The Field Guide: Applying <i>Making it Count</i> to health promotion activity with homosexually active men

This Field Guide considers a range of methods used to carry out health promotion with homosexually active men. It is a companion document to Making it count: a collaborative planning framework to reduce the incidence of HIV infection during sex between men (Hickson et al., 2003). Like Making it count, this document will be reviewed every two to three years and accompanied by training opportunities. The authors welcome comments and suggestions on this document and its use. These can be sent to: [email protected] or [email protected]. "Briefing papers" that add to the content of this guide will be produced as part of the CHAPS sector development programme. These will be available periodically from www. chapsonline.org.uk. Making it count describes a co-ordinated national framework to reduce HIV incidence occurring as a consequence of sex between men. It is intended for workers, managers, policy makers, legislators, health professionals or anyone with an investment in reducing HIV incidence among homosexually active men. This Field Guide is written for gay men's HIV health promoters. It places the theory, goals and strategic aims contained in Making it count in the context of day-to-day health promotion activity. It was developed through a range of formal interviews and informal discussion with more than 40 managers and key workers with experience and expertise in specific areas of HIV health promotion for homosexually active men. It concentrates mainly on direct contact work (Chapters 3 to 7), but also considers other types of health promotion that benefit homosexually active men by influencing the structures they live within (Chapter 8). Section one (Chapters 1 and 2) provides an overview of Making it count and the relationship between this document and that main framework. It outlines the key strategic aims of Making it count and contextualises what follows. Section two concerns direct contact with homosexually active men. Chapters 3, 4, 5 and 6 deal with different methods of carrying out direct contact work with this population. Chapter 7 considers the different target groups within the entire population of homosexually active men. It examines how to prioritise target groups using epidemiological and needs data and how best to target different groups in various settings. Section three (Chapter 8) addresses other types of health promotion interventions that are necessary including policy, community and service interventions. These are the interventions needed in order to facilitate direct contact interventions and attend to the broader determinants of sexual health for homosexually active men. It is anticipated that some (NHS) commissioners would benefit from reading this document in order to further their understanding of the range of work that they could fund. However, this document is not an implementation plan for the NHS in relation to HIV incidence among homosexually active men. Rather, Terrence Higgins Trust are currently in discussion with the Department of Health concerning further work to support the use of Making it count as the basis for Primary Care Trusts' planning and purchasing of HIV prevention activity for homosexually active men

What qualities in a potential HIV pre-exposure prophylaxis service are valued by black men who have sex with men in London? A qualitative acceptability study.

Black men who have sex with men (BMSM) have higher HIV incidence and prevalence when compared to other MSM, despite similar levels of condom use and testing. Pre-exposure prophylaxis (PrEP) could be a useful intervention to reduce these inequalities. This research therefore aims to understand the dimensions of acceptability of a potential PrEP service for BMSM aged 18-45 years in London. In-depth semi-structured interviews were conducted with 25 PrEP-eligible BMSM between April and August 2016. Interviews were recorded and transcribed verbatim, then subject to a thematic framework analysis, informed by intersectionality theory. BMSM had distinct preferences for sexual health services, which have implications for PrEP service development. Three primary domains emerged in our analysis: proximity and anonymity; quality, efficiency and reassurance; and understanding, empathy and identity. These relate, respectively, to preferences regarding clinic location and divisions from community, features of service delivery and staff characteristics. Due to concerns about confidentiality, community-based services may not be useful for this group. Careful consideration in regards to components used in service development will facilitate ongoing engagement. Interpersonal skills of staff are central to service acceptability, particularly when staff are perceived to be from similar cultural backgrounds as their patients

The Impact of First UK-Wide Lockdown (March–June 2020) on Sexual Behaviors in Men and Gender Diverse People Who Have Sex with Men During the COVID-19 Pandemic: A Cross-Sectional Survey

