The Impact of Sexual Behaviours, Risk Perceptions and the Criminalization of HIV Non-Disclosure on HIV Transmission among HIV-Negative and HIV-Positive Men Who Have Sex With Men in Toronto

Background: Men who have sex with men (MSM) continue to have disproportionately high rates of human immunodeficiency virus (HIV), even though risk factors for HIV acquisition are known and antiretroviral treatment has reduced transmission. Objectives: To characterize the sexual behaviours and risk perceptions of HIV transmission among HIV-negative and HIV-positive MSM. Methods: 150 HIV-negative and 292 HIV-positive MSM participated in the STI/HIV Co-Infection Study between September 2010 and June 2012. Participants were recruited from the Maple Leaf Medical Clinic, a primary and HIV-related care centre in Toronto. Multivariable logistic regression (MLR) models quantified the relationships between actualsexual HIV risk, HIV incidence risk index for MSM (HIRI-MSM), perceived HIV risk and willingness to take pre-exposure prophylaxis (PrEP) among HIV-negative MSM. MLR and flow chart models were used to estimate the potential impact of HIV non-disclosure laws on HIV testing rates and transmission among HIV-negative MSM, and on condom use, HIV status disclosure and proportion at risk for criminal prosecutions among HIV-positive MSM. Results: As condom use frequency with HIV-positive regular partners decreased, perceived HIV risk (Odds Ratio (OR):18.33, 95% Confidence Interval (CI):1.65-203.45) and willingness to take PrEP (OR:27.11, 95% CI:1.33-554.43) increased. Condom use frequency with casual or HIV-unknown status regular partners and the HIRI-MSM index were not associated with perceived HIV risk or PrEP willingness. The 7% (9/124) reduction in HIV testing due to fear of prosecution found in this study could increase community HIV transmission by 18.5%; the majority of transmission being driven by the unmet needs of undiagnosed HIV-positive MSM. Almost half of HIV-positive MSM were more likely to use condoms and/or disclose their HIV-positive status due to fear of prosecution and 8.6% (25/292) could be at risk for non-disclosure prosecutions given their condom use, viral load and disclosure rates. Conclusions: HIV-negative MSM using condoms less frequently with HIV-positive partners but not with HIV-unknown status or casual partners accurately gauged their sexual risk behaviour and were willing to take PrEP. HIV non-disclosure laws may incentivize safer sex practices among HIV-positive MSM; however, they may also deter HIV testing which impedes HIV prevention efforts and increases community HIV transmission .Ph.D

Trends in selective abortions of girls in India: analysis of nationally representative birth histories from 1990 to 2005 and census data from 1991 to 2011.

BACKGROUND: India's 2011 census revealed a growing imbalance between the numbers of girls and boys aged 0-6 years, which we postulate is due to increased prenatal sex determination with subsequent selective abortion of female fetuses. We aimed to establish the trends in sex ratio by birth order from 1990 to 2005 with three nationally representative surveys and to quantify the totals of selective abortions of girls with census cohort data. METHODS: We assessed sex ratios by birth order in 0·25 million births in three rounds of the nationally representative National Family Health Survey covering the period from 1990 to 2005. We estimated totals of selective abortion of girls by assessing the birth cohorts of children aged 0-6 years in the 1991, 2001, and 2011 censuses. Our main statistic was the conditional sex ratio of second-order births after a firstborn girl and we used 3-year rolling weighted averages to test for trends, with differences between trends compared by linear regression. FINDINGS: The conditional sex ratio for second-order births when the firstborn was a girl fell from 906 per 1000 boys (99% CI 798-1013) in 1990 to 836 (733-939) in 2005; an annual decline of 0·52% (p for trend=0·002). Declines were much greater in mothers with 10 or more years of education than in mothers with no education, and in wealthier households compared with poorer households. By contrast, we did not detect any significant declines in the sex ratio for second-order births if the firstborn was a boy, or for firstborns. Between the 2001 and 2011 censuses, more than twice the number of Indian districts (local administrative areas) showed declines in the child sex ratio as districts with no change or increases. After adjusting for excess mortality rates in girls, our estimates of number of selective abortions of girls rose from 0-2·0 million in the 1980s, to 1·2-4·1 million in the 1990s, and to 3·1-6·0 million in the 2000s. Each 1% decline in child sex ratio at ages 0-6 years implied 1·2-3·6 million more selective abortions of girls. Selective abortions of girls totalled about 4·2-12·1 million from 1980-2010, with a greater rate of increase in the 1990s than in the 2000s. INTERPRETATION: Selective abortion of girls, especially for pregnancies after a firstborn girl, has increased substantially in India. Most of India's population now live in states where selective abortion of girls is common. FUNDING: US National Institutes of Health, Canadian Institute of Health Research, International Development Research Centre, and Li Ka Shing Knowledge Institute

Actual sexual risk and perceived risk of HIV acquisition among HIV-negative men who have sex with men in Toronto, Canada

