Timothy Frasca

Will Gay and Bisexually Active Men at High Risk of Infection Use Over-the-Counter Rapid HIV Tests to Screen Sexual Partners?

The Food and Drug Administration may license OraQuick™, a rapid HIV test, for over-the-counter (OTC) sale. This study investigated whether HIV-uninfected, non-monogamous, gay and bisexual men who never or rarely use condoms would use the test with partners as a harm-reduction approach. Sixty participants responded to two computer-assisted self-interviews, underwent an in-depth interview, and chose whether to test themselves with OraQuick. Over 80% of the men said they would use the kit to test sexual partners or themselves if it became available OTC. Most participants understood that antibody tests have a window period in which the virus is undetectable, yet saw advantages to using the test to screen partners; 74% tested themselves in our offices. Participants offered several possible strategies to introduce the home-test idea to partners, frequently endorsed mutual testing, and highlighted that home testing could stimulate greater honesty in serostatus disclosure. Participants drew distinctions between testing regular versus occasional partners. Non-monogamous men who have sex with men, who never or rarely use condoms, may nevertheless seek to avoid HIV. Technologies that do not interfere with sexual pleasure are likely to be used when available. Studies are needed to evaluate the advantages and disadvantages of using OTC rapid HIV tests as one additional harm-reduction tool.

AWARENESS OF POST-EXPOSURE PROPHYLAXIS (PEP) AND PRE-EXPOSURE PROPHYLAXIS (PrEP) IS LOW BUT INTEREST IS HIGH AMONG MEN ENGAGING IN CONDOMLESS ANAL SEX WITH MEN IN BOSTON, PITTSBURGH, AND SAN JUAN

This study examines awareness of and experiences with post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) among 228 men recruited in Boston, Pittsburgh, and San Juan between 12/2010 and 6/2012. All of them reported having condomless anal sex with a man in the prior year. Overall, 41% had heard of PEP, ranging from 16% in San Juan to 64% in Boston. Only 21% had heard of PrEP, ranging from 8% in San Juan to 36% in Boston. Three had used PEP, and none had used PrEP. After the methods were described to participants, interest in both was high, with intentions to use PEP and PrEP respectively at 9.1 and 7.7 (10-point scale). Increased public education is needed to raise awareness of these HIV prevention methods, especially among MSM who acknowledge potential risk behavior. It also seems likely that many such men would use these methods once they become aware of them.

Home Testing Past, Present and Future: Lessons Learned and Implications for HIV Home Tests

The recent approval in the United States of the first rapid home test to diagnose HIV raises questions about its potential use and impact. We reviewed the existing literature on the unassisted use of home tests involving self-collection and testing of biological samples by untrained users—including existing HIV self-testing studies—to shed some light on what can be expected from the availability of the HIV home test. The studies reviewed showed that most participants could properly perform home tests, obtain accurate results, and interpret them—yielding high correlations with laboratory and health-professional performed tests. Users often had trouble performing blood-based tests. Participants generally understood the need to confirm positive test results. Materials accompanying HIV home tests should emphasize symptoms of acute infection and the need for additional testing when recent infection is suspected. Different home-test-based screening modalities, personalized HIV-counseling resources and HIV home test impact evaluation methods should be studied.ResumenLa aprobación reciente en los Estados Unidos del primer examen de uso casero para diagnosticar el VIH plantea una serie de interrogantes sobre su eventual uso y el impacto potencial. Revisamos la literatura existente sobre el uso sin ayuda professional de una variedad de exámenes caseros que requieren la auto-colección y testeo de muestras biológicas por parte de usuarios sin capacitación—incluyendo los estudios existentes sobre el auto-examen por VIH—para destacar lo que se podría anticipar ahora que el examen casero por VIH está disponible. Los estudios revisados demostraron que la mayoría de los participantes sí podrían llevar a cabo los exámenes caseros correctamente, obtener resultados fidedignos e interpreterlos, así produciendo correlaciones altas con los resultados de exámenes practicados por profesionales de la salud. Los usuarios con frecuencia tenían dificultades administrándose exámenes basados en muestras de sangre. Los participantes generalmente comprendían la necesidad de exámenes de confirmación. Los materiales que acompañan los exámenes caseros por VIH deberían poner énfasis en los síntomas de infecciones agudas y en la necesidad de obtener exámenes adicionales cuando se sospecha de una infección reciente. Futuros estudios sobre exámenes caseros para el VIH deberían explorar diferentes modalidades para su uso, cómo personalizar los recursos de consejería y cómo evaluar su impacto.

