Elizabeth F. Closson

Ensuring It Works: A Community-Based Approach to HIV Prevention Intervention Development for Men Who Have Sex with Men in Chennai, India

Men who have sex with men (MSM) in India have an HIV seroprevalence 22 times greater than the countrys general population and face unique challenges that may hinder the effectiveness of current HIV prevention efforts. To obtain an understanding of the logistical and sociocultural barriers MSM experience while accessing HIV prevention services, focus groups and key informant interviews were conducted with 55 MSM in Chennai, India. Qualitative data were analyzed using descriptive qualitative content analysis. Sixty-five percent of participants identified as kothi (receptive partners), 9% as panthi (insertive partners), 22% as double decker (receptive and insertive), and 4% did not disclose. Themes included: (a) fatigue with current HIV risk reduction messages; (b) increased need for non-judgmental and confidential services; and (c) inclusion of content that acknowledges individual and structural-level determinants of risk such as low self-esteem, depression, and social discrimination. MSM interventions may benefit from approaches that address multilevel psychosocial factors, including skills building and strategies to foster self-acceptance and increased social support.

Engagement with Peer Health Educators Is Associated with Willingness to Use Pre-Exposure Prophylaxis Among Male Sex Workers in Ho Chi Minh City, Vietnam

Men who have sex with men (MSM), including male sex workers (MSW), in Vietnam are at high risk for HIV transmission and acquisition, due to specific psychosocial and contextual factors including stigma and discrimination.1,2 MSW are particularly vulnerable due to the local legal environment, power dynamics (i.e., dependence on sex for livelihood), and individual-level risk.3 However, despite increasing HIV prevalence,4 few HIV prevention interventions have been specifically developed for this population. Identification of HIV prevention strategies that are tailored to the needs of MSW are urgently needed. The iPrEx trial demonstrated the efficacy of taking daily oral pre-exposure prophylaxis (PrEP) to reduce HIV transmission among MSM.5 To date, little research has specifically considered the acceptability of PrEP among MSW in Vietnam. PrEP may be a particularly useful intervention for MSW as it is a user-controlled intervention. Peer educators (PE) are valuable sources of HIV prevention information for MSW in Vietnam,6 and may have a role to play in the development and administration of PrEP interventions. We assessed factors associated with access to PE and the association between contact with a PE and willingness to take PrEP as a potential strategy for implementation of PrEP interventions. In 2010, a behavioral and psychosocial survey was undertaken with 300 MSW in Ho Chi Minh City (HCMC), Vietnam, which assessed past experience with HIV prevention activities and interest in PrEP. The survey was developed following an initial qualitative phase.6 Detailed methods have been described previously.7 Briefly, participants were recruited by PE from a Vietnamese NGO working with MSM, using venue-based sampling stratified on where participants met clients (i.e., street, brothel). Eligible participants were at least 15 years of age, biologically male, Vietnamese citizens who reported exchanging sex for money or goods at least once in the previous month. The survey was anonymous, and participants gave verbal informed consent after receiving information about the study from one of the research staff. Study procedures were approved by the Institutional Review Boards at Beth Israel Deaconess Medical Center and the Ho Chi Minh City Provincial AIDS Committee. The survey contained items pertaining to past participation in HIV prevention programs including if they had received HIV prevention materials (i.e., condoms, personal lubricant, or informational brochures), knowledge of HIV testing and counseling services, HIV/STI testing history, and contact with PE in the previous 12 months. Questions pertaining to willingness to participate in future HIV prevention interventions were adapted from prior studies by our group8 and asked if they would take a daily pill if it would protect against HIV and how likely they were to take the pill if it had side effects. Demographic and behavioral factors were also assessed. Descriptive statistics were calculated for responses regarding past HIV prevention activities and willingness to take PrEP. Logistic regression models were used to analyze the association between demographic and behavioral factors and (1) past contact with a PE; and (2) being at least “somewhat