HIV This Week

Sex frequency and sex planning among men who have sex with men in Bangkok, Thailand: implications for pre- and post-exposure prophylaxis against HIV infection.

van Griensven F, Thienkrua W, Sukwicha W, Wimonsate W, Chaikummao S, Varangrat A, Mock P. 2010. J Int AIDS Soc. 2010;13:13

Daily HIV anti-retroviral pre-exposure prophylaxis (PrEP) is being evaluated in clinical trials among men who have sex with men. However, daily PrEP may not be congruent with sexual exposure profiles of men who have sex with men. Here the authors investigate sex frequency and sex planning to identify and inform appropriate PrEP strategies for men who have sex with men. They evaluated sex frequency and sex planning in a cohort HIV-negative men who have sex with men in Bangkok, Thailand. Chi² test was used to compare reports of sex on different weekdays; logistic regression was used to identify predictors of sex frequency and sex planning. Of 823 men who have sex with men (mean  age 28.3 yrs) 86% reported sex on 2 days per week or less and 65% reported their  last sex to have been planned. Sex on the weekend (~30%) was more often reported than sex on weekdays (~23%). In multivariate analysis, use of alcohol, erectile dysfunction drugs, group sex, sex with a foreigner, buying and selling sex and a  history of HIV testing were associated with having sex on 3 days per week or more; age 22 to 29 years, not identifying as homosexual, receptive anal intercourse and not engaging in group sex were associated with unplanned sex. Intermittently dosed PrEP (as opposed to daily) may be a feasible HIV prevention strategy and should be considered for evaluation in clinical trials. Predictors of sex frequency and sex planning may help to identify those in need for daily PrEP and those who may not be able to take a timely pre-exposure dose. 

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Editors’ note: In this study, planned sex meant ‘having made intentional arrangements to have sex, e.g. you went to the park, sauna, bar, or online to find a sex partners or you had made an appointment with another man to have sex’. Two-thirds of the men in this study had planned sex on the first encounter of the last day they had sex. Given the sex frequency reported in this study, it would be possible for many men who have sex with men in Bangkok to use intermittent pre-exposure prophylaxis (PrEP), if it proved to be effective. For others who are having sex more frequently or who are less able to plan when they will have sex, a daily antiretroviral dose would be more practical. There is a daily dose effectiveness trial underway among men who have sex with men in Peru, Ecuador, USA, South Africa, and Thailand - it will report results in the next 6 months. A safety and acceptability study of intermittent PrEP among men who have sex with men is underway in Kenya and Uganda and two further safety studies are planned. If daily PrEP provides protection and intermittent PrEP is safe, the question will be whether intermittent PrEP will be effective and for which men. Local studies such as this one eventually can inform the counselling that will help men to choose a tailored approach that will work best for them.

Couple-oriented prenatal HIV counseling for HIV primary prevention: an acceptability study.

Orne-Gliemann J, Tchendjou PT, Miric M, Gadgil M, Butsashvili M, Eboko F, Perez-Then E, Darak S, Kulkarni S, Kamkamidze G, Balestre E, Desgrees du Lou A, Dabis F. BMC Public Health. 2010;10:197.

A large proportion of the 2.5 million new adult HIV infections that occurred worldwide in 2007 were in stable couples. Feasible and acceptable strategies to improve HIV prevention in a conjugal context are scarce.  In the preparatory phase of the ANRS 12127 Prenahtest multi-site HIV prevention trial, the authors assessed the acceptability of couple-oriented post-test HIV counselling and men's involvement within prenatal care services, among pregnant women, male partners, and health care workers in Cameroon, Dominican Republic, Georgia, and India. Quantitative and qualitative research methods were used:  direct observations of health services; in-depth interviews with women, men, and health care workers; monitoring of the couple-oriented post-test HIV counselling intervention; and exit interviews with couple-oriented post-test HIV counselling participants. In-depth interviews conducted with 92 key informants across the four sites indicated that men rarely participated in antenatal care services, mainly because these are traditionally and programmatically a woman's domain. However men's involvement was reported to be acceptable and needed in order to improve antenatal care and HIV prevention services. Couple-oriented post-test HIV counselling was considered by the respondents to be a feasible and acceptable strategy to actively encourage  men to participate in prenatal HIV counselling and testing and overall in  reproductive health services. One of the keys to men's involvement within prenatal HIV counselling and testing is the better understanding of couple relationships, attitudes, and communication patterns between men and women, in terms of HIV and sexual and reproductive health; this conjugal context should be taken into account in the provision of quality prenatal HIV counselling, which aims at integrated prevention of mother-to-child transmission and primary prevention of HIV.

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Editors’ note: The Prenahtest trial assessing the impact of couple-oriented post-test counselling, underway in 4 low-to-medium HIV prevalence countries, will be completed in 2011. This preparatory study revealed support for the idea of increasing men’s involvement but identified a number of barriers that first must be overcome. These include making antenatal care services more physically and interpersonally receptive to male participation and challenging gender norms to address the social barriers to male involvement. This process can help change the paternalistic, unidirectional nature of relationships between most health care providers and patients which can reveal itself as lectures without opportunities for personalised prevention messages. Testing options for men are limited to sexually transmitted disease clinics, voluntary counselling and testing services, and male circumcision programmes. Couple counselling and testing in the context of pregnancy is an opportunity to increase the testing options for men while decreasing the likelihood of transmission to infants. It is an opportunity that should not to be missed – most men and women living in a serodiscordant couple do not know their status nor that of their partner.

Bisexual concurrency, bisexual partnerships, and HIV among Southern African men who have sex with men.

