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1.  Are HIV Epidemics among Men Who Have Sex with Men Emerging in the Middle East and North Africa?: A Systematic Review and Data Synthesis 
PLoS Medicine  2011;8(8):e1000444.
A systematic review by Laith Abu-Raddad and colleagues collates and analyzes the epidemiology of HIV among men who have sex with men in Middle Eastern and North African countries.
Background
Men who have sex with men (MSM) bear a disproportionately higher burden of HIV infection than the general population. MSM in the Middle East and North Africa (MENA) are a largely hidden population because of a prevailing stigma towards this type of sexual behavior, thereby limiting the ability to assess infection transmission patterns among them. It is widely perceived that data are virtually nonexistent on MSM and HIV in this region. The objective of this review was to delineate, for the first time, the evidence on the epidemiology of HIV among MSM in MENA.
Methods and Findings
This was a systematic review of all biological, behavioral, and other related data on HIV and MSM in MENA. Sources of data included PubMed (Medline), international organizations' reports and databases, country-level reports and databases including governmental and nongovernmental organization publications, and various other institutional documents. This review showed that onsiderable data are available on MSM and HIV in MENA. While HIV prevalence continues at low levels among different MSM groups, HIV epidemics appear to be emerging in at least few countries, with a prevalence reaching up to 28% among certain MSM groups. By 2008, the contribution of MSM transmission to the total HIV notified cases increased and exceeded 25% in several countries. The high levels of risk behavior (4–14 partners on average in the last six months among different MSM populations) and of biomarkers of risks (such as herpes simplex virus type 2 at 3%–54%), the overall low rate of consistent condom use (generally below 25%), the relative frequency of male sex work (20%–76%), and the substantial overlap with heterosexual risk behavior and injecting drug use suggest potential for further spread.
Conclusions
This systematic review and data synthesis indicate that HIV epidemics appear to be emerging among MSM in at least a few MENA countries and could already be in a concentrated state among several MSM groups. There is an urgent need to expand HIV surveillance and access to HIV testing, prevention, and treatment services in a rapidly narrowing window of opportunity to prevent the worst of HIV transmission among MSM in the Middle East and North Africa.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
AIDS first emerged in the early 1980s among gay men living in the US. But, as the disease rapidly spread, it became clear that AIDS also affects heterosexual men and women. Now three decades on, more than 30 million people are infected with HIV, the virus that causes AIDS. HIV is most often spread by having unprotected sex with an infected partner and, globally, most sexual transmission of HIV now occurs during heterosexual sex. However, 5%–10% of all new HIV infections still occur in men who have sex with men (MSM, a term that encompasses homosexual, bisexual, and transgender men, and heterosexual men who sometimes have sex with men). In some countries, male-to-male sexual contact remains the most important transmission route. Moreover, although the global prevalence of HIV infection (the proportion the world's population infected with HIV) has stabilized, the prevalence of HIV infection among MSM seems to be increasing in multiple countries and new and resurgent HIV epidemics among MSM populations are being frequently reported.
Why Was This Study Done?
In the US and the UK, the MSM population is visible and has helped to raise awareness about the risks of HIV transmission through male-to-male sexual contact. In many other countries, MSM are much less visible, fearing discrimination, stigmatization (being considered socially unacceptable) or arrest. In the Middle East and North Africa (MENA, a geographical region that encompasses countries that share historical, socio-cultural, linguistic and religious characteristics), MSM are the most hidden HIV risk group. Consequently, very little is known about HIV transmission patterns among MSM in MENA. Indeed, it is widely thought that there is virtually no information available on the epidemiology (causes, distribution, and control) of HIV among MSM in this region. In this systematic review and data synthesis, the researchers use predefined search criteria to identify all the published and unpublished data on the epidemiology of HIV among MSM in MENA and combine (synthesize) these data to produce a coherent picture of the HIV epidemic in this potentially key group of people for HIV transmission in this region.
What Did the Researchers Do and Find?
The researchers identified 26 articles and 51 other country-level reports and sources of data that included data on the prevalence of male-to-male sexual contact, HIV transmission, levels of high-risk behavior, and the extent of knowledge about HIV among MSM in MENA. The prevalence of HIV infection among MSM was low in most countries but high in others. For example, the infection rate in Pakistan was 27.6% among one MSM group. Importantly, there was some evidence of increasing HIV prevalence and emerging epidemics among MSM in the region. Thus, by 2008, MSM transmission was responsible for more than a quarter of notified cases of HIV in several countries. Worryingly, MSM were involved in several types of HIV-related high risk behavior. For example, they had, on average, between 4 and 14 sexual partners in the past six months, their rates of consistent condom use were generally below 25% and, in some countries, MSM frequently reported injecting drug use, another common mode of HIV transmission. In addition, 20%–75.5% of MSM exchanged sex for money and contact between MSM and female sex workers and other female sexual partners was often common. Finally, although the level of basic knowledge about HIV/AIDS was high, the level of comprehensive knowledge was limited with a high proportion of MSM perceiving their risk of contracting HIV as low.
What Do These Findings Mean?
These findings indicate that there is considerable and increasing data about HIV transmission and risk behavior among MSM in MENA. However, the quality of this evidence varies greatly. Little has been collected over time in individual populations and, because only the visible part of the MSM populations in many MENA countries has been sampled, these findings may not be representative of all MSM in this region. Nevertheless, these findings suggest that HIV epidemics are emerging among MSM in several MENA countries. Importantly, the high levels of risk behaviors practiced by many MSM in MENA mean that MSM could become the pivotal risk group for HIV transmission in this region in the next decade. There is, therefore, an urgent need to expand HIV surveillance and access to HIV testing, prevention and treatment services among MSM in this region to limit the size of the HIV epidemic.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000444.
Information about the status of the HIV epidemic in the Middle East and North Africa can be found in the World Bank/UNAIDS/WHO report Characterizing the HIV/AIDS epidemic in the Middle East and North Africa: Time for strategic action
Information about the global HIV epidemic among men who have sex with men can be found in the World Bank report The Global HIV Epidemics among Men Who Have Sex with Men
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
HIV InSite has comprehensive information on all aspects of HIV/AIDS, including information on HIV transmission and transmission in gay men and other MSM and on safer sex
Information is available from Avert, an international AIDS charity, on all aspects of HIV/AIDS, including information on HIV, AIDS and men who have sex with men and on HIV and AIDS prevention (in English and Spanish)
The US Centers for Disease Control and Prevention also have information about HIV/AIDS among men who have sex with men (in English and Spanish)
doi:10.1371/journal.pmed.1000444
PMCID: PMC3149074  PMID: 21829329
2.  Elevated Risk for HIV Infection among Men Who Have Sex with Men in Low- and Middle-Income Countries 2000–2006: A Systematic Review 
PLoS Medicine  2007;4(12):e339.
Background
Recent reports of high HIV infection rates among men who have sex with men (MSM) from Asia, Africa, Latin America, and the former Soviet Union (FSU) suggest high levels of HIV transmission among MSM in low- and middle-income countries. To investigate the global epidemic of HIV among MSM and the relationship of MSM outbreaks to general populations, we conducted a comprehensive review of HIV studies among MSM in low- and middle-income countries and performed a meta-analysis of reported MSM and reproductive-age adult HIV prevalence data.
Methods and Findings
A comprehensive review of the literature was conducted using systematic methodology. Data regarding HIV prevalence and total sample size was sequestered from each of the studies that met inclusion criteria and aggregate values for each country were calculated. Pooled odds ratio (OR) estimates were stratified by factors including HIV prevalence of the country, Joint United Nations Programme on HIV/AIDS (UNAIDS)–classified level of HIV epidemic, geographic region, and whether or not injection drug users (IDUs) played a significant role in given epidemic. Pooled ORs were stratified by prevalence level; very low-prevalence countries had an overall MSM OR of 58.4 (95% CI 56.3–60.6); low-prevalence countries, 14.4 (95% CI 13.8–14.9); and medium- to high-prevalence countries, 9.6 (95% CI 9.0–10.2). Significant differences in ORs for HIV infection among MSM in were seen when comparing low- and middle-income countries; low-income countries had an OR of 7.8 (95% CI 7.2–8.4), whereas middle-income countries had an OR of 23.4 (95% CI 22.8–24.0). Stratifying the pooled ORs by whether the country had a substantial component of IDU spread resulted in an OR of 12.8 (95% CI 12.3–13.4) in countries where IDU transmission was prevalent, and 24.4 (95% CI 23.7–25.2) where it was not. By region, the OR for MSM in the Americas was 33.3 (95% CI 32.3–34.2); 18.7 (95% CI 17.7–19.7) for Asia; 3.8 (95% CI 3.3–4.3) for Africa; and 1.3 (95% CI 1.1–1.6) for the low- and middle-income countries of Europe.
Conclusions
MSM have a markedly greater risk of being infected with HIV compared with general population samples from low- and middle-income countries in the Americas, Asia, and Africa. ORs for HIV infection in MSM are elevated across prevalence levels by country and decrease as general population prevalence increases, but remain 9-fold higher in medium–high prevalence settings. MSM from low- and middle-income countries are in urgent need of prevention and care, and appear to be both understudied and underserved.
From a systematic review, Chris Beyrer and colleagues conclude that men who have sex with men in the Americas, Asia, and Africa have a markedly greater risk of being HIV-infected than does the general population.
Editors' Summary
Background.
AIDS (acquired immunodeficiency syndrome) first emerged in the early 1980s among gay men living in New York and California. But, as the disease rapidly spread around the world, it became clear that AIDS also affected heterosexual men and women. Now, a quarter of a century later, 40 million people are infected with human immunodeficiency virus (HIV), the organism that causes AIDS. HIV is most often spread by having unprotected sex with an infected partner and in sub-Saharan Africa, the region most badly hit by HIV/AIDS, heterosexual transmission predominates. However, globally, 5%–10% of all HIV infections are thought to be in men who have sex with men (MSM, a term that encompasses gay, bisexual, transgendered, and heterosexual men who sometimes have sex with men), and in several high-income countries, including the US, male-to-male sexual contact remains the most important HIV transmission route.
Why Was This Study Done?
In the US, the MSM population is visible and there is considerable awareness about the risks of HIV transmission associated with sex between men. In many other countries, MSM are much less visible. They remain invisible because they fear discrimination, stigmatization (being considered socially unacceptable), or arrest—sex between men is illegal in 85 countries. Consequently, MSM are often under-represented in HIV surveillance systems and in prevention and care programs. If the AIDS epidemic is going to be halted, much more needs to be known about HIV prevalence (the proportion of the population that is infected) among MSM. In this study, the researchers have done a systematic review (a type of research where the results of existing studies are brought together) on published reports of HIV prevalence among MSM in low- and middle-income countries to get a better picture of the global epidemic of HIV in this population.
