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Evidence is mounting that men who have sex with men (MSM) and other groups at high risk for HIV infection are increasingly taking risks through unsafe sexual contacts. Seven studies presented at the Centers for Disease Control and Prevention’s 2nd National HIV Prevention Conference, held in Atlanta on Aug. 12-15, 2001, demonstrated significant sexual risks being taken by individuals in eight large American cities. Studies presented at the conference also dealt with HIV testing among men with infectious syphilis, negotiated safety and risk reduction, and risk reduction counseling.
Here are summaries of some of the prevention studies presented at the conference:
• High HIV incidence among young MSM (YMSM): Results from the 1998-2000 Young Men’s Survey, which included 2,823 MSM ages 23-29 in six cities, show a high HIV incidence rate and prevalence among this cohort, particularly among African-Americans and other men of color.1
The HIV incidence rate was 5% overall, with a 16% incidence rate among African-Americans, 7% among men who identified themselves as mixed/ other race, and 5% among Hispanics. These compare with a 3% incidence rate among white YMSM surveyed. Prevalence levels were 30% among African Americans, 10% among men of mixed/other race, 15% among Hispanics, 7% among whites, and 3% among Asian-Americans.
Investigators had interviewed YMSM at public venues, providing participants with counseling and drawing blood for HIV testing. Incident infections were determined by having HIV-positive specimens tested with the Serologic Testing Algorithm for Recent HIV Seroconversions (STARHS). Out of 294 positive specimens that were STARHS-tested, 43 were incident infections.
• Increased drug use and anonymous sex among MSM: San Francisco researchers distributed a self-administered survey on drug use and sexual behavior to a sample of MSM patients undergoing rectal gonorrhea screening at San Francisco municipal STD clinics from January to October 2000. Investigators found that 7% of the 566 MSM patients who finished the survey had a positive gonorrhea diagnosis, and those with gonorrhea were more likely to be HIV-positive.2
MSM with gonorrhea also were more likely to report anonymous receptive anal sex in the past two weeks and were more likely to report having met their most recent sexual partners anonymously, including at bathhouses and over the Internet. MSM with gonorrhea also were more likely to report injection drug use over the past three months and non-injection drug use during sex, although these behaviors were lower among HIV-positive MSM with gonorrhea than among HIV-negative MSM with gonorrhea.
• HIV risk behaviors among African-American women: African-American women ages 17-44 in Atlanta were surveyed about their HIV risk behaviors. The preliminary findings showed that 70% of the 250 women surveyed reported they were sexually active. Of those, 65% said they had not used a condom every time they had sex. Also, 67% said they intended to use a condom during the next six months, although about 45% said they had not used a condom at all during the past two months.3
About 49% of those surveyed said their sexual partners had not been tested for HIV or that they didn’t know whether their partners had been tested. About 1% said their partners had been tested and were positive for HIV. Among the women, about 23% said they had never been tested for HIV, and 3% said they had tested positive for the virus.
• High prevalence of HIV and associated risk behaviors among YMSM: Using a three-stage residential probability-sampling scheme of MSM ages 18-29 in Miami Beach, investigators interviewed 100 men who completed a questionnaire and provided a specimen of oral mucosal transudate for HIV antibody testing.
HIV prevalence was 16%, with similar rates for whites and Hispanics. Nearly 46% of YMSM said they had engaged in unprotected anal intercourse within the previous 12 months.4 About 49% said they had cruised for sex at least once a month; 43% reported having had four or more anal partners in the last 12 months; and about 49% said they had had sex while high on drugs or alcohol during the last 12 months.
While two-thirds of the YMSM who tested positive for HIV said they had known they were HIV-positive, those who tested positive were almost as likely as those who tested negative to engage in unprotected anal intercourse, with rates of 40% for those who tested positive and nearly 47% for those who tested negative.
