Yeycy Donastorg

The HVTN Protocol 903 Vaccine Preparedness Study : Lessons Learned in Preparation for HIV Vaccine Efficacy Trials

Successful recruitment and retention of HIV-uninfected at-risk participants are essential for HIV vaccine efficacy trials. A multicountry vaccine preparedness study was started in 2003 to assess enrollment and retention of HIV-negative high-risk participants and to assess their willingness to participate in future vaccine efficacy trials. HIV-negative high-risk adults were recruited in the Caribbean, in Southern Africa, and in Latin America, and were followed for 1 year. Participants included men who have sex with men, heterosexual men and women, and female sex workers. History of sexually transmitted infections and sexual risk behaviors were recorded with HIV testing at 0, 6, and 12 months, and willingness to participate in future vaccine trials was recorded at 0 and 12 months. Recruitment, retention, and willingness to participate in future trials were excellent at 3 of the 6 sites, with consistent declines in risk behaviors across cohorts over time. Although not powered to measure seroincidence, HIV seroincidence rates per 100 person-years (95% confidence interval [CI]) were as follows: 2.3 (95% CI: 0.3 to 8.2) in Botswana, 0.5 (95% CI: 0 to 2.9) in the Dominican Republic, and 3.1 (95% CI: 1.1 to 6.8) in Peru. The HIV Vaccine Trials Network 903 study helped to develop clinical trial site capacity, with a focus on recruitment and retention of high-risk women in the Americas, and improved network and site expertise about large-scale HIV vaccine efficacy trials.

Strategies for Recruiting Steady Male Partners of Female Sex Workers for HIV Research

Steady male partners of female sex workers (FSW) are a key population for HIV prevention, but researchers face challenges finding and recruiting this population. We conducted 40 in-depth interviews with FSW and steady male partners of FSW in Santo Domingo, Dominican Republic about how to engage steady male partners in HIV research. Participants cautioned that male partners might be unwilling to participate because of discomfort disclosing intimate information and cultural norms of masculinity. They recommended inviting male partners to research offices, instead of venue-based recruitment, because it was more private and trust-promoting. Most participants suggested that FSW could refer their partners or men could refer their friends who have FSW partners. Participants emphasized that referrals could break down trust-related barriers that prevent male partners from participating. Establishing an environment of respect and trust in the research setting can aid referral processes as individuals who participate communicate their positive experiences to their networks.ResumenParejas fijas masculinas de mujeres trabajadores sexuales (MTS) son una población clave para la prevención de VIH, pero investigadores enfrentan desafíos para reclutar esta población. Hicimos cuarenta entrevistas en profundidad con MTS y parejas fijas masculinas de MTS en Santo Domingo, Republica Dominicana sobre como reclutar parejas masculinas en investigaciones de VIH. Participantes mencionaron que parejas fijas masculinos puede negar participación en un estudio por miedo de divulgar información intima y por normas culturales de masculinidad. Recomendaron invitar parejas masculinos a oficinas de investigación, en vez de reclutar en bares/clubes, porque oficinas son mas privado y confiado. La mayoría de participantes surgieron que MTS pueden referir sus parejas o que hombres pueden referir sus amigos quienes tienen una pareja MTS. Participantes enfatizaron que referencias podrían romper barreras relacionado a confianza que previenen que los hombres participan. Establecer un ambiente de respeto y confianza en el lugar de investigación puede facilitar el proceso de referencia porque participantes comunican su experiencia positiva con sus redes.

Amigos and amistades: the role of men's social network ties in shaping HIV vulnerability in the Dominican Republic

While mens social networks have been identified as a source of influence on sexual behaviour, less is known about the different types of friendship ties within mens networks. We analysed data from qualitative in-depth interviews with 36 men in Santo Domingo, Dominican Republic who are current or former sexual partners of female sex workers to understand how: (1) men describe trust and communication with different types of friendship ties, (2) characteristics of trust and communication reflect norms of masculinity, and (3) these friendship ties influence HIV-related behaviours. We identified a distinction between amistades, social drinking buddies who are not trusted, and amigos, trusted friends. The majority of men lacked any amigos and some had neither amigos nor amistades. In general, men reflected traditional norms of masculinity and said they did not feel they could discuss their relationships or emotional topics with other men. Trust and communication dynamics, and how norms of masculinity shape those dynamics, should be understood and addressed in the design of HIV prevention efforts with mens social networks as they have implications for the potential effectiveness of such efforts.

