20th International AIDS Conference - Melbourne, Australia

THAC02 Gay and Other Men Who Have Sex with Men (MSM): Prevention within an Accelerating Epidemic
  Oral Abstract Session : Track C
Venue: Plenary 1
Time: 24.07.2014, 14:30 - 16:00
Co-Chairs: Dédé Oetomo, Indonesia
Luiz Loures, UNAIDS

Relationship-based motives for making sexual agreements associated with HIV risk among gay male couples
C. Hoff1, D. Chakravarty1, S. Beougher1, T. Neilands2, L. Darbes2
1San Francisco State University, Center for Research and Education on Gender and Sexuality, San Francisco, United States, 2University of California, Center for AIDS Prevention Studies, San Francisco, United States

Incidence and risk factors of HIV-infection among young men who have sex with men in Bangkok, Thailand
W. Thienkrua1, S. Pattanasin1, N. Promda1, S. Winaitham1, W. Sukwicha1, T. Chemnasiri1, S. Chaikummao1, A. Varangrat1, P. Sirivongrangson2, T.H. Holtz1,3
1Thailand Ministry of Public Health - U.S. CDC Collaboration, Nonthaburi, Thailand, 2Ministry of Public Health, Department of Disease Control, Nonthaburi, Thailand, 3U.S. Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, United States

HIV serostatus disclosure and associated factors among high-risk MSM and male-to-female transgender women in Lima, Peru
R. Castillo1, K.A. Konda2,3, S.R. Leon3, A. Silva-Santisteban3, X. Salazar3, T.J. Coates2, C.F. Caceres3
1Stanford University, Stanford, United States, 2UCLA, Medicine, Los Angeles, United States, 3Universidad Peruana Cayetano Heredia, Lima, Peru

Drug use and sexual risk behaviours among men who have sex with men in Kaduna Metropolis, north central Nigeria
I. Suleiman1, O. Otibho2, J. Njab3, S.V. Olusegun3, A. Oginni3, G. Eluwa4, S. Adebajo2, B. Ahonsi5, J. Keshinro6, T. Kene6
1Population Council Nigeria, HIV Unit, Abuja, Nigeria, 2Population Council, HIV and AIDS, Abuja, Nigeria, 3Population Council Nigeria, HIV and AIDS, Abuja, Nigeria, 4Population Council Nigeria, Operations Research, HIV/AIDS, Abuja, Nigeria, 5Population Council, Abuja, Nigeria, 6Millitary HIV Research Program, Department of Defence, Abuja, Nigeria

A divergent tale of two cities: why has HIV control in men who have sex with men (MSM) differed between London and San Francisco (SF) since 2006?
C.S. Brown1,2, M. Das3,4, L. Hsu4, I. Hall5, A. Brown1, A. Aghaizu1, P. Birrell1, N. Carraher4, S. Desai1, J. Hecht6, G. Hughes1, D. Mercey7, A. Nardone1, T. Packer4, F. Post2, A. Zaman1, Z. Yin1, N. Gill1, V. Delpech1
1Public Health England, London, United Kingdom, 2King's College London, London, United Kingdom, 3University of California San Francisco, San Francisco, United States, 4San Francisco Department of Public Health, San Francisco, United States, 5Centers for Disease Control and Prevention, Atlanta, United States, 6San Francisco AIDS Foundation, San Francisco, United States, 7University College London, London, United Kingdom

Moderated discussion

L. Loures, UNAIDS

Powerpoints presentations
HIV serostatus disclosure and associated factors among high-risk MSM and male-to-female transgender women in Lima, Peru - Kelika A. Konda

Drug use and sexual risk behaviours among men who have sex with men in Kaduna Metropolis, north central Nigeria - Ibrahim Suleiman

A divergent tale of two cities: why has HIV control in men who have sex with men (MSM) differed between London and San Francisco (SF) since 2006? - Colin Stewart Brown

Rapporteur reports

Track C report by Sin How Lim

The co-chair D. Oetomo started the session by saying that while there have been sessions on treatment, rights in the conference and this is the only session that is dedicated to research on gay men, other MSM, and transgender people from all around the world.