What Did the Researchers Do and Find?
The researchers found 83 published studies that reported HIV prevalence in 38 low- and middle-income countries in Asia, Africa, the Americas, and Eastern Europe. When the results were pooled—in what statisticians call a meta-analysis—MSM were found to have a 19.3-times greater chance of being infected with HIV than the general population. This is described as a pooled odds ratio (OR) of 19.3. The researchers also did several subgroup analyses where they asked whether factors such as injection drug use (another risk factor for HIV transmission), per capita income, geographical region, or the HIV prevalence in the general population were associated with differential risk (increase in odds) of HIV infection compared to the general population. They found, for example, that in countries where the prevalence of HIV in the general population was very low (less than 1 adult in 1,000 infected) the pooled OR for MSM compared to the general population was 58.4; where it was high (more than 1 adult in 20 infected), the pooled OR for MSM was 9.6.
What Do These Findings Mean?
These findings indicate that MSM living in low- to middle-income countries have a greater risk of HIV infection than the general populations of these countries. The subgroup analyses indicate that the high HIV prevalence among MSM is not limited to any one region or income level or to countries with any specific HIV prevalence or injection drug use level. Although the small number and design of the studies included in the meta-analysis may affect the numerical accuracy of these findings, the clear trend toward a higher HIV prevalence of among MSM suggests that HIV surveillance efforts should be expanded to include MSM in those countries where they are currently ignored. Efforts should also be made to include MSM in HIV prevention programs and to improve the efficacy of these programs by investigating the cultural, behavioral, social, and public policy factors that underlie the high HIV prevalence among MSM. By increasing surveillance, research, and prevention among MSM in low- to middle-income countries, it should be possible to curb HIV transmission in this marginalized population and reduce the global burden of HIV.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040339.
The International Lesbian and Gay Association provides a world legal map on legislation affecting lesbian, gay, bisexual, and transgendered people
The International Gay and Lesbian Human Rights Commission provides a page called Off the Map: How HIV/AIDS Programming is Failing Same-Sex Practicing People in Africa
The American Foundation for AIDS Research (amfAR) has launched their MSM initiative, which is focused on providing support to front-line community groups working on providing services and doing research focused on HIV among MSM in lower income-settings
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
HIV InSite has comprehensive information on all aspects of HIV/AIDS, including a list of organizations that provide information for gay men and MSM
Information is available from Avert, an international AIDS charity, on HIV, AIDS, and men who have sex with men
The US Centers for Disease Control and Prevention provides information on HIV/AIDS and on HIV/AIDS among men who have sex with men (in English and Spanish)
doi:10.1371/journal.pmed.0040339
PMCID: PMC2100144  PMID: 18052602
3.  An Intervention to Reduce HIV Risk Behavior of Substance-Using Men Who Have Sex with Men: A Two-Group Randomized Trial with a Nonrandomized Third Group 
PLoS Medicine  2010;7(8):e1000329.
In a randomized trial of a behavioral intervention among substance-using men who have sex with men, aimed at reducing sexual risk behavior, Mansergh and colleagues fail to find evidence of a reduction in risk from the intervention.
Background
Substance use during sex is associated with sexual risk behavior among men who have sex with men (MSM), and MSM continue to be the group at highest risk for incident HIV in the United States. The objective of this study is to test the efficacy of a group-based, cognitive-behavioral intervention to reduce risk behavior of substance-using MSM, compared to a randomized attention-control group and a nonrandomized standard HIV-testing group.
Methods and Findings
Participants (n = 1,686) were enrolled in Chicago, Los Angeles, New York City, and San Francisco and randomized to a cognitive-behavioral intervention or attention-control comparison. The nonrandomized group received standard HIV counseling and testing. Intervention group participants received six 2-h group sessions focused on reducing substance use and sexual risk behavior. Attention-control group participants received six 2-h group sessions of videos and discussion of MSM community issues unrelated to substance use, sexual risk, and HIV/AIDS. All three groups received HIV counseling and testing at baseline. The sample reported high-risk behavior during the past 3 mo prior to their baseline visit: 67% reported unprotected anal sex, and 77% reported substance use during their most recent anal sex encounter with a nonprimary partner. The three groups significantly (p<0.05) reduced risk behavior (e.g., unprotected anal sex reduced by 32% at 12-mo follow-up), but were not different (p>0.05) from each other at 3-, 6-, and 12-mo follow-up. Outcomes for the 2-arm comparisons were not significantly different at 12-mo follow-up (e.g., unprotected anal sex, odds ratio = 1.14, confidence interval = 0.86–1.51), nor at earlier time points. Similar results were found for each outcome variable in both 2- and 3-arm comparisons.
Conclusions
These results for reducing sexual risk behavior of substance-using MSM are consistent with results of intervention trials for other populations, which collectively suggest critical challenges for the field of HIV behavioral interventions. Several mechanisms may contribute to statistically indistinguishable reductions in risk outcomes by trial group. More explicit debate is needed in the behavioral intervention field about appropriate scientific designs and methods. As HIV prevention increasingly competes for behavior-change attention alongside other “chronic” diseases and mental health issues, new approaches may better resonate with at-risk groups.
Trial Registration
ClinicalTrials.gov NCT00153361
Please see later in the article for the Editors' Summary
Editors' Summary
Background
AIDS first emerged in the early 1980s among gay men living in the US. As the disease spread around the world, it became clear that AIDS also affects heterosexual men and women. Now, three decades on, more than 30 million people are infected with HIV, the virus that causes AIDS. HIV is most often spread by having unprotected sex with an infected partner and, globally, most sexual transmission of HIV now occurs during heterosexual sex. However, 5%–10% of all new HIV infections still occur in men who have sex with men (MSM, a term that encompasses gay, bisexual, transgendered, and heterosexual men who sometimes have sex with men) and, in several high-income countries, male-to-male sexual contact remains the most important HIV transmission route. In the US, for example, more than half of the approximately 50,000 people who become infected with HIV every year do so through male-to-male sexual contact.
Why Was This Study Done?
In countries where MSM are the group at highest risk of HIV infection, any intervention that reduces HIV transmission in MSM should have a major effect on the overall HIV infection rate. Among MSM, sexual behaviors that increase the risk of HIV infection (for example, not using a condom, having anal sex, having sex with a partner of unknown HIV status, and having sex with many partners) are associated with the use of alcohol and noninjection drugs (for example, inhaled amyl nitrite or poppers) during or shortly before sexual encounters. In this study (Project MIX), the researchers investigate whether a group-based behavioral intervention reduces sexual risk behavior in substance-using MSM.
What Did the Researchers Do and Find?
The researchers recruited substance-using MSM from four US cities who had had risky sex at least once in the past 6 months. Participants were randomized to a cognitive-behavioral intervention or to an attention-control group; a third, nonrandomized group of MSM formed a standard HIV counseling and testing only group. All the groups had HIV counseling and testing at the start of the study and completed a questionnaire about their substance use and sexual risk behavior during their most recent anal sex encounter. The cognitive-behavior group then received six weekly 2-hour group sessions focused on reducing substance use and sexual risk behavior by helping the men change their thinking (cognition) and behavior regarding sexual risk taking. The attention-control group received six group sessions about general MSM issues such as relationships, excluding discussion of substance use, and sexual risk behavior. The participants in both of these groups completed the questionnaire about their substance use and sexual risk behavior again at 3, 6, and 12 months after the group sessions; the participants in the standard HIV counseling and testing group completed the questionnaire again about 5 months after completing the first questionnaire (to control for the time taken by the other two groups to complete the intervention). At baseline, about 67% of the participants reported unprotected anal sex and 77% reported substance use during their most recent anal sex encounter with a nonprimary partner. At the 3-month follow-up, the incidence of sexual risk behavior had fallen to about 43% in all three groups; the incidence of substance use during sex had fallen to about 50%. Risk taking and substance use remained at these levels in the intervention and attention-control groups at the later follow-up time points.
What Do These Findings Mean?
These findings suggest that this cognitive-behavioral intervention is no better at reducing sexual risk taking among substance-using MSM than is an unrelated video-discussion group or standard HIV counseling and testing. One explanation for this negative result might be that brief counseling is especially effective with people who are ready for a change such as MSM willing to enroll in an intervention trial of this type. Alternatively, just being in the trial might have encouraged all the participants to self-report reduced risk behavior. Thus, alternative scientific designs and methods might be needed to find behavioral interventions that can effectively reduce HIV transmission among substance-using MSM and other people at high risk of HIV infection. Importantly, however, these findings raise the question of whether more extensive, multilevel interventions or broader lifestyle and positive health approaches (rather than single-level or single-subject behavioral interventions) might be needed to reduce sexual risk behavior among substance-using MSM.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000329.
Information is available from the US Department of Health and Human Services on HIV prevention programs, research, and policy
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
HIV InSite has comprehensive information on all aspects of HIV/AIDS, including information on HIV transmission and transmission in gay men and other MSM, on substance abuse and HIV/AIDS, and on safer sex
Information is available from Avert, an international AIDS nonprofit, on all aspects of HIV/AIDS, including information on HIV, AIDS, and men who have sex with men and on drink, drugs, and sex (in English and Spanish)
The US Centers for Disease Control and Prevention also have information for the public and for professionals about HIV/AIDS among men who have sex with men (in English and Spanish)
The US National Institute on Drug Abuse has information on HIV/AIDS and drug abuse, including a resource aimed at educating teenagers about the link between drug abuse and the spread of HIV in the US (in English and Spanish)
doi:10.1371/journal.pmed.1000329
PMCID: PMC2927550  PMID: 20811491
4.  Episodic Sexual Transmission of HIV Revealed by Molecular Phylodynamics 
PLoS Medicine  2008;5(3):e50.
Background
The structure of sexual contact networks plays a key role in the epidemiology of sexually transmitted infections, and their reconstruction from interview data has provided valuable insights into the spread of infection. For HIV, the long period of infectivity has made the interpretation of contact networks more difficult, and major discrepancies have been observed between the contact network and the transmission network revealed by viral phylogenetics. The high rate of HIV evolution in principle allows for detailed reconstruction of links between virus from different individuals, but often sampling has been too sparse to describe the structure of the transmission network. The aim of this study was to analyze a high-density sample of an HIV-infected population using recently developed techniques in phylogenetics to infer the short-term dynamics of the epidemic among men who have sex with men (MSM).
