HIV preventive interventions, sampling methods and sexual risk behaviour among men who have sex with men

Background: Gay, bisexual and other men who have sex with men (MSM) are at high risk of HIV globally. HIV rates among MSM in Europe show increasing trends, in contrast to declining trends in the general population. During the last five years, an increase in reported HIV cases among foreign-born MSM have been observed in Sweden. Representative data about the MSM population is difficult to collect due to lack of a sampling frame. Respondent driven sampling has been developed to access hidden groups and achieve high response rates. Online sampling methods such as Web-based Respondent driven sampling and stratified sampling in a Web community are new and innovative ways of reaching MSM. Aims: To systematically gather and review evidence for HIV prevention interventions among men who have sex with men in the European Union/European Economic Area and to test and evaluate different sampling methods to study sexual risk behaviour among Men who have sex with Men. Methods: A systematic review of HIV preventive interventions among MSM applying the Highest Available Standard of Evidence grading framework was performed to inform European guidelines. Web-based respondent driven sampling was implemented to study sexual risk behaviour and Internet use among MSM. Stratified sampling in a Web community was performed to study HIV testing and prevention uptake among foreign-born MSM living in Sweden. Finally, the samples of MSM in Sweden achieved through Web-based respondent driven sampling, stratified sampling in a Web community, time location sampling and online banner survey sampling, were compared regarding sociodemographics and sexual risk behaviour for HIV. Results: In total, twenty-four interventions were reviewed and fifteen interventions were graded to be strongly, probably or possibly recommended. Condom use, peer outreach, peerled groups, and universal coverage of antiretroviral treatment were found to be strongly recommended. Web-based respondent driven sampling generated a sample of MSM whom all reported unprotected anal intercourse with at least one casual and one regular sex partner in the past twelve months. Stratified sampling in a Web community produced a sub-sample of foreign-born MSM of which 45% had tested for HIV during the past twelve months. A fifth of participants had never tested. Having talked with a prevention worker in the last year was associated with having tested for HIV in the same time frame. The four different sampling strategies used to study sexual risk behaviour among MSM in Sweden captured participant samples that differed regarding sociodemographic characteristic and reported sexual behaviour. Conclusions: Condom use, peer outreach, peer-led groups, and universal coverage of antiretroviral treatment are evidence-based corner stones of HIV preventive interventions for MSM. Web-based respondent driven sampling reached MSM engaging in sexual risk behaviour and holds promise for online interventions and referrals to prevention programmes. To achieve higher uptake of HIV testing among foreign-born MSM in Sweden outreach programmes could be scaled up and evaluated. Future studies could benefit from using different sampling methods to achieve comprehensive data and validate findings across samples of MSM

Uptake of peer-led venue-based HIV testing sites in Sweden aimed at men who have sex with men (MSM) and trans persons : a cross-sectional survey

Objectives: HIV testing among high-risk groups is a key intervention to diagnose persons living unknowingly with HIV to enable linkage to care and effective antiretroviral treatment. This study aimed to evaluate the uptake of Testpoint, the first large-scale HIV testing programme in Sweden where peer, non-healthcare personnel offered venue-based testing. Testing was performed by staff from the Swedish Foundation for Lesbian, Gay, Bisexual and Transgender Rights (RFSL Sweden) and testing was performed at the RFSL offices, gay clubs and gay cruising areas, as well as at various gay festivals. The test was a rapid test using capillary blood from a finger prick. Methods: A cross-sectional survey of all persons aged >= 18 years who came for HIV testing at one of Testpoint's locations in Sweden between 1 February and 31 December 2016. Results: 595 respondents (96% response rate) were included. Five persons were diagnosed with HIV and referred for treatment and care. A fifth of participants had never tested for HIV before. More than half of the participants were foreign born and the median age was 31 years. About one-fifth of participants stated they would not have tested through the healthcare system if Testpoint was not available. Conclusions: Testpoint reached their target population of young, foreign-born men who have sex with men (MSM) as well as first time testers and persons who stated that they would not have tested within the healthcare system. Such peer HIV testing outside the healthcare setting is a possible way of increasing uptake of testing in high-risk groups

A systematic review of adherence to oral pre-exposure prophylaxis for HIV - how can we improve uptake and adherence?

