Jerome T Galea

Don’t ask, don’t tell: patterns of HIV disclosure among HIV positive men who have sex with men with recent STI practising high risk behaviour in Los Angeles and Seattle

Objectives: A high incidence of HIV continues among men who have sex with men (MSM) in industrialised nations and research indicates many MSM do not disclose their HIV status to sex partners. Themes as to why MSM attending sexually transmitted infection (STI) clinics in Los Angeles and Seattle do and do not disclose their HIV status are identified. Methods: 55 HIV positive MSM (24 in Seattle, 31 in Los Angeles) reporting recent STI or unprotected anal intercourse with a serostatus negative or unknown partner from STI clinics underwent in-depth interviews about their disclosure practices that were tape recorded, transcribed verbatim, coded, and content analysed. Results: HIV disclosure themes fell into a continuum from unlikely to likely. Themes for “unlikely to disclose” were HIV is “nobody’s business,” being in denial, having a low viral load, fear of rejection, “it’s just sex,” using drugs, and sex in public places. Themes for “possible disclosure” were type of sex practised and partners asking/disclosing first. Themes for “likely to disclose” were feelings for partner, feeling responsible for partner’s health, and fearing arrest. Many reported non-verbal disclosure methods. Some thought partners should ask for HIV status; many assumed if not asked then their partner must be positive. Conclusions: HIV positive MSM’s decision to disclose their HIV status to sex partners is complex, and is influenced by a sense of responsibility to partners, acceptance of being HIV positive, the perceived transmission risk, and the context and meaning of sex. Efforts to promote disclosure will need to address these complex issues.

Acceptability of pre-exposure prophylaxis as an HIV prevention strategy: barriers and facilitators to pre-exposure prophylaxis uptake among at-risk Peruvian populations

This study examined pre-exposure prophylaxis (PrEP) acceptability among female sex workers, male-to-female transgendered persons and men who have sex with men in Lima, Peru. Focus groups explored social issues associated with PrEP acceptability and conjoint analysis assessed preferences among eight hypothetical PrEP scenarios with varying attribute profiles and their relative impact on acceptability. Conjoint analysis revealed that PrEP acceptability ranged from 19.8 to 82.5 out of a possible score of 100 across the eight hypothetical PrEP scenarios. Out-of-pocket cost had the greatest impact on PrEP acceptability (25.2, P < 0.001), followed by efficacy (21.4, P < 0.001) and potential side-effects (14.7, P < 0.001). Focus group data supported these findings, and also revealed that potential sexual risk disinhibition, stigma and discrimination associated with PrEP use, and mistrust of healthcare professionals were also concerns. These issues will require careful attention when planning for PrEP roll-out.

Sexual diversity social inclusion and HIV / AIDS.

Despite a number of programmes to prevent HIV among men who have sex with men (MSM) and, more generally, sexually diverse populations, gay and other homosexually active men continue to be at heightened risk of HIV and its consequences. This paper analyses some of the reasons for this situation and offers policy and programmatic recommendations to contribute to a solution. The social exclusion of MSM and transgender individuals is an overwhelming reality in the majority of countries worldwide. Although progress has been achieved in some countries, in most of the world the situation remains problematic. Present challenges to equality and to the realization of health, include the membership of groups or subcultures with high HIV prevalence, lower quality and coverage of services and programmes and the impact of higher-level influences such as laws, public policies, social norms and culture, which together configure an environment that is hostile to the integration and needs of certain groups. A social inclusion perspective on HIV prevention and AIDS-related care implies the adoption of strategies to understand and confront social vulnerability. Sexual exclusion intensifies the burden of HIV transmission and morbidity. As part of a comprehensive response there is an urgent need to: (i) improve our understanding of the characteristics and HIV burden among sexually diverse populations; (ii) creatively confront legal, social and cultural factors enhancing sexual exclusion; (iii) ensure the provision of broad-based and effective HIV prevention; (iv) offer adequate care and treatment; and (v) confront special challenges that characterize work with these populations in lower and middle-income countries.

The HOPE social media intervention for global HIV prevention in Peru: a cluster randomised controlled trial

