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1.  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
2.  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
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.  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
5.  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
6.  Health System and Personal Barriers Resulting in Decreased Utilization of HIV and STD Testing Services among At-Risk Black Men Who Have Sex with Men in Massachusetts 
AIDS Patient Care and STDs  2009;23(10):825-835.
Abstract
Testing for HIV and other sexually transmitted diseases (STD) remains a cornerstone of public health prevention interventions. This analysis was designed to explore the frequency of testing, as well as health system and personal barriers to testing, among a community-recruited sample of Black men who have sex with men (MSM) at risk for HIV and STDs. Black MSM (n = 197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered assessment, with optional voluntary HIV counseling and testing. Logistic regression procedures examined factors associated with not having tested in the 2 years prior to study enrollment for: (1) HIV (among HIV-uninfected participants, n = 145) and (2) STDs (among the entire mixed serostatus sample, n = 197). The odds ratios and their 95% confidence intervals obtained from this analysis were converted to relative risks. (1) HIV: Overall, 33% of HIV-uninfected Black MSM had not been tested for HIV in the 2 years prior to study enrollment. Factors uniquely associated with not having a recent HIV test included: being less educated; engaging in serodiscordant unprotected sex; and never having been HIV tested at a community health clinic, STD clinic, or jail. (2) STDs: Sixty percent had not been tested for STDs in the 2 years prior to study enrollment, and 24% of the sample had never been tested for STDs. Factors uniquely associated with not having a recent STD test included: older age; having had a prior STD; and never having been tested at an emergency department or urgent care clinic. Overlapping factors associated with both not having had a recent HIV or STD test included: substance use during sex; feeling that using a condom during sex is “very difficult”; less frequent contact with other MSM; not visiting a health care provider (HCP) in the past 12 months; having a HCP not recommend HIV or STD testing at their last visit; not having a primary care provider (PCP); current PCP never recommending they get tested for HIV or STDs. In multivariable models adjusting for relevant demographic and behavioral factors, Black MSM who reported that a HCP recommended getting an HIV test (adjusted relative risk [ARR] = 0.26; p = 0.01) or STD test (ARR = 0.11; p = 0.0004) at their last visit in the past 12 months were significantly less likely to have not been tested for HIV or STDs in the past 2 years. Many sexually active Black MSM do not regularly test for HIV or STDs. HCPs play a pivotal role in encouraging testing for Black MSM. Additional provider training is warranted to educate HCPs about the specific health care needs of Black MSM, in order to facilitate access to timely, culturally competent HIV and STD testing and treatment services for this population.
doi:10.1089/apc.2009.0086
PMCID: PMC2859760  PMID: 19803696
7.  Characteristics of Men Who Have Sex With Men in Southern Africa Who Seek Sex Online: A Cross-Sectional Study 
Background
Use of the Internet for finding sexual partners is increasing, particularly among men who have sex with men (MSM). In particular, MSM who seek sex online are an important group to target for human immunodeficiency virus (HIV)/sexually transmitted infection (STI) interventions because they tend to have elevated levels of sexual risk behavior and because the Internet itself may serve as a promising intervention delivery mechanism. However, few studies have examined the correlates of online sexual partner seeking among MSM in sub-Saharan Africa.
Objective
These analyses aim to describe the prevalence of using the Internet to find new male sexual partners among MSM in two southern African countries. In addition, these analyses examine the sociodemographic characteristics, experiences of discrimination and stigma, mental health and substance use characteristics, and HIV-related knowledge, attitudes, and behaviors among MSM associated with meeting sex partners online.
Methods
MSM were enrolled into a cross-sectional study across two sites in Lesotho (N=530), and one in Swaziland (N=322) using respondent-driven sampling. Participants completed a survey and HIV testing. Data were analyzed using bivariate and multivariable logistic regression models to determine which factors were associated with using the Internet to meet sex partners among MSM.
Results
The prevalence of online sex-seeking was high, with 39.4% (209/530) of MSM in Lesotho and 43.8% (141/322) of MSM in Swaziland reporting meeting a new male sexual partner online. In the multivariable analysis, younger age (adjusted odds ratio [aOR] 0.37, 95% confidence interval [CI] 0.27-0.50 per 5 years in Lesotho; aOR 0.68, 95% CI 0.49-0.93 in Swaziland), having more than a high school education (aOR 18.2, 95% CI 7.09-46.62 in Lesotho; aOR 4.23, 95% CI 2.07-8.63 in Swaziland), feeling scared to walk around in public places (aOR 1.89, 95% CI 1.00-3.56 in Lesotho; aOR 2.06, 95% CI 1.23-3.46 in Swaziland), and higher numbers of male anal sex partners within the past 12 months (aOR 1.27, 95% CI 1.01-1.59 per 5 partners in Lesotho; aOR 2.98, 95% CI 1.51-5.89 in Swaziland) were significantly associated with meeting sex partners online in both countries. Additional country-specific associations included increasing knowledge about HIV transmission, feeling afraid to seek health care services, thinking that family members gossiped, and having a prevalent HIV infection among MSM in Lesotho.
Conclusions
Overall, a high proportion of MSM in Lesotho and Swaziland reported meeting male sex partners online, as in other parts of the world. The information in this study can be used to tailor interventions or to suggest modes of delivery of HIV prevention messaging to these MSM, who represent a young and highly stigmatized group. These data suggest that further research assessing the feasibility and acceptability of online interventions will be increasingly critical to addressing the HIV epidemic among MSM across sub-Saharan Africa.
doi:10.2196/jmir.4230
PMCID: PMC4468572  PMID: 26006788
Internet; HIV; male homosexuality; southern Africa; social stigma; sexual behavior
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.  Prevalence of Consensual Male–Male Sex and Sexual Violence, and Associations with HIV in South Africa: A Population-Based Cross-Sectional Study 
PLoS Medicine  2013;10(6):e1001472.
Using a method that offered complete privacy to participants, Rachel Jewkes and colleagues conducted a survey among South African men about their lifetime same-sex experiences.
Please see later in the article for the Editors' Summary
Background
In sub-Saharan Africa the population prevalence of men who have sex with men (MSM) is unknown, as is the population prevalence of male-on-male sexual violence, and whether male-on-male sexual violence may relate to HIV risk. This paper describes lifetime prevalence of consensual male–male sexual behavior and male-on-male sexual violence (victimization and perpetration) in two South African provinces, socio-demographic factors associated with these experiences, and associations with HIV serostatus.