• HIV infection and unsafe sex among older MSM in Miami Beach: The same researchers who conducted the Miami Beach study of YMSM also looked at MSM ages 30 or older in an area of Miami that has been identified as a gay hotspot. Using a three-stage residential probability sampling scheme, investigators interviewed 113 MSM and had them complete a questionnaire and provide a specimen for HIV antibody testing.5
Of the 105 older MSM who were enrolled in the study, about 98% had been previously tested for HIV, and about one-third tested HIV-positive. Nearly 47% of the MSM reported engaging in unprotected anal intercourse while high on alcohol or drugs, and about 45% said they had engaged in unprotected anal intercourse within the past year. Those who reported engaging in unprotected anal intercourse were more likely to have had a primary partner and to have agreed with the statement "sex does not feel as good when I wear a condom."
• Resurgence in unprotected sex among Seattle MSM: Researchers gathered behavioral data from 13,145 MSM who presented for testing at Seattle’s main publicly funded alternative testing sites between 1994 and 2000. In that period, the proportion of MSM testers who reported unprotected receptive anal intercourse was 43%, while 47% reported unprotective insertive anal sex. Since then, there has been an upward trend of MSM testers reporting unprotected anal sex.6
In the 1998-1999 period, 51% of MSM testers reported unprotected receptive anal intercourse and 54% reported unprotected insertive anal sex, with the greatest increases occurring among young MSM ages 14-25 and men of color. Also, there was a 28% increase from 1994 to 2000 among MSM reporting six or more male sex partners within the previous year.
• Condom use among HIV-positive MSM: Between July 1996 and December 1999, 314 men infected with HIV were enrolled in an open cohort study that had participants complete questionnaires every four months, measuring partner-specific sexual activity and condom use. Initially, the percentage of men reporting unprotected anal intercourse was stable, ranging from 32% in 1996 to 29% in 1998. But in 2000 this increased to 43% of men reporting unprotected anal intercourse.7
HIV-positive MSM with serodiscordant partners used condoms for 64% of 9,771 acts with HIV-seronegative partners and for 62% of 1,832 acts with partners of unknown HIV status. These rates are higher than rates of condom use for acts with HIV-seropositive partners. HIV-positive MSM used condoms for only 19% of 8,277 sexual acts with HIV-seropositive partners.
• Risk reduction counseling of HIV-positive MSM: The same open cohort study of 314 HIV-positive MSM who completed questionnaires every four months also attempted to determine how regularly these men were targeted for regular STD screening and sexual risk assessment and the extent to which they were counseled about sexual risk reduction behaviors.
Researchers found that of 273 men who had a private provider for their HIV-related care, 89% had been sexually active during the previous year, with a median of four partners, although the range was from one to 150. Of the 190 men who said they’d had anal intercourse during the previous four months, 55% reported having unprotected anal intercourse.8 Prior health care provider counseling was received by 77% of these sexually active men, but during follow-up questioning, counseling was reported at only 11% of 1,714 study visits in which an interim health care provider visit was noted.
The study concluded that only a minority of HIV-positive MSM who report unprotected anal intercourse receive risk reduction counseling, and intervals between repeat counseling appear to be long.
• Negotiated safety and risk reduction within HIV-negative seroconcordant primary relationships: Negotiated safety has emerged as an alternative HIV prevention strategy among MSM in primary relationships. This typically means the partners agree to consistent condom use or avoidance of anal sex in any sexual relationships outside of the primary partnership.
In the San Francisco Bay Area, investigators recruited 316 HIV-negative MSM for a study of these behaviors. Of these, 30% reported a current primary relationship with an HIV-negative man for at least six months. Of the 94 men in a primary relationship, 39% had a negotiated safety agreement, 27% always used condoms, 24% had no anal sex, and 11% didn’t always use condoms and had inadequate negotiated safety rules.9
Of the 37 men in a negotiated safety relationship, 60% complied with their set of rules and agreed to disclose rule-breaking, but 40% were not fully compliant. Researchers found that men under age 30 were more likely to be in a negotiated safety relationship than in a 100% condom use/no anal sex primary relationship, and that this likelihood was higher for men under 30 than for men 30 and older.
Investigators concluded that while negotiated safety is an alternative prevention strategy, it potentially exposes some MSM to HIV/STD risks because of their partners’ failures to comply with the rules.