Attitude and Behavior Changes Among Gay and Bisexual Men After Use of Rapid Home HIV Tests to Screen Sexual Partners

Abstract HIV testing can now be self-administered outside clinical settings through the purchase of home testing (HT) kits. Individuals also can use the kits to perform a test on a potential sexual partner prior to intercourse. We provided a 3-month supply of HT kits to men who reported multiple male partners and little or no condom use for anal intercourse. Participants used the test kits with partners in over 100 occasions. At the end of the study, approximately half of the participants described shifts in their attitudes and/or behaviors related to sexual risk. Reported changes included increased awareness of risk, increased discussion of STI/HIV safety measures, changes in partner choice and heightened consciousness of partner thinking. Easy access to HT kits may be a risk-reduction strategy for men with a high risk profile because their regular use could have an impact beyond the specific sexual encounter.ResumenActualmente, las personas pueden comprar libremente la prueba para el VIH y auto-administrársela fuera del ámbito clínico. Asimismo, pueden ofrecer la prueba a una pareja potencial antes de tener relaciones sexuales. En un estudio, hombres que declararon tener múltiples parejas masculinas y escaso uso de condones para el coito anal, recibieron una cantidad de kits durante tres meses. Los kits fueron utilizados con parejas en más de 100 ocasiones. Al final del estudio, aproximadamente la mitad de los participantes describieron cambios en sus actitudes y/o conductas relacionadas al riesgo sexual. Los cambios relatados incluyeron: mayor conciencia del riesgo, discusiones más frecuentes de medidas de seguridad para evitar infecciones, alteraciones en el tipo de pareja buscada y mayor conciencia de los pensamientos de las parejas. Facilitar el acceso a las pruebas para el VIH puede ser una estrategia preventiva prometedora para hombres con un perfil de riesgo alto, ya que su uso regular puede tener un impacto más allá del encuentro sexual específico.

Anticipated and Actual Reactions to Receiving HIV Positive Results Through Self-Testing Among Gay and Bisexual Men

We explored anticipated and actual reactions to receiving HIV positive results through self-testing with a diverse group of 84 gay and bisexual men in New York City. Grounded Theory was used to investigate these reactions in a two-phase study, one hypothetical, followed by a practical phase in which self-tests were distributed and used. Three major themes emerged when participants were asked about their anticipated reactions to an HIV positive self-test result: managing emotional distress, obtaining HIV medical care, and postponing sexual activity. When participants were asked about their anticipated reactions to a partner’s HIV positive self-test result, five themes emerged: provide emotional support; refrain from engaging in sex with casual partner; avoid high-risk sexual activity with both main and casual partners; seek medical services; and obtain a confirmatory test result. Although none of the participants tested positive, seven of their partners did. Participants provided emotional support and linked their partners to support services. The availability of HIV self-testing kits offers potential opportunities to tackle HIV infection among individuals with high-risk practices.ResumenExploramos las reacciones anticipadas y que ocurrieron al recibir un resultado de VIH positivo con el uso de la prueba de auto test de VIH en un grupo diverso de 84 hombres gay y bisexuales en la ciudad de Nueva York. Usamos la Teoría Fundamental para investigar estas reacciones en un estudio de dos fases, una fase hipotética, y la otra práctica en la cual las pruebas de auto test de VIH fueron distribuidas y usadas. Tres temas generales surgieron cuando le preguntamos a los participantes acerca de cómo ellos reaccionarían a un resultado positivo como resultado del uso de la prueba de auto test de VIH: brindar apoyo emocional, buscar atención médica para el VIH, y evitar la actividad sexual. En cuanto a sus reacciones en caso de que su pareja recibiera un resultado positivo, hubo cinco temas: brindar apoyo emocional; evitar la actividad sexual riesgosa con la pareja casual; participar en actividades sexuales no riesgosas con la pareja principal y casual; conectar a la pareja con servicios médicos; y el deseo de obtener una prueba confirmatoria para el VIH. Aunque ninguno de los participantes resultó ser positivo, siete de sus parejas sí recibieron resultados positivos. Los participantes que se encontraron en esta situación hablaron de cómo brindar apoyo emocional y conectar a la pareja con servicios de apoyo. La disponibilidad de la prueba casera ofrece oportunidades para abordar la infección del HIV en individuos con prácticas de alto riesgo.