Methods and Findings
In a cross-sectional study conducted in 2008, men aged 18–49 y from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces provided anonymous survey data and dried blood spots for HIV serostatus assessment. Interviews were completed in 1,737 of 2,298 (75.6%) of enumerated and eligible households. From these households, 1,705 men (97.1%) provided data on lifetime history of same-sex experiences, and 1,220 (70.2%) also provided dried blood spots for HIV testing. 5.4% (n = 92) of participants reported a lifetime history of any consensual sexual activity with another man; 9.6% (n = 164) reported any sexual victimization by a man, and 3.0% (n = 51) reported perpetrating sexual violence against another man. 85.0% (n = 79) of men with a history of consensual sex with men reported having a current female partner, and 27.7% (n = 26) reported having a current male partner. Of the latter, 80.6% (n = 21/26) also reported having a female partner. Men reporting a history of consensual male–male sexual behavior are more likely to have been a victim of male-on-male sexual violence (adjusted odds ratio [aOR] = 7.24; 95% CI 4.26–12.3), and to have perpetrated sexual violence against another man (aOR = 3.10; 95% CI 1.22–7.90). Men reporting consensual oral/anal sex with a man were more likely to be HIV+ than men with no such history (aOR = 3.11; 95% CI 1.24–7.80). Men who had raped a man were more likely to be HIV+ than non-perpetrators (aOR = 3.58; 95% CI 1.17–10.9).
Conclusions
In this sample, one in 20 men (5.4%) reported lifetime consensual sexual contact with a man, while about one in ten (9.6%) reported experience of male-on-male sexual violence victimization. Men who reported having had sex with men were more likely to be HIV+, as were men who reported perpetrating sexual violence towards other men. Whilst there was no direct measure of male–female concurrency (having overlapping sexual relationships with men and women), the data suggest that this may have been common. These findings suggest that HIV prevention messages regarding male–male sex in South Africa should be mainstreamed with prevention messages for the general population, and sexual health interventions and HIV prevention interventions for South African men should explicitly address male-on-male sexual violence.
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 it soon became clear that AIDS also infects heterosexual men and women. Now, three decades on, globally, 34 million people (two-thirds of whom live in sub-Saharan Africa and half of whom are women) are infected with HIV, the virus that causes AIDS, and 2.5 million people become infected every year. HIV is most often spread by having unprotected sex with an infected partner, and 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; homosexual, bisexual, and transgender men, and heterosexual men who sometimes have consensual sex with men). Moreover, in the concentrated HIV epidemics of high-income countries (epidemics in which the prevalence of HIV infection is more than 5% in at-risk populations such as sex workers but less than 1% in the general population), male-to-male sexual contact remains the most important transmission route, and MSM often have a higher prevalence of HIV infection than heterosexual men.
Why Was This Study Done?
By contrast to high-income countries, HIV epidemics in sub-Saharan Africa are generalized—the prevalence of HIV infection is 1% or more in the general population. Because male-to-male sexual behavior is criminalized in many African countries and because homosexuality is widely stigmatized, little is known about the prevalence of consensual male–male sexual behavior in sub-Saharan Africa. This information and a better understanding of male–female sexual concurrency (having overlapping sexual relationships with men and women) and of how male-to-male transmission contributes to generalized HIV epidemics is needed to inform the design of HIV prevention strategies for use in sub-Saharan Africa. In addition, very little is known about male-on-male sexual violence. Such violence is potentially important to study because we know that male-on-female violence is associated with increased HIV risk for both victims and perpetrators. In this cross-sectional study (an investigation that measures population characteristics at a single time point), the researchers use data from a population-based household survey to investigate the lifetime prevalence of consensual male–male sexual behavior and male-on-male sexual violence (victimization and perpetration) among men in South Africa and the association of these experiences with HIV infection.
What Did the Researchers Do and Find?
About 1,700 adult men from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces of South Africa self-completed a survey that included questions about their lifetime history of same-sex experiences using audio-enhanced personal digital assistants, a data collection method that provided a totally private and anonymous environment for the disclosure of illegal and stigmatized behavior; 1,220 of them also provided dried blood spots for HIV testing. Ninety-two men (5.4% of the participants) reported consensual sexual activity (for example, anal or oral sex) with another man at some time during their life; 9.6% of the men reported that they had been forced to have sex with another man (sexual victimization), and 3% reported that they had perpetrated sexual violence against another man. Most of the men who reported consensual sex with men, including those with current male partners, reported that they had a current female partner. Men with a history of consensual male–male sexual behavior were more likely to have been a victim or perpetrator of male-on-male sexual violence than men without a history of such experiences. Finally, men who reported consensual oral or anal sex with a man were more likely to be HIV+ than men without such a history, and perpetrators of male-on-male sexual violence were more likely to be HIV+ than non-perpetrators.
What Do These Findings Mean?
These findings provide new information about male–male sexual behaviors, male-on-male sexual violence, male–female concurrency, and HIV prevalence among men in two South African provinces. The precision of these findings is likely to be affected by the small numbers of men reporting a history of consensual male–male sexual behavior and of male-on-male sexual violence. Importantly, because the study was cross-sectional, these findings cannot indicate whether the association between consensual male–male sexual behaviors and increased risk of male-on-male sexual violence is causal. Moreover, these findings may not be generalizable to other regions of South Africa or to other African countries. Nevertheless, these findings suggest that information about the risks of male–male sexual behaviors should be included in HIV prevention strategies targeted at the general population in South Africa and that HIV prevention interventions for South African men should explicitly address male-on-male sexual violence. Similar HIV prevention strategies may also be suitable for other African countries, but are likely to succeed only in countries that have, like South Africa, decriminalized consensual homosexual behavior.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001472.
This study is further discussed in a PLOS Medicine Perspective by Jerome Singh
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, including summaries of recent research findings on HIV care and treatment
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on HIV and men who have sex with men, on HIV prevention, and on AIDS in Africa (in English and Spanish)
The US Centers for Disease Control and Prevention also has information about HIV/AIDS among men who have sex with men (in English and Spanish)
Patient stories about living with HIV/AIDS are available through Avert; the charity website Healthtalkonline also provides personal stories about living with HIV
doi:10.1371/journal.pmed.1001472
PMCID: PMC3708702  PMID: 23853554
10.  HIV prevalence, incidence and risk behaviours among men who have sex with men in Yangzhou and Guangzhou, China: a cohort study 
Introduction
In China, the prevalence and incidence of HIV among men who have sex with men (MSM) in large-sized cities have drawn much attention. In contrast, there has been a paucity of research focussing on the sexual health of MSM of medium-sized cities. This study fills this important gap in the knowledge by investigating the sexual health of MSM in a medium-sized city (Yangzhou) and a large-sized city (Guangzhou).