The global COVID-19 pandemic resulted in strict social distancing measures restricting close physical contact. Men (cis and trans) and other gender diverse people who have sex with men (MGDSM) are at higher risk of sexually transmitted infections (STIs) and may have experienced changes in sexual behavior during government restrictions on social and sexual contact. We aimed to examine self-reported sexual behavior of MGDSM during the first UK-wide lockdown to identify the characteristics of the individuals who might most require sexual health promotion and clinical support. In April–May 2020, we conducted an online survey of MGDSM, promoted on social media and Grindr. Our exploratory approach used descriptive analysis to identify self-reported changes in sexual behavior and performed regression analyses to identify correlates of casual sex during the lockdown. A total of 1429 respondents completed the survey: mean age 36 years, 84% White, 97% male or trans male, 98% assigned male sex at birth, 2% female or non-binary, 65% degree educated or higher. During the lockdown, 76% reported not having any casual sex partners. While the majority reported reduced casual sex, 3% reported an increase in casual sex with one person and 2% with three or more people (group sex). About 12% of the sample engaged in casual sex with only one person and 5% with four or more sexual partners during the lockdown. Reporting casual sex during lockdown was associated with: lower level of education OR = 2.37 [95% CI 1.40–4.01]; identifying as a member of an ethnic minority OR = 2.27[1.40–3.53]; daily usage of sexual networking apps OR = 2.24[1.54–3.25]; being less anxious about contracting SARS-CoV-2 through sex OR = 1.66[1.12–2.44]; using PrEP before lockdown OR = 1.75[1.20–2.56]; continuing to use PrEP OR = 2.79[1.76–4.57]; and testing for STIs during lockdown OR = 2.65[1.76–3.99]. A quarter of respondents remained sexually active with casual partners, indicating a need to provide STI screening services and health promotion targeted to groups most likely to have need over this period. Future research is required to better understand how to support sexual and gender minorities to manage sexual risk in the context of pandemic public health initiatives

DIY HIV prevention: Formative qualitative research with men who have sex with men who source PrEP outside of clinical trials.

Pre-exposure prophylaxis (PrEP) with antiretroviral medication is an effective, evidence-based option for HIV prevention. In England, issues of cost-effectiveness and of responsibility for commissioning prevention services have so far led National Health Service (NHS) England to decide not to commission PrEP. Given the significant lag between the awareness of PrEP efficacy and the opportunity to obtain PrEP through traditional health care routes, many gay and other men who have sex with men (MSM) have turned to 'DIY PrEP', purchasing generic formulations of PrEP for themselves on the internet or via other alternative routes. However, there is very little research on DIY PrEP practices and no qualitative study with DIY PrEP users in the UK. A formative qualitative study was conducted in 2017 to inform the development of an intervention (PrEP Club) to support DIY PrEP users and improve the safety and experience of this prevention strategy. Focus groups were held with 20 MSM who are based in London and are obtaining PrEP through means other than clinical trials, to explore their accounts of sourcing and using PrEP and the experiential meanings of these. In this article, we report findings from this first, formative study and present the different practices involved in finding out about PrEP, buying it and ascertaining legitimacy of sellers and products. We reflect on the uncertainties participants described related to actually using PrEP, including deciding on drug dosing and monitoring their health. Finally, we present the results of the discussions participants had about the kind of support they had received, the help they would have liked, and their views on proposed interventions to support DIY PrEP users, such as PrEP Club

What are the motivations and barriers to pre-exposure prophylaxis (PrEP) use among black men who have sex with men aged 18-45 in London? Results from a qualitative study.

BACKGROUND: Black men who have sex with men (BMSM) have higher HIV incidence and prevalence when compared with other men who have sex with men, despite similar risk profiles. New prevention technologies, including pre-exposure prophylaxis (PrEP), may be effective in responding to these inequalities, provided they are appropriately targeted and acceptable to their intended beneficiaries. This study aims to understand the motivations and barriers of BMSM aged 18-45 to PrEP uptake. METHODS: Twenty-five BMSM recruited through geolocation social networking apps took part in in-depth interviews between April and August 2016. Intersectionality theory was used as an organising principle. Interviews were transcribed verbatim and analysed using a thematic framework analysis. RESULTS: For BMSM with heterogeneous social groups, discussions about sexual health were challenging because of the intersection of ethnic background, family history and religion. This limited conversations about PrEP to gay male friends who often held stigmatising views of condomless anal intercourse. BMSM reported exclusion from gay male spaces (online and offline) which could serve to restrict exposure to PrEP messages. Stereotypes of BMSM intersected with negative conceptions of PrEP users, limiting acknowledgement of PrEP candidacy. For those who had attempted to or successfully accessed it, PrEP was framed as a strategy to mitigate risk and to guard against further stigma associated with HIV infection. DISCUSSION: BMSM operate within a complex set of circumstances related to the intersection of their sexual, ethnic, cultural and religious identities, which shape PrEP acceptability. Interventions which seek to facilitate uptake in this group must be attentive to these. Health promotion and clinical services could seek to facilitate nuanced discussions about the merits of PrEP for those at frequent risk, perhaps while also providing publicly visible PrEP role models for BMSM and other marginalised groups

