Targeted interventions to reduce risky behaviour

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Young men who have sex with men and have detectable levels of the human immunodeficiency virus (HIV) were more likely to report condomless anal sex, including with a partner not infected with HIV, than virologically suppressed young men who have sex with men, according to an article.

HIV disproportionately affects men who have sex with men (MSM). Young MSM (YMSM, ages 13 to 29) are particularly vulnerable to HIV infection and more than one-quarter of new infections in the US occur in YMSM. The success of treatment as prevention in reducing the number of new HIV infections among YMSM relies on HIV testing, antiretroviral treatment, adherence and viral suppression among YMSM with HIV.

Behavioural approaches to improve engagement in care and medication adherence may need to occur in concert with interventions to reduce risky sexual behaviours, including condomless anal intercourse (CAI).

Dr Patrick A Wilson, of the Columbia University Mailman School of Public Health, New York, and co-authors examined differences in demographic and psycho-social factors between virologically suppressed YMSM and those with detectable HIV. The authors also sought to identify psycho-social factors associated with CAI and serodiscordant (between partners of differing HIV status) CAI among YMSM with detectable HIV viral load.

The authors studied 991 YMSM with HIV (ages 15 to 26) at 20 adolescent HIV clinics in the US from December 2009 through June 2012. Of the 991 participants, 688 (69.4%) had a detectable HIV viral load. Nearly half of the YMSM (46.2%) reported CAI in the past three months and 31.3% reported serodiscordant CAI, according to the results.

More than half (266 or 54.7%) of YMSM with detectable HIV reported CAI, while 91 (44.4% of virologically suppressed YMSM reported that behaviour. Likewise, 187 (34.9% of YMSM with detectable HIV reported CAI with a partner who was HIV-negative, while 57 (25%) of the virologically suppressed YMSM reported serodiscordant CAI, the study reports.

Analyses suggest that among YMSM with detectable HIV, those who reported problematic substance use were more likely to report CAI or serodiscordant CAI. Black YMSM with detectable viral load were less likely to report CAI or serodiscordant CAI. YMSM with detectable HIV who disclosed their HIV status to sex partners were more likely to report CAI compared with non-disclosing YMSM. Transgender study participants were less likely to report CAI than cisgender participants. Lastly, YMSM with detectable viral load who were employed were less likely to report serodiscordant CAI than those who were unemployed.

The authors note causation cannot be inferred from their study. The study sample also includes only YMSM with HIV who were linked to care and that may limit generalisability of the findings.

“Combination HIV prevention and treatment interventions, which include behavioural, biomedical and structural strategies to increase viral suppression and reduce HIV transmission risk behaviours, that target HIV-infected YMSM are needed. To truly curb HIV incidence among YMSM, we cannot solely rely on one strategy to prevent and treat HIV,” the study concludes.

Abstract
Importance: Human immunodeficiency virus (HIV) diagnoses continue to increase among young men who have sex with men (YMSM). Many YMSM living with HIV engage in sexual risk behaviors, and those who have a detectable viral load can transmit HIV to sex partners. Understanding factors that are related to sexual risk taking among virologically detectable (VL+) YMSM can inform prevention and treatment efforts.
Objectives: To describe differences between virologically suppressed (VL−) and VL+ YMSM living with HIV and to identify correlates of condomless anal intercourse (CAI) and serodiscordant CAI among VL+ YMSM.
Design, Setting, and Participants: In this cross-sectional survey conducted from December 1, 2009, through June 30, 2012, we studied 991 HIV-infected YMSM 15 to 26 years of age at 20 adolescent HIV clinics in the United States. Data analysis was conducted December 1, 2013, through July 31, 2015.
Main Outcomes and Measures: Demographic, behavioral, and psychosocial assessments obtained using audio computer-assisted self-interviews. Viral load information was obtained via blood draw or medical record abstraction.
Results: Of the 991 participants, 688 (69.4%) were VL+ and 458 (46.2%) reported CAI, with 310 (31.3%) reporting serodiscordant CAI in the past 3 months. The VL+ YMSM were more likely than the VL− YMSM to report CAI (detectable, 266 [54.7%]; suppressed, 91 [44.4%]; P = .01) and serodiscordant CAI (detectable, 187 [34.9%]; suppressed, 57 [25.0%]; P < .01). Multivariable analyses indicated that among VL+ YMSM, those reporting problematic substance use were more likely to report CAI (adjusted odds ratio [AOR], 1.46; 95% CI, 1.02-2.10) and serodiscordant CAI (AOR, 1.45; 95% CI, 1.06-1.99). Black VL+ YMSM were less likely to report CAI (AOR, 0.63; 95% CI, 0.44-0.90) or serodiscordant CAI (AOR, 0.66; 95% CI, 0.46-0.94) compared with other VL+ YMSM. In addition, VL+ YMSM who disclosed their HIV status to sex partners were more likely to report CAI compared with nondisclosing YMSM (AOR, 1.35; 95% CI, 1.01-1.81). Transgender participants were less likely to report CAI than cisgender participants (AOR, 0.35; 95% CI, 0.14-0.85). Last, VL+ YMSM who reported currently being employed were less likely to report serodiscordant CAI than those who were unemployed (AOR, 0.74; 95% CI, 0.55-0.99).
Conclusions and Relevance: Targeted multilevel interventions are needed to reduce HIV transmission risk behaviors among YMSM living with HIV, particularly among those who are VL+.

JAMA material
JAMA Paediatrics abstract


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