David S. Novak

Limited Awareness and Low Immediate Uptake of Pre-Exposure Prophylaxis among Men Who Have Sex with Men Using an Internet Social Networking Site

Background In 2010, the iPrEx trial demonstrated that oral antiretroviral pre-exposure prophylaxis (PrEP) reduced the risk of HIV acquisition among high-risk men who have sex with men (MSM). The impact of iPrEx on PrEP knowledge and actual use among at-risk MSM is unknown. Online surveys were conducted to assess PrEP awareness, interest and experience among at-risk MSM before and after iPrEx, and to determine demographic and behavioral factors associated with these measures. Methods and Findings Cross-sectional, national, internet-based surveys were administered to U.S. based members of the most popular American MSM social networking site 2 months before (n = 398) and 1 month after (n = 4 558) publication of iPrEx results. Comparisons were made between these samples with regards to PrEP knowledge, interest, and experience. Data were collected on demographics, sexual risk, and experience with post-exposure prophylaxis (PEP). Regression analyses were performed to identify factors associated with PrEP awareness, interest, and experience post-iPrEx. Most participants were white, educated, and indicated high-risk sexual behaviors. Awareness of PrEP was limited pre- and post-iPrEx (13% vs. 19%), whereas interest levels after being provided with a description of PrEP remained high (76% vs. 79%). PrEP use remained uncommon (0.7% vs. 0.9%). PrEP use was associated with PEP awareness (OR 7.46; CI 1.52–36.6) and PEP experience (OR 34.2; CI 13.3–88.4). PrEP interest was associated with older age (OR 1.01; CI 1.00–1.02), unprotected anal intercourse with ≥1 male partner in the prior 3 months (OR 1.40; CI 1.10–1.77), and perceiving oneself at increased risk for HIV acquisition (OR 1.20; CI 1.13–1.27). Conclusions Among MSM engaged in online networking, awareness of PrEP was limited 1 month after the iPrEx data were released. Utilization was low, although some MSM who reported high-risk behaviors were interested in using PrEP. Studies are needed to understand barriers to PrEP utilization by at-risk MSM.

The Future of Internet-Based HIV Prevention: A Report on Key Findings from the Men’s INTernet (MINTS-I, II) Sex Studies

The Internet and other new media have changed how men who have sex with men (MSM) find and interact with sexual partners. This social phenomenon, paired with growing evidence that use of the Internet increases MSM’s risk for HIV infection, makes it crucial that innovative technology-based HIV prevention interventions are developed for this population. In this commentary we explain why technology-based HIV prevention interventions are urgently needed; we then highlight findings from some of the first Internet-based HIV prevention for MSM studies that show the potential for future interventions; we next discuss ways for interventionists to conceptualize new media as a tool for HIV prevention; and finally we discuss emerging trends for technology-based HIV-prevention research.

Acceptability of an Internet-Based Partner Notification System for Sexually Transmitted Infection Exposure Among Men Who Have Sex With Men

US men who have sex with men (n=1848) completed an online questionnaire about their willingness to use Internet-based partner notification. Eighty-one percent reported that it would be important to them to receive a partner notification e-mail if they had been exposed to a sexually transmitted infection. Seventy percent reported that if infected, they would use a public health specialist to inform partners of possible exposure through Internet notification. There was broad acceptance of Internet partner notification by at-risk US men who have sex with men, including a willingness to receive or initiate a notification e-mail.

State-level structural sexual stigma and Hiv prevention in a national online sample of Hiv-uninfected Msm in the United States

Background:Stigmatizing social environments (of which ‘structural stigma’ is one component) negatively affect health-related outcomes. However, few studies have examined structural stigma related to sexual minority status as a risk factor for HIV outcomes among MSM. Methods:In August 2013, members of a large MSM social and sexual networking site in the United States completed a survey about HIV-prevention practices. A previously validated composite index provided values for state-level structural stigma, including density of same-sex couples, proportion of public high schools with Gay-Straight Alliances, state laws protecting sexual minorities, and public opinion toward homosexuality. Multivariable logistic generalized estimating equations assessed the relationship between structural stigma and condomless anal intercourse, use and awareness of antiretroviral-based HIV-prevention strategies (i.e. pre and postexposure prophylaxis, or PEP and PrEP), and comfort discussing male–male sex with primary care providers. Results:Among the 4098 HIV-uninfected MSM, lower state-level structural stigma was associated with decreased odds of condomless anal intercourse [adjusted odds ratio (aOR) 0.97 per one unit increase in structural stigma score, 95% confidence interval (CI) 0.94–0.99], increased odds of awareness of PEP (aOR 1.06, 95% CI 1.02–1.09), and PrEP (aOR 1.06, 95% CI 1.02–1.10), having taken PEP (aOR 1.15, 95% CI 1.05–1.26) and PrEP (aOR 1.21, 95% CI 1.01–1.44), and comfort discussing male–male sex with providers (aOR 1.08, 95% CI 1.05–1.11), after adjusting for social and state-level confounders. Conclusion:MSM living in more stigmatizing environments had decreased use of antiretroviral-based HIV-prevention strategies compared to those in less stigmatizing environments. Legal reforms protecting sexual minorities should be evaluated as structural interventions that could reduce HIV risk among MSM.

