Jeanne Ellard

Willingness to use HIV pre-exposure prophylaxis and the likelihood of decreased condom use are both associated with unprotected anal intercourse and the perceived likelihood of becoming HIV positive among Australian gay and bisexual men

Objectives To investigate willingness to use HIV pre-exposure prophylaxis (PrEP) and the likelihood of decreased condom use among Australian gay and bisexual men. Methods A national, online cross-sectional survey was conducted in April to May 2011. Bivariate relationships were assessed with χ2 or Fishers exact test. Multivariate logistic regression analysis was performed to assess independent relationships with primary outcome variables. Results Responses from 1161 HIV-negative and untested men were analysed. Prior use of antiretroviral drugs as PrEP was rare (n=6). Just over a quarter of the sample (n=327; 28.2%) was classified as willing to use PrEP. Willingness to use PrEP was independently associated with younger age, having anal intercourse with casual partners (protected or unprotected), having fewer concerns about PrEP and perceiving oneself to be at risk of HIV. Among men who were willing to use PrEP (n=327), only 26 men (8.0%) indicated that they would be less likely to use condoms if using PrEP. The likelihood of decreased condom use was independently associated with older age, unprotected anal intercourse with casual partners (UAIC) and perceiving oneself to be at increased risk of HIV. Conclusions The Australian gay and bisexual men the authors surveyed were cautiously optimistic about PrEP. The minority of men who expressed willingness to use PrEP appear to be appropriate candidates, given that they are likely to report UAIC and to perceive themselves to be at risk of HIV.

Seroconversion in context

This paper describes the accounts that homosexually active men give of their HIV seroconversion and interrogates these accounts for risk discourses. In particular, this paper asks whether the risk discourses of HIV researchers and educators are present in the mens narratives of their own seroconversion. Such discourses make reference to ‘unsafe’ sex – particularly the practice of unprotected anal intercourse, numbers of sexual partners or ‘promiscuity’, and the disinhibiting effect of drugs and alcohol. The data are drawn from an ongoing case-series study of seroconversion in which men who had seroconverted were asked to give an account of the occasion on which they believe they were infected. A number of themes were identified in the mens accounts. The mens descriptions of what they believe to be the seroconversion event indicate that their attributions, i.e., the reasons they give for their HIV infection, vary depending on the context. Within regular relationships, breakdown of negotiated safety, love and intimacy, and fatalism were among the explanations given. Seroconversion attributed to casual sexual encounters was more likely to be explained in terms of pleasure, lack of control, and with reference to particular sexual settings. The ways in which men understood their HIV infection were informed both by the risk discourse of HIV researchers and also by the discourses of love and pleasure, as well as that of control.

How homosexual men believe they became infected with HIV: the role of risk-reduction behaviors.

Objectives:A range of HIV risk reduction strategies has been described in homosexual men who practice unprotected anal intercourse (UAI), including serosorting, strategic positioning, and negotiating around an HIV-positive partners viral load. It is uncertain how commonly these behaviors might result in HIV infection. We describe sexual behaviors and associated risk reduction strategies reported by homosexual men in their accounts of their recent seroconversion. Methods:Homosexual men recently diagnosed with primary HIV infection between 2003 and 2006 were invited to participate in a nurse-administered survey. Results:Among 158 men enrolled, 143 (91%) were able to identify the high-risk event that they believed led to their HIV seroconversion, and this involved UAI in 102 (71%). Among these 102 men, 21 (21%) reported they were certain that the source partner was HIV-negative. Ten men (10%) reported insertive UAI as the highest risk behavior. Of the 21 men who reported knowing the HIV-positive partners viral load, 9 reported that the man had an undetectable viral load (43%). Conclusion:In 38% of the high-risk events involving UAI, infection occurred when the reported risk event involved serosorting, strategic positioning, or intercourse with a man whose viral load was believed to be undetectable.

