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1.  A novel approach to prevention for at-risk HIV negative men who have sex with men: Creating a teachable moment to promote informed sexual decision making 
American journal of public health  2011;101(3):539-545.
Objectives
HIV continues to disproportionately affect men who have sex with men (MSM). As a result of the impact of HIV among MSM, multiple strategies for reducing HIV risks have emerged from within the gay community. One common HIV risk reduction strategy is to limit unprotected sex partners to those who are of the same HIV status, or to serosort. Although serosorting is commonly practiced for risk reduction, it is closely linked to HIV transmission because of infrequent HIV testing, lack of HIV status disclosure, sexually transmitted infections, and acute HIV infection.
Methods
The current study tested a novel, brief, one-on-one, peer counselor-delivered intervention based on informed decision making, to address the limitations of serosorting. One hundred forty nine at-risk men were recruited and randomly assigned to an intervention condition addressing serosorting or a standard-of-care control.
Results
Men in the serosorting intervention reported fewer sexual partners (Wald X2=8.79,p=<.01) at study follow-ups.
Discussion
Addressing risks associated with serosorting in a feasible, low -cost intervention has the potential to significantly impact the HIV epidemic.
doi:10.2105/AJPH.2010.191791
PMCID: PMC3036682  PMID: 21233441
2.  Serosorting Sexual Partners and Continued Risk for HIV Transmission among Men who have Sex with Men 
Objective
The purpose of the current study was to assess whether or not men who have sex with men who limit their unprotected anal sexual partners to those who are of the same HIV status (serosort) differ in their risk for HIV transmission than MSM who do not serosort.
Methods
Cross-sectional surveys administered at a large gay pride festival (80% response rate) were collected from MSM. Univariate and multivariate logistic regressions were used to identify predictors of serosorting.
Results
Participants were self-identified as HIV negative MSM (N=628), about one third of whom engaged in serosorting (n=229). Men who serosort were more likely to believe that serosorting offered protection against HIV transmission, perceived themselves as being at no relatively higher risk for HIV transmission, and had more unprotected anal intercourse partners. Over half the sample reported their frequency of HIV testing as yearly or less frequently; this finding did not differ between serosorters and non-serosorters.
Conclusions
Men who identify as HIV negative and serosort are no more likely to know their HIV status than men who do not serosort and are at higher risk for exposure to HIV. Interventions targeting MSM must address the limitations of serosorting.
doi:10.1016/j.amepre.2007.08.004
PMCID: PMC3151147  PMID: 18022064
3.  Failure of Serosorting to Protect African American Men Who Have Sex with Men from HIV Infection 
Sexually transmitted diseases  2012;39(9):659-664.
Background
Serosorting is the practice of choosing sex partners or selectively using condoms based on a sex partner’s perceived HIV status. The extent to which serosorting protects African American (AA) and Hispanic men who have sex with men (MSM) is unknown.
Methods
We analyzed data collected from MSM STD clinic patients in Seattle, WA, 2001–10. Men were asked about the HIV status of their anal sex partners in the prior year and about their condom use with partners by partner HIV status. We defined serosorters as MSM who had unprotected anal intercourse (UAI) only with partners of the same HIV status, and compared the risk of testing HIV positive among serosorters and men who reported having UAI with partners of opposite or unknown HIV status (i.e. nonconcordant UAI). We used generalized estimating equations to evaluate the association of serosorting with testing HIV positive.
Results
A total of 6694 MSM without a prior HIV diagnosis were tested during 13,657 visits; 274 men tested HIV positive. Serosorting was associated with a lower risk of testing HIV positive than nonconcordant UAI among white MSM (2.1 vs. 4.5%, OR 0.45 95% CI 0.34–0.61), but not AA MSM (6.8 vs. 6.0%, OR 1.1 95% CI 0.57–2.2). Among Hispanics, the risk of testing HIV positive was lower among serosorters than men engaging in nonconcordant UAI, though this was not significant (4.1 vs. 6.0%, OR 0.67 95% CI 0.36–1.2).