Methods
A baseline survey and a prospective cohort study were conducted among MSM in Yangzhou and Guangzhou from July 2009 to September 2010. A total of 622 MSM (317 from Yangzhou and 305 from Guangzhou) were screened for eligibility. Prevalence and incidence of HIV infection, as well as its risk factors, were investigated.
Results
Baseline HIV prevalence was 14.5%, and overall HIV incidence density was 6.78 per 100 person-years (PY) among Yangzhou MSM. Risk factors for HIV prevalence that were significant in multivariate models were older age, married status, unprotected sex with female partners, sexually transmitted disease (STD)-associated symptoms and syphilis positivity. Risk factors for HIV incidence that were significant in multivariate models were STD-associated symptom and syphilis positivity. Compared to Yangzhou MSM, Guangzhou MSM had a lower HIV prevalence (6.2%; p<0.05) and lower overall HIV incidence density (5.77 per 100 PY). Risk factors for HIV prevalence that were significant in multivariate models were married status, unprotected anal sex with men and syphilis positivity. The single risk factor for HIV incidence that was significant in multivariate models was unprotected anal sex with men.
Conclusions
This study showed a high prevalence and incidence of HIV among Yangzhou MSM, which suggest a more serious HIV epidemic than that in large-sized cities. Further investigation targeting MSM in medium-sized cites is urgently needed to prevent the spread of the HIV epidemic in China.
doi:10.7448/IAS.17.1.18849
PMCID: PMC4188039  PMID: 25103308
HIV; prevalence; incidence; risk behaviours; men who have sex with men; Yangzhou; Guangzhou
11.  Crystal Methamphetamine Use Predicts Incident STD Infection Among Men Who Have Sex With Men Recruited Online: A Nested Case-Control Study 
Background
Among men who have sex with men (MSM), the number of newly diagnosed human immunodeficiency virus (HIV) infections has increased by approximately 60% since 1999. Factors that may be contributing to this resurgence include a widely reported increase in bacterial sexually transmitted diseases (STDs) among HIV-positive and HIV-negative MSM, as well as unsafe sexual practices.
Objective
This research was undertaken to learn more about risk behaviors associated with an incident STD among MSM.
Methods
A nested case-control study was conducted, using data from a cross-sectional Internet survey of MSM (N=2643), which investigated risk behaviors during a 6-month period in 2001. Chi-square and logistic regression methods were used to estimate the likelihood of acquiring an incident STD versus no STD.
Results
Eighty-five percent of the respondents were white, 46% were under age 30, and 80% had met sex partners online; 7% were HIV-positive. Men with an incident STD were more likely than men without an STD to report drug use (crystal methamphetamine odds ratio 3.8; 95% confidence interval 2.1-6.7; cocaine OR 2.3; 95% CI 1.2-4.2; ecstasy OR 2.2; 95% CI 1.3-3.8; Viagra OR 2.1; 95% CI 1.2-3.7), alcohol before or during sex (OR 1.9; 95% CI 1.2-2.9), and high-risk sexual behavior (unprotected anal intercourse OR 5.0; 95% CI 2.8-8.9; multiple sex partners OR 5.9; 95% CI 2.5-13.8). In the multivariate analysis, significant independent predictors associated with an incident STD were crystal methamphetamine use (adjusted OR 2.0; 95% CI 1.1-3.8), unprotected anal intercourse (adjusted OR 3.4; 95% CI 1.9-6.3), and 6 or more sex partners during the study period (adjusted OR 3.3; 95% CI 1.4-7.8).
Conclusion
Identifying and treating MSM who have STDs, or who are at increased risk for acquiring STDs, is crucial in preventing the further spread of disease. In addition, there is a need to integrate HIV/STD and substance use prevention and education into Web-based and community-based venues.
doi:10.2196/jmir.6.4.e41
PMCID: PMC1550619  PMID: 15631965
Internet; sexually transmitted diseases; methamphetamine; HIV
12.  Estimation of HIV Prevalence, Risk Factors, and Testing Frequency among Sexually Active Men Who Have Sex with Men, Aged 18–64 Years—New York City, 2002 
Journal of Urban Health   2007;84(2):212-225.
Population-based estimates of human immunodeficiency virus (HIV) prevalence and risk behaviors among men who have sex with men (MSM) are valuable for HIV prevention planning but not widely available, especially at the local level. We combined two population-based data sources to estimate prevalence of diagnosed HIV infection, HIV-associated risk-behaviors, and HIV testing patterns among sexually active MSM in New York City (NYC). HIV/AIDS surveillance data were used to determine the number of living males reporting a history of sex with men who had been diagnosed in NYC with HIV infection through 2002 (23% of HIV-infected males did not have HIV transmission risk information available). Sexual behavior data from a cross-sectional telephone survey were used to estimate the number of sexually active MSM in NYC in 2002. Prevalence of diagnosed HIV infection was estimated using the ratio of HIV-infected MSM to sexually active MSM. The estimated base prevalence of diagnosed HIV infection was 8.4% overall (95% confidence interval [CI] = 7.5–9.6). Diagnosed HIV prevalence was highest among MSM who were non-Hispanic black (12.6%, 95% CI = 9.8–17.6), aged 35–44 (12.6%, 95% CI = 10.4–15.9), or 45–54 years (13.1%, 95% CI = 10.2–18.3), and residents of Manhattan (17.7%, 95% CI = 14.5–22.8). Overall, 37% (95% CI = 32–43%) of MSM reported using a condom at last sex, and 34% (95% CI = 28–39%) reported being tested for HIV in the past year. Estimates derived through sensitivity analyses (assigning a range of HIV-infected males with no reported risk information as MSM) yielded higher diagnosed HIV prevalence estimates (11.0–13.2%). Accounting for additional undiagnosed HIV-infected MSM yielded even higher prevalence estimates. The high prevalence of diagnosed HIV among sexually active MSM in NYC is likely due to a combination of high incidence over the course of the epidemic and prolonged survival in the era of highly active antiretroviral therapy. Despite high HIV prevalence in this population, condom use and HIV testing are low. Combining complementary population-based data sources can provide critical HIV-related information to guide prevention efforts. Individual counseling and education interventions should focus on increasing condom use and encouraging safer sex practices among all sexually active MSM, particularly those groups with low levels of condom use and multiple sex partners
doi:10.1007/s11524-006-9135-5
PMCID: PMC2231634  PMID: 17295058
Condom use; HIV prevalence; HIV testing; Human immunodeficiency virus; Men who have sex with men
13.  A Mixed-Methods Study on the Acceptability of Using eHealth for HIV Prevention and Sexual Health Care Among Men Who Have Sex With Men in China 
Background
Human immunodeficiency virus (HIV) infection disproportionately affects men who have sex with men (MSM). Over half of all HIV-positive MSM in China may not know their HIV status. Mobile phones and Web interventions (eHealth) are underutilized resources that show promise for supporting HIV education, testing, and linkage to care.