Risk behavior among women enrolled in a randomized controlled efficacy trial of an adenoviral vector vaccine to prevent HIV acquisition.

Objectives:Report of risk behavior, HIV incidence, and pregnancy rates among women participating in the STEP study, which is a phase IIB trial of MRKAd5 HIV-1 gag/pol/nef vaccine in HIV-negative individuals who were at high risk of HIV-1. Design:Prospective multicenter, double-blinded, placebo-controlled trial. Methods:Women were from North American, and from Caribbean and South America (CSA) sites. Risk behavior was collected at screening and 6-month intervals. Differences in characteristics between groups were tested with chi-square, two-sided Fishers exact tests, and Wilcoxon rank-sum tests. Generalized estimating equation models were used to assess behavioral change. Results:Among 1134 enrolled women, the median number of male partners was 18; 73.8% reported unprotected vaginal sex, 15.9% unprotected anal sex and 10.8% evidence of a sexually transmitted infection in the 6 months prior to baseline. With 3344 person-years of follow-up, there were 15 incident HIV infections: incidence rate was 0.45 per 100 person-years [95% confidence interval (CI) 0.25, 0.74]. Crack cocaine use in both regions [relative risk (RR) 2.4 (1.7, 3.3)] and in CSA, unprotected anal sex [RR 6.4 (3.8, 10.7)], and drug use [RR 4.1 (2.1, 8.0)] were baseline risk behaviors associated with HIV acquisition. There was a marked reduction in risk behaviors after study enrollment with some recurrence in unprotected vaginal sex. Of 963 nonsterilized women, 304 (31.6%) became pregnant. Conclusion:Crack cocaine use and unprotected anal sex are important risk criteria to identify high-risk women for HIV-efficacy trials. Pregnancy during the trial was a common occurrence and needs to be considered in trial planning for prevention trials in women.

“I Feel Like More of a Man”: A Mixed Methods Study of Masculinity, Sexual Performance, and Circumcision for HIV Prevention

Ethnographic studies from numerous societies have documented the central role of male circumcision in conferring masculinity and preparing boys for adult male sexuality. Despite this link between masculinity, sexuality, and circumcision, there has been little research on these dynamics among men who have been circumcised for HIV prevention. We employed a mixed methods approach with data collected from recently circumcised men in the Dominican Republic (DR) to explore this link. We analyzed survey data collected six to 12 months post-circumcision (N = 293) as well as in-depth interviews conducted with a subsample of those men (n = 30). We found that 42% of men felt more masculine post-circumcision. In multivariate analysis, feeling more masculine was associated with greater concern about being perceived as masculine (OR = 1.70, 95% CI: 1.25–2.32), feeling more potent erections post-circumcision (OR = 2.25, 95% CI: 1.26–4.03), and reporting increased ability to satisfy their partners post-circumcision (OR = 2.30, 95% CI: 1.11–4.77). In qualitative interviews, these factors were all related to masculine norms of sexually satisfying one’s partner, and men’s experiences of circumcision were shaped by social norms of masculinity. This study highlights that circumcision is not simply a biomedical intervention and that circumcision programs need to incorporate considerations of masculine norms and male sexuality into their programming.