Conclusions
In at least some AA MSM populations, serosorting does not appear to be protective against HIV infection.
doi:10.1097/OLQ.0b013e31825727cb
PMCID: PMC3424487  PMID: 22902660
4.  Men having sex with men serosorting with casual partners: who, how much, and what risk factors in Switzerland, 2007-2009 
BMC Public Health  2013;13:839.
Background
Serosorting is practiced by men who have sex with men (MSM) to reduce human immunodeficiency virus (HIV) transmission. This study evaluates the prevalence of serosorting with casual partners, and analyses the characteristics and estimated numbers of serosorters in Switzerland 2007-2009.
Methods
Data were extracted from cross-sectional surveys conducted in 2007 and 2009 among self-selected MSM recruited online, through gay newspapers, and through gay organizations. Nested models were fitted to ascertain the appropriateness of pooling the datasets. Multiple logistic regression analysis was performed on pooled data to determine the association between serosorting and demographic, lifestyle-related, and health-related factors. Extrapolations were performed by applying proportions of various types of serosorters to Swiss population data collected in 2007.
Results
A significant and stable number of MSM (approximately 39% in 2007 and 2009) intentionally engage in serosorting with casual partners in Switzerland. Variables significantly associated with serosorting were: gay organization membership (aOR = 1.67), frequent internet use for sexual encounters (aOR = 1.71), having had a sexually transmitted infection (STI) at any time in the past 12 months (aOR = 1.70), HIV-positive status (aOR = 0.52), regularly frequenting sex-on-premises venues (aOR = 0.42), and unprotected anal intercourse (UAI) with partners of different or unknown HIV status in the past 12 months (aOR = 0.22). Approximately one-fifth of serosorters declared HIV negativity without being tested in the past 12 months; 15.8% reported not knowing their own HIV status.
Conclusion
The particular risk profile of serosorters having UAI with casual partners (multiple partners, STI history, and inadequate testing frequency) requires specific preventive interventions tailored to HIV status.
doi:10.1186/1471-2458-13-839
PMCID: PMC3848594  PMID: 24025364
Sexual risk behaviour; Men who have sex with men; Serosorting; HIV; Switzerland
5.  HIV Transmission Risk among HIV Seroconcordant and Serodiscordant Couples: Dyadic Processes of Partner Selection 
AIDS and behavior  2008;13(2):185-195.
Selecting sex partners of the same HIV status or serosorting is a sexual risk reduction strategy used by many men who have sex with men. However, the effectiveness of serosorting for protection against HIV is potentially limited. We sought to examine how men perceive the protective benefits of factors related to serosorting including beliefs about engaging in serosorting, sexual communication, and perceptions of risk for HIV. Participants were 94 HIV negative seroconcordant (same HIV status) couples, 20 HIV serodiscordant (discrepant HIV status) couples, and 13 HIV positive seroconcordant (same HIV status) couples recruited from a large gay pride festival in the southeastern US. To account for nonindependence found in the couple-level data, we used multilevel modeling which includes dyad in the analysis. Findings demonstrated that participants in seroconcordant relationships were more likely to believe that serosorting reduces concerns for condom use. HIV negative participants in seroconcordant relationships viewed themselves at relatively low risk for HIV transmission even though monogamy within relationships and HIV testing were infrequent. Dyadic analyses demonstrated that partners have a substantial effect on an individual’s beliefs and number of unprotected sex partners. We conclude that relationship partners are an important source of influence and, thus, intervening with partners is necessary to reduce HIV transmission risks.
doi:10.1007/s10461-008-9480-3
PMCID: PMC2937197  PMID: 18953645
HIV; serosorting; MSM; dyad; multilevel modeling
6.  Increases in sexually transmitted infections and sexual risk behaviour without a concurrent increase in HIV incidence among men who have sex with men in San Francisco: a suggestion of HIV serosorting? 
Sexually Transmitted Infections  2006;82(6):461-466.
Background
Sexually transmitted infections (STI) and unprotected anal intercourse (UAI) have been increasing among men who have sex with men (MSM) in San Francisco. However, HIV incidence has stabilised.
