Prevalence of unprotected anal intercourse among HIV-diagnosed MSM who have sex with men in the United States: a meta-analysis.
Crepaz N, Marks G, Liau A, Mullins MM, Aupont LW, Marshall KJ, Jacobs ED, Wolitski RJ; for the HIV/AIDS Prevention Research Synthesis (PRS) Team, USA. AIDS. 2009; 23:1617-29
Crepaz and colleagues set out to integrate the empirical findings on the prevalence of unprotected anal intercourse among HIV-diagnosed men who have sex with men in the United States by comprehensively searching MEDLINE, EMBASE, PsycINFO (2000-2007), hand searching bibliographic lists, and contacting researchers. Thirty US studies (n = 18 121) met selection criteria. Analyses were conducted using random-effects models and meta-regression. The prevalence of unprotected anal intercourse was considerably higher with HIV-seropositive partners (30%; 95% confidence interval 25-36) than with serostatus unknown (16%; 95% confidence interval 13-21) or HIV-seronegative partners (13%; 95% confidence interval 10-16). The prevalence of unprotected anal intercourse with either a serostatus unknown or HIV-seronegative partner was 26%. The unprotected anal intercourse prevalence did not differ by the length of the behavioural recall window but did vary by the type of anal intercourse (insertive vs. receptive). Studies with the following features had a lower unprotected anal intercourse prevalence: recruiting participants before 2000, men who have sex with men of colour being the majority of study sample, recruiting participants from medical settings, using random or systematic sampling methods, and having interviewers administer the questionnaire. Being on antiretroviral therapy, having an undetectable viral load, and reporting more than 90% medication adherence were not associated with unprotected anal intercourse. Most HIV-diagnosed men who have sex with men protect partners during sexual activity, but a sizeable percentage continues to engage in sexual behaviours that place others at risk for HIV infection and place themselves at risk for other sexually transmitted infections. Prevention with positives programs continues to be urgently needed for men who have sex with men in the United States.
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Editors’ note: Men who have sex with men who know their HIV-positive status may practice harm reduction approaches such as serosorting (only engaging in unprotected sex with seropositive partners) and strategic positioning (selectively engaging in unprotected receptive, rather than unprotected insertive anal intercourse because the per-act risk of transmission is lower. This meta-analysis quantitatively synthesized US literature, excluding studies recruiting male sex workers, methamphetamine users, and men with clinically diagnosed alcohol dependency, as well as those that recruited entirely from high-risk settings (gay brothels, sex parties, and barebacking websites). With the behavioural recall window ranging from last sex to the past 12 months (median 3 months), the study found no support for the hypothesis that clinical variables (treatment status, medication adherence, and viral load) were associated with unprotected anal intercourse. Rather, serosorting and strategic positioning appear to be intentional and deliberate HIV-related harm-reduction behaviours chosen by some HIV-positive men, The relative safety of such strategies deserves urgent investigation given that there was a 26% increase in estimated male HIV cases among American men who have sex with men over the period 2004 to 2007. In 2007, 72% of male HIV cases from 38 US areas were attributed to male-to-male sexual activity.
High HIV Prevalence Among Men Who have Sex with Men in Soweto, South Africa: Results from the Soweto Men’s Study.
Lane T, Raymond HF, Dladla S, Rasethe J, Struthers H, McFarland W, McIntyre J. AIDS Behav. 2009 Aug. [Epub ahead of print]
The Soweto Men’s Study assessed HIV prevalence and associated risk factors among men who have sex with men in Soweto, South Africa. Using respondent driven sampling recruitment methods, Lane and colleagues recruited 378 men who have sex with men (including 15 seeds) over 30 weeks in 2008. All results were adjusted for respondent driven sampling sampling design. Overall HIV prevalence was estimated at 13.2% (95% confidence interval 12.4-13.9%), with 33.9% among gay-identified men, 6.4% among bisexual-identified men, and 10.1% among straight-identified men who have sex with men. In multivariable analysis, HIV infection was associated with being older than 25 (adjusted odds ratio (AOR) 3.8, 95% CI 3.2-4.6), gay self-identification (AOR 2.3, 95% CI 1.8-3.0), monthly income less than ZAR500 (AOR 1.4, 95% CI 1.2-1.7), purchasing alcohol or drugs in exchange for sex with another man (AOR 3.9, 95% CI 3.2-4.7), reporting any URAI (AOR 4.4, 95% CI 3.5-5.7), reporting between six and nine partners in the prior 6 months (AOR 5.7, 95% CI 4.0-8.2), circumcision, (AOR 0.2, 95% CI 0.1-0.2), a regular female partner (AOR 0.2, 95% CI 0.2-0.3), smoking marijuana in the last 6 months (AOR 0.6, 95% CI 0.5-0.8), unprotected vaginal intercourse in the last 6 months (AOR 0.5, 95% CI 0.4-0.6), and STI symptoms in the last year (AOR 0.7, 95% CI 0.5-0.8). The results of the Soweto Men’s Study confirm that men who have sex with men are at high risk for HIV infection, with gay men at highest risk. HIV prevention and treatment for men who have sex with men are urgently needed.
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Editors’ note: This is the first study of men who have sex with men in Africa to use respondent driven sampling (RDS) methodology to assess both HIV prevalence and risk factors. Intriguingly, the multivariate analysis revealed that the strongest adjusted odds ratio for associations with decreased risk of HIV infection was for being circumcised. Insertive anal intercourse was reported more commonly than receptive anal intercourse (85.2% ever versus 20.6% ever) and HIV prevalence among gay-identified men was more than 3 times that of bisexual and straight-identified men who have sex with men. Since the latter groups have to date been more likely to report the exclusive practice of insertive anal intercourse with male partners, this study may be providing the hypothesis-generating evidence that would support a trial of male circumcision for HIV prevention among primarily insertive men who have sex with men. On the more immediately practical side, rapid research is needed to find out whether current messages about male circumcision for HIV prevention are reaching bisexual and straight-identified men in South Africa and other high HIV prevalence settings.