likely” to take a daily pill for HIV prevention if it had side effects. A multivariable model for each outcome was built using backwards elimination starting with all potential covariates, with a p value cutoff of 0.2 to determine the final variables to retain in the model. An alpha level of 0.05 was considered significant. Stata 12.0 (StataCorp, College Station, TX) was used for all analyses. Of 300 participants in the original study, 281 (93.7%) were HIV-uninfected and included in these analyses.9 Table 1 lists the proportion of participants who indicated previous participation in HIV prevention activities and interest in PrEP. More than 2/3 of participants had previous contact with a PE. Most (95.4%) participants indicated that they would take PrEP, although substantially fewer indicated they would take PrEP given side effects (56.7%). Table 1. Proportion of Participants Who Have Participated or Would Participate in HIV Prevention Interventions (N=281) Table 2 displays bivariate and multivariable models assessing factors associated with (1) contact with a PE in the previous year, and (2) being at least “somewhat likely” to take PrEP if it had side effects. MSW who reported previous contact with a PE (AOR 2.28, 95% CI 1.25–4.14) indicated increased willingness to use PrEP. In a multivariable model, older age (AOR 1.09, 95% CI 1.01–1.16) was associated with increased contacts with PE, and identifying as bong lâ (effeminate, AOR 0.29, 95% CI 0.11–0.75), or trai thăng (“straight boy”, AOR 0.43, 95% CI 0.23–0.80) versus bong kin (masculine) was associated with decreased contact with PE. Table 2. Bivariate and Multivariable Logistic Regression Models Assessing Factors Associated with Contact with Peer Educator in Last 12 Months and Willingness to Take Pre-Exposure Prophylaxis (PrEP) If It Involved Side Effects Participants who had previous contact with a PE more frequently indicated that they would take PrEP than those who had not. As PrEP becomes available for MSM in Vietnam, PE will likely play a large role in recruiting and educating participants about the efficacy of PrEP, adherence, and safer sex practices, and counseling related to stigma, side effects, and local resources. Training PE may increase the acceptability of PrEP for Vietnamese MSM, and their role in the expansion of PrEP services in Vietnam should be carefully considered. Given the high penetrance of PE in this population, leveraging this existing infrastructure may improve the feasibility and success of future HIV prevention interventions such as PrEP. Strategies to increase access to PE among key subpopulations are important to improve the scope and quality of programs based on this model. In this study, older men were more likely to have been reached by PE in the past year. This could reflect differences in social networks,10 and they are likely to have had more opportunities to be reached by peers, compared to younger men who have recently “come out.” Younger participants are a particularly vulnerable group, and future work should consider how to engage them in HIV prevention services.11 Participants identifying as bong lộ or trai thăng versus bong kin less frequently indicated engagement with PE. While bong lộ are more visible than other MSM identities in Vietnam,12 due to this visibility, they may also be more susceptible to stigma and therefore less likely to be willing to engage in peer education services in public settings. Similarly, trai thăng may not want to be seen in public or be less willing to engage in peer education since they identify as “straight”.12 Investments should be made to identify strategies to facilitate engagement with PE by bong lộ or trai thăng. This study has several potential limitations. Data collection relied on self-report, which could result in under- or over-reporting of sensitive behaviors. Questionnaires were administered by interviewers, which could result in social desirability bias. Finally, questions regarding side effects related to PrEP did not specify the specific side effects may be, or how severe they could be. More in-depth questions could elucidate which side effects would be barriers to taking PrEP among this population. PE may have the ability to access vulnerable hidden populations that are not reached by mainstream HIV prevention messages, which could maximize uptake of interventions such as PrEP. The results of this study indicate that integrating PE into future PrEP interventions may be an effective way to engage MSW in PrEP. The development of interventions that reach MSW and ensuring they are aware of choices and strategies for HIV prevention will be an important component of a comprehensive HIV prevention strategy in for MSW in Vietnam.