Objectives
To describe recent trends in sexual risk behaviour, STI, and HIV incidence among MSM in San Francisco and to assess whether increases in HIV serosorting (that is, selective unprotected sex with partners of the same HIV status) may contribute to preventing further expansion of the epidemic.
Methods
The study applies an ecological approach and follows the principles of second generation HIV surveillance. Temporal trends in biological and behavioural measures among MSM were assessed using multiple pre‐existing data sources: STI case reporting, prevention outreach programmatic data, and voluntary HIV counselling and testing data.
Results
Reported STI cases among MSM rose from 1998 through 2004, although the rate of increase slowed between 2002 and 2004. Rectal gonorrhoea cases increased from 157 to 389 while early syphilis increased from nine to 492. UAI increased overall from 1998 to 2004 (p<0.001) in community based surveys; however, UAI with partners of unknown HIV serostatus decreased overall (p<0.001) among HIV negative MSM, and among HIV positive MSM it declined from 30.7% in 2001 to a low of 21.0% in 2004 (p<0.001). Any UAI, receptive UAI, and insertive UAI with a known HIV positive partner decreased overall from 1998 to 2004 (p<0.001) among MSM seeking anonymous HIV testing and at the STI clinic testing programme. HIV incidence using the serological testing algorithm for recent HIV seroconversion (STARHS) peaked in 1999 at 4.1% at the anonymous testing sites and 4.8% at the STI clinic voluntary testing programme, with rates levelling off through 2004.
Conclusions
HIV incidence among MSM appears to have stabilised at a plateau following several years of resurgence. Increases in the selection of sexual partners of concordant HIV serostatus may be contributing to the stabilisation of the epidemic. However, current incidence rates of STI and HIV remain high. Moreover, a strategy of risk reduction by HIV serosorting can be severely limited by imperfect knowledge of one's own and one's partners' serostatus.
doi:10.1136/sti.2006.019950
PMCID: PMC2563862  PMID: 17151031
men who have sex with men; sexual risk behaviour; sexually transmitted infections; HIV
7.  Serosorting Is Associated with a Decreased Risk of HIV Seroconversion in the EXPLORE Study Cohort 
PLoS ONE  2010;5(9):e12662.
Background
Seroadaptation strategies such as serosorting and seropositioning originated within communities of men who have sex with men (MSM), but there are limited data about their effectiveness in preventing HIV transmission when utilized by HIV-negative men.
Methodology/Principal Findings
Data from the EXPLORE cohort of HIV-negative MSM who reported both seroconcordant and serodiscordant partners were used to evaluate serosorting and seropositioning. The association of serosorting and seropositioning with HIV seroconversion was evaluated in this cohort of high risk MSM from six U.S. cities. Serosorting was independently associated with a small decrease in risk of HIV seroconversion (OR = 0.88; 95%CI, 0.81–0.95), even among participants reporting ≥10 partners. Those who more consistently practiced serosorting were more likely to be white (p = 0.01), have completed college (p = <0.0002) and to have had 10 or more partners in the six months before the baseline visit (p = 0.01) but did not differ in age, reporting HIV-infected partners, or drug use. There was no evidence of a seroconversion effect with seropositioning (OR 1.02, 95%CI, 0.92–1.14).
Significance
In high risk HIV uninfected MSM who report unprotected anal intercourse with both seroconcordant and serodiscordant partners, serosorting was associated with a modest decreased risk of HIV infection. To maximize any potential benefit, it will be important to increase accurate knowledge of HIV status, through increased testing frequency, improved test technology, and continued development of strategies to increase disclosure.
doi:10.1371/journal.pone.0012662
PMCID: PMC2936578  PMID: 20844744
8.  Serosorting and sexual risk behaviour according to different casual partnership types among MSM: The study of one-night stands and sex buddies 
AIDS care  2011;24(2):167-173.