Methods and Findings
Sequences of the protease and reverse transcriptase coding regions from 2,126 patients, predominantly MSM, from London were compared: 402 of these showed a close match to at least one other subtype B sequence. Nine large clusters were identified on the basis of genetic distance; all were confirmed by Bayesian Monte Carlo Markov chain (MCMC) phylogenetic analysis. Overall, 25% of individuals with a close match with one sequence are linked to 10 or more others. Dated phylogenies of the clusters using a relaxed clock indicated that 65% of the transmissions within clusters took place between 1995 and 2000, and 25% occurred within 6 mo after infection. The likelihood that not all members of the clusters have been identified renders the latter observation conservative.
Conclusions
Reconstruction of the HIV transmission network using a dated phylogeny approach has revealed the HIV epidemic among MSM in London to have been episodic, with evidence of multiple clusters of transmissions dating to the late 1990s, a period when HIV prevalence is known to have doubled in this population. The quantitative description of the transmission dynamics among MSM will be important for parameterization of epidemiological models and in designing intervention strategies.
Using viral genotype data from HIV drug resistance testing at a London clinic, Andrew Leigh Brown and colleagues derive the structure of the transmission network through phylogenetic analysis.
Editors' Summary
Background.
Human immunodeficiency virus (HIV), the cause of acquired immunodeficiency syndrome (AIDS), is mainly spread through unprotected sex with an infected partner. Like other sexually transmitted diseases, HIV/AIDS spreads through networks of sexual contacts. The characteristics of these complex networks (which include people who have serial sexual relationships with single partners and people who have concurrent sexual relationships with several partners) affect how quickly diseases spread in the short term and how common the disease is in the long term. For many sexually transmitted diseases, sexual contact networks can be reconstructed from interview data. The information gained in this way can be used for partner notification so that transmitters of the disease and people who may have been unknowingly infected can be identified, treated, and advised about disease prevention. It can also be used to develop effective community-based prevention strategies.
Why Was This Study Done?
Although sexual contact networks have provided valuable information about the spread of many sexually transmitted diseases, they cannot easily be used to understand HIV transmission patterns. This is because the period of infectivity with HIV is long and the risk of infection from a single sexual contact with an infected person is low. Another way to understand the spread of HIV is through phylogenetics, which examines the genetic relatedness of viruses obtained from different individuals. Frequent small changes in the genetic blueprint of HIV allow the virus to avoid the human immune response and to become resistant to antiretroviral drugs. In this study, the researchers use recently developed analytical methods, viral sequences from a large proportion of a specific HIV-infected population, and information on when each sample was taken, to learn about transmission of HIV/AIDS in London among men who have sex with men (MSM; a term that encompasses gay, bisexual, and transgendered men and heterosexual men who sometimes have sex with men). This new approach, which combines information on viral genetic variation and viral population dynamics, is called “molecular phylodynamics.”
What Did the Researchers Do and Find?
The researchers compared the sequences of the genes encoding the HIV-1 protease and reverse transcriptase from more than 2,000 patients, mainly MSM, attending a large London HIV clinic between 1997 and 2003. 402 of these sequences closely matched at least one other subtype B sequence (the HIV/AIDS epidemic among MSM in the UK primarily involves HIV subtype B). Further analysis showed that the patients from whom this subset of sequences came formed six clusters of ten or more individuals, as well as many smaller clusters, based on the genetic relatedness of their HIV viruses. The researchers then used information on the date when each sample was collected and a “relaxed clock” approach (which accounts for the possibility that different sequences evolve at different rates) to determine dated phylogenies (patterns of genetic relatedness that indicate when gene sequences change) for the clusters. These phylogenies indicated that at least in one in four transmissions between the individuals in the large clusters occurred within 6 months of infection, and that most of the transmissions within each cluster occurred over periods of 3–4 years during the late 1990s.
What Do These Findings Mean?
This phylodynamic reconstruction of the HIV transmission network among MSM in a London clinic indicates that the HIV epidemic in this population has been episodic with multiple clusters of transmission occurring during the late 1990s, a time when the number of HIV infections in this population doubled. It also suggests that transmission of the virus during the early stages of HIV infection is likely to be an important driver of the epidemic. Whether these results apply more generally to the MSM population at risk for transmitting or acquiring HIV depends on whether the patients in this study are representative of that group. Additional studies are needed to determine this, but if the patterns revealed here are generalizable, then this quantitative description of HIV transmission dynamics should help in the design of strategies to strengthen HIV prevention among MSM.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050050.
Read a related PLoS Medicine Perspective article
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
HIV InSite has comprehensive information on all aspects of HIV/AIDS, including a list of organizations that provide information for gay men and MSM
The US Centers for Disease Control and Prevention provides information on HIV/AIDS and on HIV/AIDS among MSM (in English and Spanish)
Information is available from Avert, an international AIDS charity, on HIV, AIDS, and men who have sex with men
The Center for AIDS Prevention Studies (University of California, San Francisco) provides information on sexual networks and HIV prevention
The US National Center for Biotechnology Information provides a science primer on molecular phylogenetics
UK Collaborative Group on HIV Drug Resistance maintains a database of resistance tests
HIV i-Base offers HIV treatment information for health-care professionals and HIV-positive people
The NIH-funded HIV Sequence Database contains data on genetic sequences, resistance, immunology, and vaccine trials
doi:10.1371/journal.pmed.0050050
PMCID: PMC2267814  PMID: 18351795
5.  Bridging Sexual Boundaries: Men Who Have Sex with Men and Women in a Street-Based Sample in Los Angeles 
The purpose of the study was to determine the potential contribution of bisexual men to the spread of HIV in Los Angeles. We compare the characteristics and behaviors of men who have sex with men and women (MSMW) to men who have sex with only women (MSW) and men who have sex with only men (MSM) in Los Angeles. Men (N = 1,125) who participated in one of the two waves of data collection from 2005 to 2007 at the Los Angeles site for NIDA’s Sexual Acquisition and Transmission of HIV—Cooperative Agreement Program were recruited using Respondent Driven Sampling. Participants completed Audio Computer Assisted Self Interviews and received oral HIV rapid testing with confirmatory blood test by Western Blot and provided urine specimens for detection of recent powder cocaine, crack cocaine, methamphetamine, or heroin use. MSM, MSW, or MSMW were defined by the gender of whom they reported sex with in the past 6 months. Chi-square tests and ANOVAs were used to test independence between these groups and demographic characteristics, substance use, and sexual behaviors. We fit generalized linear random intercept models to predict sexual risk behaviors at the partner level. Men were mostly of low income, unemployed, and minority, with many being homeless; 66% had been to jail or prison, 29% had ever injected drugs, and 25% had used methamphetamine in the past 30 days. The sample had high HIV prevalence: 12% of MSMW, 65% of MSM, and 4% of MSW. MSMW were behaviorally between MSW and MSM, except that more MSMW practiced sex for trade (both receiving and giving), and more MSMW had partners who are drug users than MSW. Generalized linear random intercept models included a partner-level predictor with four partner groups: MSM, MSMW-male partners, MSMW-female partners, and MSW. The following were significantly associated with unprotected anal intercourse (UAI): MSW (AOR 0.15, 95% CI 0.08, 0.27), MSMW-female partners (AOR 0.4, 95% CI 0.27, 0.61), HIV-positive partners (AOR 2.03, 95% CI 1.31, 3.13), and being homeless (AOR 1.37, 95% CI 1.01, 1.86). The factors associated with giving money or drugs for sex were MSMW-female partners (AOR 1.70, 95% CI 1.09, 2.65), unknown HIV status partners (AOR 1.72, 95% CI 1.29, 2.30), being older (AOR 1.02, 95% CI 1.00, 1.04), history of incarceration (AOR 1.64, 95% CI 1.17, 2.29), and being homeless (AOR 1.73, 95% CI 1.27, 2.36). The following were associated with receiving money or drugs for sex: MSW (AOR 0.53, 95% CI 0.32, 0.89), African American (AOR 2.42, 95% CI 1.56, 3.76), Hispanic (AOR 1.85, 95% CI 1.12, 3.05), history of incarceration (AOR 1.44, 95% CI 1.04, 2.01), history of injecting drugs (AOR 1.57, 95% CI 1.13, 2.19), and had been recently homeless (AOR 2.14, 95% CI 1.57, 2.94). While overall HIV-positive MSM had more UAI with partners of any HIV status than MSMW with either partner gender, among HIV-positive MSMW, more had UAI with HIV-negative and HIV status unknown female partners than male partners. Findings highlight the interconnectedness of sexual and drug networks in this sample of men—as most have partners who use drugs and they use drugs themselves. We find a concentration of risk that occurs particularly among impoverished minorities—where many men use drugs, trade sex, and have sex with either gender. Findings also suggest an embedded core group of drug-using MSMW who may not so much contribute to spreading the HIV epidemic to the general population, but driven by their pressing need for drugs and money, concentrate the epidemic among men and women like themselves who have few resources.
doi:10.1007/s11524-009-9370-7
PMCID: PMC2705489  PMID: 19543837
Sexual bridging; MSMW; HIV risk behavior; HIV transmission risks
6.  Youth Living with HIV and Partner-specific Risk for the Secondary Transmission of HIV 
Sexually transmitted diseases  2009;36(7):439-444.
Summary
A comparison of risks for the secondary transmission of HIV between young HIV-infected women-who-have-sex-with-men (WSM) and men-who-have-sex-with-men (MSM) found that recent partner-specific sexual risk behaviors are high among both populations. However, differences in the specific behaviors between WSM and MSM support population-specific interventions to reduce the secondary transmission of HIV.
Background
Secondary transmission remains a significant concern among HIV-infected youth. Little is known, however, about how partner-specific sexual risk behaviors for the secondary transmission of HIV may differ between the two largest subgroups of HIV positive youth, women-who-have-sex-with-men (WSM) and men-who-have-sex-with-men (MSM),
Methods
During 2003-2004, a convenience sample of HIV-infected youth, 13-24 years of age, were recruited from 15 Adolescent Medicine Trials Network clinical sites. Approximately 10-15 youth were recruited at each site. Participants completed an ACASI survey including questions about sex partners in the past year. Cross-sectional data analyses, including bivariate and multivariable regressions using generalized estimating equations, were conducted during 2008 to compare recent partner-specific sexual risk behaviors between WSM and MSM.
Results
Of 409 participants, 91% (371) were included in this analysis, including 176 WSM and 195 MSM. Ninety-two percent (163 WSM, 177 MSM) provided information on characteristics of their sexual partners. There were significant differences between the two groups in recent partner-specific sexual risk behaviors including: lower rates of condom use at last sex among WSM (61% WSM vs. 78% MSM; p=0.0011); a larger proportion of the sex partners of MSM reported as concurrent (56% MSM vs. 36% WSM; p=0.0001); and greater use of hard drugs at last sex by MSM and/or their partner (18% MSM vs. 4% WSM; p=0.0008). When measuring risk as a composite measure of sexual risk behaviors known to be associated with HIV transmission, both groups had high rates of risky behaviors, 74.7% among young MSM compared to 68.1% of WSM.