HIV and STD Status Among MSM and Attitudes About Internet Partner Notification for STD Exposure

Objectives: This study assessed the acceptability and perceived utility of Internet-based partner notification (PN) of sexually transmitted disease (STD) exposure for men who have sex with men (MSM) by human immunodeficiency virus (HIV) serostatus. Study Design: We recruited 1848 US MSM via a banner advertisement posted on an MSM website for meeting sexual partners between October and November 2005. Results: Even though there was broad acceptance of a PN e-mail across HIV serostatus groups, HIV-infected men rated the importance of each component (e.g., information about where to get tested/treated, additional education regarding the STD exposed to, a mechanism for verifying the authenticity of the PN e-mail) lower than HIV-uninfected or status-unknown participants (all Ps <0.01). Additionally, HIV-infected participants were less likely to use the services offered within a PN e-mail (if they were to receive an e-mail notifying them of possible STD exposure in the future), and were less likely to inform their partners of possible STD exposure via an Internet notification system in the future (all Ps <0.01). A similar trend emerged about men who reported not having a previous STD compared with those who did. Men who reported no previous STD found Internet PN more acceptable. Conclusions: Overall, this study documents broad acceptance of Internet PN by at-risk MSM, regardless of HIV serostatus, including a willingness to receive or initiate PN-related e-mail. If public health officials consider using Internet notification services, they may need to anticipate and address concerns of HIV-infected MSM, and will need to use a culturally-sensitive, social marketing campaign to ensure that those who may benefit from these services are willing to use this modality for PN. Internet PN should be considered as a tool to decrease rising STD and HIV rates among MSM who use the Internet to meet sexual partners.

Asymptomatic gonorrhea and chlamydial infections detected by nucleic acid amplification tests among Boston area men who have sex with men.

Background: The purpose of this project was to determine the prevalence of asymptomatic sexually transmitted diseases (STDs) among men who have sex with men (MSM) in the Boston area who had been sexually active (oral and/or anal sex) with another male within the past year. Methods: Over a 1-month period (March 2007), asymptomatic MSM in care at a Boston community health center (n = 114) were screened for gonorrhea and chlamydia using the BD ProbeTec technique. Deidentified medical record data were analyzed and linked to prevalence monitoring results. Results: Eleven percent of the sample tested positive for one of the 2 STDs (gonorrhea or chlamydia) from at least one mucosal site. Individuals who were infected with an STD were considerably more likely to have a prior history of one or more STD infections when compared with those without an STD history (OR = 3.69; P <0.02). There were no significant differences observed in psychosocial and other behavioral risk factors between patients with or without an STD. Conclusions: Screening asymptomatic MSM using nucleic acid amplification tests (NAATs) revealed a substantial STD burden that might not have been diagnosed using traditional assays. These data are critical for the design of effective public health interventions for this population.

The Internet as a valuable tool for promoting a new framework for sexual health among gay men and other men who have sex with men.

Today, much of the contemporary knowledge about the manner in which gay men and other men who have sex with men (referred to as MSM in this commentary) construct their sexual lives exists within the context of the HIV epidemic [1]. While this may have been necessary given the extent to which HIV has impacted these communities, it has resulted in a limited understanding of the healthy expression of MSM sexuality, and has created a diseasedominated conceptualization of MSM sexual behavior. In particular, this paradigm has not fully attended to the concepts of desire, sexual pleasure, and sexual satisfaction, all of which likely affect the sexual decisions MSM make on a regular basis. The phrase ‘‘sexual health’’ has been increasingly utilized over the past decade to characterize efforts to promote the overall sexual well-being of a range of communities, and some have offered conceptualizations of this construct [2, 3]. However, to date most public health interventions for MSM have retained a focus primarily on HIV prevention without taking into account the many other aspects of MSM sexuality and sexual health. Interventionists continue to rely on disease-oriented models that are only partially effective in their goal of reducing HIV incidence, rather than taking advantage of opportunities to develop a holistic framework for promoting sexual health among MSM. In order to move towards a new era of sexual health among MSM, it is important for public health professionals and researchers to take the time to carefully articulate the range and complexity of sexuality and sexual well-being, and the manner in which it is expressed between men. Only then will it be possible to develop a sexual health framework for MSM that attends to more than an individual’s risk for HIV and sexually transmitted infection (STI) acquisition and transmission. A sexual health framework that promotes the overall well-being of MSM while also reducing HIV incidence should include three fundamental elements.

