (aOR = 3.11; 95% CI 1.24–7.80). Men who had raped a man were more likely to be HIV+ than non-perpetrators (aOR = 3.58; 95% CI 1.17–10.9).

Conclusions

In this sample, one in 20 men (5.4%) reported lifetime consensual sexual contact with a man, while about one in ten (9.6%) reported experience of male-on-male sexual violence victimization. Men who reported having had sex with men were more likely to be HIV+, as were men who reported perpetrating sexual violence towards other men. Whilst there was no direct measure of male–female concurrency (having overlapping sexual relationships with men and women), the data suggest that this may have been common. These findings suggest that HIV prevention messages regarding male–male sex in South Africa should be mainstreamed with prevention messages for the general population, and sexual health interventions and HIV prevention interventions for South African men should explicitly address male-on-male sexual violence. Please see later in the article for the Editors'' Summary     

HIV infection and risk behaviours among young gay and bisexual men in Vancouver

BACKGROUND: Young gay and bisexual men may perceive that the consequences of HIV infection have dramatically improved with the availability of highly active antiretroviral therapy. We therefore sought to identify trends in HIV infection rates and associated risk behaviours among young gay and bisexual men in Vancouver. METHODS: Prospective cohort study involving gay and bisexual men aged 18-30 years who had not previously tested HIV positive. Subjects were recruited through physicians, clinics and community outreach in Vancouver. Annually participants were tested for HIV antibodies and asked to complete a self-administered questionnaire pertaining to sociodemographic characteristics, sexual behaviours and substance use. Prevalence of HIV infection and risk behaviours were determined for eligible participants who completed a baseline questionnaire and HIV testing as of May 1998. The primary outcome was the proportion of men who reported having protected sex during the year before enrollment and who reported any episode of unprotected sex by the time of the first follow-up visit. RESULTS: A total of 681 men completed a baseline questionnaire and HIV testing as of May 1998. The median duration between baseline and the first follow-up visit was 14 months. The median age was 25 years. Most of the subjects were white and of high socioeconomic status. The majority (549 [80.6%]) reported having sex only with men; 81 (11.9%) reported bisexual activity. Of the 503 men who had one or more regular male partners, 245 (48.7%) reported at least one episode of unprotected anal sex in the year before enrollment; the corresponding number among the 537 who had one or more casual male partners was 140 (26.1%). The prevalence and incidence of HIV seropositivity were 1.8% (95% confidence interval [CI] 0.8%-2.8%) and 1.7 per 100 person-years [95% CI 0.7-2.7], respectively. Fifty-two (26.5%) of the 196 and 55 (29.7%) of the 185 men with regular partners who reported having practiced protected insertive and receptive anal sex in the year before the baseline visit reported engaging in these activities without a condom at the follow-up visit; the corresponding numbers among the 232 and 242 men with causal partners who had practiced protected insertive and receptive anal sex before the baseline visit were 43 (15.5%) and 26 (9.4%) respectively at follow-up. INTERPRETATION: The incidence of HIV infection is unacceptably high among this cohort of young gay and bisexual men. Preliminary results suggest a disturbing trend toward increasing levels of unprotected anal intercourse.     

Predictors of Bisexual Behaviour among MSM Attending Intervention Sites May Help in Prevention Interventions for This Bridge to the Heterosexual Epidemic in India: Data from HIV Sentinel Surveillance

Background

Indian cultural tradition demanding marriage, many MSM howsoever they self-identify are likely to be married or have sex with women. To consolidate India''s HIV prevention gains, it is important to understand and address the interaction between the MSM and heterosexual epidemics in India and create specific interventions for bisexual MSM. The challenge is to identify and intervene this hard to reach population. Data from HIV Sentinel Surveillance 2011 among MSM in four Indian states were analyzed to assess predictors and prevalence of bisexual behaviour in MSM.