Conclusions
These data suggest that recent partner-specific sexual risk behaviors for HIV transmission are high among young infected MSM and WSM. These findings suggest the need to offer interventions to reduce the secondary transmission of HIV to all HIV-positive youth in care. However, differences in risk behaviors between young MSM and WSM supports population-specific interventions.
doi:10.1097/OLQ.0b013e3181ad516c
PMCID: PMC2725398  PMID: 19525889
7.  Sexual behaviour, recreational drug use and hepatitis C co-infection in HIV-diagnosed men who have sex with men in the United Kingdom: results from the ASTRA study 
Journal of the International AIDS Society  2014;17(4Suppl 3):19630.
Introduction
Transmission of Hepatitis C virus (HCV) among HIV-positive men who have sex with men (MSM) in the United Kingdom is ongoing. We explore associations between self-reported sexual behaviours and drug use with cumulative HCV prevalence, as well as new HCV diagnosis.
Methods
ASTRA is a cross-sectional questionnaire study including 2,248 HIV-diagnosed MSM under care in the United Kingdom during 2011–2012. Socio-demographic, lifestyle, HIV-related and sexual behaviour data were collected during the study. One thousand seven hundred and fifty two (≥70%) of the MSM who consented to linkage of ASTRA and clinical information (prior to and post questionnaire) were included. Cumulative prevalence of HCV was defined as any positive anti-HCV or HCV-RNA test result at any point prior to questionnaire completion. We excluded 536 participants with clinical records only after questionnaire completion. Among the remaining 1,216 MSM, we describe associations of self-reported sexual behaviours and recreational drug use in the three months prior to ASTRA with cumulative HCV prevalence, using modified Poisson regression with robust error variances. New HCV was defined as any positive anti-HCV or HCV-RNA after questionnaire completion. We excluded 591 MSM who reported ever having a HCV diagnosis at questionnaire, any positive HCV result prior to questionnaire or did not have any HCV tests after the questionnaire. Among the remaining 1,195 MSM, we describe occurrence of new HCV diagnosis during follow-up according to self-reported sexual behaviours and recreational drug use three months prior to questionnaire (Fisher's exact test).
Results
Cumulative HCV prevalence among MSM prior to ASTRA was 13.3% (95% CI 11.5–15.4). Clinic- and age-adjusted prevalence ratios (95% CI) for cumulative HCV prevalence were 4.6 (3.1–6.7) for methamphetamine, 6.5 (3.5–12.1) for injection drugs, 2.3 (1.6–3.4) for gamma hydroxybutyrate (GHB), 1.6 (1.3–2.0) for nitrites, 1.7 (1.5–2.0) for all condom-less sex (CLS), 2.1 (1.7–2.5) for CLS-HIV-seroconcordant, 1.3 (0.9–1.9) for CLS-HIV-serodiscordant, 2.0 (1.6–2.5) for group sex, 1.5 (1.2–1.9) for more than 10 new sexual partners in the past year. Among 1,195 MSM with 2.2 years [IQR 1.5–2.4] median follow-up, there were 7 new HCV cases during 2,033 person-years at risk. Incidence was 3.5 per 1,000 person-years (95% CI 1.6–7.2). New HCV was recorded in 1.3% MSM who used methamphetamine versus 0.5% MSM who did not (p=0.385); 3.7% MSM who injected recreational drugs versus 0.5% MSM who did not (p=0.148); 2.9% MSM who used GHB versus 0.4% MSM who did not (p=0.003); 1.5% MSM who used nitrites versus 0.2% MSM who did not (p=0.019); 1.1% MSM having CLS versus 0.3% MSM who did not (p=0.084); 1.7% MSM having CLS-HIV-serodiscordant versus 0.4% MSM who did not (p=0.069); 0.9% MSM who had CLS-HIV-seroconcordant versus 0.5% MSM who did not (p=0.318); 0.8% MSM who had group sex versus 0.5% MSM who did not (p=0.463); and 1.6% MSM with =10 new sexual partners in the previous year versus 0.2% MSM with no or up to 9 new partners (p=0.015).
Conclusions
Self-reported recent use of recreational and injection drugs, condom-less sex and multiple new sexual partners are associated with pre-existing HCV infection and, with the exception of injection drugs, appear to be predictive of new HCV co-infection among HIV-diagnosed MSM.
doi:10.7448/IAS.17.4.19630
PMCID: PMC4224924  PMID: 25394134
8.  The Comparability of Men Who Have Sex With Men Recruited From Venue-Time-Space Sampling and Facebook: A Cohort Study 
JMIR Research Protocols  2014;3(3):e37.
Background
Recruiting valid samples of men who have sex with men (MSM) is a key component of the US human immunodeficiency virus (HIV) surveillance and of research studies seeking to improve HIV prevention for MSM. Social media, such as Facebook, may present an opportunity to reach broad samples of MSM, but the extent to which those samples are comparable with men recruited from venue-based, time-space sampling (VBTS) is unknown.
Objective
The objective of this study was to assess the comparability of MSM recruited via VBTS and Facebook.
Methods
HIV-negative and HIV-positive black and white MSM were recruited from June 2010 to December 2012 using VBTS and Facebook in Atlanta, GA. We compared the self-reported venue attendance, demographic characteristics, sexual and risk behaviors, history of HIV-testing, and HIV and sexually transmitted infection (STI) prevalence between Facebook- and VTBS-recruited MSM overall and by race. Multivariate logistic and negative binomial models estimated age/race adjusted ratios. The Kaplan-Meier method was used to assess 24-month retention.
Results
We recruited 803 MSM, of whom 110 (34/110, 30.9% black MSM, 76/110, 69.1% white MSM) were recruited via Facebook and 693 (420/693, 60.6% black MSM, 273/693, 39.4% white MSM) were recruited through VTBS. Facebook recruits had high rates of venue attendance in the previous month (26/34, 77% among black and 71/76, 93% among white MSM; between-race P=.01). MSM recruited on Facebook were generally older, with significant age differences among black MSM (P=.02), but not white MSM (P=.14). In adjusted multivariate models, VBTS-recruited MSM had fewer total partners (risk ratio [RR]=0.78, 95% CI 0.64-0.95; P=.01) and unprotected anal intercourse (UAI) partners (RR=0.54, 95% CI 0.40-0.72; P<.001) in the previous 12 months. No significant differences were observed in HIV testing or HIV/STI prevalence. Retention to the 24-month visit varied from 81% for black and 70% for white MSM recruited via Facebook, to 77% for black and 78% for white MSM recruited at venues. There was no statistically significant differences in retention between the four groups (log-rank P=.64).
Conclusions
VBTS and Facebook recruitment methods yielded similar samples of MSM in terms of HIV-testing patterns, and prevalence of HIV/STI, with no differences in study retention. Most Facebook-recruited men also attended venues where VTBS recruitment was conducted. Surveillance and research studies may recruit via Facebook with little evidence of bias, relative to VBTS.
doi:10.2196/resprot.3342
PMCID: PMC4129125  PMID: 25048694
men who have sex with men, MSM; Facebook; venue-based time sampling; online MSM; social media recruitment of MSM
9.  High-Risk Sexual and Drug Using Behaviors Among Male Injection Drug Users Who Have Sex With Men in 2 Mexico-US Border Cities 
Sexually transmitted diseases  2008;35(3):243-249.
Objectives
The population of Latino men who have sex with men (MSM) and who are also injection drug users (IDUs) is understudied. We explored risk behaviors of MSM/IDUs compared with other male IDUs in 2 Mexican border cities.
Study Design
In 2005, IDUs who had injected within the previous 30 days were recruited using respondent-driven sampling (RDS) in Tijuana and Ciudad Juárez. They underwent antibody testing for HIV, HCV, and syphilis and interviewer-administered surveys. Men were categorized as MSM if they reported ≥1 lifetime male partners. Logistic regression was used to compare MSM/IDUs with non-MSM/IDUs.
Results
A third (31%) of 377 male IDUs were categorized as MSM (47% in Tijuana and 13% in Ciudad Juárez, P <0.01). Combined RDS-adjusted prevalence of HIV and Hepatitis C was 3% (95% CI: 1, 5) and 96%, (95% CI: 94, 99) respectively, while 17% (95% CI: 2, 36) of MSM and 8% (95% CI: 3, 12) of non-MSM tested positive for syphilis antibody. In multivariate logistic regression adjusted for site, MSM/IDUs were more likely than non-MSM/IDUs to have ever used inhalants (OR: 3.4; 95% CI: 1.8, 6.2) or oral tranquilizers (OR: 2.4; 95% CI: 1.3, 4.6), received treatment for a drug problem (OR:1.9; 95% CI: 1.1, 3.2) shared needles in the last six months (OR: 2.1; 95% CI: 1.0, 4.2) and also had higher numbers of lifetime female partners (log-transformed continuous variable, OR: 1.6; 95% CI: 1.2, 2.1).
Conclusions
In these Mexican cities, the proportion of MSM among male IDUs was high. Compared with other male IDUs, MSM/IDUs were more likely to engage in behaviors placing them at risk of acquiring HIV/STIs. Culturally appropriate interventions targeting Latino MSM/IDUs are warranted.
doi:10.1097/OLQ.0b013e31815abab5
PMCID: PMC2391275  PMID: 18046263
10.  Associations between Intimate Partner Violence and Health among Men Who Have Sex with Men: A Systematic Review and Meta-Analysis 
PLoS Medicine  2014;11(3):e1001609.
Ana Maria Buller and colleagues review 19 studies and estimate the associations between the experience and perpetration of intimate partner violence and various health conditions and sexual risk behaviors among men who have sex with men.
Please see later in the article for the Editors' Summary
Background
Intimate partner violence (IPV) among men who have sex with men (MSM) is a significant problem. Little is known about the association between IPV and health for MSM. We aimed to estimate the association between experience and perpetration of IPV, and various health conditions and sexual risk behaviours among MSM.