Framework for better living with HIV in England

1 Introduction and overview 1.1 The goal, purpose and scope of the framework This framework is the first of its kind in the UK. It describes the shared aspirations of a group of agencies for the lives of people diagnosed with HIV in England. The overarching goal of the framework is: All people with HIV are enabled to have the maximum level of health, well-being, quality of life and social integration. This is no less than the majority of people in the country expect for themselves. However, numerous obstacles prevent people with HIV from achieving this goal. These obstacles are not about having the virus but about how people with the virus are treated. This overarching goal is the situation we want to bring about. We detail this goal in seventeen subsidiary goals (what we want to happen). Each of these has a number of related aims and target groups (what we want individuals and groups to do to bring about the goal). The framework starts with the individual and seeks to bring about the conditions most favourable to individual self-determination and self-empowerment. The purpose of the framework is to: • Promote and protect the rights and well-being of all people with HIV in England. • Maximise the capacity of individuals and groups of people with HIV to care for, advocate and represent themselves effectively. • Improve and protect access to appropriate, effective and sufficient information, social support and social care services. • Minimise social, economic, governmental and judicial change detrimental to the rights and well-being of people with HIV. • Build consensus among those with a responsibility for promoting the well-being and rights of people with HIV. • Provide benchmarks against which the activities of a range of key stakeholders can be assessed, critiqued and coordinated. The framework does not describe all the activities of the organisations represented in the Framework Development Group (see section 1.4). Nor can these organisations undertake all the interventions necessary within the framework. Rather, the framework seeks to mobilise and coordinate the actions of a broad range of individuals and groups, from people with HIV themselves to government ministers. The framework primarily seeks to benefit people with diagnosed HIV infection. It is concerned with the health and well-being of those diagnosed with HIV and not those with undiagnosed HIV or those who might become infected (HIV prevention).As we are concerned with the lives of people with HIV after diagnosis, this framework is not focused on increasing HIV testing or HIV diagnosis nor does it attend to the needs of the broader population affected by HIV except where they relate to people with diagnosed HIV

Online socializing among men who have sex with men and transgender people in Nairobi and Johannesburg and implications for public health-related research and health promotion: an analysis of qualitative and respondent-driven sampling survey data.

INTRODUCTION: There is little published literature about gay, bisexual and other men who have sex with men and transgender individuals (MSM and TG)'s use of social media in sub-Saharan Africa, despite repressive social and/or criminalizing contexts that limit access to physical HIV prevention. We sought to describe MSM and TG's online socializing in Nairobi and Johannesburg, identifying the characteristics of those socializing online and those not, in order to inform the development of research and health promotion in online environments. METHODS: Respondent-driven sampling surveys were conducted in 2017 in Nairobi (n = 618) and Johannesburg (n = 301) with those reporting current male gender identity or male sex assigned at birth and sex with a man in the last 12 months. Online socializing patterns, sociodemographic, sexual behaviour and HIV-testing data were collected. We examined associations between social media use and sociodemographic characteristics and sexual behaviours among all, and only those HIV-uninfected, using logistic regression. Analyses were RDS-II weighted. Thirty qualitative interviews were conducted with MSM and TG in each city, which examined the broader context of and motivations for social media use. RESULTS: Most MSM and TG had used social media to socialize with MSM in the last month (60% Johannesburg, 71% Nairobi), mostly using generic platforms (e.g. Facebook), but also gay-specific (e.g. Grindr). HIV-uninfected MSM and TG reporting riskier recent sexual behaviours had raised odds of social media use in Nairobi, including receptive anal intercourse (adjusted OR = 2.15, p = 0.006), buying (aOR = 2.24, p = 0.015) and selling sex with men (aOR = 2.17, p = 0.004). Evidence for these associations was weaker in Johannesburg, though socializing online was associated with condomless anal intercourse (aOR = 3.67, p = 0.003) and active syphilis (aOR = 13.50, p = 0.016). Qualitative findings indicated that while online socializing can limit risk of harm inherent in face-to-face interactions, novel challenges were introduced, including context collapse and a fear of blackmail. CONCLUSIONS: Most MSM and TG in these cities socialize online regularly. Users reported HIV acquisition risk behaviours, yet this space is not fully utilized for sexual health promotion and research engagement. Effective, safe and acceptable means of using online channels to engage with MSM/TG that account for MSM and TG's strategies and concerns for managing online security should now be explored, as complements or alternatives to existing outreach