Beyrer C, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, Baral S. Sex Transm Infect. 2010. [Epub ahead of print]

The sexual behaviour of men who have sex with men in southern Africa has been little studied. Beyrer et al present here the first data on bisexual partnerships and bisexual concurrency among men who have sex with men in Malawi, Namibia and Botswana. The authors conducted a cross-sectional probe of a convenience sample of 537 men who have ever reported anal sex with another man using a structured survey instrument and rapid-kit HIV screening. 34.1% of men who have sex with men were married or had a stable female partner, and 53.7% reported both male and female sexual partners in the past 6 months. Bisexual concurrency was common, with 16.6% of men who have sex with men having concurrent relationships with both a man and a woman. In bivariate analyses, any bisexual partnerships were associated with lower education (OR 1.6, 95% CI 1.1 to 2.3), higher condom use (OR 6.6, 95% CI 3.2 to 13.9), less likelihood of having ever     tested for HIV (OR 1.6, 95% CI 1.1 to 2.3), less likelihood of having disclosed sexual orientation to family (OR 0.47, 95% CI 0.32 to 0.67) and being more likely to have received money for casual sex (OR 1.9, 95% CI 1.3 to 2.7). Bisexual concurrency was associated with a higher self-reported condom use (OR 1.7, 95% CI 1.0 to 3.1), being employed (OR 1.8, 95% CI 1.2 to 2.9), lower likelihood of disclosure of sexual orientation to family (OR 0.37, 95% CI 0.22 to 0.65) and having paid for sex with men (OR 2.0, 95% CI 1.2 to 3.2).The majority of men who have sex with men in this study report some bisexual partnerships in the previous 6 months. Concurrency with sexual partners of both genders is common. Encouragingly, men reporting any concurrent bisexual activity were more likely to report condom use with sexual partners, and these men were not more likely to have HIV infection than men reporting only male partners. HIV-prevention programmes focussing on decreasing concurrent sexual partners in the African context should also target bisexual concurrency among men who have sex with men. Decriminalisation of same-sex practices will potentiate evidence-based HIV-prevention programmes targeting men who have sex with men.

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Editors’ note:  Historical and current labour migration patterns in southern Africa are thought to be major contributors to sexual concurrency, most often defined as men having two or more female sexual partners and women having two or more male partners at the same time. This is the first study of bisexual concurrency among men who have sex with men, defined as being in an ongoing sexual relationship with both a male and a female partner. Bisexuality was defined as sex with at least one man and one woman in the previous 6 months. The study population in Botswana, Namibia, and Malawi was urban and more likely to be gay-identified because the men were recruited through local human rights organisations with links to these communities of men. All three countries criminalise same sex behaviour. Although the findings cannot be generalised to the entire population of men who have sex with men, they are nonetheless thought provoking. Overall, more than half were sexually active with both men and women, one third were married to women, and one in six was in a stable relationship with a man and a woman. Men were more likely to identify as bisexual and report bisexual concurrency in settings where the social pressure to marry women was strong, such as Malawi. HIV infection prevalence was about twice as high as national estimates of HIV prevalence for men of reproductive age; however, condom use with regular and casual sex partners was higher among those in concurrent bisexual partnerships. Further research is needed to better understand the contribution of bisexuality and bisexual concurrency to African epidemics but the capacity to undertake such research and design tailored prevention programmes will depend on how quickly these countries move to decriminalise homosexuality.

HIV Transmission Rates in Thailand: Evidence of HIV Prevention and Transmission Decline. Siraprapasiri T, Peerapatanapokin W, Manne J, Niccolai L, Kunanusont C. J Acquir Immune Defic Syndr. 2010; 54:430-6

Analysis of HIV transmission rates has provided insight into the impacts of HIV-related prevention programming and policies in the United States by providing timely information beyond incidence or prevalence alone. The purpose of this analysis is to use transmission rates to assess past prevention efforts and explore trends of the epidemic in subpopulations within Thailand. Asian Epidemic Model HIV incidence and prevalence were used to calculate transmission rates over time nationally and among high-risk populations. A national HIV program implemented in Thailand in the 1990s that targeted sex workers   and the general population was correlated with a decrease in new cases despite high prevalence. The turning point of the epidemic was in 1991 when the national transmission rate was 32%. By the late 1990s, the rate dropped to less than 4%. All subpopulations experienced a rate decline; however, sex workers still experienced higher transmission rates. The declining trend in HIV transmission rates despite ever-growing prevalence indicates prevention success correlated with the national HIV program. Data from subgroup analyses provide stronger evidence of prevention success than incidence alone, as this measure demonstrates the effect of efforts and accounts for the burden of disease in the population.

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Editors’ note: This paper defines the HIV transmission rate as the new cases of HIV divided by the existing number of persons living with HIV for a specified time. It provides a measure that considers the spread of HIV by accounting for the number of people capable of transmitting HIV. How accurate the transmission rate calculated in this manner will be clearly depends on how good are the HIV incidence and prevalence estimates. Nevertheless, Thailand has clearly met the Millennium Development Goal 6 ‘to halt and reverse the spread of HIV by 2015’ through sustained reductions in HIV incidence. This resulted from the swift action that provoked dramatic changes in HIV incidence from a peak in 1991 and concerted prevention programming thereafter. These included mobilisation of non-governmental organisations, the 100% condom use campaign that went national in 1992, blood screening programmes, and active surveillance. It is unclear how accurate transmission rates calculated this way are for key populations such as men who have sex with men, people who inject drugs, and couples in which one person has HIV infection, but the need to engage these people in the design of effective tailored prevention programming and better surveillance is clear.