Objective
This mixed-methods study among MSM in China assessed technology utilization and eHealth acceptability for sexual health care.
Methods
We conducted in-depth interviews and an online survey. Qualitative analyses informed the development of the Internet survey, which was administered through two popular MSM websites. Bivariate and multivariate analysis assessed characteristics of MSM interested in eHealth for sexual health care.
Results
The qualitative sample included MSM across a range of ages, education, marital status, sexuality, and HIV testing experience. Qualitative findings included the importance of the Internet as the primary source of information about sexual health, HIV and other sexually transmitted diseases (STDs), use of the Internet to enable HIV testing opportunities by facilitating connections with both the gay community and health care providers, and mixed perceptions regarding the confidentiality of eHealth tools for sexual health. Among the Internet sample (N=1342), the average age was 30.6 years old, 82.81% (1098/1342) were single, and 53.42% (711/1331) had completed college. In the past 3 months, 38.66% (382/988) had condomless sex and 60.53% (805/1330) self-reported having ever tested for HIV. The majority of men owned computers (94.14%, 1220/1296) and mobile phones (92.32%, 1239/1342), which many had used to search for HIV/STD information and testing sites. In multivariate analysis, interest in using computers or mobile phones to support their sexual health care was associated with being a student, prior use of computers or mobile phones to search for general health information, prior use of computers or mobile phones to search for HIV/STD information, and confidentiality concerns.
Conclusions
MSM in this sample had high utilization of technology and interest in eHealth despite confidentiality concerns. Future eHealth interventions can thoughtfully and creatively address these concerns as a priority for successful implementation.
doi:10.2196/jmir.3370
PMCID: PMC4420841  PMID: 25900881
Internet; HIV; AIDS; China; men who have sex with men; mixed method; sexually transmitted diseases
14.  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
15.  The characterisation of sexual behaviour in Chinese male university students who have sex with other men: A cross-sectional study 
BMC Public Health  2008;8:250.
Background
The risks for Chinese male university students who have sex with other men (MSM) have not been compared with those for non-MSM students. This information is important for the development of targeted HIV prevention programmes for this population.
Methods
Sexually active MSM and non-MSM students were compared for demographic characteristics, sexual behaviour, and related psychosocial variables using bivariate analyses. The data were a subset drawn from a large-scale cross-sectional questionnaire survey of sexually active male students conducted at two universities in a large city in Zhejiang Province, China, in 2003.
Results
Of 1824 sexually active male students, 68 (3.7%) reported having had sex with a man at least once; 33.8% of these 68 men had also had female partners. Compared with non-MSM students, MSM students were 3–6.5 times more likely to have had sexual encounters with casual or commercial sex partners and were three times less likely to have protected sex in the past year or during their lifetime. They were three to five times more likely to have had multiple partners and 15 times more likely to have had a sexually transmitted disease (STD). In addition, the MSM students knew half as much about HIV and had less condom-decision than did non-MSM students and were two times more accepting of commercial sex. However, the MSM students were twice as aware of the risks for HIV infection.
Conclusion
MSM composed 3–4% of the male sexually active university student population studied and was found to be at greater risk than non-MSM students for STD/HIV infection. There is an urgent need for STD/HIV programmes in university health services that take into consideration the sexuality and psychosocial issues of MSM students.
doi:10.1186/1471-2458-8-250
PMCID: PMC2503976  PMID: 18647381
16.  Comparison of risk behaviors and socio-cultural profile of men who have sex with men survey respondents recruited via venues and the internet 
BMC Public Health  2010;10:232.
Background
Increasingly more men who have sex with men (MSM) are using the internet to seek sex partners, and many HIV-related studies targeting MSM collect data from gay venues in order to inform the design of prevention programs. However, internet-based MSM may have different HIV risk behaviors and associated factors from those attending venues. This study examined differences in risk behaviors and socio-cultural profiles between MSM recruited from venues (e.g., gay bars/saunas) and from the internet respectively.
Methods
An anonymous cross-sectional survey was conducted. A total of 566 Chinese MSM (340 recruited from gay-venues and 226 recruited from the internet) who self-reported having had anal or oral sex with another man in the last 12 months completed a structured questionnaire.
Results
Internet-based MSM were more likely than venue-based MSM to have engaged in unprotected anal intercourse (53.3% vs. 33.8%) or commercial sex (as clients: 12.8% vs. 5.3%; as sex workers: 6.2% vs. 1.5%), to have sought MSM partners from the internet (51.3% vs. 20.9%), and to have contracted sexually transmitted diseases (STD) in the last 12 months (4.4% vs. 0.3%). On the other hand, internet-based MSM were less likely to have multiple sex partners (58.4% vs. 75.6%) and to have used psychoactive substances (7.1% vs. 15.6%) or drunk alcohol before sex (8.8% vs. 16.2%). Moreover, internet-based MSM reported poor acceptance of their own sexual orientation, felt more discriminated against, and received less social support than venue-recruited MSM.
Conclusions
Significant differences were observed between the two groups of MSM. Segmentation and targeted interventions are recommended when designing preventive interventions.
doi:10.1186/1471-2458-10-232
PMCID: PMC2880294  PMID: 20444297
17.  Cost-Effectiveness of Pooled Nucleic Acid Amplification Testing for Acute HIV Infection after Third-Generation HIV Antibody Screening and Rapid Testing in the United States: A Comparison of Three Public Health Settings 
PLoS Medicine  2010;7(9):e1000342.
Angela Hutchinson and colleagues conducted a cost-effectiveness analysis of pooled nucleic acid amplification testing following HIV testing and show that it is not cost-effective at recommended antibody testing intervals for high-risk persons except in very high-incidence settings.
Background
Detection of acute HIV infection (AHI) with pooled nucleic acid amplification testing (NAAT) following HIV testing is feasible. However, cost-effectiveness analyses to guide policy around AHI screening are lacking; particularly after more sensitive third-generation antibody screening and rapid testing.