Among HIV-negative men who have sex with men (MSM), any incident of unprotected anal intercourse (UAI) between casual partners is usually regarded as risky for HIV transmission. However, men are increasingly using knowledge of their casual partner’s HIV-status to reduce HIV risk during UAI (i.e., serosorting). Since familiarity between casual partners may lead to higher levels of UAI and serosorting, we examined how often men have UAI and practice serosorting with three types of casual partnerships that differ in their degree of familiarity.
We included 240 HIV-negative men of the Amsterdam Cohort Study among MSM. We distinguished three types of casual partnerships: one-night stand (‘met by chance and had sex only once’); multiple-time casual partner (‘met and had sex with several times’); and the ‘regular’ casual partner (‘sex buddy’). Serosorting was defined as UAI with an HIV-concordant partner. GEE analyses were used to examine the association between type of casual partnership and sexual risk behaviour.
Analyses revealed that men with a sex buddy were more likely to have UAI than men with a one-night stand (OR[95%CI] 2.39 [1.39–4.09]). However, men with a sex buddy were also more likely to practice serosorting than men with a one-night stand (OR[95%CI] 5.20 [1.20–22.52]).
Men with a sex buddy had more UAI but also reported more serosorting than men with a one-night stand. As a result, the proportion of UAI without serosorting is lower for men with a sex buddy, and therefore men might have less UAI at risk for HIV with this partner type. However, the protective value of serosorting with a sex buddy against HIV transmission needs to be further established. At this time, we suggest that a distinction between the one-night stand and the sex buddy should be incorporated in future studies as men behave significantly different with the two partner types.
doi:10.1080/09540121.2011.603285
PMCID: PMC3561689  PMID: 21861633
men who have sex with men; serosorting; sexual behaviour; risk reduction behaviour; types of casual partnerships; unprotected anal intercourse
9.  Seroadaptive Practices: Association with HIV Acquisition among HIV-Negative Men Who Have Sex with Men 
PLoS ONE  2012;7(10):e45718.
Background
Although efficacy is unknown, many men who have sex with men (MSM) attempt to reduce HIV risk by adapting condom use, partner selection, or sexual position to the partner’s HIV serostatus. We assessed the association of seroadaptive practices with HIV acquisition.
Methodology/Principal Findings
We pooled data on North American MSM from four longitudinal HIV-prevention studies. Sexual behaviors reported during each six-month interval were assigned sequentially to one of six mutually exclusive risk categories: (1) no unprotected anal intercourse (UAI), (2) having a single negative partner, (3) being an exclusive top (only insertive anal sex), (4) serosorting (multiple partners, all HIV negative), (5) seropositioning (only insertive anal sex with potentially discordant partners), and (6) UAI with no seroadaptive practices. HIV antibody testing was conducted at the end of each interval. We used Cox models to evaluate the independent association of each category with HIV acquisition, controlling for number of partners, age, race, drug use, and intervention assignment. 12,277 participants contributed to 60,162 six-month intervals with 663 HIV seroconversions. No UAI was reported in 47.4% of intervals, UAI with some seroadaptive practices in 31.8%, and UAI with no seroadaptive practices in 20.4%. All seroadaptive practices were associated with a lower risk, compared to UAI with no seroadaptive practices. However, compared to no UAI, serosorting carried twice the risk (HR = 2.03, 95%CI:1.51–2.73), whereas seropositioning was similar in risk (HR = 0.85, 95%CI:0.50–1.44), and UAI with a single negative partner and as an exclusive top were both associated with a lower risk (HR = 0.56, 95%CI:0.32–0.96 and HR = 0.55, 95%CI:0.36–0.84, respectively).
Conclusions/Significance
Seroadaptive practices appear protective when compared with UAI with no seroadaptive practices, but serosorting appears to be twice as risky as no UAI. Condom use and limiting number of partners should be advocated as first-line prevention strategies, but seroadaptive practices may be considered harm-reduction for men at greatest risk.
doi:10.1371/journal.pone.0045718
PMCID: PMC3463589  PMID: 23056215
10.  Sexual Serosorting among Women with or at Risk of HIV Infection 
AIDS and behavior  2011;15(1):9-15.