BACKGROUND Social media technologies offer new approaches to HIV prevention and promotion of testing. We examined the efficacy of the Harnessing Online Peer Education (HOPE) social media intervention to increase HIV testing among men who have sex with men (MSM) in Peru. METHODS In this cluster randomised controlled trial, Peruvian MSM from Greater Lima (including Callao) who had sex with a man in the past 12 months, were 18 years of age or older, were HIV negative or serostatus unknown, and had a Facebook account or were willing to create one (N=556) were randomly assigned (1:1) by concealed allocation to join intervention or control groups on Facebook for 12 weeks. For the intervention, Peruvian MSM were trained and assigned to be HIV prevention mentors (peer-leaders) to participants in Facebook groups. The interventions period lasted 12 weeks. Participants in control groups received an enhanced standard of care, including standard offline HIV prevention available in Peru and participation in Facebook groups (without peer leaders) that provided study updates and HIV testing information. After accepting a request to join the groups, continued participation was voluntary. Participants also completed questionnaires on HIV risk behaviours and social media use at baseline and 12 week follow-up. The primary outcome was the number of participants who received a free HIV test at a local community clinic. The facebook groups were analysed as clusters to account for intracluster correlations. This trial is registered with ClinicalTrials.gov, number NCT01701206. FINDINGS Of 49 peer-leaders recruited, 34 completed training and were assigned at random to the intervention Facebook groups. Between March 19, 2012, and June 11, 2012, and Sept 26, 2012, and Dec 19, 2012, 556 participants were randomly assigned to intervention groups (N=278) or control groups (N=278); we analyse data for 252 and 246. 43 participants (17%) in the intervention group and 16 (7%) in the control groups got tested for HIV (adjusted odds ratio 2·61, 95% CI 1·55–4·38). No adverse events were reported. INTERPRETATION Development of peer-mentored social media communities seemed to be an efficacious method to increase HIV testing among high-risk populations in Peru. Results suggest that the HOPE social media intervention could improve HIV testing rates among MSM in Peru. FUNDING National Institute of Mental Health.

Acceptability of Oral versus Rectal HIV Preexposure Prophylaxis among Men Who Have Sex With Men and Transgender Women in Peru

Objective: Oral preexposure prophylaxis (PrEP) with antiretrovirals (ARVs) is at the forefront of biomedical HIV prevention research, and ARVs are also being tested for rectal administration to target people practicing unprotected receptive anal intercourse (URAI) and at risk of HIV infection. This study assessed the acceptability of daily oral PrEP and rectal PrEP during URAI among men who have sex with men (MSM) and transgender women (TGW) in Peru. Methods: During the 2008 HIV sentinel surveillance survey conducted in 3 Peruvian cities (Lima, Iquitos, and Pucallpa), MSM and TGW reported being “versatile,” “most of the time receptive,” and “exclusively receptive” during anal sex behavior where surveyed on their acceptability of oral and rectal PrEP. Results: Among 532 individuals, high acceptance of either oral (96.2%) or rectal (91.7%) PrEP products was reported. If both products were efficacious/available, 28.6% would prefer a pill, 57.3% a rectal lubricant, and 14.1% either. A trend toward higher acceptance was observed as receptive anal sex behavior exclusivity rose (P = .013). Being receptive most of the time (adjusted odds ratio [aOR]: 9.1, P = .01) and exclusively receptive (aOR: 7.5, P = .01), compared to being versatile, were independently associated with oral PrEP acceptability. A similar association was found with the acceptability of rectal formulations (aOR: 2.3, P = .07; and aOR: 2.5, P = .02; respectively). Conclusions: Oral and rectal PrEP were highly acceptable among Peruvian MSM and TGW, particularly among those at the highest HIV infection risk. These data can guide the implementation of PrEP programs in Peru and similar settings and populations.

The Effect of HIV-Related Immunosuppression on the Risk of Tuberculosis Transmission to Household Contacts

BACKGROUND Coinfection with human immunodeficiency virus (HIV) may modify the risk of transmitting tuberculosis. Some previous investigations suggest that patients coinfected with HIV and tuberculosis are less likely to transmit infection, whereas others do not support this conclusion. Here, we estimated the relative risk of tuberculosis transmission from coinfected patients compared to HIV-negative patients with tuberculosis. METHODS Between September 2009 and August 2012, we identified and enrolled 4841 household contacts of 1608 patients with drug-sensitive tuberculosis in Lima, Peru. We assessed the HIV status and CD4 counts of index patients, as well as other risk factors for infection specific to the index patient, the household, and the exposed individuals. Contacts underwent tuberculin skin testing to determine tuberculosis infection status. RESULTS After adjusting for covariates, we found that household contacts of HIV-infected tuberculosis patients with a CD4 count ≤250 cells/µL were less likely to be infected with tuberculosis (risk ratio = 0.49 [95% confidence interval, .24-.96]) than the contacts of HIV-negative tuberculosis patients. No children younger than 15 years who were exposed to HIV-positive patients with a CD4 count ≤250 cells/µL were infected with tuberculosis, compared to 22% of those exposed to non-HIV-infected patients. There was no significant difference in the risk of infection between contacts of HIV-infected index patients with CD4 counts >250 cells/µL and contacts of index patients who were not HIV-infected. CONCLUSIONS We found a reduced risk of tuberculosis infection among the household contacts of patients with active tuberculosis who had advanced HIV-related immunosuppression, suggesting reduced transmission from these index patients.