Introduction: Oral pre-exposure prophylaxis (PrEP) is an effective strategy to reduce the risk of HIV transmission in high risk individuals. However, the effectiveness of oral pre-exposure prophylaxis is highly dependent on user adherence, which some previous trials have struggled to optimise particularly in low and middle income settings. This systematic review aims to ascertain the reasons for non-adherence to pre-exposure prophylaxis to guide future implementation. Methods: We performed structured literature searches of online databases and conference archives between August 8, 2016 and September 16, 2017. In total, 18 prospective randomized control trials and implementation studies investigating oral pre-exposure prophylaxis were reviewed. A structured form was used for data extraction and findings summarized regarding efficacy, effectiveness, adherence and possible reasons for non-adherence. Results: Adherence varied between differing populations both geographically and socioeconomically. Common reasons for non-adherence reported over multiple studies were; social factors such as stigma, low risk perception, low decision making power, an unacceptable dosing regimen, side effects, and the logistics of daily life. Oral pre-exposure prophylaxis with included antiviral regimens was not associated with a high risk of antiviral resistance development in the reviewed studies. Conclusion: Our findings indicate that oral pre-exposure prophylaxis should be delivered within a holistic intervention, acknowledging the other needs of the targeted demographic in order to maximise acceptability. Socioeconomic factors and poor governmental policy remain major barriers to widespread implementation of pre-exposure prophylaxis

Introducing pre-exposure prophylaxis to prevent HIV acquisition among men who have sex with men in Sweden : insights from a mathematical pair formation model

Objectives Since 2017, the Public Health Agency of Sweden recommends that pre-exposure prophylaxis (PrEP) for HIV should be offered to high-risk individuals, in particular to men who have sex with men (MSM). The objective of this study is to develop a mathematical model investigating the effect of introducing PrEP to MSM in Sweden. Design A pair formation model, including steady and casual sex partners, is developed to study the impact of introducing PrEP. Two groups are included in the model: sexually high active MSM and sexually low active MSM. Three mixing assumptions between the groups are considered. Setting A gay-friendly MSM HIV/sexually transmitted infection testing clinic in Stockholm, Sweden. This clinic started offering PrEP to MSM in October 2018. Participants The model is calibrated according to detailed sexual behaviour data gathered in 2015 among 403 MSM. Results By targeting sexually high active MSM, a PrEP coverage of 3.5% of the MSM population (10% of all high actives) would result in the long-term HIV prevalence to drop considerably (close to 0%). While targeting only low actives would require a PrEP coverage of 35% for a similar reduction. The main effect of PrEP is the reduced susceptibility, whereas the increased HIV testing rate (every third month) among PrEP users plays a lesser role. Conclusions To create a multifaceted picture of the effects of interventions against HIV, we need models that include the different stages of HIV infection and real-world data on detailed sexual behaviour to calibrate the mathematical models. Our findings conclude that targeting HIV high-risk individuals, within HIV risk populations such as MSM, with PrEP programmes could greatly decrease the long-term HIV prevalence in Sweden. Therefore, risk stratification of individuals is of importance in PrEP implementation programmes, to ensure optimising the effect and cost-effectiveness of such programmes

A dynamic network model to disentangle the roles of steady and casual partners for HIV transmission among MSM

HIV is a sexually transmitted infection (STI) whose transmission process is highly dependent on the sexual network structure of the population under consideration. Most sexual behaviour data is egocentric in nature. We develop a stochastic dynamic sexual network model that utilises this type of egocentric network data. The model incorporates both steady and casual sex partners, and can be seen as a stochastic form of a generalised pair-formation model. We model the spread of an infection where individuals are susceptible, infectious, or successfully treated (and unable to transmit) and derive analytical expressions for several epidemiological quantities. We use sexual behaviour and HIV prevalence data that was gathered among 403 MSM at an STI clinic in Stockholm. To accurately capture transmission dynamics for this population, we need to explicitly model both casual sex partners and steady partnerships. Our model yields an estimate for the mean time until diagnosis followed by successful treatment that is in line with literature. This study indicates that small reductions in the time to diagnosis, and thereby, beginning of treatment, may substantially reduce HIV prevalence. Moreover, we find that moderate increases in condom use with casual sex partners have greater impact on reducing prevalence than the same increases in condom use with steady sex partners. This result demonstrates the relative importance of casual contacts on the HIV transmission dynamics among MSM in Sweden. Our results highlight the importance of HIV testing and condom-use interventions, and the role that casual and steady partners play in this, in order to turn the epidemiological trend in Sweden towards decreased HIV incidence