Serosorting, the practice of selectively engaging in unprotected sex with partners of the same HIV serostatus, has been proposed as a strategy for reducing HIV transmission risk among men who have sex with men (MSM). However, there is a paucity of scientific evidence regarding whether women engage in serosorting. We analyzed longitudinal data on women’s sexual behavior with male partners collected in the Women’s Interagency HIV Study from 2001 to 2005. Serosorting was defined as an increasing trend of unprotected anal or vaginal sex (UAVI) within seroconcordant partnerships over time, more frequent UAVI within seroconcordant partnerships compared to non-concordant partnerships, or having UAVI only with seroconcordant partners. Repeated measures Poisson regression models were used to examine the associations between serostatus partnerships and UAVI among HIV-infected and HIV-uninfected women. The study sample consisted of 1,602 HIV-infected and 664 HIV-uninfected women. Over the follow-up period, the frequency of seroconcordant partnerships increased for HIV-uninfected women but the prevalence of UAVI within seroconcordant partnerships remained stable. UAVI was reported more frequently within HIV seroconcordant partnerships than among serodiscordant or unknown serostatus partnerships, regardless of the participant’s HIV status or types of partners. Among women with both HIV-infected and HIV-uninfected partners, 41% (63 HIV-infected and 9 HIV-uninfected) were having UAVI only with seroconcordant partners. Our analyses suggest that serosorting is occurring among both HIV-infected and HIV-uninfected women in this cohort.
doi:10.1007/s10461-010-9710-3
PMCID: PMC2987377  PMID: 20490909
HIV; Unprotected sex; Serosorting; Risk reduction; Condom use
11.  RESILIENCE, SYNDEMIC FACTORS, AND SEROSORTING BEHAVIORS AMONG HIV-POSITIVE AND HIV-NEGATIVE SUBSTANCE-USING MSM 
Serosorting is commonly employed by MSM to reduce HIV risk. We hypothesize that MSM perceive serosorting to be effective, and that serosorting is predicted by resilience and inversely related to syndemic characteristics. Surveys included 504 substance-using MSM. Logistic regression models examined syndemic and resilience predictors of serosorting, separately by serostatus. For HIV-positive men, positive coping behaviors (P = .015) and coping self-efficacy (P = .014) predicted higher odds, and cognitive escape behaviors (P = .003) lower odds, of serosorting. For HIV-negative men, social engagement (P = .03) and coping self-efficacy (P = .01) predicted higher odds, and severe mental distress (P = .001), victimization history (P = .007) and cognitive escape behaviors (P = .006) lower odds, of serosorting. HIV-negative serosorters reported lower perceptions of risk for infection than non-serosorters (P < .000). Although high risk HIV-negative men may perceive serosorting to be effective, their high rates of UAI and partner change render this an ineffective risk reduction approach. Relevant public health messages are urgently needed.
doi:10.1521/aeap.2012.24.3.193
PMCID: PMC3480663  PMID: 22676460
12.  HIV status and sexual behaviour among gay men in Ottawa: considerations for public health 
BMJ Open  2014;4(9):e005065.
Objectives
HIV prevention efforts, particularly among men who have sex with men (MSM), have not achieved maximum effectiveness. A survey of MSM in Ottawa, Canada was completed to ascertain whether there were differences in how the perceived HIV status of participants and their partners influenced sexual practices.
Methods
Self-directed surveys were administered to a convenience sample of 721 MSM in Ottawa, Canada from November 2011 through May 2012. Data collection occurred at 14 sites. The survey identified whether participants identified as HIV positive, negative or unsure of their HIV status.
Results
The findings indicated variation between HIV-negative MSM and those who are unsure of their HIV status. Men who were unsure of their HIV status were less likely to report that they asked sexual partners or have had their partners ask about HIV status.
