Sexual networks, partnership patterns and behaviour of HIV positive men who have sex with men: implications for HIV/STIs transmission and partner notification

Background: In the UK, men who have sex with men (MSM) continue to be disproportionately affected with HIV and sexually transmitted infections (STI). Due to the increasing emphasis on using biomedical strategies like cART for prevention of sexual transmission of HIV, I examined HIV positive MSM’s sexual partnerships and behaviours; their attitudes towards biomedical and behavioural HIV transmission risk reduction strategies, and their association with sexual behaviour. I also examined their attitudes towards partner notification for STI, willingness and preferred methods to notify partners of STI in the future. Methods: 429 HIV positive MSM attending a central London clinic completed a computer assisted self-interview on sexual partnerships and behaviours, attitudes, preferences and willingness to notify partners for STI in the future. 24 purposively selected men participated in in-depth interviews. Results: Of 429 men, 380 men had been sexually active in the last year. The survey data showed that the prevalence of unprotected anal intercourse (UAI) with a serodiscordant (i.e., HIV negative or unknown status) primary partner and the most recent non-primary partner was high, 18.3% and 16.9% respectively. A substantial minority of men had positive attitudes towards biomedical and various behavioural HIV transmission risk reduction strategies. Duration of partnership, recreational drug use, and belief that undetectable viral load reduces the risk of HIV transmission during UAI were all independently associated with HIV transmission risk behaviours with a serodiscordant primary partner. Disclosure of HIV status and recreational drug use during sex were independently associated with UAI with the most recent serodiscordant non-primary partner. Of the 258 men who had new partners, 53% had engaged in UAI with new partners. Prevalence of anonymous partnerships was high. Stigma associated with HIV/STI diagnosis, and the venues for meeting sexual partners also influenced men’s sexual partnerships and behaviour, and disclosure of HIV status. Approximately one in five sexually active men had not tested for STI and 25% of men had been diagnosed with STI in the last year. Young age; self-reported detectable viral load status; greater number of new anal sex partners; UAI with new and concurrent partners; having a seroconcordant primary partner; frequency of engagement in group sex were independently associated with STI diagnosis in the last year. The qualitative data highlighted that the majority of men felt an emotional responsibility towards and acknowledged the personal health benefits of notifying primary and regular partners of STI. A greater proportion of men would be less willing to notify casual partners of STI in the future (21%) compared to a primary partner (5.3%) and regular partners (7.5%). Attitudes such as ‘it is not my responsibility to notify partners of STI’, and the lack of previous experience of notification were independently associated with unwillingness to notify casual partners of STI in the future. The qualitative study indicates that the lack of emotional responsibility; fear of stigma and breach of HIV-related confidentiality due to partner notification; and fear of criminalisation for HIV/STI transmission were barriers to notifying sexual partners of STI, especially casual and group sex partners. Patient-referral was the most preferred method of notifying partners of STI in the future, particularly a primary partner; whereas there was greater willingness for notifying regular, casual, and group sex partners using remote self-led methods, provider referral or an anonymous e-card. The acceptability of sending an anonymous e-card and taking a home sampling kit for partners, and telephone assessment of partners for STI by clinic staff was low to moderate. Conclusion: The findings of this study underscore the need for sustained interventions to ensure sexual health of HIV positive MSM and prevent HIV/STI in MSM. They highlight that cART should be offered to sexually active HIV positive MSM, especially those in serodiscordant partnerships irrespective of CD4 cell count to minimize the risk of onward HIV transmission in this population. Frequent STI testing of sexually active men should be integral part of routine HIV care. Various partner notification choices should be offered to those diagnosed with STI. Interventions to reduce stigma associated with homosexuality and HIV continue to remain vital in this population. Research examining the feasibility, acceptability, effectiveness, and cost effectiveness of integrating brief behavioural interventions to enhance regular STI testing, adherence to cART, address recreational drug use and mental health needs, and promote safer sex with routine HIV care is urgently needed

Patterns of sexualised recreational drug use and its association with risk behaviours and sexual health outcomes in men who have sex with men in London, UK: a comparison of cross-sectional studies conducted in 2013 and 2016

