A cross-sectional study of knowledge of sex partner serostatus among high-risk Peruvian men who have sex with men and transgender women: implications for HIV prevention.

BACKGROUND: Knowledge of a sex partner's HIV serostatus can influence sexual behavior and inform harm-reduction strategies. We sought to determine how often Peruvian men who have sex with men (MSM) and transgender women (TW) knew the HIV serostatus of their sex partners, if this knowledge was associated with any predictive factors or unprotected anal intercourse (UAI), and if UAI was associated with partner serostatus. METHODS: We analyzed data from the 2008 Peruvian MSM Sentinel Surveillance Survey. Data were collected by CASI about each participant's three most recent male sex partners. Primary outcome was knowledge of a partner's HIV test result. Multivariate analysis assessed the effect of age, education, sexual identity, number of male partners, alcohol use during intercourse, type of partnership and length of partnership using logistic regression. RESULTS: 735 participants provided data on 1,643 of their most recent sex partners from the last 3 months. 179/735 (24.4%) of all participants knew HIV test results for at least one of their 3 most recent partners, corresponding to 230/1643 (14.0%) of all sexual partnerships in the last 3 months. In multivariate analysis, casual (OR: 0.27, 95% CI: 0.17-0.42) and exchange sex (OR: 0.31, 95% CI: 0.11-0.88) partners, compared to stable partners, were negatively associated with knowledge of partner serostatus, whereas relationships lasting longer than one night (<3 months OR: 2.20, 95% CI: 1.39-3.51; 3 months to 1 year OR: 3.00, 95% CI: 1.80-5.01; ≥ 1 year OR: 4.13, 95% CI: 2.40-7.10) were positively associated with knowledge of partner serostatus. Knowledge of partner serostatus was not associated with unprotected anal intercourse with that partner. CONCLUSIONS: Few MSM and TW in Peru know their partners' HIV serostatus. Our findings suggest that the type and length of partnership influence the likelihood of knowing a partner's serostatus. Further research should explore the contexts and practices of partner communication, their effect on sexual behavior, and interventions to promote discussion of HIV testing and serostatus as an HIV prevention strategy in this population.

Acceptability of oral versus rectal HIV preexposure prophylaxis among men who have sex with men and transgender women in Peru.

OBJECTIVE: Oral preexposure prophylaxis (PrEP) with antiretrovirals (ARVs) is at the forefront of biomedical HIV prevention research, and ARVs are also being tested for rectal administration to target people practicing unprotected receptive anal intercourse (URAI) and at risk of HIV infection. This study assessed the acceptability of daily oral PrEP and rectal PrEP during URAI among men who have sex with men (MSM) and transgender women (TGW) in Peru. METHODS: During the 2008 HIV sentinel surveillance survey conducted in 3 Peruvian cities (Lima, Iquitos, and Pucallpa), MSM and TGW reported being "versatile," "most of the time receptive," and "exclusively receptive" during anal sex behavior where surveyed on their acceptability of oral and rectal PrEP. RESULTS: Among 532 individuals, high acceptance of either oral (96.2%) or rectal (91.7%) PrEP products was reported. If both products were efficacious/available, 28.6% would prefer a pill, 57.3% a rectal lubricant, and 14.1% either. A trend toward higher acceptance was observed as receptive anal sex behavior exclusivity rose (P = .013). Being receptive most of the time (adjusted odds ratio [aOR]: 9.1, P = .01) and exclusively receptive (aOR: 7.5, P = .01), compared to being versatile, were independently associated with oral PrEP acceptability. A similar association was found with the acceptability of rectal formulations (aOR: 2.3, P = .07; and aOR: 2.5, P = .02; respectively). CONCLUSIONS: Oral and rectal PrEP were highly acceptable among Peruvian MSM and TGW, particularly among those at the highest HIV infection risk. These data can guide the implementation of PrEP programs in Peru and similar settings and populations.

Male circumcision and risk of HIV acquisition among MSM.

OBJECTIVES: To assess the association between male circumcision, insertive anal sex practices, and HIV acquisition in a cohort of MSM. METHODS: Data were from 1824 HSV-2-seropositive, HIV-seronegative MSM, 1362 (75%) from Peru and 462 (25%) from the US, who participated in a randomized placebo-controlled trial of HSV-2 suppression for HIV prevention (HPTN 039). Circumcision status was determined by examination at enrollment. HIV testing was done every 3 months for up to 18 months. Partner-specific sexual behavior for up to the last three partners during the previous 3 months was analyzed. RESULTS: There was no significant association between male circumcision and HIV acquisition in univariate analysis [relative risk (RR) = 0.84, 95% confidence interval (CI) 0.50-1.42]. In a prespecified multivariate analysis that assumed a linear relationship between the proportion of insertive acts and effect of circumcision on HIV acquisition, the interaction between circumcision and proportion of insertive acts was not significant (P = 0.11). In an exploratory analysis that categorized behavior with recent partners by proportion of insertive acts (<60 or ≥60% insertive acts), circumcision was associated with a nonstatistically significant 69% reduction in the risk of HIV acquisition (RR = 0.31, 95% CI 0.06-1.51) among men who reported at least 60% of insertive acts with recent male partners. CONCLUSION: Circumcision does not have a significant protective effect against HIV acquisition among MSM from Peru and US, although there may be reduced risk for men who are primarily insertive with their male partners. This association needs to be investigated across diverse cohorts of MSM.