A performance assessment of web-based respondent driven sampling among workers with precarious employment in Sweden

Objectives: Precarious employment (PE) is a social determinant of poor health of workers. However, this population usually lack a sampling frame, making it challenging to identify the characteristics of this group. Web-based respondent driven sampling (webRDS) recruits individuals online through the social network and can provide population estimates. This study aims to assess the performance of webRDS in a population of workers with PE. Method: WebRDS was used for recruitment and data collection in the PRecarious EMployment In Stockholm (PREMIS) study. Cross-sectional questionnaire data was collected between November 2016 and May 2017. Eligible participants were living and/or working in Stockholm County, 18-65 years old, had a personal identification number and were currently employed. WebRDS performance was assessed by the total sample size, length of recruitment chains, sample composition, sample proportions and estimated RDSII population proportions with confidence intervals. Results: The webRDS process resulted in a sample of 358 recruits and a total sample of 415 participants, recruited over 1-15 waves. Of the participating seeds and recruits, 60% and 48%, respectively, successfully recruited at least one peer. The sample composition stabilized for all variables assessed. The sample proportions and RDSII estimates differed by 1-8% and the confidence intervals included the sample proportions for all variables except one. Conclusions: WebRDS successfully recruited a sufficient sample of workers with precarious employment from which population estimates could be made. Future studies should consider implementing webRDS on a national level in order to further study this population

African tick bite fever in returning Swedish travellers : Report of two cases and aspects of diagnostics

Introduction: African tick-bite fever, caused by Rickettsia africae, is endemic in rural areas of sub-Saharan Africa and a possible cause of fever in returning Swedish travellers. Two patients are presented, and the advantages and disadvantages of different diagnostic methods are discussed. Patients and methods: Two middle-aged men fell ill with fever after returning home from South Africa. Both had single eschars and one also presented with a lymph node swelling. Samples were taken for serology, general bacterial culture from the wound (Patient 1) using a swab and additionally for Patient 2 PCR of a skin biopsy from the eschar. Results and discussion: Both patients seroconverted one month after onset. Real-time PCR of the biopsy was positive, where sequencing of the gltA gene was 99–100% consistent with R. africae. A drop of fluid from the biopsy contained a sufficient number of bacteria to also allow for isolation of rickettsiae in Vero cell culture. Direct molecular detection by PCR from a swab used for bacteria culture from the eschar from Patient 1 also yielded a positive result. In conclusion, the findings highlight the usefulness of swabs for early non-invasive diagnosis of African tick-bite fever in febrile travellers

Knowledge of the abortion law and key legal issues of sexual and reproductive health and rights among recently arrived migrants in Sweden : a cross-sectional survey

Background: Sexual and reproductive health and rights (SRHR), including access and information on the laws and policies related to abortion, varies considerably between countries. Migrants may have limited knowledge of SRHR and related resources in their new country. This study investigates migrants' knowledge of the right to safe and legal abortion and other associated factors including the recent law on sexual consent, the legal age for sexual consent and age to marry in Sweden. Methods: We conducted a cross-sectional study from 2018 to 2019 among recent migrants attending high schools or Swedish language schools. Descriptive statistics were computed on the knowledge of the Swedish abortion law and other legal aspects. Univariable and multivariable logistic regression analyses were conducted to assess if migrants' socio-demographic characteristics were associated with knowledge (i.e. correct/incorrect) of the Swedish abortion law and other key SRHR-related legal issues. Results: Of the total 6,263 participants, 3,557 (57%) responded about whether it is legal to have an induced abortion in Sweden, and of these, 2,632 (74%) answered incorrectly. While more than half (61%) of the respondents knew the sexual consent law, nearly half (48%) did not know that sexual consent is also required for married couples. About 90% correctly responded that it is illegal to have sex with a minor (under the age of 15) and were aware of the legal age (18 years) to marry in Sweden. Incorrect knowledge of the Swedish abortion law was associated with being religious (adjusted odds ratio (AOR), 2.12; 95% confidence interval (CI), 1.42-3.15), not having previous sexual health education (AOR, 1.68; 95% CI, 1.38-2.05), coming from a country with predominantly restrictive abortion laws (AOR, 1.46; 95% CI, 1.16-1.84), low level of education (AOR, 1.29; 95% CI, 1.04-1.61) and having a temporary residence permit (AOR, 1.27; 95% CI, 1.02-1.57). Conclusion: We found a substantial lack of knowledge among migrants of reproductive age in Sweden regarding important laws and policies of SRHR, particularly the right to abortion. SRHR-related programmes and comprehensive sexual health education for recently arrived migrants could include components to increase knowledge of legal and safe abortions and other laws concerning SRHR