Methods and Findings
We searched 13 electronic databases up to 23 October 2013 to identify research studies reporting the odds of health conditions or sexual risk behaviours for MSM experiencing or perpetrating IPV. Nineteen studies with 13,797 participants were included in the review. Random effects meta-analyses were performed to estimate pooled odds ratios (ORs). Exposure to IPV as a victim was associated with increased odds of substance use (OR = 1.88, 95% CIOR 1.59–2.22, I2 = 46.9%, 95% CII2 0%–78%), being HIV positive (OR = 1.46, 95% CIOR 1.26–1.69, I2 = 0.0%, 95% CII2 0%–62%), reporting depressive symptoms (OR = 1.52, 95% CIOR 1.24–1.86, I2 = 9.9%, 95% CII2 0%–91%), and engagement in unprotected anal sex (OR = 1.72, 95% CIOR 1.44–2.05, I2 = 0.0%, 95% CII2 0%–68%). Perpetration of IPV was associated with increased odds of substance use (OR = 1.99, 95% CIOR 1.33–2.99, I2 = 73.1%). These results should be interpreted with caution because of methodological weaknesses such as the lack of validated tools to measure IPV in this population and the diversity of recall periods and key outcomes in the identified studies.
Conclusions
MSM who are victims of IPV are more likely to engage in substance use, suffer from depressive symptoms, be HIV positive, and engage in unprotected anal sex. MSM who perpetrate IPV are more likely to engage in substance use. Our results highlight the need for research into effective interventions to prevent IPV in MSM, as well as the importance of providing health care professionals with training in how to address issues of IPV among MSM and the need to raise awareness of local and national support services.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Intimate partner violence (IPV, also called domestic violence) is a common and widespread problem. Globally, nearly a third of women are affected by IPV at some time in their life, but the prevalence of IPV (the proportion of the population affected by IPV) varies widely between countries. In central sub-Saharan Africa, for example, nearly two-thirds of women experience IPV during their lifetime, whereas in East Asia only one-sixth of women are affected. IPV is defined as physical, sexual, or emotional harm that is perpetrated on an individual by a current or former partner or spouse. Physical violence includes hitting, kicking, and other types of physical force; sexual violence means forcing a partner to take part in a sex act when the partner does not consent; and emotional abuse includes threatening a partner by, for example, stalking them or preventing them from seeing their family. The adverse effects of IPV for women include physical injury, depression and suicidal behaviour, and sexual and reproductive health problems such as HIV infection and unwanted pregnancies.
Why Was This Study Done?
IPV affects men as well as women. Men can be subjected to IPV either by a female partner or by a male partner in the case of men who have sex with men (MSM, a term that encompasses homosexual, bisexual, and transgender men, and heterosexual men who sometimes have sex with men). Recent reviews suggest that the prevalence of IPV in same-sex couples is as high as the prevalence of IPV for women in opposite-sex relationships: reported lifetime prevalences of IPV in homosexual male relationships range between 15.4% and 51%. Little is known, however, about the adverse health effects of IPV on MSM. It is important to understand how IPV affects the health of MSM so that appropriate services and interventions can be provided to support MSM who experience IPV. In this systematic review (a study that identifies all the research on a given topic using predefined criteria) and meta-analysis (a study that combines the results of several studies using statistical methods), the researchers investigate the associations between the experience and perpetration of IPV and various health conditions and sexual risk behaviours among MSM.
What Did the Researchers Do and Find?
The researchers identified 19 studies that investigated associations between IPV and various health conditions or sexual risk behaviours (for example, unprotected anal sex, a risk factor for HIV infection) among MSM. The associations were expressed as odds ratios (ORs); an OR represents the odds (chances) that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure. The researchers estimated pooled ORs from the data in the individual studies using meta-analysis. The pooled lifetime prevalence of experiencing any IPV (which was measured in six studies) was 48%. Exposure to IPV as a victim was associated with an increased risk of substance (alcohol or drug) use (OR = 1.88, data from nine studies), reporting depressive symptoms (OR = 1.52, data from three studies), being HIV positive (OR = 1.46, data from ten studies), and engagement in unprotected sex (OR = 1.72, data from eight studies). Perpetration of IPV was associated with an increased risk of substance abuse (OR = 1.99, data from six studies).
What Do These Findings Mean?
These findings suggest that MSM frequently experience IPV and that exposure to IPV is associated with several adverse health conditions and sexual risk behaviours. There were insufficient data to estimate the lifetime prevalence of IPV perpetration among MSM, but these findings also reveal an association between IPV perpetration and substance use. The accuracy of these findings is limited by heterogeneity (variability) between the studies included in the meta-analyses, by the design of these studies, and by the small number of studies. Despite these and other limitations, these findings highlight the need to undertake research to identify interventions to prevent IPV among MSM and to learn more about the health effects of IPV among MSM. They highlight the importance of health care professionals being aware that IPV is a problem for MSM and of training these professionals to assess MSM for IPV. Finally, these results highlight the need to improve the availability and effectiveness of support services to which health care professionals can refer MSM experiencing or perpetrating IPV.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001609.
The World Health Organization provides detailed information on intimate partner violence
The US Centers for Disease Control and Prevention provides information about IPV and a fact sheet on understanding IPV that includes links to further resources
The UK National Health Service Choices website has a webpage about domestic violence, which includes descriptions of personal experiences
The US National Domestic Violence Hotline provides confidential help and support to people experiencing IPV, including MSM; its website includes personal stories of IPV
The US Gay Men's Domestic Violence Project/GLBTQ Domestic Violence Project provides support and services to MSM experiencing IPV; its website includes some personal stories
The UK not-for-profit organization Respect runs two advice lines: the Men's Advice Line provides advice and support for men experiencing domestic violence and abuse and the Respect Phoneline provides advice for domestic violence perpetrators and for professionals who would like further information about services for those using violence/abuse in their intimate partner relationships
The UK not-for-profit organization ManKind Initiative also provides support for male victims of IPV
The UK not-for-profit organization Broken Rainbow UK provides help and support for lesbians and MSM experiencing IPV
MedlinePlus provides links to other resources about domestic violence (in English and Spanish)
The UK charity Galop gives advice and support to people who have experienced biphobia, homophobia, transphobia, sexual violence, or domestic abuse
doi:10.1371/journal.pmed.1001609
PMCID: PMC3942318  PMID: 24594975
11.  Diagnosing HIV in Men Who Have Sex with Men: An Emergency Department's Experience 
AIDS Patient Care and STDs  2012;26(4):202-207.
Abstract
In the United States, men who have sex with men (MSM) constitute the risk group in which the prevalence of new HIV infection is increasing. The percentage of undiagnosed HIV infection and HIV risk behaviors in MSM and non-MSM participating in an emergency department-based rapid HIV screening program were compared. Medical records of all male patients participating in the program from May 2008 to October 2010 were reviewed. MSM were identified as male or male-to-female patients reporting oral and/or anal sex with a male. Males eligible for testing were aged 18 or older, English-speaking, not known to be HIV infected, and able to decline testing. A total of 6672 males were approached for testing; 5610 (84.1%) accepted, 366 (6.5%) were MSM, and 5244 (93.5%) were non-MSM. A total of 90.7% were black. Median age was 41. Fifty-nine MSM (16.1%) were diagnosed with HIV compared to 81 (1.5%) non-MSM. MSM were 10 times more likely than non-MSM to have undiagnosed HIV infection (odds ratio [OR] 10.4, 95% confidence interval [CI] 7.3, 14.0). HIV-infected MSM (median age, 26) were younger than non-MSM (median age, 41). HIV-infected non-MSM were 2 times more likely than MSM to have CD4 counts less than 200 cells per microliter. MSM were more likely to report previous HIV testing (OR 1.9, 95% CI 1.4, 2.5) and risk behaviors, including sex without a condom (OR 2.0, 95% CI 1.5, 2.6), sex with an HIV-infected partner (OR 14.6, 95% CI 8.3, 25.6) and sex with a known injection drug user (OR 4.1, 95% CI 2.0, 8.4). Further investigation of emergency department-based HIV testing and risk reduction programs targeting MSM is warranted.
doi:10.1089/apc.2011.0303
PMCID: PMC3317392  PMID: 22356726
12.  The impact of HIV and high-risk behaviours on the wives of married men who have sex with men and injection drug users: implications for HIV prevention 
Background
HIV/AIDS in India disproportionately affects women, not by their own risks, but by those of their partners, generally their spouses. We address two marginalized populations at elevated risk of acquiring HIV: women who are married to men who also have sex with men (MSM) and wives of injection drug users (IDUs).
Methods
We used a combination of focus groups (qualitative) and structured surveys (quantitative) to identify the risks that high-risk men pose to their low-risk wives and/or sexual partners. Married MSM were identified using respondent-driven recruitment in Tamil Nadu, India, and were interviewed by trainer assessors. A sample of wives of injection drug users in Chennai were recruited from men enrolled in a cohort study of the epidemiology of drug use among IDUs in Chennai, and completed a face-to-face survey. Focus groups were held with all groups of study participants, and the outcomes transcribed and analyzed for major themes on family, HIV and issues related to stigma, discrimination and disclosure.
Results
Using mixed-methods research, married MSM are shown to not disclose their sexual practices to their wives, whether due to internalized homophobia, fear of stigma and discrimination, personal embarrassment or changing sexual mores. Married MSM in India largely follow the prevailing norm of marriage to the opposite sex and having a child to satisfy social pressures. Male IDUs cannot hide their drug use as easily as married MSM, but they also avoid disclosure. The majority of their wives learn of their drug-using behaviour only after they are married, making them generally helpless to protect themselves. Fear of poverty and negative influences on children were the major impacts associated with continuing drug use.
Conclusions
We propose a research and prevention agenda to address the HIV risks encountered by families of high-risk men in the Indian and other low- and middle-income country contexts.
doi:10.1186/1758-2652-13-S2-S7
PMCID: PMC2890976  PMID: 20573289
13.  HIV prevalence and risk behaviors among men who have sex with men and inject drugs in San Francisco 
The dual risks of male-to-male sex and drug injection have put men who have sex with men and inject drugs (MSM-IDU) at the forefront of the HIV epidemic, with the highest rates of infection among any risk group in the United States. This study analyzes data collected from 357 MSM-IDU in San Francisco between 1998 and 2002 to examine how risk behaviors differ by HIV serostatus and self-identified sexual orientation and to assess medical and social service utilization among HIV-positive MSM-IDU. Twenty-eight percent of the sample tested HIV antibody positive. There was little difference in risk behaviors between HIV-negative and HIV-positive MSM-IDU. Thirty percent of HIV-positive MSM-IDU reported distributive syringe sharing, compared to 40% of HIV negatives. Among MSM-IDU who reported anal intercourse in past 6 months, 70% of positives and 66% of HIV negatives reported unprotected anal intercourse. HIV status varied greatly by self-identified sexual orientation: 46% among gay, 24% among bisexual, and 14% among heterosexual MSM-IDU. Heterosexual MSM-IDU were more likely than other MSM-IDU to be homeless and to trade sex for money or drugs. Gay MSM-IDU were more likely to have anal intercourse. Bisexual MSM-IDU were as likely as heterosexual MSM-IDU to have sex with women and as likely as gay-identified MSM-IDU to have anal intercourse. Among MSM-IDU who were HIV positive, 15% were currently on antiretroviral therapy and 18% were currently in drug treatment, and 87% reported using a syringe exchange program in the past 6 months. These findings have implications for the development of HIV interventions that target the diverse MSM-IDU population.
doi:10.1093/jurban/jti023
PMCID: PMC3456175  PMID: 15738321
MSM; Injection drug user; Methamphetamine; HIV; Epidemiology; MSM-IDU; Sexual risk
14.  Sexual health of ethnic minority MSM in Britain (MESH project): design and methods 
BMC Public Health  2010;10:419.