Conclusions
The results of this study indicate that some MSM may base decisions about HIV prevention on discussion about HIV status with their partners, rather than condom use. These practices may increase, rather than decrease, HIV transmission. Survey findings and extant literature demonstrate a need to inform MSM about the limitations of serosorting as a prevention strategy, and to provide facilitated access to sexually transmitted infection testing and treatment to further reduce onward HIV transmission.
doi:10.1136/bmjopen-2014-005065
PMCID: PMC4170207  PMID: 25239290
PUBLIC HEALTH
13.  POSITIVE, NEGATIVE, UNKNOWN 
Serosorting (i.e., engaging in unprotected sex with partners known to be of the same serostatus) can be a difficult process for men who have sex with men (MSM) who frequently make assumptions about their partners’ serostatus. This process can be further complicated by a partner’s dishonesty as well as other individual and contextual factors. The present study specifically examined how assumptions of serostatus made about unknown serostatus partners impact on the sexual behavior of 110 alcohol-abusing HIV-positive MSM. Although previous research has shown that HIV-positive MSM are more likely to serosort with other known HIV-positive men than with known HIV-negative men, our data suggest that unprotected sex behavior may not be specifically driven by whether or not they made assumptions of seroconcordance or serodiscordance. The types of assumptions these HIV-positive MSM made about their unknown status sexual partners and the basis for such assumptions were also examined. Owing to the ambiguities involved in assumptions of a partner’s serostatus in sexual encounters, the “unknown status” partner category is analytically distinct from “known status” categories, and needs to be more fully explored because of its impact on perceived serosorting, rather than actual serosorting, among HIV-positive men.
doi:10.1521/aeap.2006.18.2.139
PMCID: PMC1994777  PMID: 16649959
14.  HIV seroadaptation among individuals, within sexual dyads, and by sexual episodes, men who have sex with men, San Francisco, 2008 
AIDS care  2011;23(3):261-268.
“Seroadaptation” comprises sexual behaviors to reduce the risk of HIV acquisition and transmission based on knowing one’s own and one’s sexual partners’ serostatus. We measured the prevalence of seroadaptive behaviors among men who have sex with men (MSM) recruited through time-location sampling (TLS) across three perspectives: by individuals (N=1,207 MSM), among sexual dyads (N=3,746 partnerships), and for sexual episodes (N=63,789 episodes) in the preceding six months. Seroadaptation was more common than 100% condom use when considering the consistent behavioral pattern of individuals (adopted by 39.1% vs. 25.0% of men, respectively). Among sexual dyads 100% condom use was more common than seroadaptation (33.1% vs. 26.4%, respectively). Considering episodes of sex, not having anal intercourse (65.0%) and condom use (16.0%) were the most common risk reduction behaviors. Sex of highest acquisition and transmission risks (unprotected anal intercourse with a HIV serodiscordant or unknown status partner in the riskier position) occurred in only 1.6% of sexual episodes. In aggregate, MSM achieve a high level of sexual harm reduction through multiple strategies. Detailed measures of seroadaptive behaviors are needed to effectively target HIV risk and gauge the potential of serosorting and related sexual harm reduction strategies on the HIV epidemic.
doi:10.1080/09540121.2010.507748
PMCID: PMC3076302  PMID: 21347888
15.  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
16.  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
17.  HIV serosorting as a harm reduction strategy: Evidence from Seattle, Washington 
AIDS (London, England)  2009;23(18):2497-2506.
Objective
We sought to estimate how serosorting may affect HIV prevalence and individual risk among MSM in Seattle, Washington, and how the results vary under different assumptions of HIV testing frequency, heterogeneity in sexual behavior, and condom use.
Methods
We developed a deterministic mathematical model of HIV transmission dynamics. Data from the 2003 random digit dial study of MSM conducted in Seattle, Washington (n = 400) are used to parameterize the model.
Results
Predicted population-level HIV prevalence as well as an individual’s risk of HIV acquisition decreases when the odds of serosorting are increased in the mathematical model. In our model based on observed levels of serosorting, we predict an HIV prevalence of 16%. In contrast, if serosorting were eliminated in the population, we predict that HIV prevalence would increase to 24.5%. However, our findings depend on rates of condom use, mean anal sex contact rates, and HIV testing in the population.