Risk factors for HIV seroconversion in homosexual men in Australia

BACKGROUND Rates of newly acquired HIV infection are increasing in Australia, and sexual contact between men accounts for 85% of cases. OBJECTIVE To investigate behavioural risk factors for HIV seroconversion among gay and bisexual men from Sydney and Melbourne, Australia. METHODS 103 men with newly acquired HIV infection were recruited from clinics in Sydney and Melbourne and behavioural risk factor questionnaires were administered between January 2003 and October 2004. Results were compared with a cross sectional and a cohort study performed by our group that enrolled similar populations of men. RESULTS The majority of seroconverters (73%) reported more than five sexual partners in the last six months. Ninety-five men (92%) were able to identify a high-risk event (HRE) that they thought had led to their HIV seroconversion. Most (70%) reported receptive unprotected anal intercourse (UAI), insertive UAI, or both at their HRE. Sixteen men (16%) reported no UAI in the preceding six months including the HRE. Men were more likely to report receptive UAI at their HRE when they perceived a partner to be HIV-negative as compared with when they perceived a partner to be HIV-positive (P = 0.05). Injection drug use was reported by 22% of the men in the previous six months, and 62% reported intoxication with alcohol (> or =5 drinks) or mood altering recreational drug use at the HRE. CONCLUSIONS Gay and bisexual men who have recently seroconverted are highly sexually active and report high rates of unprotected anal intercourse and recreational drug use at the HRE.

Investigating combination HIV prevention: isolated interventions or complex system

Treatment as prevention has mobilized new opportunities in preventing HIV transmission and has led to bold new UNAIDS targets in testing, treatment coverage and transmission reduction. These will require not only an increase in investment but also a deeper understanding of the dynamics of combining behavioural, biomedical and structural HIV prevention interventions. High‐income countries are making substantial investments in combination HIV prevention, but is this investment leading to a deeper understanding of how to combine interventions? The combining of interventions involves complexity, with many strategies interacting with non‐linear and multiplying rather than additive effects.

Willingness to use HIV pre-exposure prophylaxis has declined among Australian gay and bisexual men: Results from repeated national surveys, 2011-2013

Abstract:We surveyed willingness to use pre-exposure prophylaxis (PrEP) and the likelihood of decreased condom use among Australian gay and bisexual men in 2011 and 2013 (n = 2384). Willingness to use PrEP declined from 28.2% to 23.3% [adjusted odds ratio = 0.83, 95% confidence interval (CI): 0.68 to 1.00, P = 0.050]. Willingness to use PrEP was the greatest among men with HIV-positive partners and among those who had taken HIV postexposure prophylaxis. Among men willing to use PrEP, the likelihood of decreased condom use remained stable between 2011 and 2013 (8.0% vs. 11.9%; adjusted odds ratio = 1.40, 95% CI: 0.80 to 2.45, P = 0.23). A minority of men remain willing to use PrEP and appear to be appropriate candidates for it.

HIV risk among Australian men travelling overseas: networks and context matter

Increasing international mobility presents a risk for communicable disease transmission. Overseas-acquired HIV infections have been increasingly observed across Australian jurisdictions. This includes a mix of men emigrating from countries with high HIV prevalence and men travelling abroad. There is currently little research exploring international mobility and HIV risk, and as a consequence the increase of men acquiring HIV while travelling overseas is poorly understood. This paper draws on data from a qualitative study exploring the risk perspectives and experiences of 14 Australian men who acquired HIV while travelling overseas in the years between 2000 and 2009. Participants articulated a strong desire to distance themselves from the identity of a tourist. Social networks were highlighted as important entry points to engage with other foreign travellers and expatriates. These networks were highly influential and were understood by the participants to provide guidance on how they should negotiate the local scene, including where to meet sex partners. Limited discussion of safe sex and HIV was mentioned in these contexts. The findings suggest that prevalent social norms and social networks play an influential role in how participants negotiate sex and social relations in overseas settings. These networks could potentially provide sites for effective HIV-prevention programmes.

