HIV-infected MSM in Lima, Peru reported frequent unprotected anal intercourse with both HIV-infected and HIV-uninfected sex partners, had a high prevalence of syphilis and HSV-2 infections, and did not show evidence of engaging in strategies to reduce risk of HIV transmission during unprotected intercourse. Frequent reports of high-risk sexual behavior among men already diagnosed with HIV infection point to the need for “prevention for positives” interventions that specifically target secondary HIV transmission among MSM [8
Our findings are consistent with other studies that have shown high rates of unprotected intercourse among HIV-infected MSM in the U.S., Europe, and the Caribbean [18
]. The remarkable aspect of our study is the large number of HIV-infected MSM who specified recent high-risk sexual practices with HIV-uninfected partners, coupled with the absence of any discernible harm-reduction strategies. Insertive unprotected anal intercourse (UAI) with an HIV-uninfected male partner, a practice where estimated risk for HIV transmission is 0.82% per-act [24
], was reported by 33.6% of all HIV-infected MSM during the previous six months. Men who knew they were HIV-infected were equally as likely as undiagnosed men to engage in insertive UAI with an HIV-uninfected male partner. In addition, MSM with known HIV infection were more likely to engage in both insertive and receptive UAI exclusively with HIV-uninfected men than with HIV-infected or unknown serostatus men. These observations probably represent the indiscriminate practice of unprotected intercourse with all sex partners regardless of their HIV status in a society where HIV-infected men rarely disclose their HIV status to sex partners (Fig. 1). Yet the implications of these unprotected serodiscordant partnership patterns for HIV transmission in the community cannot be ignored. Prevention interventions for Peruvian MSM that address routine condom use during intercourse with partners of discordant or unknown HIV serostatus should also introduce concepts of disclosure of HIV status, harm reduction, and negotiated safety. Although serosorting and seropositioning can not be advocated as effective methods of HIV prevention, informed discussion of these concepts can assist HIV-infected Peruvian men to begin to openly acknowledge and negotiate the impact of HIV and STIs on their sexuality and sexual practices.
Although unsurprising, the high prevalence of co-infection with syphilis or HSV-2 in the study sample has important implications for secondary HIV transmission in the population. While the number of infections diagnosed among all MSM in the study was high (55.0% HSV-2 seropositive, 10.0% with active syphilis), the rate of infections in the subset of HIV-infected MSM was substantially higher (79.8% HSV-2 seropositive; 21.0% with active syphilis; p<0.001). Previous studies have highlighted the link between syphilis or HSV-2 infection and HIV acquisition, independent of sexual risk behavior, among MSM in Peru [4
]. Given the endemic nature of these STIs in Peruvian MSM populations, it is difficult to differentiate their role in augmenting secondary HIV transmission by HIV-infected MSM from their role in increasing primary HIV acquisition by HIV-uninfected men. Biological strategies for STI prevention and management among MSM in Peru are necessary to address the epidemiologic context where STIs disproportionately, though not exclusively, involve HIV-infected MSM. Routine care of HIV-infected and high-risk uninfected MSM should include regular and frequent STI screening, including testing for syphilis, gonorrhea and chlamydia (at all anatomic sites of sexual contact), as well as HSV-2 antibody testing and consideration of HSV-2 antiviral therapy [26
Although not directly addressed by our findings, social norms and epidemiologic patterns present in Lima’s urban neghborhoods provide the context for individual behavioral and biological risk factors for secondary HIV transmission observed among MSM in our study. Community behavioral norms neglecting condom use are reflected in individuals’ patterns of behavior, independent of their HIV status [28
]. Stigma against people with HIV inhibits disclosure of HIV infection to sex partners and deters initiation of condom use or other safer sex practices that might suggest a person is HIV-infected [9
]. Poverty and socioeconomic marginalization of gay men leads many to engage in compensated sex for economic survival [30
]. A high baseline prevalence of STIs heightens risk for the continued spread of HIV and STIs in the community [31
]. Deficiencies in public health resources limit access to the diagnostic, treatment, and public health services (such as third-party partner notification and expedited partner therapy) that could reduce the spread of HIV and other STIs in the population [32
]. In addition to modifying individual risk behaviors, interventions to reduce secondary transmission of HIV must account for and address the larger ecological context of MSM in Peru [33
Our findings have several limitations that may limit their generalizability. Participants were recruited from an STI clinic setting and are by definition a high-risk subpopulation. The prevalence of sexual risk behaviors and STIs in this group is likely to be higher than that of HIV-infected MSM in the general population. In addition, though information was collected on specific sexual practices in the last six months and during the last sex act, we do not have detailed information on behavior with different partner types or in different contexts. As many people consider unprotected intercourse less risky in the setting of a stable relationship or when on stable antiretroviral therapy, knowledge of the specific circumstances in which behaviors are practiced can be as important as the behavior itself. We also did not collect information on the time since initial diagnosis for men with known HIV infection. This information is potentially important in that there is often a transient decrease in high-risk sexual behavior during the time period immediately following a diagnosis of HIV infection [36
]. Analysis of sexual risk behavior among MSM with known HIV infection according to the length of time since diagnosis could further illuminate the risk practices outlined in our report. Similarly, the study instrument was not specifically designed to assess serosorting or seropositioning practices among HIV-infected MSM. In order to assess risk of HIV acquisition for uninfected MSM, all participants were asked how often they had unprotected intercourse with “HIV-negative partners” and with “HIV-positive or unknown serostatus partners,” resulting in a loss of depth and subtlety in thoroughly understanding risk reduction behaviors of the HIV-infected participants. Despite these limitations, our findings provide important information for understanding secondary HIV transmission among MSM in Peru and suggest important areas for additional research and analysis.
The behavioral and biological risk profiles of Peruvian HIV-infected MSM reported here indicate significant risk for continued HIV transmission and expansion of the HIV epidemic among MSM in Peru. Although we cannot make determinations regarding the effectiveness of counseling and testing programs for modifying high-risk sexual behavior [15
], it is clear that in this population knowledge of HIV-infected status is not associated with a significant reduction in sexual risk behavior. In addition, there was no evidence of harm reduction practices such as serosorting and seropositioning. Although these strategies are not reliable methods for HIV prevention, they do represent an open engagement with problems of sexuality in the context of HIV infection that Peruvian MSM should be encouraged to address. Finally, population-level interventions that target community behavioral norms of condom use and public health issues of STI control in Peru are critical to modifying the contexts in which risk factors for HIV/STI transmission of individual HIV-infected MSM are located. Secondary HIV prevention strategies that specifically address the needs of HIV-infected MSM should be developed in Peru as part of larger efforts to alter the behavioral and biological dynamics of HIV/STI transmission in the population, and need to be introduced immediately.