• HIV testing and infection among men with syphilis in Chicago: Chicago investigators collected data on 897 men with infectious syphilis who had reported to the Chicago Department of Public Health between Jan. 1, 1998, and July 31, 2000. They found that 18% of the men with infectious syphilis were MSM and 82% were heterosexual. Of the 897 men, 39% knew their HIV infection status, including 55% of MSM and 36% of heterosexual men. Of 90 MSM, 48% were HIV-infected. Of heterosexual men, 6% were HIV-positive.10 Men who had more than five recent sex partners were more likely to be HIV-positive, as were MSM.
Researchers concluded that 34% of the men with infectious syphilis who had high-risk behaviors had never been tested for HIV. This included 30% of MSM and 35% of heterosexuals.
1. Valleroy LA, MacKellar DM, Mei JV, et al. High HIV incidence among 23-29-year-old men who have sex with men in 6 U.S. cities. Abstract 474. Presented at the 2nd National HIV Prevention Conference, sponsored by the Centers for Disease Control and Prevention. Atlanta; Aug. 12-15, 2001.
2. Kim A, Kent C, Klausner J. Higher levels of drug use and patterns of anonymous sex among MSM diagnosed with rectal gonorrhea, San Francisco, 2000. Abstract 709. Presented at the 2nd National HIV Prevention Conference, sponsored by the Centers for Disease Control and Prevention. Atlanta; Aug. 12-15, 2001.
3. Yancey EM, Murphy F, Goodin LM. Analysis of levels and predictors of HIV risk behavior among African-American women, ages 17-44 years: Prevention and intervention implications. Abstract 587. Presented at the 2nd National HIV Prevention Conference, sponsored by the Centers for Disease Control and Prevention. Atlanta; Aug. 12-15, 2001.
4. Webster RD, Roark RA, Lu JJ, et al. High prevalence of HIV and associated risk behaviors among 23-29-year-old men who have sex with men living in a South Florida resort community. Abstract 253. Presented at the 2nd National HIV Prevention Conference, sponsored by the Centers for Disease Control and Prevention. Atlanta; Aug. 12-15, 2001.
5. Webster RD, Roark RA, Lu JJ, et al. HIV infection and unsafe sex among older men who have sex with men living in Miami Beach, Florida. Abstract 255. Presented at the 2nd National HIV Prevention Conference, sponsored by the Centers for Disease Control and Prevention. Atlanta; Aug. 12-15, 2001.
6. White E, Wood B, Goldbaum G. Resurgence in unprotected sex among MSM attending publicly-funded HIV test sites in Seattle. Abstract 828. Presented at the 2nd National HIV Prevention Conference, sponsored by the Centers for Disease Control and Prevention. Atlanta; Aug. 12-15, 2001.
7. Lampinen TM, Critchlow CW, Holmes KK, et al. A cohort study of sexual practices and condom use among HIV-1 seropositive men who have sex with other men (MSM), 1996-2000. Abstract 759. Presented at the 2nd National HIV Prevention Conference, sponsored by the Centers for Disease Control and Prevention. Atlanta; Aug. 12-15, 2001.
8. Lampinen TM, Critchlow CW, Nelson PJ, Kiviat NB. Longitudinal study of risk reduction counseling of HIV-positive MSM by their health care providers. Abstract 890. Presented at the 2nd National HIV Prevention Conference, sponsored by the Centers for Disease Control and Prevention. Atlanta; Aug. 12-15, 2001.
9. Guzman R, Colfax G, Mansergh G, et al. Negotiated safety and risk reduction within HIV-negative seroconcordant primary relationships in a diverse sample of men who have sex with men (MSM). Abstract 592. Presented at the 2nd National HIV Prevention Conference, sponsored by the Centers for Disease Control and Prevention. Atlanta; Aug. 12-15, 2001.
10. Ciesielski CA, Boghani S. Factors associated with HIV testing and HIV infection among men with infectious syphilis in Chicago. Abstract 622. Presented at the 2nd National HIV Prevention Conference, sponsored by the Centers for Disease Control and Prevention. Atlanta; Aug. 12-15, 2001.