Integration of Social, Cultural, and Biomedical Strategies into an Existing Couple-Based Behavioral HIV/STI Prevention Intervention: Voices of Latino Male Couples

Introduction Successful HIV prevention and treatment requires evidence-based approaches that combine biomedical strategies with behavioral interventions that are socially and culturally appropriate for the population or community being prioritized. Although there has been a push for a combination approach, how best to integrate different strategies into existing behavioral HIV prevention interventions remains unclear. The need to develop effective combination approaches is of particular importance for men who have sex with men (MSM), who face a disproportionately high risk of HIV acquisition. Materials and Methods We collaborated with Latino male couples and providers to adapt Connect ‘n Unite, an evidence-based intervention for Black male couples, for Latino male couples. We conducted a series of three focus groups, each with two cohorts of couples, and one focus group with providers. A purposive stratified sample of 20 couples (N = 40, divided into two cohorts) and 10 providers provided insights into how to adapt and integrate social, cultural, and biomedical approaches in a couples-based HIV/AIDS behavioral intervention. Results The majority (N = 37) of the couple participants had no prior knowledge of the following new biomedical strategies: non-occupational post-exposure prophylaxis (nPEP); pre-exposure prophylaxis (PrEP); and HIV self-testing kits. After they were introduced to these biomedical interventions, all participants expressed a need for information and empowerment through knowledge and awareness of these interventions. In particular, participants suggested that we provide PrEP and HIV self-testing kits by the middle or end of the intervention. Providers suggested a need to address behavioral, social and structural issues, such as language barriers; and the promotion of client-centered approaches to increase access to, adaptation of, and adherence to biomedical strategies. Corroborating what couple participants suggested, providers agreed that biomedical strategies should be offered after providing information about these tools. Regarding culturally sensitive and responsive approaches, participants identified stigma and discrimination associated with HIV and sexual identity as barriers to care, language barriers and documentation status as further barriers to care, the couple-based approach as ideal to health promotion, and the need to include family topics in the intervention. Discussion We successfully adapted an evidence-based behavioral HIV prevention intervention for Latino male couples. The adapted intervention, called Conectando Latinos en Pareja, integrates social, cultural, behavioral and biomedical strategies to address the HIV epidemic among Latino MSM. The study highlights the promise regarding the feasibility of implementing a combination approach to HIV prevention in this population.

Inner Contradictions Among Men Who Bareback

Barebacking, or intentional unprotected anal intercourse when HIV transmission can occur, emerged as a descriptive term in the 1990s, and marked greater acceptance by gay and bisexual men of dispensing with condom use under certain circumstances. In an exploratory study of men who used Internet sites to meet partners and reported recent episodes of barebacking, respondents outlined numerous strategies they deployed to avoid HIV infection instead of universal condom use. However, in interviews many participants acknowledged uneasiness with the flaws in their chosen strategies, and the contradiction between their urgent desire to remain HIV-free and their sexual practices. For some, the dissonance between the conflicting cognitions could be resolved through self-justification, mental compartmentalization, or invincibility beliefs so that barebacking could continue. For this subpopulation, continued reiteration of cognitive-based prevention messages has the potential to reinforce rather than undermine their attachment to inadequate strategies for disease avoidance.

Project Gel a Randomized Rectal Microbicide Safety and Acceptability Study in Young Men and Transgender Women

