Significant HIV prevention intervention gains have been made since the advent of the epidemic. Nonetheless, some have argued convincingly that recent prevention efforts have been woefully insufficient to curb the HIV epidemic among MSM (Fenton, 2010
; Jaffee, Valdiserri, & De Cock, 2007
; Wolitski, Valdiserri, Denning, & Levine, 2001
). Others argue that the needs of YMSM in particular have not been addressed adequately (Harper, 2007a
; Mustanski et al., 2007
). In describing the current status of HIV prevention efforts, Stall and colleagues (2009
, p. 625) argue, “In terms of our effectiveness in the fight against AIDS among MSM in the United States, we are currently running in place.” YMSM, and in particular YMSM of color, have received relatively little attention in terms of behavioral intervention development. This reflects a general trend of HIV intervention research in this population that is not commensurate to the magnitude of the epidemic in the population (Harper, 2007b
The development of effective behavioral HIV prevention interventions is particularly important given that most school-based sexual education programs in the U.S. do not address the needs of YMSM. Most sex-education programs in the U.S. have been mandated to incorporate an abstinence-based curriculum, which underscores sexual abstinence (until marriage) as the best behavioral prevention method to HIV/STI (Santelli et al., 2006
). Abstinence-based programs historically have excluded discussions on same-sex sexuality and its associated health risks. Excluding this material from curricula is harmful to youth, not only because of its inscribed heteronormative assumptions, but because abstinence-only programs can leave adolescents, but in particular YMSM, misinformed about the benefits of condom use and the risks associated with unprotected anal sex (Fine & McClelland, 2006
; Santelli et al., 2006
). Furthermore, because same-sex marriage is currently illegal on a federal level and in the majority of U.S. states, abstinence until marriage messages are, at best, irrelevant to sexual minority youth.
Overall, recent meta-analyses suggest that HIV behavioral interventions for adult MSM are efficacious (Herbst, Beeker, et al., 2007
; Johnson et al., 2008
; Vergidis & Falagas, 2009
). Behavioral interventions administered at three levels – individual, group, and community – appear to effectively reduce risky sexual behaviors associated with HIV and STI transmission. For example, Johnson and colleagues (2008)
found that among 40 interventions compared to a minimal or no HIV prevention control group, the average reduction in occasions of or partners for unprotected anal sex was 27%. Herbst and colleagues (2007a)
similarly found significant reductions in UAI in their meta-analysis of individually-administered, group level, and community level intervention for MSM. Group and community level interventions in particular are promising, due to cost effectiveness (Herbst, Fielding, et al., 2007
). However, many projects have described difficulty with recruitment and participation in group-based interventions. Meta-analysis also has found behavioral interventions are efficacious in reducing sexual risk in a variety of adolescent populations (Johnson, Carey, Marsh, Levin, & Scott-Sheldon, 2003
Reviews of HIV behavioral interventions highlight the paucity of published, YMSM-specific HIV prevention interventions (Harper, 2007a
; Mustanski et al., 2007
). Accordingly, reviews of existing interventions have led to a call for more attention to YMSM (Lyles et al., 2007
). For example, of the 26 currently CDC endorsed DEBIs (Diffusion of Effective Behavioral Intervention; www.effectiveinterventons.org
), none are tailored for adolescent MSM, and only one is targeted at emerging adult MSM (MPowerment). Given that federal prevention funding can be tied to implementation of a DEBI, the lack of DEBIs tested among YMSM can limit prevention work with this population.
There are a few notable YMSM-specific HIV prevention projects and interventions worthy of mention. Remafedi (1994)
conducted one of the first YMSM-specific individual-level HIV interventions. He examined the effects of cognitive-behavioral HIV risk-assessment and reduction counseling on short-term changes in HIV knowledge, beliefs, and behaviors among a YMSM sample. Results showed a significant pre-post reduction in anal intercourse as well as an increase in condom use. Equally important is that this was one of the first studies to highlight HIV risk differences between YMSM and adult MSM. However, the lack of a control group and random assignment to condition limit knowledge about this intervention’s efficacy.