Background
Men who have sex with men (MSM) remain the group most at risk of acquiring HIV infection in Britain. HIV prevalence appears to vary widely between MSM from different ethnic minority groups in this country for reasons that are not fully understood. The aim of the MESH project was to examine in detail the sexual health of ethnic minority MSM living in Britain.
Methods/Design
The main objectives of the MESH project were to explore among ethnic minority MSM living in Britain: (i) sexual risk behaviour and HIV prevalence; (ii) their experience of stigma and discrimination; (iii) disclosure of sexuality; (iv) use of, and satisfaction with sexual health services; (v) the extent to which sexual health services (for treatment and prevention) are aware of the needs of ethnic minority MSM.
The research was conducted between 2006 and 2008 in four national samples: (i) ethnic minority MSM living in Britain; (ii) a comparison group of white British MSM living in Britain; (iii) NHS sexual health clinic staff in 15 British towns and cities with significant ethnic minority communities and; (iv) sexual health promotion/HIV prevention service providers. We also recruited men from two "key migrant" groups living in Britain: MSM born in Central or Eastern Europe and MSM born in Central or South America.
Internet-based quantitative and qualitative research methods were used. Ethnic minority MSM were recruited through advertisements on websites, in community venues, via informal networks and in sexual health clinics. White and "key migrant" MSM were recruited mostly through Gaydar, one of the most popular dating sites used by gay men in Britain. MSM who agreed to take part completed a questionnaire online. Ethnic minority MSM who completed the online questionnaire were asked if they would be willing to take part in an online qualitative interview using email.
Service providers were identified through the British Association of Sexual Health and HIV (BASHH) and the Terrence Higgins Trust (THT) CHAPS partnerships. Staff who agreed to take part were asked to complete a questionnaire online.
The online survey was completed by 1241 ethnic minority MSM, 416 men born in South and Central America or Central and Eastern Europe, and 13,717 white British MSM; 67 ethnic minority MSM took part in the online qualitative interview. In addition 364 people working in sexual health clinics and 124 health promotion workers from around Britain completed an online questionnaire.
Discussion
The findings from this study will improve our understanding of the sexual health and needs of ethnic minority MSM in Britain.
doi:10.1186/1471-2458-10-419
PMCID: PMC2916902  PMID: 20630087
15.  Sexual Mixing Patterns and Partner Characteristics of Black MSM in Massachusetts at Increased Risk for HIV Infection and Transmission 
Black men who have sex with men (MSM) are at increased risk for HIV infection in the United States compared to other MSM. The aim of this study was to investigate Black MSM’s sexual mixing patterns and partner characteristics in relation to sexual risk taking, as a possible explanation for this observed increase in HIV incidence. Between January and July 2008, 197 Black MSM were recruited via modified respondent-driven sampling and completed optional pretest and post-test HIV serological testing, counseling, and a demographic, behavioral, and psychosocial assessment battery. Bivariate and multivariable logistic regression procedures were used to examine predictors of risky sex across partner types. Overall, 18% of the sample was HIV-infected; 50% reported unprotected intercourse with men, 30% with women, and 5% with transgender partners. Fifty-three percent identified as bisexual or straight, although all reported oral or anal sex with another man in the prior 12 months. Significant predictors of engaging in at least one episode of: (1) serodiscordant unprotected anal sex (UAS) with a male partner in the past 12 months: individuals at risk for social isolation (AOR = 4.23; p = 0.03), those with unstable housing (AOR = 4.19; p = 0.03), and those who used poppers at least weekly during sex (AOR = 5.90; p = 0.05); (2) UAS and/or unprotected vaginal intercourse with a female partner in the past 12 months: those with unstable housing (AOR = 4.85; p = 0.04), those who used cocaine at least weekly during sex (AOR = 16.78; p = 0.006), being HIV-infected (AOR = 0.07; p = 0.02), and feeling social norms favor condom use (AOR = 0.60; p = 0.05); (3) UAS with the participants’ most recent nonmain male sex partner: use of alcohol and drugs during last sex by participant (AOR = 4.04; p = 0.01), having sex with a Hispanic/Latino male (AOR = 2.71; p = 0.04) or a Black male (AOR = 0.50; p = 0.05) compared to a White male, and lower education (AOR = 1.31; p = 0.02). Findings suggest that sexual risk behaviors of Black MSM differ across partner type and by the characteristics of their sexual networks and that this subpopulation of MSM are at high risk for HIV acquisition and transmission. Effective prevention strategies need to address the distinct sexual and behavioral risk patterns presented by different sexual partnerships reported by Black MSM.
doi:10.1007/s11524-009-9363-6
PMCID: PMC2704278  PMID: 19466554
HIV/AIDS; STD; African American/Black; MSM; Prevention
16.  Consistent condom use with regular, paying, and casual male partners and associated factors among men who have sex with men in Tamil Nadu, India: findings from an assessment of a large-scale HIV prevention program 
BMC Public Health  2013;13:827.
Background
Men who have sex with men (MSM) are a marginalized population at high risk for HIV infection. Promoting consistent condom use (CCU) during anal sex is a key risk reduction strategy for HIV prevention among MSM. To inform effective HIV prevention interventions, we examined the factors associated with CCU among MSM with their regular, paying, and casual partners, as well as with all three types of partners combined.
Methods
Data for this analysis were from a large-scale bio-behavioural survey conducted during 2009–2010 in Tamil Nadu, India. MSM aged 18 years or older were recruited for the survey using time-location cluster sampling at cruising sites in four districts of Tamil Nadu. Binary logistic regression analyses were conducted to assess the association of CCU with selected socio-demographic characteristics and other contextual factors.
Results
Among 1618 MSM interviewed, CCU during anal sex with regular, paying, and a casual male partner was 45.3%, 50.8% and 57.9%, respectively. CCU with all three types of partners combined was 52.6%. Characteristics associated with increased odds for CCU with MSM having all three types of partners combined were frequent receptive anal sex acts with regular partners (adjusted odds ratio [AOR] 2.17, 95% confidence interval [CI] 1.01-4.65), fewer number of casual partners (AOR 3.41, 95% CI 1.50-7.73) and membership in a community-based organization (CBO) for MSM (AOR 3.54, 95% CI 1.62-7.74). CCU with regular partners was associated with membership in a CBO (AOR 1.96, 95% CI 1.23-3.11), whereas CCU with paying, and casual male partners was associated with perceived higher risk of acquiring HIV (AOR 1.92, 95% CI 1.22-3.01) and exposure to any HIV prevention intervention (AOR 3.62, 95% CI 1.31-10.0), respectively. Being aged 26 years or older, being in debt, and alcohol use were factors associated with inconsistent condom use across partner types.
Conclusion
HIV interventions among MSM need to promote CCU with all types (regular, paying, and causal) of male partners, and need to reach MSM across all age groups. In addition to enhancing interventions that focus on individual level risk reduction, it is important to undertake structural interventions that promote social acceptance of same-sex sexuality and address contextual barriers to condom use such as alcohol use.
doi:10.1186/1471-2458-13-827
PMCID: PMC3854867  PMID: 24020613
Men who have sex with men; MSM; Condom use; Male sexual partners; Sexual risk; Tamil Nadu; India
17.  Predictors of HIV and Syphilis among Men Who Have Sex with Men in a Chinese Metropolitan City: Comparison of Risks among Students and Non-Students 
PLoS ONE  2012;7(5):e37211.
Background
Men who have sex with men (MSM) are at a substantial risk of HIV, given rising HIV prevalence in urban China. Adolescent and adult students often take HIV-related risk as part of sexual exploration. We compared the risks of HIV and syphilis infections and risky sexual behaviors between student and non-student among urban MSM.
Methods
Respondent driven sampling approach was used to recruit men who were self-identified as MSM in Chongqing Metropolitan City in southwestern China in 2009. Each participant completed a computer-assisted self-interview which collected demographic and behavioral data, and provided blood specimens for HIV and syphilis testing. Multivariable logistic regression analyses identified predictors for HIV and syphilis infections while comparing student and non-student MSM.
Results
Among 503 MSM participants, 36.4% were students, of whom 84.2% were in college. The adjusted prevalence of HIV infection was 5.5% (95% confidence interval [CI]: 2.1%–10.2%) in students and 20.9% (95% CI: 13.7%–27.5%) in non-students; the adjusted prevalence of syphilis was 4.4% (95% CI: 0.7%–9.0%) in students and 7.9% (95% CI: 3.6%–12.9%) in non-students (P = 0.12). Two groups had similar risky sexual behaviors such as number of sexual partners and exchanging sex for money. Multivariate analysis showed that students had lower HIV prevalence than non-students (adjusted odds ratio [AOR]: 0.3; 95% CI: 0.1–0.8) adjusting for age, ethnicity and other variables.
Conclusion
Student MSM have lower HIV and similar syphilis prevalence compared with non-student MSM. However, due to a shorter duration of sexual experience and high prevalence of at-risk sexual behaviors among student MSM, HIV risk might be quite high in students as in non-students.
doi:10.1371/journal.pone.0037211
PMCID: PMC3356386  PMID: 22623994
18.  Homonegativity, Substance Use, Sexual Risk Behaviors, and HIV Status in Poor and Ethnic Men Who Have Sex with Men in Los Angeles 
This study evaluates associations between internalized homonegativity and demographic factors, drug use behaviors, sexual risk behaviors, and HIV status among men who have sex with men (MSM) and with men and women (MSM/W). Participants were recruited in Los Angeles County using respondent-driven sampling (RDS) and completed the Internalized Homonegativity Inventory (IHNI) and questionnaires on demographic and behavioral factors. Biological samples were tested for HIV and for recent cocaine, methamphetamine, and heroin use. The 722 MSM and MSM/W participants were predominantly African American (44%) and Hispanic (28%), unemployed (82%), homeless (50%), and HIV positive (48%) who used drugs in the past 6 months (79.5%). Total and Personal Homonegativity, Gay Affirmation, and Morality of Homosexuality IHNI scores were significantly higher for African American men than for other ethnicities, for MSM/W than for MSM, for recent cocaine users than for recent methamphetamine users, and for HIV-seronegative men than for HIV-seropositive men. Linear regression showed the Gay Affirmation scale significantly and inversely correlated with the number of sexual partners when controlling for effects of ethnicity/race and sexual identification, particularly for men who self-identified as straight. Highest IHNI scores were observed in a small group of MSM/W (n = 62) who never tested for HIV. Of these, 26% tested HIV positive. Findings describe ways in which internalized homophobia is a barrier to HIV testing and associated HIV infection and signal distinctions among participants in this sample that can inform targeted HIV prevention efforts aimed at increasing HIV testing.
doi:10.1007/s11524-009-9372-5
PMCID: PMC2705491  PMID: 19526346
Homophobia; Homonegativity; Drug abuse; Gay men; Bisexual men; HIV
19.  The Potential Impact of Pre-Exposure Prophylaxis for HIV Prevention among Men Who Have Sex with Men and Transwomen in Lima, Peru: A Mathematical Modelling Study 
PLoS Medicine  2012;9(10):e1001323.