Methods and Findings
We conducted a cost-effectiveness analysis of pooled NAAT screening that assessed the prevention benefits of identification and notification of persons with AHI and cases averted compared with repeat antibody testing at different intervals. Effectiveness data were derived from a Centers for Disease Control and Prevention AHI study conducted in three settings: municipal sexually transmitted disease (STD) clinics, a community clinic serving a population of men who have sex with men, and HIV counseling and testing sites. Our analysis included a micro-costing study of NAAT and a mathematical model of HIV transmission. Cost-effectiveness ratios are reported as costs per quality-adjusted life year (QALY) gained in US dollars from the societal perspective. Sensitivity analyses were conducted on key variables, including AHI positivity rates, antibody testing frequency, symptomatic detection of AHI, and costs. Pooled NAAT for AHI screening following annual antibody testing had cost-effectiveness ratios exceeding US$200,000 per QALY gained for the municipal STD clinics and HIV counseling and testing sites and was cost saving for the community clinic. Cost-effectiveness ratios increased substantially if the antibody testing interval decreased to every 6 months and decreased to cost-saving if the testing interval increased to every 5 years. NAAT was cost saving in the community clinic in all situations. Results were particularly sensitive to AHI screening yield.
Conclusions
Pooled NAAT screening for AHI following negative third-generation antibody or rapid tests is not cost-effective at recommended antibody testing intervals for high-risk persons except in very high-incidence settings.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Since 1981, acquired immunodeficiency syndrome (AIDS) has killed about 25 million people and about 30 million people are now infected with the human immunodeficiency virus (HIV), which causes AIDS. HIV, which is most often transmitted through unprotected sex with an infected partner or injection drug use, infects and kills immune system cells, leaving infected individuals susceptible to other infectious diseases. The first, often undiagnosed stage of HIV infection—acute HIV infection (AHI)—lasts a few weeks and sometimes involves a flu-like illness. During AHI, the immune system responds to HIV by beginning to make antibodies that recognize the virus but seroconversion—the appearance of detectable amounts of antibody in the blood—takes 6–12 weeks. During the second, symptom-free stage of HIV infection, which can last many years, the virus gradually destroys the immune system so that by the third stage of infection unusual infections (for example, persistent yeast infections) begin to occur. The final stage of infection (AIDS) is characterized by multiple severe infections and by the development of unusual cancers.
Why Was This Study Done?
Antiretroviral drugs control HIV infections but don't cure them. It is very important, therefore, to prevent HIV transmission by avoiding HIV risk behaviors that increase the risk of HIV infection such as having sex without a condom or with many partners. Individuals with AHI in particular need to avoid high-risk behaviors because these people are extremely infectious. However, routine tests for HIV infection that measure antibodies in the blood often give false-negative results in people with AHI because of the time lag between infection and seroconversion. Nucleic acid amplification testing (NAAT), which detects HIV genetic material in the blood, is a more accurate way to diagnose AHI but is expensive. In this study, the researchers investigate whether pooled NAAT screening (specimens are pooled before testing to reduce costs) for AHI in clinic settings after third-generation antibody testing is a cost-effective HIV prevention strategy. That is, does the gain in quality-adjusted life years (QALY, a measure of the quantity and quality of life generated by healthcare interventions) achieved by averting new HIV infections outweigh the costs of pooled NAAT screening?
What Did the Researchers Do and Find?
The researchers combined effectiveness data from a US study in which AHI was detected using pooled NAAT in three settings (sexually transmitted disease [STD] clinics, a community clinic serving men who have sex with men [MSM], and HIV counseling/testing sites) with a “micro-costing” study of NAAT and a mathematical model of HIV transmission. They then calculated the costs per QALY gained (the cost-effectiveness ratio) as a result of HIV prevention by identification and notification of people with AHI through pooled NAAT screening compared with repeat antibody testing. Pooled NAAT for AHI screening following annual antibody testing (the recommended testing interval for high-risk individuals), they estimate, would cost US$372,300 and US$484,400 per QALY gained for the counseling/testing sites and STD clinics, respectively, whereas pooled NAAT for AHI screening was cost-saving for the community clinic serving MSM. The cost-effectiveness ratio increased for the counseling/testing sites and STD clinics when the antibody testing interval was decreased to 6 months but remained cost-saving for the community clinic. With an antibody testing interval of 5 years, pooled NAAT was cost-saving in all three settings.
What Do These Findings Mean?
Cost-effectiveness ratios of US$100,000–US$200,000 are considered acceptable in the US. These results suggest therefore, that the cost of pooled NAAT screening for AHI following negative third-generation antibody testing is not acceptable at the recommended testing interval for high-risk individuals except in settings where HIV infection is very common such as clinics serving MSM. The researchers reach a similar conclusion in a separate cost-effectiveness analysis of pooled NAAT screening following a negative rapid HIV test. Although the accuracy of these results depends on numerous assumptions made in the cost-effectiveness analyses (for example, the degree to which awareness of HIV status affects the behavior of people with AHI), sensitivity analyses (investigations of the effect of altering key assumptions) show that these findings are not greatly affected by changes in many of these assumptions. Thus, the researchers conclude, NAAT screening should be reserved for settings that serve populations in which there are very high levels of new HIV infection.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000342.
The US Centers for Disease Control and Prevention provides information on HIV infection and AIDS and on HIV testing and diagnosis
HIV InSite has information on all aspects of HIV/AIDS
Information is available from Avert, an international AIDS nonprofit organization on many aspects of HIV/AIDS, including HIV testing (in English and Spanish)
MedlinePlus has links to further resources on AIDS (in English and Spanish)
The UK National Institute of Health and Clinical Excellence has a page on measuring effectiveness and cost-effectiveness
doi:10.1371/journal.pmed.1000342
PMCID: PMC2946951  PMID: 20927354
18.  Walking the line: Stimulant use during sex and HIV risk behavior among Black urban MSM 
Drug and alcohol dependence  2010;110(0):30-37.
Background
Although the association of stimulant use to sexual risk taking and HIV transmission has been well documented among white gay men, stimulant use during sex continues to be under-explored among Black men who have sex with men (MSM).
Methods
Black MSM (n = 197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered quantitative assessment and optional HIV counseling and testing. Bivariate logistic regression procedures were employed to examine the association of demographics, sexual risk, and other psychosocial factors with stimulant use (at least monthly during sex in the past 12 months). Variable elimination using the backward selection process was used to fit two separate final multivariable logistic regression models examining stimulant use as the outcome and HIV sexual risk in the past 12 months by gender as the primary predictor: (1) Model 1: HIV sexual risk behavior with a casual male sex partner as a primary, forced predictor; (2) Model 2: HIV sexual risk behavior with a female sex partner as primary, forced predictor.