Objective: London has one of the highest identified prevalence of chemsex (sexualised recreational drug use) among men who have sex with men (MSM) in Europe. We examine MSM’s patterns of chemsex and its association with HIV/STI risk behaviours, STI diagnoses, and sexual healthcare-seeking behaviours, including if HIV testing behaviour met UK national guidelines (3-monthly if engaging in chemsex). Methods: Cross-sectional survey data from 2013 (n=905) and 2016 (n=739) were collected using anonymous, self-administered questionnaires from MSM recruited in commercial gay venues in London, UK. Descriptive and multivariable analyses, stratified by self-reported HIV status, were conducted. Adjusted prevalence ratios (aPR) with 95% confidence intervals (CI) were calculated. Results: Comparing the 2013 and 2016 surveys; chemsex prevalence in the past year remained stable, in both HIV-negative/unknown-status MSM (20.9% in 2013 vs 18.7% in 2016, p=0.301) and HIV-positive MSM (41.6% in 2013 vs 41.7% in 2016, p=0.992). Combined 2013-2016 data showed that compared to other MSM, those reporting chemsex were more likely to report HIV/STI risk behaviours, including condomless anal intercourse with serodifferent HIV-status partners (HIV-negative/unknown-status men: aPR 2.36, 95% CI 1.68-3.30; HIV-positive men: aPR 4.19, 95% CI 1.85-9.50), and STI diagnoses in the past year (HIV-negative/unknown-status men: aPR 2.10, 95% CI 1.64-2.69; HIV-positive men: aPR 2.56, 95% CI 1.57-4.20). 69.0% of HIV-negative/unknown-status men reporting chemsex attended sexual health clinics and 47.6% had tested for HIV more than once in the past year. Conclusions: Chemsex in London MSM remained stable but high, particularly among HIV-positive men. Irrespective of HIV status, chemsex was associated with engagement in HIV/STI risk behaviours. Frequency of HIV testing in the past year among HIV-negative/unknown-status men was below national recommendations. Promoting combination prevention strategies, including 3-monthly HIV/STI testing, access to PrEP/ART, and behavioural interventions among MSM reporting chemsex, remain vital to address sexual health inequalities in MSM

The association between region of birth and sexually transmitted infections among people of black Caribbean ethnicity attending sexual health services in England, 2015.

BACKGROUND/INTRODUCTION: In England, people of Black Caribbean (BC) ethnicity are disproportionately affected by sexually transmitted infections (STIs), but it is unclear whether this varies by their region of birth. AIM(S)/OBJECTIVES: To examine differences in STI diagnoses among UK- and Caribbean-born BC people. METHODS: Data on STI diagnoses in BC people attending specialist sexual health services (SHSs) during 2015 and living in England were obtained from the GUMCAD STI surveillance system, the national surveillance system for STIs in England. Associations between being UK- or Caribbean-born and each of several STI diagnoses were examined, using univariate and multivariable generalised estimated equations logistic regression models adjusted for sexual orientation, place of residence (London vs. non-London), HIV status, area-level deprivation, and STI diagnosis in the last year. All analyses were stratified by age (<25 vs. ≥25 years). RESULTS: In 2015, 63,568 BC people made 108,881 attendances at specialist SHSs; 81.9% of these attendances were made by UK-born BCs. The median age (years) was 26 for UK-born and 35 for Caribbean-born people (p≤0.001). Chlamydia, gonorrhoea and non-specific genital infection (NSGI) were the most commonly diagnosed STIs among UK- (5.8%, 2.1% and 2.8%) and Caribbean-born people (4.5%, 1.7% and 3.5%) respectively. Among BCs aged under 25, no significant differences in STIs were found between UK- and Caribbean-born people. Among BCs aged ≥25, compared to Caribbean-born people, those who were UK-born were more likely to be diagnosed with chlamydia (AOR 1.15 [95%C.I. 1.04-1.27]); gonorrhoea (AOR 1.23 [95%C.I. 1.06-1.45]) and genital herpes (AOR 1.23 [95% C.I. 1.10-1.56]) and less likely to be diagnosed with NSGI (AOR 0.89 [95% C.I. 0.80-0.99]) and Trichomoniasis (AOR 0.84 [95% C.I. 0.71-0.99]). DISCUSSION/CONCLUSION: STI diagnoses in BC people aged ≥25 attending specialist SHSs vary by region of birth. Country of birth may have an influence on social and sexual networks and therefore transmission of STIs

Home sampling for sexually transmitted infections and HIV in men who have sex with men: A prospective observational study

To determine uptake of home sampling kit (HSK) for STI/HIV compared to clinic-based testing, whether the availability of HSK would increase STI testing rates amongst HIV infected MSM, and those attending a community-based HIV testing clinic compared to historical control. Prospective observational study in three facilities providing STI/HIV testing services in Brighton, UK was conducted. Adult MSM attending/contacting a GUM clinic requesting an STI screen (group 1), HIV infectedMSM attending routine outpatient clinic (group 2), and MSM attending a community-based rapid HIV testing service (group 3) were eligible. Participants were required to have no symptomatology consistent with STI and known to be immune to hepatitis A and B (group 1). Eligiblemen were offered a HSK to obtain self-collected specimens as an alternative to routine testing. HSK uptake compared to conventional clinicbased STI/HIV testing in group 1, increase in STI testing rates due to availability of HSK compared to historical controls in group 2 and 3, and HSK return rates in all settings were calculated. Among the 128 eligible men in group 1, HSK acceptance was higher (62.5% (95%CI: 53.5-70.9)) compared to GUM clinic-based testing (37.5% (95% CI: 29.1-46.5)), (p = 0.0004). Two thirds of eligibleMSM offered an HSK in all three groups accepted it, but HSK return rates varied (highest in group 1, 77.5%, lowest in group 3, 16%). HSK for HIV testing was acceptable to 81%of men in group 1. Compared to historical controls, availability of HSK increased the proportion ofMSM testing for STIs in group 2 but not in group 3. HSK for STI/ HIV offers an alternative to conventional clinic-based testing for MSM seeking STI screening. It significantly increases STI testing uptake in HIV infected MSM. HSK could be considered as an adjunct to clinic-based services to further improve STI/HIV testing in MSM