C. Hoff presented the gay couple study conducted in San Francisco from February, 2012 to August, 2013. A total of 441 couples completed a computerized survey simultaneously, but separately, that queried their sexual agreements and behaviors. The study aims to determine motivations to make sexual agreement and whether such motivations were associated with HIV sexual risk, agreement maintenance, and relationship and sexual satisfaction.  Motivation for making sexual agreements yielded two factors: relationship quality enhancement motive (RQEM) (7 items, alpha=0.84) and sex-life enhancement motive (SLEM) while sexual risk was defined as unprotected anal intercourse with an outside partner of discordant or unknown serostatus in the past 90 days. Men who reported higher relationship-enhancement motivation were less likely to engage in sexual risk with outside partners regardless of agreement type. Monogamous men who report higher relationship-enhancement motivation were also less likely to break their agreements, were more satisfied with their relationship, and were more sexually satisfied. Hoff concluded that motivations for making sexual agreements vary. Future prevention interventions for gay couples, regardless of their agreement type, should address relationship-based motivations for making sexual agreements and relationship satisfaction to maintain sexual agreements.

S. Pattanasin from the Ministry of Health of Thailand estimated HIV incidence among Young MSM (YMSM) enrolled in Bangkok MSM Cohort Study. Young MSM were recruited at venues, Internet, male sexual health clinics, and social or friendship networks of outreach workers. Between 2006 and 2010, a total of 1744 young MSM were enrolled into a cohort study and followed every four months for 60 months. HIV testing was routinely performed at every visit based on oral fluid samples, with serologic confirmation of all reactive specimens and all non-reactive specimens obtained after February 2010. Data on sexual and drug use behaviors in the preceding four months were collected using audio computer-assisted self-interviews. Baseline HIV-prevalence was 21% (n=151). Overall incidence density was 7.5 per 100 per person years. Survival graphs of probability of seroconversion over 6 years were presented. Multivariate risk factors for HIV-incidence were: unprotected receptive anal intercourse (Adjusted Hazard Ratio, AHR, 2.8), being paid for sex (AHR 2.2), having a casual sexual encounter at a sauna (AHR 1.9), or at home (AHR 1.6), and living alone or with a roommate (AHR 1.5). Consistent with previous studies, estimated HIV prevalence and incidence density among YMSM in Bangkok are high. Pattanasin concluded that combination HIV prevention interventions that reduce HIV infection in YMSM are urgently needed.

K. Konda conducted a study on disclosure of HIV status and its relationship with HIV risks among MSM and transgender women (TW) in Lima, Peru.  As part of a community-level HIV prevention intervention, the study enrolled 718 MSM/TW. At baseline, 31.6% of the 559 participants who had been tested previously for HIV reported HIV serostatus disclosure to at least one sex partner. At 9- and 18- months,  32.9% and 33.2% had disclosed HIV status to a sex partner respectively. Being HIV seropositive and lacking money for basic needs decreased likelihood of disclosure (AHR 0.55 and 0.58, respectively). Having a stable partner, being with a partner for more than 2 years, and having a partner with disclosed HIV status were positively associated with disclosure (AHR 1.45, 1.67, 1.86, respectively. Konda concluded that HIV serostatus disclosure, especially positive status, by MSM/TW to sex partners was infrequent. Identification of factors associated with HIV status disclosure can potentially inform interventions to increase risk communication among MSM/TW. HIV serostatus disclosure within partnership should be promoted, potentially in the context of couple-based HIV testing.  

I. Suleiman examined the association between recreational drug use and sexual risk behaviours among 1470 MSM visiting MSM health clinic in Kaduna Metropolis in north central Nigeria. Data for the study were obtained from structured intake forms administered between May 2013 to January 2014. Suleiman described the demography and geography of Kaduna (56% of population in Kaduna state are Muslim; 46% Christian) and the health clinic involved in the study. Socio-demographics of the sample were then presented. About 36% reportedly used recreational drugs with majority substances reported to be alcohol (23%) and marijuana (18.6%). More worrisome was the level of risky sexual behaviors reported by the participants: 77% engaged in unprotected sex with a casual partner in the last three months, 72% engaged in transactional sex in the last six months, 61% in multiple sexual partnerships. Slight more than half of the participants (56%) reported comprehensive knowledge of HIV (UNAIDS indicators), about 11% reported a history of STI in the past 6 months and 6% tested positive for HIV. MSM who used recreational drugs were more likely to have engaged in unprotected sex (Adjusted OR= 3.67; transactional sex (AOR= 3.90) and multiple sexual partnerships (AOR=9.36) compared to those that did not. Interventions that target both risky sexual behaviours and recreational drug use are urgently needed for MSM.