HIV testing, care, and treatment experiences among the steady male partners of female sex workers living with HIV in the Dominican Republic

ABSTRACT Male steady partners of female sex workers (FSW) living with human immunodeficiency virus (HIV) represent a key population for treatment as prevention and/or pre-exposure prophylaxis interventions. This study uses data collected from male steady partners who were referred by FSW living with HIV participating in a multi-level HIV prevention and care intervention in Santo Domingo, Dominican Republic. We conducted a socio-behavioral survey and HIV testing with all men (nu2009=u200964) and 16 in-depth interviews with a sub-sample to obtain more depth. Thirty-five of the 64 participants were living with HIV; 27 were previously diagnosed and 8 were diagnosed during our study. As a result, 45% of men were members of sero-discordant sexual partnerships. Of men with no previous HIV diagnosis (nu2009=u200937), 15 had never been tested for HIV and nine had not been tested in the past two years. Ninety-three percent of men previously diagnosed with HIV reported receiving HIV care in the past 6 months and 78% were taking anti-retrovirals. Low HIV testing was partly due to men not feeling at risk for HIV, despite having an HIV-infected partner. Additionally, a lack of tailored care inhibited engagement in anti-retroviral treatment for those infected. HIV testing was low, highlighting a need for test-and-treat strategies. Men not living with HIV would benefit from regular testing and would be good candidates for pre-exposure prophylaxis. While almost all men who had been diagnosed with HIV were engaged in care and adherent to anti-retroviral therapy, future research should assess whether they are achieving optimal HIV outcomes for their health and prevention of ongoing transmission.

The Association Between Men’s Concern About Demonstrating Masculine Characteristics and Their Sexual Risk Behaviors: Findings from the Dominican Republic

Quantitative analyses exploring the relationship between masculinities and men’s sexual risk behaviors have most commonly used one dimension of masculinities: men’s gender ideology. Examining other dimensions may enhance our understanding of and ability to intervene upon this relationship. In this article, we examined the association between gender role conflict/stress (GRC/S)—men’s concern about demonstrating masculine characteristics—and three different sexual risk behaviors (having two or more sex partners in the last 30xa0days; never/inconsistent condom use with non-steady partners; and drinking alcohol at last sex) among a sample of heterosexual men in the Dominican Republic who were participating in an HIV prevention intervention (nxa0=xa0293). The GRC/S Scale we used was adapted for this specific cultural context and has 17 items (αxa0=xa00.75). We used logistic regression to assess the relationship between GRC/S and each sexual behavior, controlling for sociodemographic characteristics. In adjusted models, a higher GRC/S score was significantly associated with increased odds of having two or more sex partners in the past 30xa0days (AOR 1.33, 95xa0% CI 1.01–1.74), never/inconsistent condom use with non-steady partners (AOR 1.45, 95xa0% CI 1.04–2.01), and drinking alcohol at last sex (AOR 1.56, 95xa0% CI 1.13–2.17). These results highlight the importance of expanding beyond gender ideology to understanding the influence of GRC/S on men’s sexual risk behaviors. Interventions should address men’s concern about demonstrating masculine characteristics to reduce the social and internalized pressure men feel to engage in sexual risk behaviors.

Sexual Pleasure and Function, Coital Trauma, and Sex Behaviors After Voluntary Medical Male Circumcision Among Men in the Dominican Republic

