HIV This Week

Baral S, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, Beyrer C. HIV prevalence, risks for HIV infection, and human rights among men who have sex with men (MSM) in Malawi, Namibia, and Botswana. PLoS ONE. 2009;4(3):e4997.

In the generalized epidemics of HIV in southern sub-Saharan Africa, men who have sex with men have been largely excluded from HIV surveillance and research. Epidemiologic data for men who have sex with men in southern Africa are among the sparsest globally, and HIV risk among these men has yet to be characterized in the majority of countries. A cross-sectional anonymous probe of 537 men recruited with non-probability sampling among men who reported ever having had sex with another man was conducted in Malawi, Namibia, and Botswana using a structured survey instrument and HIV screening with the OraQuick© rapid test kit. The HIV prevalence among those between the ages of 18 and 23 was 8.3% (20/241); 20.0% (42/210) among those 24-29; and 35.7% (30/84) among those older than 30 for an overall prevalence of 17.4% (95% CI 14.4-20.8). In multivariate logistic regressions, being older than 25 (aOR 4.0, 95% CI 2.0-8.0), and not always wearing condoms during sex (aOR 2.6, 95% CI 1.3-4.9) were significantly associated with being HIV-positive. Sexual concurrency was common with 16.6% having ongoing concurrent stable relationships with a man and a woman and 53.7% had both male and female sexual partners in proceeding 6 months. Unprotected anal intercourse was common and the use of petroleum-based lubricants was also common when using condoms. Human rights abuses, including blackmail and denial of housing and health care was prevalent with 42.1% (222/527) reporting at least one human rights abuse. Men who have sex with men are at higher risk of HIV exposure for HIV infection and human rights abuses in Malawi, Namibia, and Botswana. Concurrency of sexual partnerships with partners of both genders may play important roles in HIV spread in these populations. Further epidemiologic and evaluative research is needed to assess the contribution of men who have sex with men to southern Africa’s HIV epidemics and how best to mitigate this. These countries should initiate and adequately fund evidence-based and targeted HIV prevention programs for men who have sex with men.

Editors’ note: This simple epidemiology and human rights study, the first to link individual level rights abrogation to HIV biological outcomes in the African context, was implemented through collaboration with local community groups and can be replicated in similar settings. The overall findings of a high risk of exposure to both HIV and human rights abuses, in these three high HIV prevalence countries that criminalize same sex behaviour among consenting adults, are striking. Effective HIV prevention programming for men who have sex with men, particularly younger men, in Botswana, Malawi, and Namibia requires urgent governmental attention with dedicated funding and creative innovations, including use of the internet to reach this hidden population, training of health care providers, and strategies to address and minimise human rights abuses.

Human papillomavirus is a common sexually transmitted agent that causes anogenital cancer and pre-cancer lesions that have an inflammatory infiltrate, may be friable, and bleed. Chin-Hong and colleagues aimed to determine the association between anal HPV infection and HIV acquisition using a prospective cohort study design. They recruited 1409 HIV-negative men who have sex with men from a community-based setting in Boston, Denver, New York, and San Francisco. The authors used Cox proportional hazards regression modeling and assessed the independent association of HPV infection with the rate of acquisition of HIV infection. Of 1409 participants contributing 4375 person-years of follow-up, 51 HIV-seroconverted. The median number of HPV types in HPV-infected HIV-seroconverters was 2 (interquartile range 1-3) at the time of HIV seroconversion. After adjustment for sexual activity, substance use, occurrence of other sexually transmitted infections, and demographic variables, there was evidence (P = 0.002) for the effect of infection with at least two HPV types (hazard ratio 3.5, 95% confidence interval 1.2-10.6) in HIV seroconversion. The authors conclude that anal HPV infection is independently associated with HIV acquisition. Studies that incorporate high-resolution anoscopy to more accurately identify HPV-associated disease are needed to determine the relationship between HPV-associated disease and HIV seroconversion.

Editors’ note: HPV disease has long been considered to be opportunistic, taking advantage of HIV-induced immunosuppression but not increasing the risk of HIV acquisition. If, as this first study to do so suggests, anal HPV infection is independently associated with HIV acquisition, immunizing HPV-unexposed people to prevent invasive cancer and anogenital warts may have the potential to reduce the risk of HIV acquisition through anal sex.

New HIV infections are being observed among men who have sex with men (MSM). Understanding the fusion of risky sexual behaviours, stimulant drug use, and erectile dysfunction drug use with HIV seroconversion may provide direction for focused intervention. During the follow-up period (1998-2008), Ostrow and colleagues identified 57 HIV seroconverters among 1667 initially HIV-seronegative men. Time to seroconversion was modelled using Cox proportional hazards regression analysis for 7 combinations of sex drugs (inhaled nitrites or “poppers”, stimulants, and erectile dysfunction drugs) used at the current or previous semi-annual visit, adjusting for other risk factors including sexual behaviour, alcohol and other drugs used, and depression. Model-based adjusted attributable risks were then calculated. The risk of seroconversion increased linearly with the number of unprotected receptive anal sex partners, with hazard ratios ranging from 1.73 [95% confidence interval (CI): 0.75 to 4.01] for 1 partner, to 4.23 (95% CI: 1.76 to 10.17) for 2-4 partners, and to 14.21 (95% CI: 6.27 to 32.20) for 5+ partners, independent of other risk factors. After adjustment, risks for seroconversion increased from 2.99 (95% CI: 1.02 to 8.76) for men who reported using stimulants only (1 drug) to 8.45 (95% CI: 2.67 to 26.71) for men who reported using all 3 sex drugs. The use of any of the 7 possible sex drug combinations accounted for 63% of the 9-year HIV seroincidence in the Multicenter AIDS Cohort Study. When contributions of increased unprotected receptive anal sex partners and combination drug use were analyzed together, the total attributable risk for HIV seroconversion was 74%, with 41% attributable to unprotected receptive anal sex partners alone and a residual of 33% due to other direct or indirect effects of sex drug use. Use of poppers, stimulants, and erectile dysfunction drugs increased risk for HIV seroconversion significantly in this cohort. These data reinforce the importance of implementing interventions that target drug reduction as part of comprehensive and efficacious HIV prevention strategies.

Editors’ note: Whether or not and how vasoactive sex drug use could increase the likelihood of HIV infection through unprotected sex, over and above the disinhibiting effects of drug use, is unclear. Nonetheless, the magnitude of the risk posed by the use of stimulant, poppers, and erectile dysfunction drugs is clear – among men who used all three drugs the relative hazard for HIV seroconversion was 8 times that of men who reported no use of these sex drugs. With noninjection substance use seemingly on the increase among men who have sex with men, particularly the use of erectile dysfunction drugs as men age, attention addressed to the linked epidemics of substance use and high-risk sex should inform tailored harm reduction and safer sex strategies.

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