Lionel Fugon

Factors associated with unprotected anal intercourse among men who have sex with men in Douala, Cameroon.

Objectives Research on men who have sex with men (MSM) in sub-Saharan Africa was neglected for a long time. The objective of this study was to understand factors associated with unprotected anal intercourse (UAI) with male partners among a group of MSM living in the city of Douala, Cameroon. Methods In 2008, a survey on the sexual activity and practices of MSM was set up in Douala in collaboration with a local community-based organisation. Data were collected among a convenience sample of 168 MSM during face-to-face interviews with trained interviewers. Results A total of 142 individuals reported sexual activity during the previous 6 months, among whom 80 (57%) reported UAI with male partners. In a multivariate logistic regression model adjusted for the frequency of sexual intercourse, not having had access to prevention interventions and not knowing any HIV-infected person were both independently associated with a higher risk of UAI. Other factors associated with this higher risk included having had a stable male partnership at some point in ones life and not having been out of Douala for more than 4 weeks during the previous year. Conclusions This community-based research is the first study of MSM in Cameroon and the HIV transmission risks they face. Results show the importance of HIV prevention interventions from peers, and underline the need to maintain efforts to develop specific interventions targeting MSM more efficiently in the African context.

Acceptability of an "on-demand" pre-exposure HIV prophylaxis trial among men who have sex with men living in France.

Abstract Although predictors of willingness to take daily, self-administered pre-exposure HIV prophylaxis (PrEP) for men who have sex with men (MSM) have been studied in the context of several PrEP trials internationally, little is known about MSM interested in participating in a trial on the use of PrEP on an “on -demand” basis, i.e., taking a first dose of combined tenofovir/emtricitabine a few hours before possible HIV sexual exposure and a second dose a few hours afterwards. A double-blind placebo randomized PrEP trial will soon begin in France to evaluate the effectiveness of PrEP in terms of reducing HIV infection rates, among MSM self-administering “on-demand” PrEP. To assess potential participants’ characteristics associated with willingness to participate in the trial and identify barriers and facilitators to implementation, MSM completed a self-administered questionnaire, distributed via gay venues and community websites. Among the 443 respondents who reported being HIV-negative, 40% reported being interested in participating. Factors independently associated with interest included: reporting lower educational level, more than 20 male sexual partners in the previous year, reporting unprotected anal sex with casual partners and preferring PrEP follow-up visits in a devoted area within a hospital. There is great interest in participating in a future “on-demand” PrEP trial among HIV-negative MSM and particularly in those at potentially high risk of HIV exposure. Providing confidentiality and tailored counseling during PrEP follow-up are important issues.

Access to and use of unauthorised online HIV self-tests by internet-using French-speaking men who have sex with men

Objectives Although not authorised in France, HIV self-tests are easily available online. The authors questioned French-speaking internet-using men who have sex with men (MSM) concerning their access to and use of such tests. Methods Online questionnaire on sex websites and gay and HIV community websites. A multivariate logistic regression for rare events was used to identify factors associated with accessing self-tests. Results 9169 MSM completed the questionnaire. 2748 (30%) were aware of online self-tests, but only 82 of those aware and not already HIV positive (3.5%) declared having accessed one and only 69 using it. In the multivariate model, living ones sex-life with men in absolute secrecy (odds ratio (OR)=3.90, 95% CI 1.73 to 8.76), knowing of the tests via a sex partner (OR=3.42, CI 1.39 to 8.41) or an internet search engine (OR=2.18, CI 1.26 to 3.74) but not through the general (OR=0.21, CI 0.11 to 0.42) or the gay press (OR=0.34, CI 0.16 to 0.73), having unprotected anal intercourse with a casual partner in the preceding year (OR=1.90, CI 1.17 to 3.06), using self-tests for other diseases (OR=2.66, CI 1.43 to 4.90), using poppers (OR=2.23, CI 1.35 to 3.67) and doping products (OR=3.53, CI 1.55 to 8) in the preceding year, having done a traditional HIV test but not in the preceding year (OR=1.93, CI 1.14 to 3.32), never having had suicidal thoughts (OR=0.54, CI 0.32 to 0.90) and living in the provinces (OR=1.80, CI 1.01 to 3.25) were all independently associated with accessing self-tests. Conclusions Although readiness to admit use of unauthorised medical products may have influenced results, few MSM aware of the existence of self-tests actually declared having accessed one. Accessing the self-test was independently associated with both living ones sex-life with men in total secrecy and having had unprotected anal intercourse in the last 12 months, indicating that autonomous self-testing may reduce barriers to testing for this vulnerable population.