BACKGROUNDnVoluntary medical male circumcision (VMMC) is effective in decreasing the risk of HIV acquisition. As men resume sexual activity after circumcision, it will be important to study their satisfaction with the procedure, sexual pleasure and function, coital trauma, and risk compensation (RC), which can hamper or facilitate the long-term success of VMMC programs.nnnAIMnTo assess mens satisfaction with VMMC, sexual pleasure and function, coital trauma, and RC after VMMC.nnnMETHODSnThis is a cohort study of circumcised men who presented for follow-up 6 to 24 months after VMMC. Logarithmic binomial regression was performed to explore factors associated with any increase in the number of sex partners after VMMC as a measurement of RC.nnnMAIN OUTCOME MEASURESn(i) Mens satisfaction with their VMMC; (ii) sexual pleasure and function after VMMC; (iii) coital trauma; and (iv) RC.nnnRESULTSnOf 454 circumcised men, 362 (80%) returned for a follow-up visit 6 to 24 months after VMMC. Almost all (98%) were satisfied with the outcome of their VMMC; most (95%) reported that their female partners were satisfied with their circumcision. Two thirds (67%) reported enjoying sex more after VMMC and most were very satisfied or somewhat satisfied (94%) with sexual intercourse after VMMC. Sexual function improved and reported sex-induced coital injuries decreased significantly in most men after VMMC. There was an increase in the proportion of men who reported at least two sexual partners after VMMC compared with baseline. In multivariate analysis, having sex with a woman they met the same day (adjusted relative risk = 1.7, 95% CIxa0= 1.2-2.4) and having at least two sexual partners at baseline (adjusted relative riskxa0= 0.5, 95% CIxa0=xa00.3-0.8) were associated with the outcome of any increase in the number of partners after VMMC.nnnCLINICAL IMPLICATIONSnVMMC can be offered to Dominican men for HIV prevention without adversely affecting sexual pleasure or function. The procedure substantially reduces coital trauma.nnnSTRENGTHS & LIMITATIONSnThis is the first report of long-term overall satisfaction, sexual pleasure/function and sex behaviors in the context of VMMC outside of Africa. Limitations of the study included the reliance on self-reported sex behaviors, the lack of physiologic measurement of penile sensitivity and the lack of follow up data beyond 24 months, which precludes the assessment of longer term RC.nnnCONCLUSIONnThe study confirmed mens long-term satisfaction with the outcome of their VMMC. VMMC improved sexual pleasure and function for most men and significantly decreased coital injuries. There was mixed evidence of RC. Brito MO, Khosla S, Pananookooln S, etxa0al. Sexual Pleasure and Function, Coital Trauma, and Sex Behaviors After Voluntary Medical Male Circumcision Among Men in the Dominican Republic. Jxa0Sex Med 2017;14:526-534.

Violence from a Sexual Partner is Significantly Associated with Poor HIV Care and Treatment Outcomes among Female Sex Workers in the Dominican Republic.

Background: Female sex workers (FSWs) experience high rates of violence from their sexual partners. Although violence is associated with HIV risk behaviors among FSWs, there is limited evidence on the association between violence and HIV treatment outcomes. Methods: We analyzed data from a socio-behavioral survey with a cohort of FSWs living with HIV in the Dominican Republic (n = 268) to describe the burden of violence from a sexual partner in the last 6 months. We assessed the relationship between violence and HIV treatment outcomes, comparing findings across 2 types of sexual partners: intimate partners and clients. Results: Nearly one-fifth of women (18.3%) experienced violence in the last 6 months. More women experienced violence from an intimate partner (12.3%) than a client (8.3%), with some (2.6%) reporting both. Although violence from an intimate partner was significantly associated with not currently being on antiretroviral treatment [ART; adjusted odds ratio (AOR): 4.05, 95% confidence interval (CI): 1.00 to 16.36] and missing an ART dose in the last 4 days (AOR: 5.26, 95% CI: 1.91 to 14.53), violence from a client was associated with never having received HIV care (AOR: 2.85, 95% CI: 1.03 to 7.92) and ever interrupting ART (AOR: 5.45, 95% CI: 1.50 to 19.75). Conclusions: Violence from a sexual partner is associated with poor HIV treatment outcomes among FSWs. Different patterns by type of partner reflect how relationship dynamics may influence these associations. Violence prevention and support services should be tailored based on type of partner. Violence screening and referrals should be integrated into HIV care services for FSWs to improve their health and reduce ongoing transmission.

Competition and Humiliation: How Masculine Norms Shape Men’s Sexual and Violent Behaviors

We use data collected from in-depth interviews with men (n = 30) in the Dominican Republic to explore how men’s concern about being perceived as masculine influences their interactions with their social networks and how those interactions drive men’s sexual behaviors and use of violence. Men’s sexual and violent behaviors were shaped by the need to compete with other men for social status. This sense of competition also generated fear of humiliation for failing to provide for their families, satisfy sexual partners, or being openly disrespected. In an effort to avoid humiliation within a specific social group, men adapted their behaviors to emphasize their masculinity. Additionally, men who were humiliated recouped their masculinity by perpetrating physical or emotional violence or finding new sexual partners. These findings emphasize the need for understanding these social dynamics to better understand men’s violent and sexual behaviors.