Methods

Between March-May 2011, 4682 men (15–49 years) who had anal/oral sex with a male partner in the past month, attending intervention sites and consenting for an un-linked anonymous survey answered an 11- item questionnaire and provided blood for HIV test by finger stick at 19 designated surveillance sites.

Results

Of 4682 MSM tested overall, 5% were illiterate, 51% reported only receptive anal intercourse, 21% only penetrative and 28% both. 36% MSM had ever received money for sex. Overall 6.8% were HIV infected. 44% MSM were bisexual in the last six months. On multivariate analysis, ‘being bisexual’ was found to be independently associated with ‘older age’: 26–30 years [AOR = 3.1, 95% CI(2.7, 3.7)], >30 years [AOR = 6.5, 95% CI(5.5, 7.7)]; ‘reporting penetrative behaviour alone’ with other men [AOR = 5.8, 95% CI(4.8, 7.0), p<0.01] and ‘reporting both penetrative and receptive behaviour’ [AOR = 2.7, 95% CI(2.3, 3.1) p<0.01]. Those who both paid and received money for sex [AOR = 0.49, 95% CI (0.38, 0.62)] were significantly less likely to be bisexual.

Conclusions

A substantial proportion of men receiving services from Targeted Intervention programs are bisexual and the easy opportunity for intervention in this setting should be capitalised upon. Focusing on older MSM, as well as MSM who show penetrative behaviour with other men, could help in reaching this population.     

Fertility Desires among Men and Women Living with HIV/AIDS in Nairobi Slums: A Mixed Methods Study

Objectives

Fertility desires require new understanding in a context of expanding access to antiretroviral therapy for people living with HIV/AIDS in Sub-Saharan Africa. This paper studies the fertility desires and their rationales, of slum-dwelling Kenyan men and women living with HIV/AIDS who know their serostatus, but have different antiretroviral therapy treatment statuses. It addresses two research questions: How do people living with HIV/AIDS consider their future fertility? What factors contribute to an explanation of fertility desires among people living with HIV/AIDS.

Methods

A mixed methods study (survey [n = 513] and in-depth interviews [n = 41]) with adults living with HIV/AIDS living in Nairobi slums was conducted in 2010. Regression analyses assess independent relationships between fertility desires and socio-demographic factors. Analyses of in-depth interviews are used to interpret the statistical analyses of fertility desires.

Results

Our analyses show that fertility desires are complex and ambivalent, reflecting tensions between familial and societal pressures to have children versus pressures for HIV (re-)infection prevention. More than a third (34%) of men and women living with HIV expressed future fertility desires; however, this is significantly lower than in the general population. Factors independently associated with desiring a child among people living with HIV/AIDS were age, sex, number of surviving children, social support and household wealth of the respondent.

Discussion

Increasing access to ART is changing the context of future childbearing for people living with HIV/AIDS. Prevailing values mean that, for many people living with HIV/AIDS, having children is seen as necessary for a “normal” and healthy adult life. However, the social rewards of childbearing conflict with moral imperatives of HIV prevention, presenting dilemmas about the “proper” reproductive behaviour of people living with HIV/AIDS. The health policy and service delivery implications of these findings are explored.     

Awareness of HIV Status,Prevention Knowledge and Condom Use among People Living with HIV in Mozambique

Objective

To determine factors associated with HIV status unawareness and assess HIV prevention knowledge and condom use among people living with HIV/AIDS (PLHIV) in Mozambique.

Design

Cross-sectional household-based nationally representative AIDS Indicator Survey.

Methods

Analyses focused on HIV-infected adults and were weighted for the complex sampling design. We identified PLHIV who had never been tested for HIV or received their test results prior to this survey. Logistic regression was used to assess factors associated with HIV status unawareness.