C. Brown presented an interesting study that compares the HIV epidemic and responses to the epidemic in MSM in San Francisco and London. Extensive HIV surveillance and behavioural data from 2004 in both cities were compared to evaluate how differences in risk behaviour, testing and treatment coverage may account for the possible divergent trends. First, HIV prevelances were marked different in the two cities (8.7% in London versus 24% in SF). From 2006, in London new HIV diagnoses rose from 563 to 696 per 100,000 MSM, and proportion of prevalent infections undiagnosed remained static at 20-25%. Because of higher uptake of HIV testing in SF, new diagnoses and the proportion undiagnosed fell, from 694 to 442 and from 21.7% to 7.5%. The proportion of new diagnoses is now higher in London than SF. Overall, HIV testing of HIV-negative MSM increased in both cities but in 2011 was less frequent and annual coverage remained lower in London (16.9%) than SF (34.4%). The proportions of newly-diagnosed MSM linked into care within 3 months (94.5% vs. 82.9%) and total-diagnosed remaining in care (96.0% vs. 76.9%) and virally suppressed (81.7% vs. 65.1%) in 2010 was higher in London, which could be explained by universal health coverage in UK versus US. Though fallen in London, reported serodiscordant condomless anal intercourse among MSM was higher in London HIV-negative MSM than SF (17.6% vs. 9.8%). The apparent reduced proportion of undiagnosed HIV infections and new diagnoses in SF may be associated with the higher proportion of HIV-negative MSM reporting annual HIV testing and safer sex, despite better retention in care and higher viral suppression in London. The findings highlight the critical importance for prevention of very high rates of HIV testing, awareness, and disclosure of HIV status. Brown suggested that London may benefit from SF-type intensive interventions. However, achieving the testing patterns and status disclosure of SF’s smaller, denser, higher prevalence MSM network will be challenging. Furthermore, the safety myth of negative-negative serosorting should be challenged (awareness of HIV status is low) and further study needs to disaggregate HIV-positive/negative MSM risk by viral suppression and use of pre-exposure prophylaxis.

An audience member asked Hoff about the consistency of reporting of sexual agreement within gay male couples in the study. Hoff replied that the study used the individual-level data and the study adjusted the difference between couples. There was a lively discussion about the last presentation as the audience observed other differences between SF and London which could explain some differences reported by Brown (London being much bigger city than SF, the city planning is more problematic in London than SF, migration patterns, etc). One audience member advocated for multilingual and multicultural HIV prevention programs for MSM in both cities. Another audience member commented on the highly challenging environment in which Suleiman’s study was conducted (homosexuality is criminalized and stigmatized in Nigeria) and applauded the effort of Suleiman for conducting and presenting the study at the conference. One audience member questioned the utility of a ‘gay-identified’ environment or community-based program in Nigeria. Suleiman reported that there is a lot of internalized homophobia among MSM in Nigeria and that it was important for the staff at health clinics to be professional, ensure confidentiality and build trust with MSM clients. Konda shared her experience in Peru in which MSM-friendly clinics have been instrumental in providing services to MSM. 

Co chair L. Loures from UNAIDS summarized the session by alerting that HIV epidemic is expanding among MSM globally compared to other populations. Decriminalization of homosexuality and scaling up of prevention efforts are needed to combat this rising epidemic.

Track C report by Maria Veras

1. The study presented data on couples motivations for making sexual agreements and explore whether those were associated with HIV risk, agreement maintenance, and relationship and sexual satisfaction. Data are from a longitudinal study, in San Francisco, CA, between 2012-2013, among 441 couples recruited through active and passive strategies. Couples were interviewed every 6 months. Factor analysis was used to explore facilitators of agreement. Outcomes: sex risk, sex and broken agreement. Men who report higher relationship-enhancement motivation were less likely to engage in sexual risk with outside partnership regardless of agreement type. Monogamous men who report higher relationship motivation were also less likely to break their agreements, were more satisfied with their relationship, and were more satisfied with sex life. Discussion: data presented here came from individual’s response, and although the study did interviewed both partners they didn’t look at discrepancies between the partners. Also was not possible answer on the type of agreement made.