Pretreatment antiretroviral exposure from recreational use

The international community has overcome many obstacles in making HIV antiretroviral (ARV) medication available globally, but ARV resistance in treatment-naive individuals remains an implementation challenge. The subject of many recent reports,1-3 worries abound that pretreatment ARV resistance is related to treatment failure and that further increases in the rates of pretreatment ARV resistance might “jeopardise the global HIV response”.1,2 Largely attributed to transmitted resistance, pretreatment ARV exposure such as inadequate treatment outside of sanctioned care networks is believed to be a contributing factor.3 While investigating HIV-risk behaviour in South Africa,4 we learned of a preventable form of pretreatment ARV exposure that has gone largely unreported and may accelerate rates of pretreatment ARV resistance: the recreational use of ARVs referred to by our informants as “whoonga”. Whereas whoonga has received significant media attention since 2010, the first and only report in the medical literature documenting the recreational use of ARVs appeared years earlier from the United States. In discussions with HIV-infected individuals in Miami about prescription drug diversion, Inciardi and colleagues learned that some individuals abuse efavirenz for its “intoxicating” effects and use ritonavir to enhance the effects of illicit drugs such as methamphetamine and 3,4-methylenedioxymethamphetamine (MDMA/ecstasy).5 Claims about the psychoactive effects of these ARVs are supported by scientific case reports.6,7 Similar ARV abuse patterns in South Africa have been reported in the social science literature and news media. Larkan and colleagues provide an account of individuals smoking efavirenz in Western Cape and summarise media reports that ARVs are combined with illicit drugs such as opiates, methamphetamine, and/or marijuana to make drug cocktails.8 Whoonga, believed to be one such cocktail, brought media attention to the problem of recreational ARV use in Kwazulu-Natal because of its addictive potential, its association with criminal activity, and the challenge it posed to ARV rollout.9 Even local experts who maintain that whoonga is heroin and does not contain ARVs acknowledge that a number of South African drug abusers use ARVs recreationally.10 Although essentially a substance abuse problem, the implications for HIV treatment are broad. For example, diversion of ARVs, in addition to impacting adherence, reduces ARV supply and limits access to treatment. Criminal behaviour related to diversion of ARVs endangers patients and healthcare providers while deterring others from seeking care. Finally, the recreational use of ARVs further stigmatises HIV-infected patients and their communities and may undermine donor willingness to fund ARV treatment.8 In addition to these impacts, when untreated HIV-infected individuals are exposed to ARVs recreationally, they are at risk for acquiring resistance.8 Mutations conferring resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs) such as efavirenz are among the most common in individuals with pretreatment ARV resistance.1-3 Interestingly, serum concentrations of ARVs including efavirenz have been detected in some HIV-infected individuals with pretreatment ARV resistance who deny prior history of ARV treatment.3 To help explain some of these findings, researchers may wish to inquire specifically about recreational ARV use or use of drug cocktails when assessing pretreatment ARV exposure. Expanding pretreatment ARV resistance screening will help to minimize the risk that this form of pretreatment ARV exposure poses; however, a comprehensive strategy to investigate this problem also involves expanding substance abuse research. Existing substance abuse surveillance methods have not reported on the phenomenon,11,12 and they may need to be improved if we are to understand the extent of pretreatment ARV exposure from recreational ARV use. Systematic research is also needed to explore the chemical makeup of South African street drugs, the abuse liability of ARVs, and the bioavailability and likelihood of developing resistance when ARVs are smoked or otherwise administered inappropriately. Given the high prevalence and complex medical, psychosocial, and political context of HIV in southern Africa, it is important that treatment strategies adapt to emerging issues like recreational ARV use. We may decrease the recreational use of ARVs, decrease drug diversion, and improve adherence to HIV treatment if we avoid ARVs used recreationally when developing ARV treatment guidelines or distribute ARVs to patients in a way that minimizes the potential for misuse. The recreational use of ARVs also serves as a reminder that ARV treatment is not synonymous with HIV treatment and demonstrates the importance of access to effective community-based mental health and substance abuse services.

HIV Prevention Needs Among Street-Based Male Sex Workers in Providence, Rhode Island

We examined data derived from a needs assessment of the personal and social characteristics and HIV risk behavior of street-based male sex workers, in Providence, Rhode Island, who engage in transactional sexual intercourse with other men. Substance use, injected drugs, needle sharing, and psychosocial distress were highly prevalent among the sample. History of physical, sexual, and emotional abuse was associated with increased risk of condomless anal sexual intercourse with paying male clients.

Intimacy versus Isolation: A Qualitative Study of Sexual Practices among Sexually Active HIV-Infected Patients in HIV Care in Brazil, Thailand, and Zambia

The success of global treatment as prevention (TasP) efforts for individuals living with HIV/AIDS (PLWHA) is dependent on successful implementation, and therefore the appropriate contribution of social and behavioral science to these efforts. Understanding the psychosocial context of condomless sex among PLWHA could shed light on effective points of intervention. HPTN 063 was an observational mixed-methods study of sexually active, in-care PLWHA in Thailand, Zambia, and Brazil as a foundation for integrating secondary HIV prevention into HIV treatment. From 2010–2012, 80 qualitative interviews were conducted with PLWHA receiving HIV care and reported recent sexual risk. Thirty men who have sex with women (MSW) and 30 women who have sex with men (WSM) participated in equal numbers across the sites. Thailand and Brazil also enrolled 20 biologically-born men who have sex with men (MSM). Part of the interview focused on the impact of HIV on sexual practices and relationships. Interviews were recorded, transcribed, translated into English and examined using qualitative descriptive analysis. The mean age was 25 (SD = 3.2). There were numerous similarities in experiences and attitudes between MSM, MSW and WSM across the three settings. Participants had a high degree of HIV transmission risk awareness and practiced some protective sexual behaviors such as reduced sexual activity, increased use of condoms, and external ejaculation. Themes related to risk behavior can be categorized according to struggles for intimacy and fears of isolation, including: fear of infecting a sex partner, guilt about sex, sexual communication difficulty, HIV-stigma, and worry about sexual partnerships. Emphasizing sexual health, intimacy and protective practices as components of nonjudgmental sex-positive secondary HIV prevention interventions is recommended. For in-care PLWHA, this approach has the potential to support TasP. The overlap of themes across groups and countries indicates that similar intervention content may be effective for a range of settings.