Results

Of persons with positive HIV test results (N = 1182), 61% (95% confidence interval [CI] 57–65%) were unaware of their serostatus. Men had twice the odds of being unaware of their serostatus compared with women [adjusted odds ratio (aOR) 2.05, CI 1.40–2.98]. PLHIV in the poorest wealth quintile were most likely to be unaware of their serostatus (aOR 3.15, CI 1.09–9.12) compared to those in the middle wealth quintile. Most PLHIV (83%, CI 79–87%) reported not using a condom during their last sexual intercourse, and PLHIV who reported not using a condom during their last sexual intercourse were more likely to be unaware of their serostatus (aOR 2.32, CI 1.57–3.43) than those who used a condom.

Conclusions

Knowledge of HIV-positive status is associated with more frequent condom use in Mozambique. However, most HIV-infected persons are unaware of their serostatus, with men and persons in the poorest wealth quintile being more likely to be unaware. These findings support calls for expanded HIV testing, especially among groups less likely to be aware of their HIV status and key populations at higher risk for infection.     

Factors Associated with HIV Prevalence and HIV Testing in Sierra Leone: Findings from the 2008 Demographic Health Survey

BackgroundThe Sierra Leone Demographic Health Survey 2008 found an HIV prevalence of 1.5%. This study investigates associations with HIV infection and HIV testing.MethodsHouseholds were selected using stratified multi-stage sampling. In all selected households women aged 15–49 were eligible. In every second household men aged 15–59 were also eligible. Participants were asked to consent for anonymous HIV testing. All participants interviewed and tested were analysed. Multiple logistic regression identified associations with HIV infection, undiagnosed infection and with ever having a voluntary HIV test among sexually active participants.ResultsOf 7495 invited 86% (6,475) agreed to an interview and HIV test. Among 96 HIV positive participants, 78% had never taken a voluntary HIV test so were unaware of their serostatus, and 86% were sexually active in the last 12 months among whom 96% did not use a condom at last intercourse. 11% of all participants had previously voluntarily tested. Among women who had tested, 60% did so in antenatal care. We found that those living in an urban area, and those previously married, were more likely to be HIV infected. Voluntary HIV testing was more common in those aged 25–44, living in an urban area, females, having secondary or higher education, having first sexual intercourse at age 17 years or older, and using condoms at last sex. Although 82% of men and 69% of women had heard of HIV, only 35% and 29% respectively had heard of antiretroviral therapy.ConclusionsThe HIV prevalence in Sierra Leone has been stable. HIV testing, however, is uncommon and most infected individuals are unaware of their serostatus. This could allow the epidemic to escalate as individuals with undiagnosed infection are unlikely to change their behaviour or access treatment. Improving knowledge and increasing testing need to remain central to HIV prevention interventions in Sierra Leone.     

Alcohol Use and Transactional Sex among Women in South Africa: Results from a Nationally Representative Survey

Background

Transactional sex is a risk factor for HIV infection. Alcohol use may increase the risk of transactional sex. No nationally-representative studies have examined the relationship between multiple dimensions of alcohol use and transactional sex in women in South Africa. The aim of the study was to examine the relationship between alcohol dependence, binge drinking and frequency of drinking in the past month and transactional sex in adult women in South Africa.

Methods

A cross-sectional study using multi-stage, cluster sampling collected data from a nationally representative sample of 5,969 women aged 16–55 years in 2012. The analysis conducted for this paper was restricted to women reporting sexual activity in the past 12 months (n = 3,594). Transactional sex was defined as having received money/gifts in exchange for sex with any sex partner in the past year. Alcohol use measures included: alcohol dependence (≥2 positive responses to the CAGE questionnaire); binge drinking (≥4 drinks for women on one occasion); and drinking frequency in the previous month. Logistic regression models were built to test the hypotheses that each dimension of alcohol use was associated with transactional sex.