Health Care Access and Sexually Transmitted Infection Screening Frequency Among At-Risk Massachusetts Men Who Have Sex With Men

OBJECTIVES We sought to assess risk exposures, health care access, and screening rates for HIV and sexually transmitted infections (STIs) among men who have sex with men (MSM) in Massachusetts. METHODS We used a modified respondent-driven sampling method to collect data between March 2006 and May 2007. Overall, 126 MSM completed a survey. RESULTS Seventy percent of participants reported unprotected receptive anal intercourse with at least 1 nonmonogamous male partner; 50% reported having had a previous STI. Although 98% had visited a health care provider in the previous year, 39% had not been screened for STIs during the previous 2 years. Bisexual respondents were less likely to have told their health care providers that they engage in male-to-male sexual contact (OR = 4.66; P < .001), less likely to have been tested for STIs during in the previous 2 years (OR = 6.91; P < .001), and more likely to engage in insertive anal intercourse without a condom with an HIV-infected partner (OR = 5.04; P < .005) than were non-bisexual respondents. CONCLUSIONS Clinicians need to assess sexual risk-taking behaviors and more routinely screen for STIs among sexually active men regardless of disclosure of a history of having sex with men.

Partner notification after STD and HIV exposures and infections: knowledge, attitudes, and experiences of Massachusetts men who have sex with men.

Objectives. We assessed Boston-area men who have sex with men (MSM) in terms of their knowledge of partner notification (PN)/partner counseling and referral services (PCRS) and intentions to use such services if exposed to/infected with a sexually transmitted disease (STD) or human immunodeficiency virus (HIV) in the future. Methods. The study used a convenience sample of STD clinic patients (n=48) and a modified respondent-driven sampling method (n=70) to reach a diverse sample of MSM (total sample n=118) in Massachusetts. Participants completed a one-on-one, open-ended, semistructured qualitative interview and quantitative survey. Results. Overall, white, HIV-infected MSM had the highest level of knowledge about PN activities. MSM who were unfamiliar with PN were disproportionately nonwhite and HIV-uninfected. Participants were more likely to notify past partners of HIV exposure than STD exposure. The preferred method of PN for the majority of MSM was direct person-to-person notification. Notably, nonwhite participants were more likely to endorse Massachusetts Department of Public Health PN services than white MSM, who preferred involvement of primary care providers. Conclusions. PN is an important public health strategy for treating and preventing STDs and HIV among at-risk populations, especially MSM who engage in sexual behavior with anonymous or otherwise non-notifiable sexual partners. Although many MSM had an understanding of the ethical desirability of informing exposed partners and recognized the value of preventative behaviors, they require further education to overcome barriers to PN as well as to gain knowledge of the various methods of both traditional and nontraditional notification, such as Internet PN.

Evaluation of an Innovative Internet-based Partner Notification Program for Early Syphilis Case Management, Washington, DC, January 2007―June 2008

Background: The Internet has become a common venue for meeting sex partners and planning participation in risky sexual behavior. In this article, we evaluate the first 18 months of the Washington, DC, Department of Health Internet-based Partner Notification (IPN) program for early syphilis infections, using the standard Centers for Disease Control and Prevention (CDC) Disease Investigation Specialist (DIS) disposition codes, as well as Washington, DC, Department of Healths IPN-specific outcomes for pseudonymous partners. Methods: We analyzed DIS disposition codes and IPN-specific outcomes from all early syphilis investigations initiated January 2007–June 2008. Internet partners were defined as sex partners for whom syphilis exposure notification was initiated by e-mail because no other locating information existed. If the e-mails resulted in additional locating information, we used the standard CDC disposition codes. Alternatively, the following IPN-specific outcomes were used: Informed of Syphilis Exposure, Informed of General STD Exposure, Not Informed or Unable to Confirm Receipt of General STD Exposure. Results: From the 361 early syphilis patients, a total of 888 sex partners were investigated, of which 381 (43%) were via IPN. IPN led to an 8% increase in the overall number of syphilis patients with at least one treated sex partner, 26% more sex partners being medically examined and treated if necessary, and 83% more sex partners notified of their STD exposure. Conclusions: IPN augmented traditional syphilis case management and aided in the location, notification, testing, and treatment of partners. Conversely, without IPN, these 381 partners would not have been investigated.