2. This study assessed the incidence and risk factors of HIV infection, in a subsample of the Bangkok MSM Cohort Study, examining young MSM, 18-24 years of age. The participants were enrolled from 2006 - 2010. It is a non-probability sampling, from venues, Internet, a male sexual health clinic, and through outreach workers and friends. Initial testing was oral fluid confirmed by 3 rapid tests. HIV prevalence was 21%, at baseline. A total of 494 non-infected MSM were included. Incidence rate was 7,5/100 persons-year. HIV infection was lower among those in a relationship. Risk factors for seroconvertion were: living alone, being engaged in commercial sex, casual sex at sauna or at home, report and unprotected insertive/receptive anal sex. Questions from the audience: what can we do with this situation? One thing mentioned is that Medical Council in Thailand is implementing new guidelines allowing test without parental consent for young people. Questions on intergeneration sex were collected but not included in this analysis.

3. Data were from a study in Peru, exploring disclosure of HIV serostatus among high-risk MSM and Transgender Women in Peru. An ethnographic approach was used to recruit participants (n=718) to assess the effectiveness of an 18-month community-level, HIV prevention intervention. Intervention was not successful. This analysis included HIV status disclosure and sexual risk behaviors at baseline, 9 and 18 months. GEE models were used to “disclosure to the last 3 partners”. At baseline HIV status was self-reported. Participants then had undergone HIV test as part of the study. At baseline, 42% reported disclosing to their sexual partners, 27% of those who were HIV positive vs. 45% of HIV negatives.  Disclose outside sex partnership was 80%, mostly to family members or friends. Disclosure did not increase during follow-up. The most influential factor associated to disclosure was partner disclosure. Being in a stable relationship also was facilitated disclosure. Being HIV+ at baseline decreased disclosure level. At qualitative interviews the reasons for the disclose/not disclose were explored: fear of violence and dissolution of the relationship prevent participants to disclose.

4. Data from a drug use and sexual risk behaviors among men who have sex with men in Kaduna Metropolis, North central Nigeria, were presented. This is a descriptive study of data collected on routine of MSM who attended a community health clinic, friendly to vulnerable population, such as MSM, FSW, drug users. Between May of 2013 and January of 2014, a total of 1470 MSM were interviewed.  The majority (53%) was young, 15-24 years, 68% had secondary school education, 11% were married and 64,3% did not use drugs. Among those who reported using drugs, most of them used marijuana and alcohol. 77% engaged in unprotected sex, 72% in transactional sex, 56% comprehensive knowledge of HIV. Seroprevalence of HIV infection was 5.6% HIV (twice the country’s average). Recreational drugs were associated to unprotected sex. The discussion session mentioned the crucial role communities clinic, such as the one reported, that could make a difference in a context of criminalization such as Nigeria right now.

5.This study compared HIV control in San Francisco and London. The 2 cities have comparable MSM hubs. While SF decline in the undiagnosed, new diagnoses and incidence estimates, London remains largely static. The two cities have different approaches towards ART initiation: SF at any CD4 cell count and London CD4<350. HIV testing of HIV-negative MSM increased in both cities but in 2011 was less frequent and annual coverage remained lower in London (16.9%) than SF (34.4%). In a single clinic setting retesting was achieved slightly more in one year in London than that was seen within six months in SF. Looking at HIV Cascade: London’s main problem is the high proportion of men who remain unaware of their status. Increasing retention for SF may allow for even greater reduction in HIV transmission, as well as increased individual benefit. SF has innovative testing campaign highlighting the lack of safety in negative-negative serosorting. Authors acknowledge some caveats, such as MSM denominator assumptions; reporting mechanisms. Apparent reduced proportion of undiagnosed HIV and new diagnoses in SF may be due to: higher proportion of HIV-negative MSM reporting more regular HIV testing (and possible retesting); increased condom use, disclosure, and seroadaptive practices, in addition to a culture of ‘positive’ openness.  Discussion: SF has single and planned system, is also better financial resources, more money. Several from the audience pointed out to the importance of the findings for policy makers.

Chairs: we need to understand the nature of the current MSM epidemic, update our knowledge. MSM is out of control in this moment, structure issues need to be taken into consideration. Local understanding is essential. Innovation, communities play an essential role, more interest in talking about gay marriage than aids epidemic. Intervention studies are needed. The challenge to the community is to come up with programs. 


    The organizers reserve the right to amend the programme.