Gabriela Gomez and colleagues developed a mathematical model of the HIV epidemic among men who have sex with men and transwomen in Lima, Peru to explore whether HIV pre-exposure prophylaxis could be a cost-effective addition to existing HIV prevention strategies.
Background
HIV pre-exposure prophylaxis (PrEP), the use of antiretroviral drugs by uninfected individuals to prevent HIV infection, has demonstrated effectiveness in preventing acquisition in a high-risk population of men who have sex with men (MSM). Consequently, there is a need to understand if and how PrEP can be used cost-effectively to prevent HIV infection in such populations.
Methods and Findings
We developed a mathematical model representing the HIV epidemic among MSM and transwomen (male-to-female transgender individuals) in Lima, Peru, as a test case. PrEP effectiveness in the model is assumed to result from the combination of a “conditional efficacy” parameter and an adherence parameter. Annual operating costs from a health provider perspective were based on the US Centers for Disease Control and Prevention interim guidelines for PrEP use. The model was used to investigate the population-level impact, cost, and cost-effectiveness of PrEP under a range of implementation scenarios. The epidemiological impact of PrEP is largely driven by programme characteristics. For a modest PrEP coverage of 5%, over 8% of infections could be averted in a programme prioritising those at higher risk and attaining the adherence levels of the Pre-Exposure Prophylaxis Initiative study. Across all scenarios, the highest estimated cost per disability-adjusted life year averted (uniform strategy for a coverage level of 20%, US$1,036–US$4,254) is below the World Health Organization recommended threshold for cost-effective interventions, while only certain optimistic scenarios (low coverage of 5% and some or high prioritisation) are likely to be cost-effective using the World Bank threshold. The impact of PrEP is reduced if those on PrEP decrease condom use, but only extreme behaviour changes among non-adherers (over 80% reduction in condom use) and a low PrEP conditional efficacy (40%) would adversely impact the epidemic. However, PrEP will not arrest HIV transmission in isolation because of its incomplete effectiveness and dependence on adherence, and because the high cost of programmes limits the coverage levels that could potentially be attained.
Conclusions
A strategic PrEP intervention could be a cost-effective addition to existing HIV prevention strategies for MSM populations. However, despite being cost-effective, a substantial expenditure would be required to generate significant reductions in incidence.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Without a vaccine, the only ways to halt the global HIV epidemic are prevention strategies that reduce transmission of the HIV virus. Up until recently, behavioral strategies such as condom use and reduction of sexual partners have been at the center of HIV prevention. In the past few years, several biological prevention measures have also been shown to be effective in reducing (though not completely preventing) HIV transmission. These include male circumcision, treatment for prevention (giving antiretroviral drugs to HIV-infected people, before they need it for their own health, to reduce their infectiousness) and pre-exposure prophylaxis (or PrEP), in which HIV-negative people use antiretroviral drugs to protect themselves from infection. One PrEP regimen (a daily pill containing two different antiretrovirals) has been shown in a clinical trial to reduce new infections by 44% in of men who have sex with men (MSM). In July 2012, the US Food and Drug Administration approved this PrEP regimen to reduce the risk of HIV infection in uninfected men and women who are at high risk of HIV infection and who may engage in sexual activity with HIV-infected partners. The approval makes it clear that PrEP needs to be used in combination with safe sex practices.
Why Was This Study Done?
Clinical trials have shown that PrEP can reduce HIV infections among participants, but they have not examined the consequences PrEP could have at the population level. Before decision-makers can decide whether to invest in PrEP programs, they need to know about the costs and benefits at the population level. Besides the price of the drug itself, the costs include HIV testing before starting PrEP, as well as regular tests thereafter. The health benefits of reducing new HIV infections are calculated in “disability-adjusted life years” (or DALYs) averted. One DALY is equal to one year of healthy life lost. Other benefits include future savings in lifelong HIV/AIDS treatment for every person whose infection is prevented by PrEP.
This study estimates the potential costs and health benefits of several hypothetical PrEP roll-out scenarios among the community of MSM in Lima, Peru. The scientists chose this community because many of the participants in the clinical trial that showed that PrEP can reduce infections came from this community, and they therefore have some knowledge on how PrEP affects HIV infection rates and behavior in this population. Because the HIV epidemic in Lima is concentrated among MSM, similar to most of Latin America and several other developed countries, the results might also be relevant for the evaluation of PrEP in other places.
What Did the Researchers Do and Find?
For their scenarios, the researchers looked at “high coverage” and “low coverage” scenarios, in which 20% and 5% of uninfected individuals use PrEP, respectively. They also divided the MSM community into those at lower risk of becoming infected and those at higher risk. The latter group consisted of transwomen at higher risk (transsexuals and transvestites with many sexual partners) and male sex workers. In a “uniform coverage” scenario, PrEP is equally distributed among all MSM. “Prioritized scenarios” cover transwomen at higher risk and sex workers preferentially. Two additional important factors for the estimated benefits are treatment adherence (i.e., whether people take the pills they have been prescribed faithfully over long periods of time even though they are not sick) and changes in risk behavior (i.e., whether the perceived protection provided by PrEP leads to more unprotected sex).
The cost estimates for PrEP included the costs of the drug itself and HIV tests prior to PrEP prescription and at three-month intervals thereafter, as well as outreach and counseling services and condom and lubricant promotion and provision.
To judge whether under the various scenarios PrEP is cost-effective, the researchers applied two commonly used but different cost-effectiveness thresholds. The World Health Organization's WHO-CHOICE initiative considers an intervention cost-effective if its cost is less than three times the gross domestic product (GDP) per capita per DALY averted. For Peru, this means an intervention should cost less than US$16,302 per DALY. The World Bank has more stringent criteria: it considers an intervention cost-effective for a middle-income country like Peru if it costs less than US$500 per DALY averted.
The researchers estimate that PrEP is cost-effective in Lima's MSM population for most scenarios by WHO-CHOICE guidelines. Only scenarios that prioritize PrEP to those most likely to become infected (i.e., transwomen at higher risk and sex workers) are cost-effective (and only barely) by the more stringent World Bank criteria. If the savings on antiretroviral drugs to treat people with HIV (those who would have become infected without PrEP) are included in the calculation, most scenarios become cost-effective, even under World Bank criteria.
The most cost-effective scenario, namely, having a modest coverage of 5%, prioritizing PrEP to transwomen at higher risk and sex workers, and assuming fairly high adherence levels among PrEP recipients, is estimated to avert about 8% of new infections among this community over ten years.
What Do these Findings Mean?
These findings suggest that under some circumstances, PrEP could be a cost-effective tool to reduce new HIV infections. However, as the researchers discuss, PrEP is expensive and only partly effective. Moreover, its effectiveness depends on two behavioral factors—adherence to a strict drug regimen and continued practicing of safe sex—both of which remain hard to predict. As a consequence, PrEP alone is not a valid strategy to prevent new HIV infections. It needs instead to be considered as one of several available tools. If and when PrEP is chosen as part of an integrated prevention strategy will depend on the specific target population, the overall funds available, and how well its cost-effectiveness compares with other prevention measures.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001323.
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
NAM/aidsmap provides basic information about HIV/AIDS, summaries of recent research findings on HIV care and treatment, and a section on PrEP
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including HIV prevention
AVAC Global Advocacy for HIV Prevention provides up-to-date information on HIV prevention, including PrEP
The US Centers for Disease Control and Prevention also has information on PrEP
The World Health Organization has a page on its WHO-CHOICE criteria for cost-effectiveness
doi:10.1371/journal.pmed.1001323
PMCID: PMC3467261  PMID: 23055836
20.  Understanding the High Prevalence of HIV and Other Sexually Transmitted Infections among Socio-Economically Vulnerable Men Who Have Sex with Men in Jamaica 
PLoS ONE  2015;10(2):e0117686.
Objectives
This study estimates HIV prevalence among men who have sex with men (MSM) in Jamaica and explores social determinants of HIV infection among MSM.
Design
An island-wide cross-sectional survey of MSM recruited by peer referral and outreach was conducted in 2011. A structured questionnaire was administered and HIV/STI tests done. We compared three groups: MSM who accepted cash for sex within the past 3 months (MSM SW), MSM who did not accept cash for sex (MSM non-SW), and MSM with adverse life events (ever raped, jailed, homeless, victim of violence or low literacy).
Results
HIV prevalence among 449 MSM was 31.4%, MSM SW 41.1%, MSM with adverse life events 38.5%, 17 transgender MSM (52.9%), and MSM non-SW without adverse events 21.0%. HIV prevalence increased with age and number of adverse life events (test for trend P < 0.001), as did STI prevalence (P = 0.03). HIV incidence was 6.7 cases/100 person-years (95% CI: 3.74, 12.19). HIV prevalence was highest among MSM reporting high-risk sex; MSM SW who had been raped (65.0%), had a STI (61.2%) and who self identified as female (55.6%). Significant risk factors for HIV infection common to all 3 subgroups were participation in both receptive and insertive anal intercourse, high-risk sex, and history of a STI. Perception of no or little risk, always using a condom, and being bisexual were protective.
Conclusion
HIV prevalence was high among MSM SW and MSM with adverse life events. Given the characteristics of the sample, HIV prevalence among MSM in Jamaica is probably in the range of 20%. The study illustrates the importance of social vulnerability in driving the HIV epidemic. Programs to empower young MSM, reduce social vulnerability and other structural barriers including stigma and discrimination against MSM are critical to reduce HIV transmission.
doi:10.1371/journal.pone.0117686
PMCID: PMC4319820  PMID: 25659122
21.  Recruitment-Adjusted Estimates of HIV Prevalence and Risk Among Men Who Have Sex with Men: Effects of Weighting Venue-Based Sampling Data 
Public Health Reports  2011;126(5):635-642.