The balancing act: Exploring stigma, economic need and disclosure among male sex workers in Ho Chi Minh City, Vietnam

In Vietnam, there is an emerging HIV epidemic among men who have sex with men (MSM). Male sex workers engage in high-risk sexual behaviours that make them particularly vulnerable to HIV infection. In 2010, 23 MSM in Ho Chi Minh City (HCMC) who recently received payment for sex with another man completed in-depth qualitative interviews exploring motivations for sex work, patterns of sex work disclosure and experiences of social stigma. Interviews were recorded, transcribed and translated into English and analysed using a qualitative descriptive approach. Low wages, unstable employment and family remittances were motivating factors for MSM in HCMC to sell sex. Participants described experiences of enacted and felt social stigma related to their involvement in sex work. In response, they utilised stigma management techniques aimed at concealment of involvement in sex work. Such strategies restricted sexual communication with non-paying sex partners and potentially limited their ability to seek social support from family and friends. Departing from decontextualized depictions of sex work disclosure, our findings describe how decisions to reveal involvement in sex work are shaped by social and structural factors such as social stigma, techniques to minimise exposure to stigma, economic imperatives and familial responsibilities.

Transactional sex and the challenges to safer sexual behaviors: a study among male sex workers in Chennai, India

ABSTRACT Male sex workers (MSW) are a significant but invisible population in India who are at risk for HIV/sexually transmitted infections (STIs). Few studies from India have documented HIV risk factors and motivations for sex work in this population. Between 2013 and 2014, a community-based convenience sample of 100 MSW in Chennai (south India) completed a baseline risk assessment as part of a behavioral intervention. Participants were ≥18 years, and reported current sex work. We report medians and proportions, and Wilcoxon–Mann–Whitney and chi-square tests are used to examine differences between sex work and sexual behavior measures by income source. Participants were engaged in sex work for 5.0 years (IQR = 2.3–10.0), and earned 3000 (IQR = 2000–8000) Rupees (<50 USD) per month from sex work. Sixty-four percent reported ever testing for HIV and 20.2% for any STI. The most common reasons for starting sex work were money (83.0%) and pleasure (56.0%). Compared to participants with an additional source of income, those whose only source of income was sex work reported more male clients in the past month (10.0 vs. 6.0, p = .017), as well as more condomless anal sex acts with male clients (8.0 vs. 5.0, p = .008). Nearly 70.0% were offered more money not to use a condom during sex with a client, and 74.2% reported accepting more money not to use a condom. Three-quarters reported having experienced difficulty using condoms with clients. MSW in India engage in high levels of sexual risk for HIV/STIs. Money appears to be a driving factor for engaging in sex work and condomless sex with clients. HIV prevention interventions with MSW should focus on facilitating skills that will support their ability to negotiate sexual safety in the context of monetary disincentives.

Exploring strategies for PrEP adherence and dosing preferences in the context of sexualized recreational drug use among MSM: a qualitative study