The Mpowerment Project, the aforementioned CDC DEBI, is perhaps the most widely disseminated intervention designed specifically for young adult MSM (ages 18-29; (Kegeles, Hays, Pollack, & Coates, 1999
). The theory underlying Mpowerment is based on two premises – that learned behavior (e.g. safe sex) occurs through modeling and peer influence; and that a diffusion process is required to spread the new behavior through the community (Zimmerman et al, 1997; Hays et al., 2003
). Accordingly Mpowerment is categorized as a community-level intervention, and it employs a multi-systemic approach by advocating for personal empowerment at the individual level as well as community outreach and development. To this end, it is dependent upon a group of core members and volunteers to provide outreach to the community in the form of safer sex materials and information (Hays, Rebchook, & Kegeles, 2003
; Kegeles, Hays, & Coates, 1996
). The intervention has been implemented widely in a variety of settings, and several studies lend support to Mpowerment’s efficacy, both in terms of cost effectiveness and HIV sexual risk reduction (Hays et al., 2003
; Kahn, Kegeles, Hays, & Beltzer, 2001
; Rebchook, Kegeles, Huebner, & Team, 2006
Although not YMSM specific, Blake and colleagues (2001) conducted one of the only studies to examine the effect of a school/community-level intervention related to LGB youth health. Using data from the 1995 Massachusetts Youth Risk Behavior Survey (YRBS), these researchers found that LGB youth were significantly more likely to endorse higher rates of substance use, sexual risk behaviors, and suicide attempts compared to their heterosexual classmates. At the time of the study, 28% of Massachusetts high schools had applied for and received “Safe School Grants.” These allowed schools to supplement teacher training related to LGB issues, including LGB health and LGB sensitive HIV instruction. LGB youth in these schools engaged in fewer sexual risk behaviors than LGB youth in regular health classes. Overall, the authors conclude that LGB affirming school environments matter because they make a positive difference in the lives of LGB youth. However, due to the intervention design, it is not possible to disentangle effects of school climates that may lead to applying for grants to support LGB sensitive instruction, from the effects of such instruction.
Social networks also serve as a potential medium for behavioral intervention administration. Amirkhanian and colleagues (2003) developed an innovative social network intervention in Russia and Bulgaria for YMSM. This intervention makes use of “friendship network leaders” who provide members in their social network information on HIV transmission and risk reduction. It is based on the premise that individuals in the same social network are behaviorally similar and are amenable to behavioral change via group norms, attitudes, and expectations (Amirkhanian et al., 2005
). Evaluation of this intervention indicated that it led to reductions in unprotected sex compared to a control group of YMSM.
The use of the Internet as an HIV risk reduction strategy has gained popularity in recent years. The Internet is a potentially effective tool for administering HIV prevention interventions because it is cost-effective and can be used to reach wider and less accessible populations (Dufour et al., 2000
; Mustanski, 2001
). A recent meta-analysis examined the efficacy of computer or technology-based behavioral interventions on HIV risk reduction and found similar efficacy rates between these and traditional behavioral interventions (Noar, Black, & Pierce, 2009
). Moreover, the Internet appears to be a promising HIV intervention platform for YMSM in particular (Seal et al., 2000
). A recent study found that among urban YMSM, many used the Internet to obtain information about their sexual health and to connect to gay community (Mustanski, Lyons, & Garcia, 2010b
). Evidence also suggests that increasing rates of YMSM are meeting their first sexual partners online (Bolding et al., 2007
Given the general dearth of published YMSM-specific HIV prevention interventions, it is not surprising that there are a very limited number of YMSM-tested biomedical interventions. HIV biomedical interventions in which adult MSM have participated include: circumcision, HIV vaccine candidates, and the use of preexposure/ postexposure prophylaxis medications. Currently, the efficacy of biomedical HIV interventions in adult MSM populations remains unclear. If one or more of these approaches proves to be effective among adult MSM, it will be important to further evaluate their efficacy among YMSM before they are deployed in this population, as biological and behavioral differences across development may moderate their effectiveness.
