Negotiating sexual safety in the era of biomedical HIV prevention: relationship dynamics among male couples using pre-exposure prophylaxis.

Up to two-thirds of new cases of HIV transmission between gay, bisexual and other men who have sex with men in the USA are attributed to primary relationships. Understanding the relationship dynamics and sexual agreements of male-male couples can provide insight into HIV transmission patterns and prevention needs in this population. The daily use of antiretroviral pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV, but its negotiation and use within social and intimate relationship contexts remain understudied. We conducted semi-structured qualitative interviews with 20 male couples (n = 40 men) in which at least one partner was either using or in the process of initiating PrEP. Congruent with a theoretical focus on social theories of relationships and negotiated risk, couples were interviewed about relationship dynamics, trust, communication and sexual health practices, including their perception and use of PrEP. Overall, we found that couples showed heightened trust and communication when establishing open, sexual agreements and demonstrated high awareness of sexual risks and health practices in the context of PrEP use. This study demonstrates how understanding relationship dynamics can better inform HIV prevention and sexual health promotion efforts for male couples at risk of HIV.

A Pilot Randomized Controlled Trial of an Integrated In-person and Mobile Phone Delivered Counseling and Text Messaging Intervention to Reduce HIV Transmission Risk among Male Sex Workers in Chennai, India.

Men who have sex with men (MSM) are at increased risk for HIV infection in India, particularly those who engage in transactional sex with other men (i.e., male sex workers; MSW). Despite the need, HIV prevention efforts for Indian MSW are lacking. As in other settings, MSW in India increasingly rely on the use of mobile phones for sex work solicitation. Integrating mobile phone technology into an HIV prevention intervention for Indian MSW may mitigate some of the challenges associated with face-to face approaches, such as implementation, lack of anonymity, and time consumption, while at the same time proving to be both feasible and useful. This is a pilot randomized controlled trial to examine participant acceptability, feasibility of study procedures, and preliminary efficacy for reducing sexual risk for HIV. MSW (N = 100) were equally randomized to: (1) a behavioral HIV prevention intervention integrating in-person and mobile phone delivered HIV risk reduction counseling, and daily, personalized text or voice messages as motivating "cognitive restructuring" cues for reducing condomless anal sex (CAS); or (2) a standard of care (SOC) comparison condition. Both groups received HIV counseling and testing at baseline and 6-months, and completed ACASI-based, behavioral and psychosocial assessments at baseline, 3, and 6 months. Mixed-effects regression procedures specifying a Poisson distribution and log link with a random intercept and slope for month of follow-up was estimated to assess the intervention effect on the primary outcomes: (1) CAS acts with male clients who paid them for sex, and (2) CAS acts with male non-paying sexual partners-both outcomes assessed over the past month. The intervention was both feasible (98% retention at 6-months) and acceptable (>96% of all intervention sessions attended); all intervention participants rated the intervention as "acceptable" or "very acceptable." A reduction in the reported number of CAS acts with male clients who paid them for sex in the past month was seen in both study conditions. MSW in the intervention condition reported a faster rate of decline in the number of CAS acts with male clients in the past month from the baseline to both the 3-month (B = -1.20; 95% CI -1.68, -0.73; p < 0.0001) and 6-month (B = -2.44; 95% CI -3.35, -1.53; p < 0.00001) assessment visits compared to the SOC condition. Post-hoc contrasts indicated that, at 3 months, participants in the intervention condition reported 1.43 (SD = 0.29) CAS acts with male clients in the past month compared to 4.85 (SD = 0.87) in the control condition (p = 0.0003). Furthermore, at 6 months, the intervention condition participants reported 0.24 (SD = 0.09) CAS acts with male clients in the past month compared to 2.79 (SD = 0.79) in the control condition (p < 0.0001). Findings are encouraging and provide evidence of feasibility and acceptability, and demonstrate initial efficacy (for reducing sexual risk for HIV) of a behavioral HIV prevention intervention for Indian MSW that combines daily, personalized text or voice messages with mobile phone-delivered sexual risk reduction counseling and skills building. Future testing of the intervention in a fully powered randomized controlled efficacy trial is warranted.