Results
One-third (34%) of Black MSM reported using stimulants monthly or more frequently during sex in the past 12 months. The following factors were independently associated with stimulant use during sex: (1) Model 1: unprotected anal sex with a casual male sex partner in the past 12 months (AOR = 2.61; 95% CI = 1.06–6.42; p = 0.01), older age (AOR = 1.09; 95% CI = 1.05–1.15; p < 0.001), erectile dysfunction (ED) medication use monthly or more during sex in the past 12 months (AOR = 7.81; 95% CI = 1.46–41.68; p = 0.02), problematic alcohol use (AOR = 3.31; 95% CI = 1.312–8.38; p = 0.005), and higher HIV treatment optimism (AOR = 0.86; 95% CI = 0.76–0.97; p = 0.01). (2) Model 2: unprotected vaginal or anal sex with a female partner in the past 12 months (AOR = 3.54; 95% CI = 1.66–7.56; p = 0.001), older age (AOR = 1.10; 95% CI = 1.05–1.14; p < 0.001), ED use monthly or more during sex in the past 12 months (AOR = 3.70; 95% CI = 1.13–12.13; p = 0.03), clinically significant depressive symptoms (CES-D) at the time of study enrollment (AOR = 3.11; 95% CI = 1.45–6.66; p = 0.004), and supportive condom use norms (AOR = 0.69; 95% CI = 0.49–0.97; p = 0.03).
Conclusion
Frequent stimulant use is an important factor in HIV and STD sexual risk among Black MSM, particularly for older men and those with co-occurring psychosocial morbidities. HIV and STD prevention interventions in this population may benefit from addressing the precipitants of stimulant use and sexual risk taking.
doi:10.1016/j.drugalcdep.2010.01.017
PMCID: PMC3947405  PMID: 20334986
Stimulant use; Black; MSM; HIV; Sexual risk behavior
19.  HIV and Syphilis Prevalence Among Men Who Have Sex With Men: A Cross-Sectional Survey of 61 Cities in China 
The prevalence of human immunodeficiency virus and syphilis among men who have sex with men in China is high, yet the 2 epidemics are largely geographically separate. Characteristics of the overall population surveyed as well as segments within this population are described.
Background. Human immunodeficiency virus (HIV) has rapidly spread among men who have sex with men (MSM) in China in recent years; the magnitude of the epidemic is unclear. We sought to test 3 hypotheses: (1) The prevalence of both HIV and syphilis among MSM in China is high, (2) the 2 epidemics each have unique geographical distributions, and (3) demographic and sexual behavior characteristics are different among segments of the MSM population in China.
Methods. A total of 47 231 MSM from 61 cities in China participated in a cross-sectional survey conducted from February 2008 to September 2009. Demographic and behavioral data were collected and analyzed and blood samples tested for HIV and syphilis. Three subgroups among the broader MSM sample were described. Main outcome measures were HIV and syphilis prevalence.
Results. An overall prevalence of 4.9% (2314/47 231; 95% confidence interval [CI], 4.7%–5.1%) for HIV and 11.8% (5552/47 231; 95% CI, 11.5%–12.0%) for syphilis was found. Syphilis-positive MSM had the highest HIV prevalence, 12.5% (693/5552; 95% CI, 11.6%–13.4%). However, correlations between HIV and syphilis prevalence were found in only 3 of 6 geographical regions (Northwest: r = 0.82, P = .0253; East: r = 0.78, P = .0004; and South-central: r = 0.63, P = .0276). Three subgroups—nonlocal MSM, Internet-using MSM, and female-partnering MSM—were found to have different profiles of characteristics and behaviors.
Conclusions. HIV and syphilis prevalences among MSM in China are high and the 2 epidemics are largely separate geographically. Three segments of the Chinese MSM population each have different demographic and sexual risk “profiles” that suggest high potential for bridging infection across geographies, generations, and sexes.
doi:10.1093/cid/cit210
PMCID: PMC3689345  PMID: 23580732
HIV; syphilis; MSM; China
20.  An Internet-Based Intervention (Condom-Him) to Increase Condom Use Among HIV-Positive Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial 
JMIR Research Protocols  2013;2(2):e39.
Background
In the recent years, the Internet has been used as a medium to find sexual partners and engage in risky sexual behavior. This has changed the way in which men having have sex with men (MSM) seek sexual partners and has increased the number of high-risk sexual encounters. Therefore, developers of human immunodeficiency virus (HIV)-prevention interventions have also started using the Internet as a viable medium to promote safe sexual behaviors. However, much of the efforts thus far have been aimed at HIV-negative rather than HIV-positive MSM. HIV-positive individuals continue to engage in risky sexual behaviors and thus constitute an important group in which HIV prevention strategies need to be addressed. Therefore, HIV prevention in HIV-positive MSM is a critical issue.
Objective
Condom-Him, an Internet-based intervention tailored to increase condom use among HIV-positive MSM, was developed with the aim of improving condom use, self-efficacy, and intentions to use condoms among these individuals. The acceptability and feasibility of this Internet-based intervention will be examined in a pilot study.
Methods
We will perform a randomized controlled parallel-group superiority trial. HIV-positive MSM who currently engage in unprotected anal sex will be recruited for the study. Participants will be randomly assigned using a one-to-one allocation ratio generated by the computer program. The researchers will be blinded to participant’s group assignment. Participants will be assigned either to use the Condom-Him intervention (experimental arm) or to view a list of websites containing HIV/AIDS related information (control arm). Self-administered questionnaires will be provided online before randomization (baseline) and two weeks after intervention (post-test).
Results
The study will include a total of 60 participants with 30 in each group. The results from this pilot study will provide further evidence for a larger study to examine the effectiveness of this intervention and will provide a cost-effective and widely accessible approach to HIV prevention for HIV-positive MSM.
Conclusions
Internet-based interventions for HIV-positive MSM, a population that has been under-represented in the efforts for positive prevention of HIV within Canada, have the potential to provide a cost-effective strategy, which influences the way in which information is accessed and provided to high-risk individuals. The advantages of an Internet-based intervention include the potential to provide consistency in the delivery of an intervention and the ability to disseminate the intervention to a wider population. Internet-based interventions are perceived as vital tools in combating HIV infection within the realm of social media. Therefore, it is important to determine the feasibility and acceptability of these interventions before implementing them.