Is monkeypox an STI? The societal aspects and healthcare implications of a key question

This letter explores the societal aspects and healthcare implications that underlie thinking about monkeypox, in the 2022 outbreak, as a sexually transmitted infection (STI). The authors examine what underlies this question, exploring what is an STI, what is sex, and what is the role of stigma in sexual health promotion. The authors argue that, in this specific outbreak, monkeypox is an STI among men who have sex with men (MSM). The authors highlight the need of critically thinking about how to communicate effectively, the role of homophobia and other inequalities, and the importance of the social sciences

Perceptions and Practicalities Influencing Pre-exposure Prophylaxis Adherence Among Men Who Have Sex with Men in England.

PrEP is highly effective for HIV prevention but requires adequate adherence. In this paper we use the perceptions and practicalities approach (PAPA) to identify factors that influenced PrEP adherence using qualitative data from the PROUD study. From February 2014 to January 2016, we interviewed 41 gay, bisexual and other men-who-have-sex-with-men and one trans woman who were enrolled in the study. We purposively recruited participants for interview based on trial arm allocation, adherence and sexual risk behaviours. The interviews were conducted in English, audio-recorded, transcribed, coded and analysed using framework analysis. Participants in general were highly motivated to use and adhere to PrEP, and this was linked to strong perceptions of personal necessity for PrEP as they felt at risk of HIV and viewed PrEP as highly effective. On the other hand, concerns about side effects and HIV resistance did inhibit PrEP initiation and adherence although this was uncommon. Practical factors such as daily routine, existing habitual pill-taking and pill storage impacted adherence. Drug and alcohol use rarely caused participants to miss doses. These findings indicate that using the principals of PAPA to unpick influencers of PrEP use, could help tailor adherence support in PrEP programmes

Factors associated with reporting antibiotic use as STI prophylaxis among HIV PrEP users: findings from a cross-sectional online community survey, May-July 2019, UK.

OBJECTIVES: The use of antibiotics as pre-exposure or postexposure prophylaxis for sexually transmitted infection (STI) prevention (STI prophylaxis) is not currently recommended in the UK, but there is evidence that self-prescribing occurs among those at greatest risk. We present the prevalence and factors associated with STI prophylaxis among a community sample of HIV pre-exposure prophylaxis (PrEP) users. METHODS: The 2019 online PrEP User Survey ran between 17 May and 1 July. Eligible participants included UK residents reporting HIV PrEP use or having tried to obtain HIV PrEP since January 2017. STI prophylaxis use was defined as reporting buying antibiotics to prevent STIs, either privately or through the internet; this question was only asked to HIV PrEP users. Factors associated with STI prophylaxis use were assessed using univariable and multivariable logistic regression. RESULTS: Overall, 9% (167/1856) of HIV PrEP users reported STI prophylaxis use; 97% were gay or bisexual men, 84% reported white ethnicity, 55% resided in London and 69% were aged ≥35 years. Factors associated with STI prophylaxis included: reporting ≥5 compared with 1-4 condomless sex partners in the past 6 months (12% vs 5.6%, adjusted odds ratio (aOR)=1.80; 95% CI 1.22 to 2.64), reporting chemsex drug use compared with no sexualised drug use in the past 12 months (13% vs 6.0%, aOR=1.88; 95% CI 1.20 to 2.93) and reporting an STI diagnosis in the past 12 months (12% vs 6.6%, aOR=1.54; 95% CI 1.08 to 2.18). Variables not significant in multivariable analyses included: ethnicity, age, residence and HIV PrEP sourcing. CONCLUSIONS: Approximately 1 in 10 HIV PrEP users from this community sample reported self-prescribed STI prophylaxis. STI prophylaxis was associated with sexual behaviour known to facilitate STI transmission and with a history of recent STIs acquisition. Given the potential risk of antimicrobial resistance, sexual health clinicians should consider asking attendees, especially HIV PrEP users, about the use of antibiotics as STI prophylaxis, to inform appropriate counselling, testing and management