Results

About 6.3% (n = 225) of sexually active women reported transactional sex. Almost a third (30.6%) of sexually active women had ever drunk alcohol, and 19.2% were current (past month) drinkers. Among lifetime drinkers, 28.0% were alcohol dependent and 56.6% were binge drinkers. Alcohol dependent women were twice as likely to report transactional sex (AOR 2.0, 95% CI 1.1–4.3, p<0.05) than those not alcohol dependent. Binge drinkers were 3.1 times more likely to have had transactional sex (95% CI 1.5–6.6, p<0.01) than non-binge drinkers. There was no significant relationship between frequency of drinking in the past month and transactional sex.

Conclusion

Alcohol dependency and binge drinking are significantly associated with transactional sex in South African women. HIV prevention programmes need to target these women, and address both their alcohol use, as well as the HIV risks associated with transactional sex.     

The factors influencing transactional sex among young men and women in 12 sub-Saharan African countries

Transactional sex may put young women and young men in sub-Saharan Africa at increased risk of contracting sexually transmitted infections (STIs), including HIV/AIDS. This behavior may also put young women at higher risk of pregnancy and childbearing. Policymakers and program managers need to know what factors put youth at increased risk. We investigated this issue using logistic regression analyses of data from male and female modules of Demographic and Health Surveys from 12 sub-Saharan African countries. We found that young men and young women are at greater risk of engaging in transactional sex than are older people. Unmarried young women and young men were significantly more likely to engage in transactional sex than married youth. Based on these results, our conclusions were that programs geared toward reducing the incidence of transactional sex or protecting men and women already in transactional sexual relationships should be aimed at both young women and young men. Due to our finding that unmarried young women and young men are more vulnerable to experiencing transactional sex, programs to prevent transactional sex should be specifically directed to this subgroup of young people.     

The factors influencing transactional sex among young men and women in 12 sub‐Saharan African countries

Abstract

Transactional sex may put young women and young men in sub‐Saharan Africa at increased risk of contracting sexually transmitted infections (STIs), including HIV/AIDS. This behavior may also put young women at higher risk of pregnancy and childbearing. Policymakers and program managers need to know what factors put youth at increased risk. We investigated this issue using logistic regression analyses of data from male and female modules of Demographic and Health Surveys from 12 sub‐Saharar African countries. We found that young men and young women are at greater risk of engaging in transactional sex than are older people. Unmarried young women and young men were significantly more likely to engage in transactional sex than married youth. Based on these results, our conclusions were that programs geared toward reducing the incidence of transactional sex or protecting men and women already in transactional sexual relationships should be aimed at both young women and young men. Due to our finding that unmarried young women and young men are more vulnerable to experiencing transactional sex, programs to prevent transactional sex should be specifically directed to this subgroup of young people.     

Giving or Receiving Something for Sex: A Cross-Sectional Study of Transactional Sex among Ugandan University Students

Objective

This study sought to determine the prevalence of transactional sex among university students in Uganda and to assess the possible relationship between transactional sex and sexual coercion, physical violence, mental health, and alcohol use.

Methods

In 2010, 1954 undergraduate students at a Ugandan university responded to a self-administered questionnaire that assessed mental health, substance use, physical violence and sexual behaviors including sexual coercion and transactional sex. The prevalence of transactional sex was assessed and logistic regression analysis was performed to measure the associations between various risk factors and reporting transactional sex.

Results

Approximately 25% of the study sample reported having taken part in transactional sex, with more women reporting having accepted money, gifts or some compensation for sex, while more men reporting having paid, given a gift or otherwise compensated for sex. Sexual coercion in men and women was significantly associated with having accepted money, gifts or some compensation for sex. Men who were victims of physical violence in the last 12 months had higher probability of having accepted money, gifts or some compensation for sex than other men. Women who were victims of sexual coercion reported greater likelihood of having paid, given a gift or otherwise compensated for sex. Respondents who had been victims of physical violence in last 12 months, engaged in heavy episodic drinking and had poor mental health status were more likely to have paid, given a gift or otherwise compensated for sex.