Hepatitis B infection and association with other sexually transmitted infections among men who have sex with men in Peru.

To assess the epidemiology of hepatitis B virus (HBV) infection among men who have sex with men (MSM) in Peru, we evaluated the prevalence and associated risk factors for HBV serologic markers among participants of a HIV sentinel surveillance conducted in 2002-2003. The standardized prevalences for total antibodies to hepatitis B core antigen (anti-HBc) and hepatitis B surface antigen (HBsAg) were 20.2% and 2.8%, respectively. Individuals with human immunodeficiency virus (HIV-1) infection had significantly higher anti-HBc (44.3% versus 19.3%) and HBsAg (9.5% versus 2.3%) prevalences than uninfected men. Increasing age (adjusted odds ratio [AOR] = 1.06), versatile sexual role (AOR = 1.59), sex in exchange for money/gifts (AOR = 1.58), syphilis (AOR = 1.74), HIV-1 infection (AOR = 1.64), and herpes simplex virus type 2 (HSV-2, AOR = 2.77) infection were independently associated with anti-HBc positivity, whereas only HIV-1 infection (AOR = 3.51) and generalized lymph node enlargement (AOR = 3.72) were associated with HBsAg positivity. Pre-existing HBV infection is very common among Peruvian MSM and was correlated with sexual risk factors. MSM in Peru constitute a target population for further HBV preventive and treatment interventions.

Effect of aciclovir on HIV-1 acquisition in herpes simplex virus 2 seropositive women and men who have sex with men: a randomised, double-blind, placebo-controlled trial.

BACKGROUND: Across many observational studies, herpes simplex virus type 2 (HSV-2) infection is associated with two-fold to three-fold increased risk for HIV-1 infection. We investigated whether HSV-2 suppression with aciclovir would reduce the risk of HIV-1 acquisition. METHODS: We undertook a double-blind, randomised, placebo-controlled phase III trial in HIV-negative, HSV-2 seropositive women in Africa and men who have sex with men (MSM) from sites in Peru and the USA. Participants were randomly assigned by block randomisation to twice daily aciclovir 400 mg (n=1637) or matching placebo (n=1640) for 12-18 months, and were seen monthly for dispensation of study drug, adherence counselling and measurement by pill count and self-reporting, and risk reduction counselling, and every 3 months for genital examination and HIV testing. The primary outcome was HIV-1 acquisition and secondary was incidence of genital ulcers. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00076232. FINDINGS: 3172 participants (1358 women, 1814 MSM) were included in the primary dataset (1581 in aciclovir group, 1591 in control group). The incidence of HIV-1 was 3.9 per 100 person-years in the aciclovir group (75 events in 1935 person-years of follow-up) and 3.3 per 100 person-years in the placebo group (64 events in 1969 person-years of follow-up; hazard ratio 1.16 [95% CI 0.83-1.62]). Incidence of genital ulcers on examination was reduced by 47% (relative risk 0.53 [0.46-0.62]) and HSV-2 positive genital ulcers by 63% (0.37 [0.31-0.45]) in the aciclovir group. Adherence to dispensed study drug was 94% in the aciclovir group and 94% in the placebo group, and 85% of expected doses in the aciclovir group and 86% in the placebo group. Retention was 85% at 18 months in both groups (1028 of 1212 in aciclovir group, 1030 of 1208 in placebo group). We recorded no serious events related to the study drug. INTERPRETATION: Our results show that suppressive therapy with standard doses of aciclovir is not effective in reduction of HIV-1 acquisition in HSV-2 seropositive women and MSM. Novel strategies are needed to interrupt interactions between HSV-2 and HIV-1.

Role versatility among men who have sex with men in urban Peru.

Role versatility refers to the practice in which individual men who have sex with men (MSM) play both insertive and receptive sexual roles over time. Versatility has been thought to be relatively uncommon among Latin American MSM but possibly rising. Versatility has also been shown to be a potentially large population-level risk factor for HIV infection. In this study we examine the correlates of versatile behavior and identity among 2,655 MSM in six Peruvian cities. Versatile behavior with recent male partners was found in 9% of men and versatile ("moderno") identity was reported by 16%. Significant predictors included high education, white-collar occupation, sex work, and residence in Lima. Age was not significant in any analysis. Since sex work is negatively correlated with other predictors, versatile men appear to comprise two distinct sub-populations. Insertive-only men appear to play a strong role in bridging the HIV epidemic between MSM and women.