Objectives
We investigated the impact of recruitment bias within the venue-based sampling (VBS) method, which is widely used to estimate disease prevalence and risk factors among groups, such as men who have sex with men (MSM), that congregate at social venues.
Methods
In a 2008 VBS study of 479 MSM in New York City, we calculated venue-specific approach rates (MSM approached/MSM counted) and response rates (MSM interviewed/MSM approached), and then compared crude estimates of HIV risk factors and seroprevalence with estimates weighted to address the lower selection probabilities of MSM who attend social venues infrequently or were recruited at high-volume venues.
Results
Our approach rates were lowest at dance clubs, gay pride events, and public sex strolls, where venue volumes were highest; response rates ranged from 39% at gay pride events to 95% at community-based organizations. Sixty-seven percent of respondents attended MSM-oriented social venues at least weekly, and 21% attended such events once a month or less often in the past year. In estimates adjusted for these variations, the prevalence of several past-year risk factors (e.g., unprotected anal intercourse with casual/exchange partners, ≥5 total partners, group sex encounters, at least weekly binge drinking, and hard-drug use) was significantly lower compared with crude estimates. Adjusted HIV prevalence was lower than unadjusted prevalence (15% vs. 18%), but not significantly.
Conclusions
Not adjusting VBS data for recruitment biases could overestimate HIV risk and prevalence when the selection probability is greater for higher-risk MSM. While further examination of recruitment-adjustment methods for VBS data is needed, presentation of both unadjusted and adjusted estimates is currently indicated.
PMCID: PMC3151180  PMID: 21886323
22.  Bias in Online Recruitment and Retention of Racial and Ethnic Minority Men Who Have Sex With Men 
Background
The Internet has become an increasingly popular venue for men who have sex with men (MSM) to meet potential sex partners. Given this rapid increase in online sex-seeking among MSM, Internet-based interventions represent an important HIV (human immunodeficiency virus) prevention strategy. Unfortunately, black and Hispanic MSM, who are disproportionately impacted by the HIV epidemic in the United States, have been underrepresented in online research studies.
Objective
Our objective was to examine and quantify factors associated with underrecruitment and underretention of MSM of color in an online HIV behavioral risk research study of MSM recruited from an online social networking site.
Methods
Internet-using MSM were recruited through banner advertisements on MySpace.com targeted at men who reported in their MySpace profile their age as at least 18 and their sexual orientation as gay, bisexual, or unsure. Multivariable logistic regression models were used to estimate the odds stratified by race and ethnicity of the MySpace user clicking through the banner advertisement. To characterize survey retention, Kaplan-Meier survival curves and multivariable Cox proportional hazards models identified factors associated with survey dropout.
Results
Over 30,000 MySpace users clicked on the study banner advertisements (click-through rate of 0.37%, or 30,599 clicks from 8,257,271 impressions). Black (0.36% or 6474 clicks from 1,785,088 impressions) and Hispanic (0.35% or 8873 clicks from 2,510,434 impressions) MySpace users had a lower click-through rate compared with white (0.48% or 6995 clicks from 1,464,262 impressions) MySpace users. However, black men had increased odds of click-through for advertisements displaying a black model versus a white model (adjusted odds ratio [OR] = 1.83, 95% confidence interval [CI] 1.72 - 1.95), and Hispanic participants had increased odds of click-through when shown an advertisement displaying an Asian model versus a white model (adjusted OR = 1.70, 95% CI 1.62 - 1.79). Of the 9005 men who consented to participate, 6258 (69%) completed the entire survey. Among participants reporting only male sex partners, black non-Hispanic and Hispanic participants were significantly more likely to drop out of the survey relative to white non-Hispanic participants (hazard ratio [HR] = 1.6, 95% CI 1.4 - 1.8 and HR = 1.3, 95% CI 1.1 - 1.4, respectively). Men with a college-level of education were more likely to complete the survey than those with a high-school level of education (HR = 0.8, 95% CI 0.7 - 0.9), while men who self-identified as heterosexual were more likely to drop out of the survey compared with men who self-identified as gay (HR = 2.1, 95% CI 1.1 - 3.7).
Conclusions
This analysis identified several factors associated with recruitment and retention of MSM in an online survey. Differential click-through rates and increased survey dropout by MSM of color indicate that methods to recruit and retain black and Hispanic MSM in Internet-based research studies are paramount. Although targeting banner advertisements to MSM of color by changing the racial/ethnic composition of the advertisements may increase click-through, decreasing attrition of these study participants once they are engaged in the survey remains a challenge.
doi:10.2196/jmir.1797
PMCID: PMC3221372  PMID: 21571632
HIV infections/prevention and control; Internet; homosexuality male; research methodology; behavioral research
23.  Internet-Based Methods May Reach Higher-Risk Men who have Sex with Men Not Reached Through Venue-Based Sampling§ 
The Open AIDS Journal  2012;6:83-89.
Background:
Internet-based sampling methods may reach men who have sex with men (MSM) who don’t attend physical venues frequented by MSM and may be at higher risk of HIV infection.
Methods:
Multivariate logistic regression was used to examine characteristics of adult MSM participants in 2 studies conducted in the same 5 U.S. cities: the 2003-2005 National HIV Behavioral Surveillance System (NHBS) which used sampling from physical MSM venues (e.g., bars, clubs) and the 2007 Web-based HIV Behavioral Surveillance (WHBS) pilot which used sampling through online banner advertisements.
Results:
Among 5024 WHBS MSM, 95% attended a physical MSM venue in the past 12 months, and 75% attended weekly. WHBS MSM who were black, aged 18-21 years, not college educated, bisexual- or heterosexual-identifying, and reported unknown HIV serostatus were less likely to have attended a physical MSM venue in the past 12 months (all p<0.01). Compared to NHBS MSM, WHBS MSM were more likely to be white, younger, college-educated, report unknown HIV serostatus, report unprotected anal intercourse with a casual partner, and have first met that partner online (all p<0.0001). WHBS MSM were less likely to have been under the influence of drugs during most recent sex (p=0.01) or not know their sex partner’s HIV serostatus (p<0.0001).
Conclusions:
Many MSM recruited online also attended physical venues, but attendance varied by sub-group. Participants in WHBS and NHBS differed, and WHBS may represent a group of MSM at higher risk of HIV infection. These findings suggest that an internet-based method may be a useful supplement to NHBS.
doi:10.2174/1874613601206010083
PMCID: PMC3462429  PMID: 23049657
MSM; HIV; internet; gay; sex.
24.  HIV prevalence and factors associated with HIV infection among men who have sex with men in Cameroon 
Journal of the International AIDS Society  2013;16(4Suppl 3):18752.
Introduction
Despite men who have sex with men (MSM) being a key population for HIV programming globally, HIV epidemiologic data on MSM in Central Africa are sparse. We measured HIV and syphilis prevalence and the factors associated with HIV infection among MSM in Cameroon.
Methods
Two hundred and seventy-two and 239 MSM aged ≥18 from Douala and Yaoundé, respectively, were recruited using respondent-driven sampling (RDS) for this cross-sectional surveillance study in 2011. Participants completed a structured questionnaire and HIV and syphilis testing. Statistical analyses, including RDS-weighted proportions, bootstrapped confidence intervals and logistic regressions, were used.
Results
Crude and RDS-weighted HIV prevalence were 28.6% (73/255) and 25.5% (95% CI 19.1–31.9) in Douala, and 47.3% (98/207) and 44.4% (95% CI 35.7–53.2) in Yaoundé. Active syphilis prevalence in total was 0.4% (2/511). Overall, median age was 24 years, 62% (317/511) of MSM identified as bisexual and 28.6% (144/511) identified as gay. Inconsistent condom use with regular male partners (64.1%; 273/426) and casual male and female partners (48.5%; 195/402) was common, as was the inconsistent use of condom-compatible lubricants (CCLs) (26.3%; 124/472). In Douala, preferring a receptive sexual role was associated with prevalent HIV infection [adjusted odds ratio (aOR) 2.33, 95% CI 1.02–5.32]. Compared to MSM without HIV infection, MSM living with HIV were more likely to have ever accessed a health service targeting MSM in Douala (aOR 4.88, 95% CI 1.63–14.63). In Yaoundé, MSM living with HIV were more likely to use CCLs (aOR 2.44, 95% CI 1.19–4.97).
Conclusions
High HIV prevalence were observed and condoms and CCLs were used inconsistently indicating that MSM are a priority population for HIV prevention, treatment and care services in Douala and Yaoundé. Building the capacity of MSM community organizations and improving the delivery and scale-up of multimodal interventions for MSM that are sensitive to concerns about confidentiality and the complex individual, social, community-level and policy challenges are needed to successfully engage young MSM in the continuum of HIV care. In addition to scaling up condom and CCL access, evaluating the feasibility of novel biomedical interventions, including antiretroviral pre-exposure prophylaxis and early antiretroviral therapy for MSM living with HIV in Cameroon, is also warranted.
doi:10.7448/IAS.16.4.18752
PMCID: PMC3852127  PMID: 24321114
Men who have sex with men (MSM); HIV/AIDS; epidemiology; Africa; prevalence; respondent-driven sampling (RDS); homosexuality; prevention; risk factors; sexual behaviour
25.  An examination of social network characteristics of drug using men who have sex with men (MSM) 
Sexually transmitted infections  2008;84(6):420-424.
Objectives
The purpose of this study was to compare the social network characteristics of men who have sex with men (MSM) to non-MSM (NMSM) in a sample of predominately African American drug users. Specifically, we were interested in examining the differences in structure of the networks and drug and sexual risk partners within the network.
Methods
Data came from 481 male participants who reported having >=1 sex partner in the past 90 days. MSM was defined as having sex with a male. Data on social network composition were collected using a Social Network Inventory.
Results
Of 481 men, 7% (n=32) were categorized as MSM. Nearly two-thirds of MSM did not identify as gay. MSM were more likely to be HIV positive as compared to men who did not have sex with men. Social networks of MSM were younger and a greater proportion were HIV positive. After adjusting for HIV status, networks of MSM were less dense, indicating fewer connections among network members. Among injection drug using men in the sample, MSM reported a greater number of needle sharing networks than NMSM.
Conclusions
These findings underscore the importance of including social network factors in investigations of HIV risk among MSM. Further studies should focus on dynamics within a network and how they may operate to affect behavior and health.
doi:10.1136/sti.2008.031591
PMCID: PMC2799418  PMID: 19028939
MSM; social networks; HIV

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