Conclusions

University students in Uganda are at high risk of transactional sex. Young men and women may be equally vulnerable to the risks and consequences of transactional sex and should be included in program initiatives to prevent transactional sex. The role of sexual coercion, physical violence, mental health, and alcohol use should be considered when designing interventions for countering transactional sex.     

HIV Infection and Sexual Risk among Men Who Have Sex with Men and Women (MSMW): A Systematic Review and Meta-Analysis

Objectives

To estimate the number of men who have sex with men and women who are HIV-positive in the United States, and to compare HIV prevalence rates between men who have sex with men and women, men who have sex with men only, and men who have sex with women exclusively.

Methods

Following PRISMA guidelines, we conducted a systematic review and meta-analysis of reports referencing HIV prevalence and men who have sex with men and women. We searched PubMed and Ovid PsycINFO for peer-reviewed, U.S.-based articles reporting on HIV prevalence among men who have sex with men and women. We conducted event rate, effect size, moderation and sensitivity analyses.

Results

We estimate that 1.0% of U.S. males are bisexually-behaving, and that 121,800 bisexually-behaving men are HIV-positive. Men who have sex with men and women are less than half as likely to be HIV-positive as men who have sex with men only (16.9% vs. 33.3%; OR = 0.41, 95% CI: 0.31, 0.54), but more than five times as likely to be HIV-positive as men who have sex with women exclusively (18.3% vs. 3.5%; OR = 5.71, 95% CI: 3.47, 9.39). They are less likely to engage in unprotected receptive anal intercourse than men who have sex with men only (15.9% vs. 35.0%; OR = 0.36, 95% CI: 0.28, 0.46). Men who have sex with men and women in samples with high racial/ethnic minority proportions had significantly higher HIV prevalence than their counterparts in low racial/ethnic minority samples.

Conclusions

This represents the first meta-analysis of HIV prevalence in the U.S. between men who have sex with men and women and men who have sex with men only. Data collection, research, and HIV prevention and care delivery specifically tailored to men who have sex with men and women are necessary to better quantify and ameliorate this population’s HIV burden.     

Is risk of Kaposi's sarcoma in AIDS patients in Britain increased if sexual partners came from United States or Africa?

OBJECTIVE--To determine whether the risk of Kaposi''s sarcoma in patients with AIDS is increased by sexual contact with groups from abroad with a high incidence of Kaposi''s sarcoma. DESIGN--Analysis of risk of Kaposi''s sarcoma in patients with AIDS, according to country of origin of their sexual partners. SETTING--United Kingdom. PATIENTS--2830 patients with AIDS reported to the Communicable Disease Surveillance Centre and the Communicable Disease (Scotland) Unit up to March 1990, of whom 566 had Kaposi''s sarcoma. MAIN OUTCOME MEASURES--Percentage of patients with AIDS who had Kaposi''s sarcoma. RESULTS--537 of 2291 homosexual or bisexual men (23%) with AIDS had Kaposi''s sarcoma; 10% (14/135) of the men and women who acquired HIV by heterosexual contact had Kaposi''s sarcoma. None of the 316 subjects who acquired HIV through non-sexual routes had Kaposi''s sarcoma. Kaposi''s sarcoma was more common among homosexual men whose likely source of infection included the United States (171/551, 31%) or Africa (9/34, 26%) than among those infected in the United Kingdom (119/625, 19%) (p less than 0.05). CONCLUSION--The data suggest that Kaposi''s sarcoma is caused by a sexually transmissible agent which was introduced into the British homosexual population mainly from the United States [corrected].     

Risk factors for infection with human immmunodeficiency virus among European expatriates in Africa.