Transactional sex and the challenges to safer sexual behaviors: a study among male sex workers in Chennai, India.

Male sex workers (MSW) are a significant but invisible population in India who are at risk for HIV/sexually transmitted infections (STIs). Few studies from India have documented HIV risk factors and motivations for sex work in this population. Between 2013 and 2014, a community-based convenience sample of 100 MSW in Chennai (south India) completed a baseline risk assessment as part of a behavioral intervention. Participants were ≥18 years, and reported current sex work. We report medians and proportions, and Wilcoxon-Mann-Whitney and chi-square tests are used to examine differences between sex work and sexual behavior measures by income source. Participants were engaged in sex work for 5.0 years (IQR = 2.3-10.0), and earned 3000 (IQR = 2000-8000) Rupees (<50 USD) per month from sex work. Sixty-four percent reported ever testing for HIV and 20.2% for any STI. The most common reasons for starting sex work were money (83.0%) and pleasure (56.0%). Compared to participants with an additional source of income, those whose only source of income was sex work reported more male clients in the past month (10.0 vs. 6.0, p = .017), as well as more condomless anal sex acts with male clients (8.0 vs. 5.0, p = .008). Nearly 70.0% were offered more money not to use a condom during sex with a client, and 74.2% reported accepting more money not to use a condom. Three-quarters reported having experienced difficulty using condoms with clients. MSW in India engage in high levels of sexual risk for HIV/STIs. Money appears to be a driving factor for engaging in sex work and condomless sex with clients. HIV prevention interventions with MSW should focus on facilitating skills that will support their ability to negotiate sexual safety in the context of monetary disincentives.

Case report: Development of vesicouterine and vesicovaginal fistulas after uterine rupture.

Vesicouterine fistulas are an extremely rare fistula occurring between the bladder and uterus and most commonly occur after lower segment cesarean sections. There are fewer than 100 case reports documenting vesicouterine fistulas, with most managed with open or laparoscopic surgical techniques. We present a novel case, including diagnostic evaluation and robotic-assisted repair, of a simultaneous vesicovaginal and vesicouterine fistula that developed after a uterine rupture that was complicated by multiple cystotomies. A robotic approach affords good visibility of the deep pelvis while still allowing for mobilization of the omentum as an interposition graft, with the benefit of a minimally-invasive approach.

A narrative review of the role of the Male Stress Incontinence Grading Scale in the surgical management of male stress urinary incontinence.

Background and Objective: Surgical treatment for male stress urinary incontinence (SUI) includes transobturator slings and artificial urinary sphincters (AUSs). Historically, 24-hour pad weights have been used to objectively grade the severity of male SUI and guide management decisions. In 2016, the Male Stress Incontinence Grading Scale (MSIGS) was developed as a scoring system for the standing cough test (SCT). This test can be performed at the time of initial consultation and is non-invasive, with significantly less burden to the patient compared to historical measures of male SUI. Methods: A review of the reconstructive literature was conducted using PubMed and Google Scholar, reviewing articles that discuss the development of MSIGS, its correlation with objective measures of male SUI, and its use in guiding the choice of anti-incontinence surgical management. Key Content and Findings: MSIGS has been shown to have a strong positive correlation with the 24-hour pad weight test and the subjective patient-reported pads per day (PPD). An MSIGS of 3 or 4 is used to recommend a patient for AUS placement and a score of 1 or 2 for male sling placement. Patient reported satisfaction rates were 95% for AUS and 96.5% for sling. Further, over 91% of men in the study reported they would recommend their selected procedure to other men with a similar condition. Conclusions: The MSIGS is a non-invasive, efficient, and cost-effective way to evaluate men with SUI. The in-office SCT can be quickly and easily adopted into any clinical practice and provides immediate objective information that can be used to better counsel patients on anti-incontinence surgery selection.