Trial Registration
Clinicaltrials.gov: NCT01726153; http://clinicaltrials.gov/ct2/show/NCT01726153 (Archived by WebCite at http://www.webcitation.org/6Jljzip8B).
doi:10.2196/resprot.2723
PMCID: PMC3806407  PMID: 24132072
HIV-positive; men having sex with men; condom use; self-efficacy; intention; HIV prevention; pilot study; intervention
21.  Risk Factors for Syphilis and Prevalence of HIV, Hepatitis B and C among Men Who Have Sex with Men in Beijing, China: Implications for HIV Prevention 
AIDS and behavior  2008;13(4):663-670.
To examine the correlates for syphilis and the prevalence for HIV, hepatitis B, hepatitis C among men-who-have-sex-with-men (MSM) in Beijing, China. A total of 541 MSM was recruited using peer-referral, community outreach, and Internet. Questionnaire-based interviews provided information including, demographics, sexual and other risk behaviors. HIV prevalence was 4.8%, syphilis 19.8%, HCV 0.4% and HBsAg 6.5%. The median number of lifetime male sex partners was ten. In the past 3 months, 20.7% drank alcohol ≥1 times per week. In the past month, 21.3 and 14.6% had unprotected anal intercourse with regular and casual male sex partners, respectively. Syphilis infection was associated with less education, alcohol use, finding male sex partners through bathhouses/public washrooms/parks, and diagnoses of sexual transmitted diseases (STDs). Syphilis is now epidemic among Beijing's MSM. Prevention efforts are urgent as HIV prevalence is already near 5%. Education, condom promotion, STD control, and alcohol-related intervention are needed urgently.
doi:10.1007/s10461-008-9503-0
PMCID: PMC2747785  PMID: 19082879
China; Men who have sex with men; Syphilis; HIV; Sexually transmitted disease (STD); Risk behavior
22.  Partner Notification After STD and HIV Exposures and Infections: Knowledge, Attitudes, and Experiences of Massachusetts Men Who Have Sex with Men 
Public Health Reports  2009;124(1):111-119.
SYNOPSIS
Objectives
We assessed Boston-area men who have sex with men (MSM) in terms of their knowledge of partner notification (PN)/partner counseling and referral services (PCRS) and intentions to use such services if exposed to/infected with a sexually transmitted disease (STD) or human immunodeficiency virus (HIV) in the future.
Methods
The study used a convenience sample of STD clinic patients (n=48) and a modified respondent-driven sampling method (n=70) to reach a diverse sample of MSM (total sample n=118) in Massachusetts. Participants completed a one-on-one, open-ended, semistructured qualitative interview and quantitative survey.
Results
Overall, white, HIV-infected MSM had the highest level of knowledge about PN activities. MSM who were unfamiliar with PN were disproportionately nonwhite and HIV-uninfected. Participants were more likely to notify past partners of HIV exposure than STD exposure. The preferred method of PN for the majority of MSM was direct person-to-person notification. Notably, nonwhite participants were more likely to endorse Massachusetts Department of Public Health PN services than white MSM, who preferred involvement of primary care providers.
Conclusions
PN is an important public health strategy for treating and preventing STDs and HIV among at-risk populations, especially MSM who engage in sexual behavior with anonymous or otherwise non-notifiable sexual partners. Although many MSM had an understanding of the ethical desirability of informing exposed partners and recognized the value of preventative behaviors, they require further education to overcome barriers to PN as well as to gain knowledge of the various methods of both traditional and nontraditional notification, such as Internet PN.
PMCID: PMC2602936  PMID: 19413033
23.  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
24.  ANRS–COM'TEST: description of a community-based HIV testing intervention in non-medical settings for men who have sex with men 
BMJ Open  2012;2(2):e000693.
Objective
To describe a community-based HIV testing programme.
Design and setting
An intervention of HIV voluntary testing conducted in non-medical settings in four French cities.
Participants
Men who have sex with men (MSM).
Intervention
Counselling and rapid HIV testing staffed by trained personnel from an HIV/AIDS community-based organisation.
Primary and secondary outcome measures
The population that has taken hold of the intervention and the satisfaction of participants. Data were collected on demographics, HIV testing history, sexual practices and satisfaction with the testing programme.
Results
532 MSM were tested between February 2009 and June 2010, of whom 49 (9%) were tested two or more times. 468 MSM (88%) had casual male partners in the previous 6 months, and 152 (35%) reported having unprotected anal intercourse with risky casual partners (HIV infected or HIV serostatus unknown). 159 men (30%) had not been tested in the previous 2 years, and 50 (31%) of whom had unprotected anal intercourse with risky casual partners. Among the 15 patients who tested positive (2.8%), 12 (80%) received confirmation and were linked to care (median CD4 cell count =550/mm3). Satisfaction was high: 92% reported being ‘very satisfied’ with their experience. Steps of counselling and testing procedure were respected by testers and difficulties in handling tests were rare.
Conclusions
This community-based HIV testing programme reached high-risk MSM, of whom a substantial proportion had not been tested lately. This novel service supplements pre-existing HIV testing services and increases access to HIV testing in high-risk groups.
Article summary
Article focus
How extend testing facilities to reach and test for HIV more MSM and diagnose HIV-infected MSM earlier?
The presence of peers and non-clinical staff members who address sexuality more openly and avoid medical jargon during counselling sessions could offset cultural barriers and reduce fears of HIV and associated stigma.
The article describes an experimental programme of community-based HIV testing: the population reached, the quality of the programme and the satisfaction of participants.
Key messages
This community-based HIV testing and counselling programme reaches MSM with high-risk sexual behaviour, a substantial proportion of whom has not tested for HIV recently.
Community testers are able to perform rapid HIV test into a comprehensive prevention approach in line with participant's life.
2.8% of participants tested positive. Infection was confirmed in all cases, 80% were linked to care. Cases were diagnosed at early stages of disease.
Strengths and limitations of this study
This HIV testing and counselling programme is exclusively based on MSM community, and continuing the prevention counselling with the awareness of the HIV serostatus includes testing into a comprehensive prevention approach.
Community-based HIV testing programmes may be attractive and efficient in large urban areas (like Paris), but perhaps less so in smaller cities, where an outreach approach may work better.
The number of HIV diagnoses was small; the prevalence and median CD4 count among the few HIV-infected participants should therefore be interpreted with caution.
doi:10.1136/bmjopen-2011-000693
PMCID: PMC3323802  PMID: 22466158
25.  HIV-1 Transmission during Early Infection in Men Who Have Sex with Men: A Phylodynamic Analysis 
PLoS Medicine  2013;10(12):e1001568.