Using Conjoint Analysis to Measure the Acceptability of Rectal Microbicides Among Men Who Have Sex with Men in Four South American Cities

Conjoint Analysis (CJA), a statistical market-based technique that assesses the value consumers place on product characteristics, may be used to predict acceptability of hypothetical products. Rectal Microbicides (RM)—substances that would prevent HIV infection during receptive anal intercourse—will require acceptability data from potential users in multiple settings to inform the development process by providing valuable information on desirable product characteristics and issues surrounding potential barriers to product use. This study applied CJA to explore the acceptability of eight different hypothetical RM among 128 MSM in Lima and Iquitos, Peru; Guayaquil, Ecuador; and Rio de Janeiro, Brazil. Overall RM acceptability was highest in Guayaquil and lowest in Rio. Product effectiveness had the greatest impact on acceptability in all four cities, but the impact of other product characteristics varied by city. This study demonstrates that MSM from the same region but from different cities place different values on RM characteristics that could impact uptake of an actual RM. Understanding specific consumer preferences is crucial during RM product development, clinical trials and eventual product dissemination.ResumenEl Análisis Conjunto (CJA por sus siglas en inglés) es una técnica estadística de mercadotecnia que sirve para evaluar la valoración que los consumidores otorgan a las características de un producto, y que puede ser usada para predecir la aceptabilidad de productos hipotéticos. Para el desarrollo de microbicidas rectales (MR)—sustancias que podrían prevenir la infección por VIH durante el coito anal receptivo—es necesario contar con datos de aceptabilidad, características deseadas y probables barreras para el empleo de MR por usuarios potenciales, en múltiples escenarios. Este estudio aplica CJA para explorar la aceptabilidad de ocho diferentes MR hipotéticos entre 128 HSH en Lima e Iquitos, Perú; Guayaquil, Ecuador; y Río de Janeiro, Brasil. En general, la más alta aceptabilidad se dio en Guayaquil y la más baja en Río. La eficacia del producto tuvo el mayor impacto sobre la aceptabilidad en las cuatro ciudades, pero el impacto de otras características del producto varió por ciudades. Este estudio demuestra que los HSH, aunque son de la misma región, pero de diferentes ciudades, otorgan valores distintos a las características de los MR, lo cual podría afectar el uso de un MR real. Es crucial entender las preferencias específicas de los consumidores durante la investigación, desarrollo y eventual difusión de los MR.

Lubricant use among men who have sex with men reporting receptive anal intercourse in Peru: implications for rectal microbicides as an HIV prevention strategy.

This study assessed lubricant use during receptive anal intercourse (RAI) among Peruvian men who have sex with men (MSM) and willingness to use a hypothetical rectal microbicide (RM) formulated as a lubricant to prevent HIV infection. Data were collected from 843 Peruvian MSM for the 2008 HIV Sentinel Surveillance using a computerized self-interview. Half of the participants reported using a lubricant with their last sex partner during RAI, while 77% were willing to use a lubricant to prevent HIV transmission. Lubricant use with last sex partner was significantly associated with unprotected RAI (odds ratio [OR] 1.59, 95% confidence interval [CI], 1.23, 2.05; P < 0.001) and willingness to use a future lubricant RM (OR 1.56, 95% CI: 1.24, 1.95; P < 0.001). This study provides information on the behaviours associated with lubricant use and non-use among MSM practicing RAI in Peru that should inform future RM studies in Peru and other Latin American countries.

Innovative approaches to cohort retention in a community-based HIV / STI prevention trial for socially marginalized Peruvian young adults.

Background The conduct of longitudinal clinical trials must involve effective strategies to retain study participants in order to ensure internal validity, adequate statistical power and generalizability of results. Purpose In a large trial in Peru, we implemented various retention strategies to maintain high participation rates over time. Methods Novel participant retention strategies were used to follow highly marginalized populations for two years because traditional locator information, such as telephone numbers and official identification (eg, passport, drivers license, the local equivalent of a social security number) were often unreliable or unavailable. These strategies included detailed preliminary ethnographic research to identify the behaviours of key target groups, approaches to develop strong informal bonds between project staff and participants outside of study settings, and methods to enhance positive participant attitudes towards the study. Results The overall study retention rate after two years was 84%, even though only 26% of the study populations supplied complete locator information (telephone, address and the names of two friends). Limitations The retention strategies used were labour intensive and iterative, which could prove difficult to replicate. Conclusions The two-year retention rate in this study was sufficient to maintain required sample sizes. The methods used to maintain contact with the populations were labour intensive, low tech and adequate for these populations and could be used to retain study participants in other marginalized, urban, low-income areas.

The role of human papillomavirus in human immunodeficiency virus acquisition in men who have sex with men: a review of the literature.

Human Papillomavirus (HPV) infection is the most common sexually transmitted infection (STI) worldwide. Incidence rates of HPV infection among human immunodeficiency virus (HIV)-infected individuals are well documented and are several-fold higher than among HIV-uninfected individuals. Few studies have demonstrated an increased risk for acquiring HIV infection in those with HPV infection, and this risk seems to be higher when HPV strains are of high-risk oncogenic potential. The estimated prevalence of high-risk oncogenic HPV infection is highest in men who have sex with men (MSM), a particularly vulnerable group with high prevalence rates of HIV infection and other STIs. In this paper, we provide a comprehensive review of the available literature on the role of HPV infection in HIV acquisition. Our review includes data from cross-sectional and longitudinal studies.