Conclusions
Under realistic scenarios of sexual behavior and testing frequency for MSM in the US, serosorting can be an effective harm reduction strategy.
doi:10.1097/QAD.0b013e328330ed8a
PMCID: PMC2886722  PMID: 19834319
HIV/AIDS; mathematical modeling; homosexual men; HIV testing
18.  Sexual Partner Selection and HIV Risk Reduction Among Black and White Men Who Have Sex with Men 
American journal of public health  2010;100(3):503-509.
Objectives
In the US, black men who have sex with men (BMSM) are diagnosed with HIV at a rate far exceeding other men. However, many studies report no substantial increase in risk behavior among BMSM. Here we examine a partner selection strategy as a potential risk factor for HIV among BMSM and white MSM (WMSM).
Methods
Cross-sectional surveys were collected from self-reported HIV negative BMSM and WMSM attending a gay pride festival in Atlanta, GA.
Results
HIV negative WMSM were more likely to report having unprotected anal intercourse with HIV negative men, and HIV negative BMSM were more likely to report unprotected anal intercourse with HIV status unknown partners. Furthermore, WMSM were more likely to endorse serosorting (limiting unprotected partners to those who have the same HIV status) beliefs and favorable HIV disclosure beliefs than BMSM.
Conclusions
WMSM appear to be using risk reduction strategies to reduce the likelihood of HIV infection more so than BMSM. Partner selection strategies have serious limitations; however they may explain in part the disproportionate number of HIV infections among BMSM.
doi:10.2105/AJPH.2008.155903
PMCID: PMC2820059  PMID: 20075328
ethnicity; men who have sex with men; risk behavior; perceptions of risk
19.  An emerging HIV risk environment: a preliminary epidemiological profile of an MSM POZ Party in New York City 
Sexually Transmitted Infections  2005;81(5):373-376.
Objective: To develop a preliminary epidemiological description of a men who have sex with men (MSM) "POZ Party," an emerging sex environment for HIV+ MSM.
Methods: As part of a pilot study in New York City in 2003, data were collected using a brief, behavioural intercept survey at entry to POZ Party events. Domains include demographic characteristics, history of HIV infection, motivations for attending POZ parties, lifetime and recent exposure to drugs (including use during POZ Party events), and recent sexual practices (both within both POZ Party venues as well as in non-POZ Party venues).
Results: Predominantly white and over the age of 30, subjects in the sample include a broad range of years living with HIV infection. Motivations for using a POZ Party venue for sexual partnering include relief from burdens for serostatus disclosure, an interest in not infecting others, and opportunities for unprotected sexual exchange. High rates of unprotected sex with multiple partners are prevalent in the venue. Although the sample evidences high rates of lifetime exposure to illicit drugs, relatively little drug use was reported in these sexual environments. These reports are consistent with evidence from direct observation at the venues themselves, in which no drug use was apparent.
Conclusion: Serosorting among HIV+ MSM may reduce new HIV infections, a stated interest of both POZ Party organisers and participants alike. However, high rates of unprotected anal intercourse within these venues signal continued risk for STIs. Additionally, unprotected sexual contact with HIV partners and status unknown partners outside POZ Party venues heightens concern for diffusion of HIV superinfection.
doi:10.1136/sti.2005.014894
PMCID: PMC1745031  PMID: 16199734
20.  SEXUAL RISK BEHAVIOR AND RISK REDUCTION BELIEFS AMONG HIV-POSITIVE YOUNG MEN WHO HAVE SEX WITH MEN 
AIDS and behavior  2013;17(4):1515-1523.