Sexual behaviours, HIV testing, and the proportion of men at risk of transmitting and acquiring HIV in London, UK, 2000-13: a serial cross-sectional study

BACKGROUND: HIV incidence in men who have sex with men (MSM) in the UK has remained unchanged over the past decade despite increases in HIV testing and antiretroviral therapy (ART) coverage. In this study, we examine trends in sexual behaviours and HIV testing in MSM and explore the risk of transmitting and acquiring HIV. METHODS: In this serial cross-sectional study, we obtained data from ten cross-sectional surveys done between 2000 and 2013, consisting of anonymous self-administered questionnaires and oral HIV antibody testing in MSM recruited in gay social venues in London, UK. Data were collected between October and January for all survey years up to 2008 and between February and August thereafter. All men older than 16 years were eligible to take part and fieldworkers attempted to approach all MSM in each venue and recorded refusal rates. Data were collected on demographic and sexual behavioural characteristics. We analysed trends over time using linear, logistic, and quantile regression. FINDINGS: Of 13 861 questionnaires collected between 2000 and 2013, we excluded 1985 (124 had completed the survey previously or were heterosexual reporting no anal intercourse in the past year, and 1861 did not provide samples for antibody testing). Of the 11 876 eligible MSM recruited, 1512 (13%) were HIV positive, with no significant trend in HIV positivity over time. 35% (531 of 1505) of HIV-positive MSM had undiagnosed infection, which decreased non-linearly over time from 34% (45 of 131) to 24% (25 of 106; p=0·01), while recent HIV testing (ie, in the past year) increased from 26% (263 of 997) to 60% (467 of 777; p<0·0001). The increase in recent testing in undiagnosed men (from 29% to 67%, p<0·0001) and HIV-negative men (from 26% to 62%, p<0·0001) suggests that undiagnosed infection might increasingly be recently acquired infection. The proportion of MSM reporting unprotected anal intercourse (UAI) in the past year increased from 43% (513 of 1187) to 53% (394 of 749; p<0·0001) and serosorting (exclusively) increased from 18% (207 of 1132) to 28% (177 of 6369; p<0·0001). 268 (2%) of 11 570 participants had undiagnosed HIV and reported UAI in the past year were at risk of transmitting HIV. Additionally 259 (2%) had diagnosed infection and reported UAI and non-exclusive serosorting in the past year. Although we did not collect data on antiretroviral therapy or viral load, surveillance data suggests that a small proportion of men with diagnosed infection will have detectable viral load and hence might also be at risk of transmitting HIV. 2633 (25%) of 10 364 participants were at high risk of acquiring HIV (defined as HIV-negative MSM either reporting one or more casual UAI partners in the past year or not exclusively serosorting). The proportions of MSM at risk of transmission or acquisition changed little over time (p=0·96 for MSM potentially at risk of transmission and p=0·275 for MSM at high risk of acquiring HIV). Undiagnosed men reporting UAI and diagnosed men not exclusively serosorting had consistently higher partner numbers than did other MSM over the period (median ranged from one to three across surveys in undiagnosed men reporting UAI, two to ten in diagnosed men not exclusively serosorting, and none to two in other men). INTERPRETATION: An increasing proportion of undiagnosed HIV infections in MSM in London might have been recently acquired, which is when people are likely to be most infectious. High UAI partner numbers of MSM at risk of transmitting HIV and the absence of a significant decrease in the proportion of men at high risk of acquiring the infection might explain the sustained HIV incidence. Implementation of combination prevention interventions comprising both behavioural and biological interventions to reduce community-wide risk is crucial to move towards eradication of HIV. FUNDING: Public Health England

Optimising partner notification outcomes for bacterial sexually transmitted infections: a deliberative process and consensus

Partner notification (PN) is an essential element of sexually transmitted infection (STI) control. It enables identification, treatment and advice for sexual contacts who may benefit from additional preventive interventions, such as HIV pre-exposure prophylaxis (PrEP). PN is most effective in reducing STI transmission in a population when it reaches individuals who are most likely to have a STI, and to engage in sexual behaviour that facilitates STI transmission, including having multiple and/or new sex partners. Outcomes of PN practice need to be measurable in order to inform standards. They need to address all five stages in the cascade of care: elicitation of partners, establishing contactable partners, notification, testing and treatment. In the United Kingdom, established outcome measures cover only the first three stages and do not take into account the type of sexual partnership. We report on an evidence-based process used to develop new PN outcomes and inform standards of care. We undertook a systematic literature review, evaluation of published information on types of sexual partnership, and a modified Delphi process to reach consensus. We propose six new PN outcome measures at five stages of the cascade, including stratification for sex partnership type. Our framework for PN outcome measurement has potential to contribute in other domains, notably Covid-19