Abstract Background Theory suggests that perceived human immunodeficiency virus (HIV) risk and actual HIV risk behaviour are cyclical whereby engaging in high risk behaviour can increase perceived risk, which initiates precautionary behaviour that reduces actual risk, and with time reduces perceived risk. While current perceived risk may impact future actual risk, it is less clear how previous actual risk shapes current perceived risk. If individuals do not base their current perceived risk on past behaviour, they lose the protective effect of perceived risk motivating precautionary behaviour. Our goal was to determine the impact of actual risk on perceived risk. Methods Sexually active men who have sex with men (MSM) were recruited at the Maple Leaf Medical Clinic in downtown Toronto from September 2010 to June 2012. Participants completed a socio-behavioural questionnaire using an Audio Computer Assisted Self-Interview (ACASI). Actual HIV risk (primary predictor) was constructed by applying principal component analysis (PCA) to eight sexual risk survey questions and comprised three components which reflected sex with casual partners, sex with HIV-positive regular partners and sex with HIV unknown status regular partners. Perceived HIV risk (outcome) was measured by asking participants what the chances were that they would ever get HIV. Multivariable logistic regression was used to measure the association between actual and perceived HIV risk. Results One hundred and fifty HIV-negative MSM were recruited (median age 44.5 years [IQR 37–50 years]). Twenty percent of MSM perceived their HIV risk to be high. The odds of having a high perceived risk was significantly higher in those with high actual HIV risk indicated by low condom use with an HIV-positive regular partner compared to those with low actual HIV risk indicated by high condom use with an HIV-positive regular partner (Odds Ratio (OR) 18.33, 95 % confidence interval (CI) 1.65–203.45). Older age was associated with lower perceived risk but only age 40–49 compared to less than 30 was statistically significant (OR 0.12, 95 % CI 0.016–0.86). The odds of having high perceived risk was significantly associated with men who used poppers in the previous 6 months compared to those who did not use poppers (OR 5.64, 95 % CI 1.20–26.48). Conclusions Perceived HIV risk increased significantly as condom use with an HIV-positive regular partner decreased. However, perceived HIV risk was not associated with condom use with casual partners or HIV unknown status regular partners, even though these behaviours could be considered risky. The relationship between perceived and actual risk in HIV studies is complex and has implications on how health care workers address the issue of risky sexual behaviour and perceived risk

Actual sexual risk and perceived risk of HIV acquisition among HIV-negative men who have sex with men in Toronto, Canada

Abstract Background Theory suggests that perceived human immunodeficiency virus (HIV) risk and actual HIV risk behaviour are cyclical whereby engaging in high risk behaviour can increase perceived risk, which initiates precautionary behaviour that reduces actual risk, and with time reduces perceived risk. While current perceived risk may impact future actual risk, it is less clear how previous actual risk shapes current perceived risk. If individuals do not base their current perceived risk on past behaviour, they lose the protective effect of perceived risk motivating precautionary behaviour. Our goal was to determine the impact of actual risk on perceived risk. Methods Sexually active men who have sex with men (MSM) were recruited at the Maple Leaf Medical Clinic in downtown Toronto from September 2010 to June 2012. Participants completed a socio-behavioural questionnaire using an Audio Computer Assisted Self-Interview (ACASI). Actual HIV risk (primary predictor) was constructed by applying principal component analysis (PCA) to eight sexual risk survey questions and comprised three components which reflected sex with casual partners, sex with HIV-positive regular partners and sex with HIV unknown status regular partners. Perceived HIV risk (outcome) was measured by asking participants what the chances were that they would ever get HIV. Multivariable logistic regression was used to measure the association between actual and perceived HIV risk. Results One hundred and fifty HIV-negative MSM were recruited (median age 44.5 years [IQR 37–50 years]). Twenty percent of MSM perceived their HIV risk to be high. The odds of having a high perceived risk was significantly higher in those with high actual HIV risk indicated by low condom use with an HIV-positive regular partner compared to those with low actual HIV risk indicated by high condom use with an HIV-positive regular partner (Odds Ratio (OR) 18.33, 95 % confidence interval (CI) 1.65–203.45). Older age was associated with lower perceived risk but only age 40–49 compared to less than 30 was statistically significant (OR 0.12, 95 % CI 0.016–0.86). The odds of having high perceived risk was significantly associated with men who used poppers in the previous 6 months compared to those who did not use poppers (OR 5.64, 95 % CI 1.20–26.48). Conclusions Perceived HIV risk increased significantly as condom use with an HIV-positive regular partner decreased. However, perceived HIV risk was not associated with condom use with casual partners or HIV unknown status regular partners, even though these behaviours could be considered risky. The relationship between perceived and actual risk in HIV studies is complex and has implications on how health care workers address the issue of risky sexual behaviour and perceived risk

Prosecution of non-disclosure of HIV status: Potential impact on HIV testing and transmission among HIV-negative men who have sex with men.