The pattern of cases of AIDS in Belgium suggests that Europeans infected with human immunodeficiency virus (HIV) acquired the infection in Africa. The prevalence of infection was assessed in Belgian advisers and European expatriates and risk factors for infection defined in a case-control study of expatriate men. Fifteen (1.1%) of 1401 Belgian advisers working in Africa and 41 (0.9%) of 4564 European expatriates living in Africa, were positive for antibody to HIV in a voluntary screening programme in Belgium. Among subjects with antibody to HIV the ratio of men to women was 3:1. These subjects did not have a history of intravenous drug abuse or blood transfusion and only one was homosexual. In a case-control study of 33 expatriate men who had antibody to HIV and 119 controls the men with antibody reported significantly more female sexual partners, who were more commonly local; and significantly more sexual contact with prostitutes in Africa. They had a significantly higher prevalence of history of sexually transmitted disease and had received significantly more injections by unqualified staff in Africa during the previous five years. No specific sexual practices were associated with having antibody to HIV. After multivariate analysis sexual contact with local women (adjusted odds ratio 14.7; 95% confidence interval 2.81 to 76.9), sexual contact with prostitutes (adjusted odds ratio 10.8 (1.6 to 71.9), and injections by unqualified staff (adjusted odds ratio 13.5 (3.7 to 49.8) remained independent risk factors for infection. European expatriates in Africa were at increased risk from infection with HIV and were a means of introducing HIV into the heterosexual population in Europe. Transmission from women to men by vaginal intercourse seemed to be the most probable route of infection.     

Factors Associated with Problem Drinking among Women Employed in Food and Recreational Facilities in Northern Tanzania

Background

There is growing evidence that alcohol consumption is associated with increased risk of HIV infection. To determine factors associated with problem drinking, we analyzed data collected in two prospective cohorts of at-risk female food and recreational facility workers in northern Tanzania.

Methods

We enrolled HIV seronegative women aged 18–44 years and employed in the towns of Geita, Kahama, Moshi, and Shinyanga. At enrolment, women were interviewed to obtain information about alcohol use, using CAGE and AUDIT screening scales, and risk factors for HIV infection. Blood and genital samples were collected for detection of HIV and sexually transmitted infections (STIs). We characterized alcohol use, concordance, and agreement of the scales, and examined the associations between characteristics of participants and problem drinking as defined by both scales using logistic regression. Lastly, we assessed problem drinking as a risk factor for recent sexual behavior and prevalent STIs.

Results

Among enrollees, 68% women reported ever drinking alcohol; of these 76% reported drinking alcohol in the past 12 months. The prevalence of problem drinking was 20% using CAGE and 13% using AUDIT. Overall concordance between the scales was 75.0% with a Kappa statistic of 0.58. After adjusting for age, independent factors associated with problem drinking, on both scales, were marital status, occupation, facility type, increasing number of lifetime sexual partners, and transactional sex in the past 12 months. In addition, women who were problem drinkers on either scale were more likely to report having ≥1 sexual partner (CAGE: aOR = 1.56, 95% confidence interval, CI: 1.10–2.23; AUDIT: aOR = 2.00, 95% CI: 1.34–3.00) and transactional sex (CAGE: aOR = 1.79, 95% CI: 1.26–2.56; AUDIT: aOR = 1.51, 95% CI: 1.04–2.18), in the past 3 months.

Conclusion

These findings suggest that interventions to reduce problem drinking in this population may reduce high-risk sexual behaviors and contribute in lowering the risk of HIV infection.     

HIV Infection and Awareness among Men Who Have Sex with Men–20 Cities,United States, 2008 and 2011