With young men who have sex with men (YMSM) continuing to be disproportionately affected by the HIV/AIDS epidemic in the U.S., secondary prevention efforts with this population take on increasing significance. We surveyed 200 HIV-positive YMSM (ages 16–24, 66% Black, 18% Latino, 7% White, 7% Multiracial/Other) recruited from 14 HIV primary care sites to examine associations of unprotected anal intercourse (UAI) and partner HIV status with endorsement of serosorting, sexual positioning, and viral load beliefs. Proportions of participants engaging in UAI one or more times during the past three months were consistent across type of UAI (insertive or receptive) and partner status. Belief that an undetectable viral load reduces infectiousness was significantly associated with insertive UAI (p<.05) and receptive UAI (p<.05) with HIV-negative or unknown-status partners and receptive UAI with HIV-positive partners (p<.01). Endorsement of belief in serosorting was significantly associated with receptive UAI (p<.01) and insertive UAI (p<.05) with HIV-positive male partners. Implications for sexual behavior and risk reduction beliefs in this population are discussed.
doi:10.1007/s10461-012-0155-8
PMCID: PMC3361604  PMID: 22350830
Young men who have sex with men (YMSM); HIV-positive; risk reduction; secondary prevention; serosorting
21.  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
22.  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
23.  Seroadaptation among Men Who Have Sex with Men: Emerging Research Themes 
Current HIV/AIDS reports  2013;10(4):305-313.
Seroadaptation describes a diverse set of potentially harm-reducing behaviors that use HIV status to inform sexual decision making. Men who have sex with men (MSM) in many settings adopt these practices, but their effectiveness at preventing HIV transmission is debated. Past modeling studies have demonstrated that serosorting is only effective at preventing HIV transmission when most men accurately know their HIV status, but additional modeling is needed to address the effectiveness of broader seroadaptive behaviors. The types of information with which MSM make seroadaptive decisions is expanding to include viral load, treatment status, and HIV status based on home-use tests, and recent research has begun to examine the entire seroadaptive process, from an individual’s intentions to seroadapt to their behaviors to their risk of acquiring or transmitting HIV and other STIs. More research is needed to craft clear public health messages about the risks and benefits of seroadaptive practices.
doi:10.1007/s11904-013-0188-2
PMCID: PMC3946930  PMID: 24234489
Serosorting; Seropositioning; HIV/AIDS; Prevention; Risk reduction; Behavioral aspects; Men who have sex with men (MSM); STIs; Seroadaptive practices
24.  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
25.  HIV risk reduction behaviours in gay men 
AIDS (London, England)  2009;23(2):243-252.
Objective
A range of risk reduction behaviours in which homosexual men practise unprotected anal intercourse (UAI) has been described. We aimed to assess the extent of any reduction in HIV risk associated with these behaviours.
Design
A prospective cohort study of HIV-negative homosexual men in Sydney, Australia.
Methods
Men were followed up with 6-monthly detailed behavioural interviews and annual testing for HIV. The four risk reduction behaviours (behaviourally defined) examined were serosorting, negotiated safety, strategic positioning, and withdrawal during receptive UAI (UAI-R).
Results
In 88% of follow-up periods in which UAI was reported, it occurred in the context of consistent risk reduction behaviours. Compared with those who reported no UAI, the risk of HIV infection was not raised in negotiated safety [hazard ratio = 1.67, 95% confidence interval (CI) 0.59–4.76] and strategic positioning (hazard ratio = 1.54, 95% CI 0.45–5.26). Serosorting outside negotiated safety was associated with an intermediate rate of HIV infection (hazard ratio = 3.11, 95% CI 1.09–8.88). Withdrawal was associated with a higher risk than no UAI (hazard ratio = 5.00, 95% CI 1.94–12.92). Patterns of UAI differed greatly according to partner’s serostatus. Men who reported serosorting were less likely to report either strategic positioning or withdrawal.
Conclusion
Each behaviour examined was associated with an intermediate HIV incidence between the lowest and highest risk sexual behaviours. The inverse association between individual behaviours suggests that men who practise serosorting rely on this protection. The high prevalence of these behaviours demands that researchers address the contexts and risks associated with specific types of UAI.
doi:10.1097/QAD.0b013e32831fb51a
PMCID: PMC2768371  PMID: 19098494
Australia; cohort study; HIV; homosexuality; male; risk factor; risk reduction

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