Non-disclosure criminal prosecutions among gay, bisexual and other men who have sex with men (MSM) are increasing, even though transmission risk is low when effective antiretroviral treatment (ART) is used. Reduced HIV testing may reduce the impact of HIV "test and treat" strategies. We aimed to quantify the potential impact of non-disclosure prosecutions on HIV testing and transmission among MSM.MSM attending an HIV and primary care clinic in Toronto completed an audio computer-assisted self-interview questionnaire. HIV-negative participants were asked concern over non-disclosure prosecution altered their likelihood of HIV testing. Responses were characterized using cross-tabulations and bivariate logistic regressions. Flow charts modelled how changes in HIV testing behaviour impacted HIV transmission rates controlling for ART use, condom use and HIV status disclosure.150 HIV-negative MSM were recruited September 2010 to June 2012. 7% (9/124) were less or much less likely to be tested for HIV due to concern over future prosecution. Bivariate regression showed no obvious socio/sexual demographic characteristics associated with decreased willingness of HIV testing to due concern about prosecution. Subsequent models estimated that this 7% reduction in testing could cause an 18.5% increase in community HIV transmission, 73% of which was driven by the failure of HIV-positive but undiagnosed MSM to access care and reduce HIV transmission risk by using ART.Fear of prosecution over HIV non-disclosure was reported to reduce HIV testing willingness by a minority of HIV-negative MSM in Toronto; however, this reduction has the potential to significantly increase HIV transmission at the community level which has important public health implications

Willingness and eligibility to donate blood under 12-month and 3-month deferral policies among gay, bisexual, and other men who have sex with men in Ontario, Canada.

In Canada, gay, bisexual and other men who have sex with men (GBMSM) are a population that are willing to donate blood, if eligible, but have a history of ineligibility and deferrals due to concerns that their blood poses an increased risk of HIV entering the blood supply. Our objective was to examine the proportion of GBMSM who are willing and eligible to donate under the 12-month deferral policy (implemented in 2016) and the 3-month deferral policy (implemented in 2019). Data for this study comes from the #iCruise study, a mixed cohort study designed to examine sexual health outreach experiences through online services and mobile apps among GBMSM in Ontario. A total of 910 participants were recruited between July 2017 and January 2018. Eligibility criteria include identify as male (cisgender or transgender); at least 14 years old; having had sex with a man in the previous year or identifying as sexually/romantically attracted to other men or identifying as gay, bisexual, queer or two-spirit; and living or working in Ontario or having visited Ontario four or more times in the past year. Participants completed a baseline and a follow-up questionnaire. A subset of #iCruise participants (n = 447) further completed this questionnaire. Willingness and eligibility to donate blood were assessed under 12-month and 3-month deferral policies. Of the 447 GBMSM surveyed, 309 (69.1%) reported a general interest in donating blood. 109 (24.4%) GBMSM were willing, 75 (16.7%) were eligible, and 24 (5.4%) were both willing and eligible to donate blood under the 12-month deferral policy. Under the 3-month deferral policy, willingness and eligibility to donate blood increased significantly to 42.3% and 29.3%, respectively. The percent of GBMSM who were both willing and eligible to donate blood also increased significantly to 12.3% under the 3-month deferral policy. The increase in willingness to donate blood varied by age, ethnicity, and geographic residence of participants whereas the increase in eligibility to donate blood varied by education level of participants. Under the 3-month deferral policy, GBMSM who were 50 years or older, identified as bisexual or other, had a lower education level, and who were not 'out' to others were more likely to be eligible to donate. GBMSM who reported a general interest in donating blood were more likely to be willing to donate blood under both deferral policies. The most common reason for not being interested in donating blood was the MSM deferral policy itself; many participants interpreted the policy as discriminatory for 'singling out' GBMSM or self-assed themselves as ineligible. Among study participants, both willingness and eligibility to donate blood was significantly higher under the 3-month deferral policy. The results suggest that a time-based reduction to a 3-month deferral policy is impactful but limited. Future research should measure GBMSM's willingness and eligibility under the individual risk-based assessment (to be implemented in 2022)

HIV transmission potential among HIV-negative aware and unaware MSM.

<p>HIV transmission potential among HIV-negative aware and unaware MSM.</p

HIV transmission potential taking into account antiretroviral therapy (ART) use among men who have sex with men (MSM) engaging in anal sex.

<p>Where p = D[SxK(1-ε)xα] + D[S(1-K)xα] + (1-D)[C(1-ε)xα] + (1-D)[(1-C)xα] <b>Constant values throughout analysis:</b> D- Proportion who disclose among those who are aware of their status (71.86%) S- Proportion who agree to sex after disclosure among those who are aware of their status (69.90%) K- Proportion who use a condom after disclosure among those aware of their status (70.90%) C- Proportion who use a condom if no disclosure among those aware of their status (60%) d- Proportion who disclose among those who do not know their status (0%) c- Proportion who use a condom if no disclosure among those who do not know their status (53%) ε- Condom effectiveness during anal intercourse (70%) α- Probability of transmission through unprotected anal intercourse <b>Non-constant values throughout analysis:</b> A-HIV-positive aware.</p

Characteristics of HIV-negative MSM and their associations with HIV testing due to concern about prosecution.

<p>Characteristics of HIV-negative MSM and their associations with HIV testing due to concern about prosecution.</p