Over half of HIV infections in the United States occur among men who have sex with men (MSM). Awareness of infection is a necessary precursor to antiretroviral treatment and risk reduction among HIV-infected persons. We report data on prevalence and awareness of HIV infection among MSM in 2008 and 2011, using data from 20 cities participating in the 2008 and 2011 National HIV Behavioral Surveillance System (NHBS) among MSM. Venue-based, time-space sampling was used to recruit men for interview and HIV testing. We analyzed data for men who reported ≥1 male sex partner in the past 12 months. Participants who tested positive were considered to be aware of their infection if they reported a prior positive HIV test. We used multivariable analysis to examine differences between results from 2011 vs. 2008. HIV prevalence was 19% in 2008 and 18% in 2011 (p = 0.14). In both years, HIV prevalence was highest among older age groups, blacks, and men with lower education and income. In multivariable analysis, HIV prevalence did not change significantly from 2008 to 2011 overall (p = 0.51) or in any age or racial/ethnic category (p>0.15 in each category). Among those testing positive, a greater proportion was aware of their infection in 2011 (66%) than in 2008 (56%) (p<0.001). In both years, HIV awareness was higher for older age groups, whites, and men with higher education and income. In multivariable analysis, HIV awareness increased from 2008 to 2011 overall (p<0.001) and for all age and racial/ethnic categories (p<0.01 in each category). In both years, black MSM had the highest HIV prevalence and the lowest awareness among racial/ethnic groups. These findings suggest that HIV-positive MSM are increasingly aware of their infections.     

Learning that circumcision is protective against HIV: risk compensation among men and women in Cape Town, South Africa

Objectives

We examined whether knowledge of the HIV-protective benefits of male circumcision (MC) led to risk compensating behavior in a traditionally circumcising population in South Africa. We extend the current literature by examining risk compensation among women, which has hitherto been unexplored.

Methods

We used data on Xhosa men and women from the 2009 Cape Area Panel Study. Respondents were asked if they had heard that MC reduces a man’s risk of contracting HIV, about their perceived risk of contracting HIV, and condom use. For each gender group we assessed whether risk perception and condom use differed by knowledge of the protective benefits of MC using bivariate and then multivariate models controlling for demographic characteristics, HIV knowledge/beliefs, and previous sexual behaviors. In a further check for confounding, we used data from the 2005 wave to assess whether individuals who would eventually become informed about the protective benefits of circumcision were already different in terms of HIV risk perception and condom use.

Results

34% of men (n = 453) and 27% of women (n = 690) had heard that circumcision reduces a man’s risk of HIV infection. Informed men perceived slightly higher risk of contracting HIV and were more likely to use condoms at last sex (p<0.10). Informed women perceived lower HIV risk (p<0.05), were less likely to use condoms both at last sex (p<0.10) and more generally (p<0.01), and more likely to forego condoms with partners of positive or unknown serostatus (p<0.01). The results were robust to covariate adjustment, excluding people living with HIV, and accounting for risk perceptions and condom use in 2005.

Conclusions

We find evidence consistent with risk compensation among women but not men. Further attention should be paid to the role of new information regarding MC, and drivers of HIV risk more broadly, in modulating sexual behavior among women.     

Prostitution and risk of HIV: male partners of female prostitutes.

OBJECTIVE--To describe risk behaviours for infection with HIV in male sexual partners of female prostitutes. DESIGN--A cross sectional study. SETTING--Genitourinary medicine clinic, St Mary''s Hospital, London. SUBJECTS--112 self identified male sexual partners of female prostitutes: 101 who reported commercial sexual relationships only, five who reported non-commercial relationships only, and six who reported both commercial and non-commercial relationships. MAIN OUTCOME MEASURES--Reported risk behaviours for infection with HIV. RESULTS--Of the 40 men who had had previous HIV tests or were tested during the study, two (5%) were infected with HIV. Of the men who would answer the questions, 34/94 reported having sex with other men, 2/105 reported using injected drugs, 8/105 had a history of blood transfusion, 14/108 reported a past history of gonorrhoea, 44/102 reported paying for sex abroad, and 8/92 said that they had also been paid for sex. Of the 55 men who reported paying for vaginal intercourse in the past year, 45 (82%) said that they had always used a condom. In contrast, of the 11 non-paying partners of prostitutes, only two (18%) reported ever using a condom with their partners. CONCLUSIONS--Men who have sex with female prostitutes cannot be assumed to be at risk of infection with HIV only by this route: homosexual contact may place them at greater risk. Despite the heterogeneity among male sexual partners of prostitutes, patterns of use of condoms were uniform when they were considered as a reflection of the type of relationship a man had with a female prostitute rather than a consequence of an individual''s level of risk.     