Female-Driven Multiple Concurrent Sexual Partnership Systems in a Rural Part of a Southern Tanzanian Province.

Multiple concurrent sexual relationships are one of the major challenges to HIV prevention in Tanzania. This study aims to explore sexual behaviour patterns including the practice of multiple concurrent sexual partnerships in a rural Tanzanian setting.This qualitative study used focus group discussions and in-depth interviews with men and women from the community as well as ethnographic participant observations. The data was collected during 16 months of fieldwork in 2007, 2008, and 2009. The focus group discussions and in-depth interviews were transcribed verbatim and translated into English. The data was analysed through the process of latent content analysis. An open coding coding process was applied to create categories and assign themes.Mafiga matatu was an expression used in this society to describe women's multiple concurrent sexual partners, usually three partners, which was described as a way to ensure social and financial security for their families as well as to achieve sexual pleasure. Adolescent initiation ceremonies initiated and conducted by grand mothers taught young women why and how to engage successfully in multiple concurrent sexual relationships. Some men expressed support for their female partners to behave according to mafiga matatu, while other men were hesitant around this behaviour. Our findings indicate that having multiple concurrent sexual partners is common and a normative behaviour in this setting. Economical factors and sexual pleasure were identified as drivers and viewed as legitimate reason for women to have multiple concurrent sexual partnerships.Structural changes improving women's financial opportunities and increasing gender equality will be important to enable women to not depend on multiple concurrent sexual partnerships for financial security. Future research should explore how normative sexual behaviour changes as these structural changes take place

Prevalence, risk factors, treatment uptake and treatment outcome of hepatitis C virus in people who inject drugs at the needle and syringe program in Uppsala, Sweden

Background The World Health Organization has set a goal to reach world elimination of hepatitis C virus (HCV) by 2030. Needle and syringe programs (NSP) for people who inject drugs (PWID) are crucial to achieve this goal. The NSP in Uppsala, Sweden, was opened in 2016 and has since 2018 provided HCV treatment for PWID. The aim of this study was to investigate HCV prevalence, risk factors and treatment uptake and outcome in NSP participants. Methods Data from 450 PWID registered at the Uppsala NSP between 2016-11-01 and 2021-12-31 were collected from the national quality registry InfCare NSP. Data from the 101 PWID treated for HCV at the Uppsala NSP were collected through patient journal review. Descriptive and inferential analysis was performed. Ethical approval was obtained from the Ethical Review Board in Uppsala (dnr 2019/00215). Results The mean age was 35 years. 75% were males (336/450), and 25% were females (114/450). The overall HCV prevalence was 48% (215/450) with a declining trend over time. Factors associated with a higher risk of HCV were older age at registration (OR 1.025, 95% CI 1.004–1.046), lower age at injection drug debut (OR 0.963, 95% CI 0.932–0.996), lower education level (OR 1.829, 95% CI 1.185–2.821) and higher number of total visits at the NSP (OR 1.005, 95% CI 1.001–1.009). The overall HCV treatment uptake was 47% (101/215), of which 77% (78/101) completed HCV treatment. The HCV treatment compliance was 88% (78/89). 99% (77/78) were cured with a sustained virologic response 12 weeks after completed treatment. The reinfection rate over the study period was 9/77 (11.7%); all were male with mean age of 36. Conclusions HCV prevalence, treatment uptake and treatment outcome have improved since the opening of the Uppsala NSP. However, further measures are needed to reach the HCV elimination goal. Outreach HCV treatment programs for PWID should be explored and evaluated in combination with further implementation of low-threshold programs