The efficacy of male circumcision in preventing HIV infection in MSM populations is doubtful. A recent meta-analysis examining the association of circumcision status and HIV infection in approximately 53,567 MSM across fifteen observational studies failed to find a strong relationship between circumcision status and HIV status, and between circumcision and STI incidence (Millett, Flores, Marks, Reed, & Herbst, 2008). The effect was not significant even among MSM who primarily engaged in insertive anal sex. Researchers have suggested that the efficacy of circumcision as an HIV prevention strategy is likely dependent upon a number of other behavioral correlates of sexual risk (Sawires et al., 2007
The use of either preexposure (PrEP) or postexposure (PEP) prophylaxis medications as a biomedical intervention to combat HIV has gained steady attention in the MSM community in recent years (Voetsch, Heffelfinger, Begley, Jafa-Bhushan, & Sullivan, 2007
). Nonetheless, awareness and use of these as HIV prevention strategies remains modest (Liu et al., 2008). Grant and colleagues (2010) recently published the first multinational study examining the efficacy of PrEP among MSM. Result of the study showed that a once-daily pill provided an average of 44% additional protection against HIV infection to MSM and transgendered women who have sex with men, who also received a comprehensive package of traditional prevention services. The level of protection shown varied widely depending on how consistently participants used PrEP. Among those whose took their daily dose on 90% of days, HIV risk was reduced by roughly 73%. Among those who missed more than 10% of their doses, HIV risk was reduced by only about 21%. Given these effects, pharmacological prevention in the near term is likely to require both high levels of adherence and also continued practice of safer sex behaviors. This is not always the case; Golub and colleagues (2008) found that 21% of their PEP-using sample reported engaging in risky sexual behavior during their 28-day medication period. No studies have published results testing the efficacy of prophylaxis medications in YMSM, however such trials are ongoing and results are expected in the next few years.
Finally, similar to prophylaxis medications, rectal microbicides are another biological approach to prevent HIV infection. Rectal microbicides are applied directly to the rectal mucosa to prevent HIV acquisition. Currently, no clinical trials have demonstrated the efficacy of microbicides among MSM and in women, no vaginal microbicide has yet to be found effective (McGowan, 2010). Although more than 50 potential microbicides are being investigated for possible vaginal use, it’s not clear yet which of them will be suitable for rectal use. The rectum and the vagina differ significantly in structure and natural ecologies. Although most microbicides research is now focused on vaginal use, research and development of rectal microbicides is a growing segment in the field.
Secondary prevention refers to prevention efforts targeting HIV positive individuals. Given that participants in these interventions have HIV, the ultimate goal is to reduce HIV transmission to others. For a variety of reasons, research on secondary prevention was not initiated in the U.S. until much later than research on primary prevention (Fisher, Smith, & Lenz, 2010). Crepaz and colleagues (2009) recently provided evidence suggesting a higher prevalence of UAI among HIV positive MSM compared to HIV negative or unknown HIV status MSM, indicating a particular need for secondary prevention among MSM. Like much of HIV prevention research, few secondary prevention interventions have focused on YMSM. Moreover, the secondary prevention work among adult MSM is scant, and findings are mixed. Crepaz and colleges (2006) published a meta-analysis suggesting that secondary prevention is an efficacious HIV prevention approach. Notably the analysis included studies of all HIV at-risk groups, not just MSM. Rotheram-Borus and colleagues (2004) conducted a secondary prevention intervention comprised of a majority (69%) of young gay and bisexual participants (ages 16-29). They found that, compared to participants in a delayed-intervention condition, intervention arm participants increased their proportion of protected sexual acts. Conversely, Rosser and colleagues (2010) conducted a randomized control trial to test the efficacy an MSM-specific secondary prevention intervention. Results indicated participants reported similar decreases in serodiscordant UAI across groups tailored for HIV positive MSM, HIV negative MSM, and a contrast prevention video arm. In this case, tailoring the intervention to HIV positive MSM did not provide benefits beyond the generic intervention.
Perhaps secondary prevention interventions are not consistently effective because we do not know the mechanisms that underlie their success. Consistent with this claim, few studies have investigated effective components of positive prevention interventions. Sikkema and colleagues (2010) argue that the reduction of psychological distress is the underlying mechanism of success in secondary prevention. These researchers theorize that enhancing psychological health will positively influence sexual risk behavior (Sikkema et al., 2010); therefore, secondary prevention intervention efforts should include mental health enhancement as a core focus. We suggest further research investigating these mechanisms of change in secondary prevention research, as well as more research among YMSM.