Objectives The purpose of Project Gel was to determine the safety and acceptability of rectal microbicides in young men who have sex with men (MSM) and transgender women (TGW) at risk of HIV infection. Methods MSM and TGW aged 18–30 years were enrolled at three sites; Pittsburgh, PA; Boston, MA; and San Juan, PR. Stage 1A was a cross-sectional assessment of sexual health and behavior in MSM and TGW. A subset of participants from Stage 1A were then enrolled in Stage 1B, a 12-week evaluation of the safety and acceptability of a placebo rectal gel. This was followed by the final phase of the study (Stage 2) in which a subset of participants from Stage 1B were enrolled into a Phase 1 rectal safety and acceptability evaluation of tenofovir (TFV) 1% gel. Results 248 participants were enrolled into Stage 1A. Participants’ average age was 23.3 years. The most common sexually transmitted infection (STIs) at baseline were Herpes simplex (HSV)-2 (16.1% by serology) and rectal Chlamydia trachomatis (CT) (10.1% by NAAT). 134 participants were enrolled into Stage 1B. During the 12 week period of follow-up 2 HIV, 5 rectal CT, and 5 rectal Neisseria gonorrhea infections were detected. The majority of adverse events (AEs) were infections (N = 56) or gastrointestinal (N = 46) and were mild (69.6%) or moderate (28.0%). Of the participants who completed Stage 1B, 24 were enrolled into Stage 2 and randomized (1:1) to receive TFV or placebo gel. All participants completed Stage 2. The majority of AEs were gastrointestinal (N = 10) and of mild (87.2%) or moderate (10.3%) severity. Conclusions In this study we were able to enroll a sexually active population of young MSM and TGW who were willing to use rectal microbicides. TFV gel was safe and acceptable and should be further developed as an alternative HIV prevention intervention for this population. Trial Registration ClinicalTrials.gov NCT01283360

Influence of Partner Type on Acceptability and Likelihood of Use of a Rectal Microbicide Among Young Men Who Have Sex With Men in the United States and Puerto Rico

This study examined how acceptability of placebo gel with receptive anal intercourse (RAI) and likelihood of future rectal microbicide use varied across partner types. Because no rectal microbicide is available yet, use of placebo permitted the study of gel use behavior in real-life circumstances. A total of 87 men who have sex with men (MSM) aged 18 to 30 years inserted placebo gel rectally before RAI during 12 weeks. Using mixed-methods design, participants completed a behavioral questionnaire and in-depth interview. In all, 62 men (71.3%) reported gel use with a lover (i.e., spouse equivalent, boyfriend), 32 (36.8%) with a one-night stand (i.e., man with whom you had sex once), and 29 (33.3%) with an “other” male partner. While gel acceptability was high across partner types, use with lovers was facilitated by trust and familiarity; yet trust made participants believe protection was less necessary. Conversely, participants expressed high likelihood of using gel with one-night stands, whom they perceived as riskier; yet they felt less comfortable discussing gel with them, often resorting to covert use or forgoing gel. A successful microbicide will be positioned as a sexual pleasure enhancer so that men can present it to their lovers and other partners as a gel that improves sex and secondarily prevents human immunodeficiency virus (HIV).

Adaptation of a Couple-Based HIV/STI Prevention Intervention for Latino Men Who Have Sex With Men in New York City:

Predominantly Spanish-speaking Latino men who have sex with men (MSM) and their same-sex partners continue to be at high risk for HIV and STIs. Behavioral research has identified how relationship dynamics for male couples are associated with sexual risk behavior. Connect ‘n Unite (CNU), an evidence-based HIV/STI prevention intervention originally created for Black MSM and their same-sex partners, was adapted for predominantly Spanish-speaking Latino MSM and their same-sex partners on the assumption that its key elements would be translatable while its efficacy would be retained. A systematic adaptation process utilizing qualitative methods was used, including intervention adaptation sessions with 20 predominantly Spanish-speaking Latino gay couples and 10 health service providers. The process included five steps: (1) engaging community stakeholders, (2) capturing the lived experiences of Latino gay couples, (3) identifying intervention priorities, (4) integrating the original intervention’s social cognitive theory into a relationship-oriented, ecological framework for Latino gay couples, and (5) adapting intervention activities and materials. The adapted intervention, which we called Latinos en Pareja or Latinos in a Relationship, incorporates elements that effective HIV prevention interventions share, including: a solid theoretical foundation; emphasis on increasing risk reduction norms, sexual communication skills and social support for protection; and guidance on how to utilize available, culturally and linguistically appropriate services. The systematic adaptation approach used for a couples-based HIV prevention intervention also can be employed by other researchers and community stakeholders to adapt evidence-based interventions that promote wellness, linkage to care, and disease prevention for populations not originally targeted.