ABSTRACT The use of recreational drugs while having sex is associated with increased HIV incidence among men who have sex with men (MSM). Taking a daily antiretroviral pill, or pre-exposure prophylaxis (PrEP) is a biomedical intervention to prevent HIV. However, the efficacy of PrEP is closely tied with high levels of adherence. While PrEP has the potential to reduce HIV acquisition, the use of recreational drugs may impede adherence. We explored perceptions of PrEP utilization and regimen preferences among 40 HIV-negative, MSM who reported concurrent recreational drug use and condomless anal sex with a man. Semi-structured qualitative interviews were conducted and the data were analyzed using a qualitative descriptive approach. Participants perceived that it would be challenging to take PrEP while high on crystal meth, crack, powder cocaine, ecstasy and/or GHB. However, men identified strategies for using PrEP when they were not high on these drugs, including taking the pill when they started their day and integrating PrEP into an established routine, such as when taking other medications or preparing for sex. PrEP regimen preferences seemed to be shaped by the frequency in which participants used drugs and their ability to plan for sex. Taking PrEP everyday was appealing for those who regularly engaged in sexualized recreational drug use. Accounts depict these sexual interactions as frequent but unpredictable. A daily regimen would allow them to be prepared for sex without having to plan. An event-driven regimen was acceptable to men who occasionally used recreational drugs in the context of sex. For this group, sex usually occurred was generally prearranged. Patterns of sex and recreational drug use figured largely into participants’ framings of how they would use PrEP. These behaviors will likely play a role in the uptake of and adherence to PrEP among this population.

Applying behavioral activation to sustain and enhance the effects of contingency management for reducing stimulant use among individuals with HIV infection

ABSTRACT There is a high prevalence of stimulant use among HIV-infected individuals, which is associated with suboptimal antiretroviral therapy (ART) adherence, HIV treatment interruptions, detectable HIV viral load, and transmission of HIV via increased sexual risk behavior. Contingency management (CM) is an initially effective treatment for stimulant use. However, the effects of CM are not sustained after the active intervention has ended. One potential contributor to the intractability of existing treatments may be a lack of attention to replacement activities or the role of depressed mood. Behavioral activation (BA) is an evidence-based approach for depression that involves identifying and participating in pleasurable, goal-directed activities. As a potential approach to address the CM rebound effect – informed by our formative qualitative research with the participant population – we conducted an open pilot trial of an intervention combining CM-BA for HIV-infected individuals with stimulant use disorder. Participants completed weekly BA therapy sessions (10–16 sessions) and thrice-weekly toxicology screenings (12 weeks); contingencies were rewarded for negative toxicology tests to support reengagement into positive life activities. Major assessments were conducted at baseline, 3-, and 6-months. Toxicology screening was repeated prior to the 6-month assessment. Eleven participants with stimulant use disorder enrolled; 7 initiated treatment and completed the full intervention. The mean age was 46 (SD = 5.03) and 14% identified as a racial/ethnic minority. Of the completers, the mean change score in self-reported stimulant use within the past 30 days (within-person change; reduction in self-reported stimulant use) was 4.14 days at 3 months and 5.0 days at 6 months [Cohen’s d = 0.89]. The mean change score in weekly toxicology screens (reduction in positive toxicology screens) was .71 at 3 months and 1 at 6 months [Cohen’s d = 1.05]. Exit interviews indicated that the integrated intervention was well received and acceptable. This study provides preliminary evidence that a combined CM-BA intervention for this population was feasible (100% retention at 6-months), acceptable (100% of intervention sessions attended; participants rated the intervention ‘acceptable’ or ‘very acceptable’), and may be an option to augment the potency and sustained impact of CM for this population. Future pilot testing using a randomized controlled design is warranted.

“I Wasn’t in My Right Mind”: Qualitative Findings on the Impact of Alcohol on Condom Use in Patients Living with HIV/AIDS in Brazil, Thailand, and Zambia (HPTN 063)

PurposeThere have been significant biomedical improvements in the treatment and prevention of HIV over the past few decades. However, new transmissions continue to occur. Alcohol use is a known barrier to medication adherence and consistent condom use and therefore may affect treatment as prevention (TasP) efforts. The purpose of this study was to further explore how alcohol is associated with condom use and sexual transmission behavior in three international cities.MethodHIV Prevention Trials Network 063 was an observational mixed-methods study of HIV-infected patients currently in care in Rio de Janeiro, Brazil; Chiang Mai, Thailand; and Lusaka, Zambia. Across these three global cities, 80 qualitative interviews were conducted from 2010 to 2012. From these interviews, quotes related to substance use, almost all of which were alcohol, were analyzed using thematic analysis to identify how the use was related to sexual transmission behaviors.ResultsOverall, the theme that alcohol impairs cognitive abilities emerged from the data and included the following subthemes: expectancies, impaired decision-making, loss of control, and less concern for others. Themes specific to international settings and risk subgroups were also identified.ConclusionOur analysis identified how alcohol influences sexual transmission behavior in HIV patients in three international settings. These findings may provide direction for content development for future secondary prevention interventions to effectively implement TasP internationally.