Australian Gay and Bisexual Men’s Attitudes to HIV Treatment as Prevention in Repeated,National Surveys, 2011-2013

Objective

Assess the acceptability of HIV treatment as prevention and early antiretroviral treatment among gay and bisexual men in Australia and any changes in attitudes over time.

Methods

National, online, cross-sectional surveys of gay and bisexual men were repeated in 2011 and 2013. Changes in attitudes to HIV treatment over time were assessed with multivariate analysis of variance. The characteristics of men who agreed that HIV treatment prevented transmission and thought that early treatment was necessary were identified with multivariate logistic regression.

Results

In total, 2599 HIV-negative, untested and HIV-positive men participated (n = 1283 in 2011 and n = 1316 in 2013). Attitudes changed little between 2011 and 2013; most participants remained sceptical about the preventative benefits of HIV treatment. In 2013, only 2.6% of men agreed that HIV treatment prevented transmission; agreement was associated with being HIV-positive, having an HIV-positive regular partner, and having received HIV post-exposure prophylaxis. In contrast, 71.8% agreed that early antiretroviral treatment is necessary; younger men were more likely and HIV-positive men and participants with HIV-positive partners were much less likely to agree with this.

Conclusions

Promoting the individual health benefits of HIV treatment rather than its preventative benefits remains more acceptable to Australian gay and bisexual men.     

Population sizes,HIV prevalence,and HIV prevention among men who paid for sex in sub-Saharan Africa (2000–2020): A meta-analysis of 87 population-based surveys

BackgroundKey populations, including sex workers, are at high risk of HIV acquisition and transmission. Men who pay for sex can contribute to HIV transmission through sexual relationships with both sex workers and their other partners. To characterize the population of men who pay for sex in sub-Saharan Africa (SSA), we analyzed population size, HIV prevalence, and use of HIV prevention and treatment.Methods and findingsWe performed random-effects meta-analyses of population-based surveys conducted in SSA from 2000 to 2020 with information on paid sex by men. We extracted population size, lifetime number of sexual partners, condom use, HIV prevalence, HIV testing, antiretroviral (ARV) use, and viral load suppression (VLS) among sexually active men. We pooled by regions and time periods, and assessed time trends using meta-regressions. We included 87 surveys, totaling over 368,000 male respondents (15–54 years old), from 35 countries representing 95% of men in SSA. Eight percent (95% CI 6%–10%; number of surveys [N_s] = 87) of sexually active men reported ever paying for sex. Condom use at last paid sex increased over time and was 68% (95% CI 64%–71%; N_s = 61) in surveys conducted from 2010 onwards. Men who paid for sex had higher HIV prevalence (prevalence ratio [PR] = 1.50; 95% CI 1.31–1.72; N_s = 52) and were more likely to have ever tested for HIV (PR = 1.14; 95% CI 1.06–1.24; N_s = 81) than men who had not paid for sex. Men living with HIV who paid for sex had similar levels of lifetime HIV testing (PR = 0.96; 95% CI 0.88–1.05; N_s = 18), ARV use (PR = 1.01; 95% CI 0.86–1.18; N_s = 8), and VLS (PR = 1.00; 95% CI 0.86–1.17; N_s = 9) as those living with HIV who did not pay for sex. Study limitations include a reliance on self-report of sensitive behaviors and the small number of surveys with information on ARV use and VLS.ConclusionsPaying for sex is prevalent, and men who ever paid for sex were 50% more likely to be living with HIV compared to other men in these 35 countries. Further prevention efforts are needed for this vulnerable population, including improved access to HIV testing and condom use initiatives. Men who pay for sex should be recognized as a priority population for HIV prevention.

Caroline Hodgins and colleagues investigate the HIV prevalence, population sizes, and HIV prevention among men who paid for sex in sub-Saharan Africa (2000-2020).