Internet-using men who have sex with men would be interested in accessing authorised HIV self-tests available for purchase online

Abstract Men who have sex with men (MSM) recruited in sex venues have been shown to be interested in accessing HIV home-tests if reliable and authorised tests were available. To what extent is this true for MSM recruited online? In an online survey in French on the use of unauthorised HIV home-tests purchased online, MSM previously unaware of the existence of these tests were asked if they would be interested in accessing them if these tests were authorised. Among 5908 non-HIV positive respondents, 86.5% expressed interest. Independent variables associated with interest included: being younger, living in smaller towns, having a job but not tertiary education and living in a conventional family with ones parents or a wife and family. Interested men were also more likely to have never done the standard HIV test or not in the last year, to have casual sex partners but on average not more than once a week, to take sexual risks with these partners, to live their sex-lives with men in absolute secrecy and yet often to try to make a date to see their sex partners again. Of the 5109 respondents interested in accessing self-tests purchasable online, 4362 (85.4%) answered an open question on their reasons for being interested. Using thematic analysis, principle themes identified proved to be similar to those found in earlier studies with MSM recruited in sex venues: convenience, rapidity accessing results and privacy. In answer to a closed question, men not interested chose as reasons: satisfaction with current method, doubts about reliability, not wanting to be alone when discovering results and fear of incorrect use. In conclusion, although the online questionnaire may have introduced selection bias over-representing men already interested, many Internet-using MSM are interested in accessing self-tests available for purchase online.

Buprenorphine/naloxone as a promising therapeutic option for opioid abusing patients with chronic pain: reduction of pain, opioid withdrawal symptoms, and abuse liability of oral oxycodone.

&NA; In opioid‐dependent individuals with chronic pain, buprenorphine/naloxone may be an effective therapeutic option using adequate dose and paying attention to withdrawal symptoms and pain. &NA; Few studies have examined abuse of prescription opioids among individuals with chronic pain under buprenorphine/naloxone (Bup/Nx) maintenance. The current 7‐week inpatient study assessed oral oxycodone self‐administration by patients with chronic pain who had a history of opioid abuse. Participants (n = 25) were transitioned from their preadmission prescribed opioid to Bup/Nx. All of the participants were tested under each of the sublingual Bup/Nx maintenance doses (2/0.5, 8/2 or 16/4 mg) in random order. During each maintenance period, participants could self‐administer oxycodone orally (0, 10, 20, 40 or 60 mg prescription opioids) or receive money during laboratory sessions. Drug choice (percentage) was the primary dependent variable. Subjective ratings of clinical pain and withdrawal symptoms also were measured. Mann‐Whitney tests compared percentage of drug choice for each active oxycodone dose to placebo. Logistic regression analyses identified correlates of oxycodone preference, defined as 60% or greater choice of oxycodone compared to money. Pain was significantly reduced while participants were maintained on Bup/Nx compared to preadmission ratings. No differences in percentage drug choice were observed between the active oxycodone doses and placebo under each Bup/Nx maintenance dose. However, factors associated with oxycodone preference were lower Bup/Nx maintenance dose, more withdrawal symptoms and more pain. These data suggest that Bup/Nx was effective in reducing pain and supplemental oxycodone use. Importantly, adequate management of pain and withdrawal symptoms by Bup/Nx may reduce oxycodone preference in this population.