Erik Volz and colleagues use HIV genetic information from a cohort of men who have sex with men in Detroit, USA to dissect the timing of onward transmission during HIV infection.
Please see later in the article for the Editors' Summary
Background
Conventional epidemiological surveillance of infectious diseases is focused on characterization of incident infections and estimation of the number of prevalent infections. Advances in methods for the analysis of the population-level genetic variation of viruses can potentially provide information about donors, not just recipients, of infection. Genetic sequences from many viruses are increasingly abundant, especially HIV, which is routinely sequenced for surveillance of drug resistance mutations. We conducted a phylodynamic analysis of HIV genetic sequence data and surveillance data from a US population of men who have sex with men (MSM) and estimated incidence and transmission rates by stage of infection.
Methods and Findings
We analyzed 662 HIV-1 subtype B sequences collected between October 14, 2004, and February 24, 2012, from MSM in the Detroit metropolitan area, Michigan. These sequences were cross-referenced with a database of 30,200 patients diagnosed with HIV infection in the state of Michigan, which includes clinical information that is informative about the recency of infection at the time of diagnosis. These data were analyzed using recently developed population genetic methods that have enabled the estimation of transmission rates from the population-level genetic diversity of the virus. We found that genetic data are highly informative about HIV donors in ways that standard surveillance data are not. Genetic data are especially informative about the stage of infection of donors at the point of transmission. We estimate that 44.7% (95% CI, 42.2%–46.4%) of transmissions occur during the first year of infection.
Conclusions
In this study, almost half of transmissions occurred within the first year of HIV infection in MSM. Our conclusions may be sensitive to un-modeled intra-host evolutionary dynamics, un-modeled sexual risk behavior, and uncertainty in the stage of infected hosts at the time of sampling. The intensity of transmission during early infection may have significance for public health interventions based on early treatment of newly diagnosed individuals.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Since the first recorded case of AIDS in 1981, the number of people infected with HIV, the virus that causes AIDS, has risen steadily. About 34 million people are currently HIV-positive, and about 2.5 million people become newly infected with HIV every year. Because HIV is usually transmitted through unprotected sex with an infected partner, individuals can reduce their risk of infection by abstaining from sex, by having only one or a few partners, and by always using condoms. Most people do not become ill immediately after infection with HIV, although some develop a short flu-like illness. The next stage of HIV infection, which may last more than ten years, also has no major symptoms, but during this stage, HIV slowly destroys immune system cells. Eventually, the immune system can no longer fight off infections by other disease-causing organisms, and HIV-positive people then develop one or more life-threatening AIDS-defining conditions, including unusual infections and specific types of cancer. HIV infection can be controlled, but not cured, by taking a daily cocktail of antiretroviral drugs.
Why Was This Study Done?
The design of effective programs to prevent the spread of HIV/AIDS depends on knowing how HIV transmissibility varies over the course of HIV infection. Consider, for example, a prevention strategy that focuses on increasing treatment rates: antiretroviral drugs, in addition to reducing illness and death among HIV-positive people, reduce HIV transmission from HIV-positive individuals. “Treatment as prevention” can only block transmissions that occur after diagnosis and entry into care. However, the transmissibility of HIV per sexual contact depends on a person's viral load, which peaks during early HIV infection, when people are often unaware of their HIV status and may still be following the high-risk patterns of sexual behavior that caused their own infection. Epidemiological surveillance data (information on HIV infections within populations) can be used to estimate how many new HIV infections occur within a population annually (HIV incidence) and the proportion of the population that is HIV-positive (HIV prevalence), but cannot be used to estimate the timing of transmission events. In this study, the researchers use “phylodynamic analysis” to estimate HIV incidence and prevalence and the timing of HIV transmission during infection. HIV, like many other viruses, rapidly accumulates genetic changes. The timing of transmission influences the pattern of these changes. Viral phylodynamic analysis—the quantitative study of how epidemiological, immunological, and evolutionary processes shape viral phylogenies (evolutionary trees)—can therefore provide estimates of transmission dynamics.
What Did the Researchers Do and Find?
The researchers obtained HIV sequence data (collected for routine surveillance of antiretroviral resistance mutations) and epidemiological surveillance data (including information on the stage of infection at diagnosis) for 662 HIV-positive men who have sex with men living in the Detroit metropolitan area of Michigan. They constructed a phylogenetic tree from the sequences using a “relaxed clock” approach and then fitted an epidemiological model (a mathematical model that represents the progress of individual patients through various stages of HIV infection) to the sequence data. Their approach, which integrates surveillance data and genetic data, yielded estimates of HIV incidence and prevalence among the study population similar to those obtained from surveillance data alone. However, it also provided information about HIV transmission that could not be obtained from surveillance data alone. In particular, it allowed the researchers to estimate that, in the current HIV epidemic among men who have sex with men in Detroit, 44.7% of HIV transmissions occur during the first year of infection.
What Do These Findings Mean?
The robustness of these findings depends on the validity of the assumptions included in the researchers' population genetic model and on the accuracy of the data fed into the model, and may not be generalizable to other cities or to other risk groups. Nevertheless, the findings of this analysis, which can be repeated in any setting where HIV sequence data for individual patients can be linked to patient-specific clinical and behavioral information, have important implications for HIV control strategies based on the early treatment of newly diagnosed individuals. Because relatively few infected individuals are diagnosed during early HIV infection, when the HIV transmission rate is high, it is unlikely, suggest the researchers, that the “treatment as prevention” strategy will effectively control the spread of HIV unless there are very high rates of HIV testing and treatment.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001568.
This study is further discussed in a PLOS Medicine Perspective by Timothy Hallett
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 and summaries of recent research findings on HIV care and treatment
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on HIV treatment as prevention (in English and Spanish)
The PLOS Medicine Collection Investigating the Impact of Treatment on New HIV Infections provides more information about HIV treatment as prevention
A PLOS Computational Biology Topic Page (a review article that is a published copy of record of a dynamic version of the article as found in Wikipedia) about viral phylodynamics is available
The US National Institute of Health–funded HIV Sequence Database contains HIV sequences and tools to analyze these sequences
Patient stories about living with HIV/AIDS are available through Avert; the charity website Healthtalkonline also provides personal stories about living with HIV
doi:10.1371/journal.pmed.1001568
PMCID: PMC3858227  PMID: 24339751

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