‘We just don’t know’: ambivalence about treatment strategies in the Australian community-based HIV media

The community-based HIV media in Australia provide a unique arena for the negotiation of competing models of medicine between activists, clinicians, government and people living with HIV/AIDS. This article examines how these media have interpreted developments in HIV treatment strategies since the introduction of new treatments in 1996, and identifies the discursive elements employed in journalistic constructions of the temporality and character of HIV medicine. A discourse of ambivalence recurs throughout this journalism, framing the negotiated shifts in treatment strategies as evidence of the uncertainty and unpredictability of HIV medicine. Associated with this discourse are metaphors of medical ambivalence that employ provocative imagery such as fashion, rollercoaster, obstacle course and guessing game to shore up a notion of the volatility of HIV medicine. This article participates in ongoing engagements between the communities and clinicians affected by HIV/AIDS and, more broadly, in the production of knowledge around medicine and the media.

Human Papillomavirus 16–Specific T-Cell Responses and Spontaneous Regression of Anal High-Grade Squamous Intraepithelial Lesions

BACKGROUND Most anal cancers are attributable to persistent human papillomavirus type 16 (HPV-16) infection. The anal cancer precursor, high-grade squamous intraepithelial lesion (HSIL), frequently regresses spontaneously. We hypothesized that T-cell responses are associated with HSIL regression. METHODS In men who have sex with men undergoing anal cytology and high-resolution anoscopy, we measured responses to HPV-16 oncogenic proteins E6 and E7, using the CD25/CD134 assay for CD4(+) antigen-specific T cells and intracellular cytokine staining for CD4(+) and CD8(+) antigen-specific T cells. RESULTS Of 134 participants (mean [SD] age, 51 [9.3] years; 31 [23.1%] infected with human immunodeficiency virus), 51 (38.1%) had HSIL. E6- and E7-specific CD4(+) T-cell responses were detected in 80 (59.7%) and 40 (29.9%) of the participants, respectively, and E6- and E7-specific CD8(+) T-cell responses were each detected in 25 (18.7%). HSIL was significantly associated with E7-specific CD8(+) T-cell responses (odds ratio, 4.09 [95% confidence interval, 1.55-10.77], P = .004), but not with any CD4(+) T-cell response (P ≥ .09). Twenty-six participants had HSIL a mean of 1 year before measurement of T-cell responses, and 6 (23%) of them were regressors. Five regressors (83%) had E6-specific CD4(+) T-cell responses vs 7 of 20 (35%) nonregressors (Pexact = .065). CONCLUSIONS Systemic HPV-16 E6- and E7-specific T-cell responses were common in men who have sex with men. E6-specific CD4(+) T-cell responses may be associated with recent HSIL regression. CLINICAL TRIALS REGISTRATION NCT02007421.

Recently diagnosed gay men talk about HIV treatment decisions

UNLABELLED Background In recent years, there has been increasing evidence that early initiation of antiretroviral therapy (ART) may provide health benefits for those infected with HIV. There has also been significant discussion about the role of HIV treatment in preventing onward transmission of the virus. Early provision and uptake of ART to people recently diagnosed with HIV could achieve both individual and public health outcomes. The success of such an initiative relies, in part, on the preparedness of those recently diagnosed with HIV to engage with the therapy. METHODS The HIV Seroconversion Study collects both quantitative and qualitative data from people in Australia who have recently been diagnosed with HIV. During 2011-2012, 53 gay or bisexual men recruited across Australia took part in semistructured interviews as part of the study. The men were asked about their knowledge and experience of, and their decisions about whether or not to commence, HIV treatment. RESULTS The interviews identified differing levels of knowledge about HIV treatments and divergent views about the health and prevention benefits of ART. For some, treatments provided a sense of control over the virus; others were apprehensive and distrustful, and preferred to resist commencing treatments for as long as possible. CONCLUSIONS If early initiation of treatment is to be encouraged, appropriate measures must be in place to ensure recently diagnosed individuals have access to the appropriate information and the support they need to enable them to make informed choices and, if necessary, to address their fears.