Harmful alcohol consumption and patterns of substance use in HIV-infected patients receiving antiretrovirals (ANRS-EN12-VESPA Study): relevance for clinical management and intervention

Abstract Alcohol abuse affects secondary prevention and disease progression in HIV-infected patients, and adherence and response to treatment in those chronically treated. The objective of this study was to estimate the prevalence of harmful alcohol consumption (HAC) using various indicators and identify which groups of patients may require specific targeted interventions for HAC risk reduction. A cross-sectional survey, based on a random sample representative of people living with HIV/AIDS (PLWHA) was carried out in 102 French hospital departments delivering HIV care. As alcohol abuse is particularly detrimental to patients receiving highly active antiretroviral therapy (HAART), we focused only on those individuals receiving HAART with complete alcohol assessment (CAGE, AUDIT-C, regular binge drinking, N=2340). Collected information included medical and socio-demographic data, HIV risk behaviors, adherence to treatment and substance and alcohol use, together with depression, anxiety, and experience of attempted suicide or sex work. HAC prevalence was evaluated as follows: 12% (CAGE score ≥2), 27% (AUDIT-C), and 9% (regular binge drinking). Three groups were at higher risk of HAC: men who have sex with men using stimulants, polydrug users, and to a lesser degree, ex-drug users. Innovative intervention strategies to reduce HAC and improve HIV prevention and HAART adherence in various PLWHA populations need urgent testing and implementation. Such interventions for alcohol risk reduction remain central to promoting improved HIV prevention and assuring HAART effectiveness in these populations.

Non-adherence to aspirin in patients undergoing coronary stenting: Negative impact of comorbid conditions and implications for clinical management

BACKGROUND Premature discontinuation of and reduced adherence to antiplatelet therapy have been identified as major risk factors for stent thrombosis and poor prognosis after acute coronary syndrome. AIM We aimed to identify correlates of non-adherence to aspirin among patients who had undergone coronary stenting. METHODS We prospectively included all patients who had undergone coronary stenting in our institution. Response to aspirin was assessed during the hospital phase with arachidonic acid-induced platelet aggregation (AA-Ag) and only good responders to aspirin (AA-Ag<30%) were included in the study for longitudinal assessment (n=308). Response to aspirin was reassessed 1 month after hospital discharge and non-responders received a directly observed intake of aspirin to exclude any biological non-response due to bioavailability problems. After excluding patients with such problems, response to aspirin based on platelet function testing was used to estimate non-adherence to aspirin after coronary stenting. A logistic regression model was used to identify predictors of non-adherence. RESULTS Non-adherence to aspirin concerned 14% of the study sample (n=43). After adjustment for age, those who reported the highest risk of non-adherence to aspirin were migrants (odds ratio [95% confidence interval], 8.3 [3.5-19.8], followed by patients receiving treatment for diabetes (4.5 [1.9-10.9]). Smokers had a threefold risk of non-adherence (3.1 [1.4-6.9]). CONCLUSIONS Non-adherence to aspirin is relatively frequent in populations at high risk of cardiovascular events. Appropriate case management and special interventions targeting these groups need to be implemented to avoid fatal events and assure long-term adherence to treatment.

Coming out of the Nkuta: disclosure of sexual orientation associated with reduced risk behavior among MSM in Cameroon.

The situation of sexual minorities in Cameroon is a human rights issue (Alternatives Cameroun, Adefho, Human Rights Watch, IGLHRC, 2010; Alternatives Cameroun, IGLHRC, Center for Human Rights, Global Rights, 2010). In this country, homosexuality is not only subject to social rejection but is also punishable by prison sentences. Although local MSM organizations, supported by a few human rights organizations, are fighting against this situation, legislation shall shortly become harsher,passing from 5 to 15 years imprisonment. Studies and reports have shownthatMSMarevictimsofdiverse formsofphysicaland/or psychological violence (Gueboguo, 2006, 2008), such as blackmail using disclosure of sexual orientation as a threat. In Cameroon, HIV prevalence is estimated to be 5.3% in the general population (UNAIDS, 2009). Among the MSM population, high proportions of sexual risk practices have been documented (Henry et al., 2010). Although country-level prevalence data in MSM are unavailable, studies in neighboring countries have shown much higher prevalence in MSM than in the general population (Baral, Sifakis, Cleghorn, & Beyrer, 2007; Wade et al., 2005). Access to existing national prevention and care programs remains difficult for MSM in Cameroon. The national strategy to fight the HIV epidemic and provide sexual prevention messages is still almost uniquely directed at heterosexuals (Henry et al., 2010). Prevention actions for MSM are often left to the goodwill of local community-based organizations working in complex and hostile social, political, and sometimes legal environments, where few people are mobilized on the subject. The difficulty in disclosing one’s sexual orientation compounds these problems. Thecriminalizationofsame-sexrelationshipsandsocial rejection as outlined above emphasize the importance of researching sexual orientation disclosure in Cameroon. A greater understanding of factors associated with disclosure could help actors better respond to basic needs of MSM, including health issues. Data on sexual orientation disclosure were collected and analyzed as part of a study in 2008 (local CBO Alternatives Cameroun initiative supported by Coalition PLUS and AIDES) on a convenience sample of 168 MSM in Douala. Participation eligibility criteria were as follows: aged 18 or older, living in Douala for at least 6 months, and having had sexual intercourse with a man at least once during one’s life. Study participants were administered an 85-item questionnaire during face-to-face interviews with trained Alternatives-Cameroun members. The questions explored the following domains: sociodemographic charE. Henry (&) Coalition PLUS, Tour ESSOR, 14 rue Scandicci, 93500 Pantin, France e-mail: ehenry@coalitionplus.org

Empowering HIV testing as a prevention tool: Targeting interventions for high-risk men who have sex with men

Abstract In France, HIV testing can be easily performed in free and anonymous voluntary counselling testing (VCT) centres. The recent national study among French men who have sex with men (MSM) showed that 73% of those already tested for HIV had been tested in the previous two years. Nothing is known about the risk behaviours of MSM attending VCT centres. This study aimed to characterize sexual risk behaviours of MSM tested for HIV in such centres and identify factors associated with inconsistent condom use (ICU). A cross-sectional study was conducted from March to December 2009 in four VCT centres where a self-administered questionnaire was proposed to all MSM about to have a HIV test. ICU was defined as reporting non-systematic condom use during anal intercourse with casual male partners. Among the 287 MSM who fully completed their questionnaire, 44% reported ICU in the previous six months. Among those who had been already tested, 63% had had their test in the previous two years. Factors independently associated with ICU included: never avoiding one-night stands, not having been recently HIV tested, experiencing difficulty in using condoms when with a HIV negative partner or when under the influence of drugs or alcohol and finally, reporting to have had a large number of casual male partners in the previous six months. The rate of recently tested MSM was high in our study. Nevertheless, this rate was lower than that found in the last national study. Furthermore those not recently tested were significantly more likely to report high risk behaviours. We therefore recommend that further efforts be made to adapt the offer of both HIV testing and counselling to meet the specific needs of hard-to-reach MSM. Accordingly, an additional community-based offer of HIV testing to reach most-at-risk MSM is forthcoming in France.

The “Swiss Statement”: Who knows about it? How do they know? What are its effects on people living with HIV/AIDS?

Abstract The publication of the “Swiss Statement” in 2008 shook the international HIV prevention and advocacy scene. HIV behavioral research has provided us with some studies focusing on the potential changes that new prevention strategies can produce, but results are not conclusive. Besides, there is a lack of data concerning awareness of these kinds of prevention strategies on real-life settings, studying mainly the behavior of people recruited in different types of trials (e.g., circumcision, pre and post-exposure prophylaxis). The present study aims to (1) identify the factors associated with awareness of the “Swiss Statement” among PLWHA, (2) determine in which setting they became aware of it, and (3) look for potential, behavioral, and/or emotional changes as a consequence of this awareness. In order to achieve these three objectives, we used the data collected by a community-based survey called “HIV, Hepatitis and you.” In order to determine the factors associated with the awareness of the Swiss Statement, univariate and multivariate logistic regression were performed. Main results show that among the 997 HIV-positive people answering the questionnaire, 57% knew about the Swiss Statement, and that their main source of information was the associative setting, while 30% declared having found out about it from their doctor. As for the factors associated with the awareness of the Swiss Statement, we found that the following variables were significantly associated with such awareness: living in stable housing, having a CD4 count above 350 cell/mm3, having an undetectable viral load, being in contact with a HIV-solidarity network, feeling of belonging to the LGBT community, and filling out the questionnaire online. The results of this study point out that interventions addressed to improve access to health-related information for PLWHA facing socioeconomical difficulties and isolation are strongly needed.