Metrics of Sexual Behavior Stigma Among Cisgender Men Who Have Sex With Men in 9 Cities Across the United States.

Men who have sex with men (MSM) in the United States are stigmatized for their same-sex practices, which can lead to risky sexual behavior, potentiating risk for human immunodeficiency virus (HIV) infection. Improved measurement is necessary for accurately reporting and mitigating sexual behavior stigma. We added 13 sexual behavior stigma items to local surveys administered in 2017 at 9 sites in the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance system, which uses venue-based, time-sampling procedures to survey cisgender MSM in US Census Metropolitan Statistical Areas. We performed exploratory factor analytical procedures on site-specific (Baltimore, Maryland; Denver, Colorado; Detroit, Michigan; Houston, Texas; Nassau-Suffolk, New York; Portland, Oregon; Los Angeles, California; San Diego, California; and Virginia Beach-Norfolk, Virginia) and pooled responses to the survey items. A 3-factor solution-"stigma from family" (α = 0.70), "anticipated health-care stigma" (α = 0.75), and "general social stigma" (α = 0.66)-best fitted the pooled data and was the best-fitting solution across sites. Findings demonstrate that MSM across the United States experience sexual behavior stigma similarly. The results reflect the programmatic utility of enhanced stigma measurement, including tracking trends in stigma over time, making regional comparisons of stigma burden, and supporting evaluation of stigma-mitigation interventions among MSM across the United States.

HIV and employment among Black men who have sex with men in Baltimore.

Employment status is a key social determinant of health, and many populations in the United States that are impacted by HIV have unequal access to education and employment opportunities which contributes to HIV-related disparities. Black men who have sex with men (BMSM) are one of the groups most heavily burdened by HIV. With improved health outcomes associated with advancements in HIV treatment, research suggests that more people living with HIV want to work. This study describes employment among BMSM living in Baltimore, assesses differences in employment by HIV status and assesses predictors of full-time employment among BMSM. The study found that BMSM have limited access to full-time employment and that this disparity is even more pronounced among BMSM living with HIV. Men living with HIV were less likely to be employed full-time compared to men not living with HIV controlling for education and social contextual factors (OR 0.40 95% CI (0.22-0.73)). HIV will most likely have important implications for employment patterns and trajectories of BMSM over the life course. Additional research is needed among BMSM living with HIV to understand work histories and experiences, facilitating factors, and the impact of various work experiences on the health and wellbeing.

Evaluating HIV Surveillance Completeness Along the Continuum of Care: Supplementing Surveillance With Health Center Data to Increase HIV Data to Care Efficiency.

BACKGROUND: HIV surveillance is essential to quantifying the impact of the epidemic and shaping HIV programs. The Maryland Department of Health (MDH) historically conducted HIV Data to Care (D2C) activities using surveillance data to identify individuals who were not in HIV care; however, most case investigations concluded that the individuals in question were currently engaged in care. This suggests that delays and gaps in laboratory reporting to HIV surveillance exist and the proportion of HIV-positive Marylanders who are truly in care is underestimated. Therefore, solely relying on surveillance data might not be an efficient method for identifying not in care HIV cases. SETTING: Through the Partnerships for Care (P4C) project, MDH conducted targeted D2C efforts on HIV patients from 4 health centers. METHODS: The expanded D2C model that MDH created during P4C integrated clinical data as a secondary data source to enhance the surveillance data used to estimate HIV patient care engagement. MDH matched and compared health center electronic health records with HIV surveillance data to assess completeness of HIV case and laboratory reporting. RESULTS: HIV case ascertainment was high (99.9%) for the P4C cohort (N = 927), but differences in estimated care engagement and viral suppression between data sources revealed incomplete laboratory reporting and that patients received care from multiple providers. Analyzing the clinical data leads to the resolution of several reporting gaps, which improved surveillance data quality over time. CONCLUSIONS: Health departments should validate their HIV surveillance completeness. Triangulating surveillance data with clinical data generated more accurate depictions of care engagement and increased D2C efficiency.

Impact of Providing Preexposure Prophylaxis for Human Immunodeficiency Virus at Clinics for Sexually Transmitted Infections in Baltimore City: An Agent-based Model.

BACKGROUND: Preexposure prophylaxis (PrEP) greatly reduces the risk of human immunodeficiency virus (HIV) acquisition, but its optimal delivery strategy remains uncertain. Clinics for sexually transmitted infections (STIs) can provide an efficient venue for PrEP delivery. METHODS: To quantify the added value of STI clinic-based PrEP delivery, we used an agent-based simulation of HIV transmission among men who have sex with men (MSM). We simulated the impact of PrEP delivery through STI clinics compared with PrEP delivery in other community-based settings. Our primary outcome was the projected 20-year reduction in HIV incidence among MSM. RESULTS: Assuming PrEP uptake and adherence of 60% each, evaluating STI clinic attendees and delivering PrEP to eligible MSM reduced HIV incidence by 16% [95% uncertainty range, 14%-18%] over 20 years, an impact that was 1.8 (1.7-2.0) times as great as that achieved by evaluating an equal number of MSM recruited from the community. Comparing strategies where an equal number of MSM received PrEP in each strategy (ie, evaluating more individuals for PrEP in the community-based strategy, because MSM attending STI clinics are more likely to be PrEP eligible), the reduction in HIV incidence under the STI clinic-based strategy was 1.3 (1.3-1.4) times as great as that of community-based delivery. CONCLUSIONS: Delivering PrEP to MSM who attend STI clinics can improve efficiency and effectiveness. If high levels of adherence can be achieved in this population, STI clinics may be an important venue for PrEP implementation.

The Impact of Preexposure Prophylaxis Among Men Who Have Sex With Men: An Individual-Based Model.

OBJECTIVES: Preexposure prophylaxis (PrEP) is recommended for preventing HIV infection among individuals at high risk, including men who have sex with men (MSM). Although its individual-level efficacy is proven, questions remain regarding population-level impact of PrEP implementation. DESIGN: We developed an agent-based simulation of HIV transmission among MSM, accounting for demographics, sexual contact network, HIV disease stage, and use of antiretroviral therapy. We use this framework to compare PrEP delivery strategies in terms of impact on HIV incidence and prevalence. RESULTS: The projected reduction in HIV incidence achievable with PrEP reflects both population-level coverage and individual-level adherence (as a proportion of days protected against HIV transmission). For example, provision of PrEP to 40% of HIV-negative MSM reporting more than one sexual partner in the last 12 months, taken with sufficient adherence to provide protection on 40% of days, can reduce HIV incidence by 9.5% (95% uncertainty range: 8%-11%) within 5 years. However, if this could be increased to 80% coverage on 80% of days (eg, through mass campaigns with a long-acting injectable formulation), a 43% (42%-44%) reduction in HIV incidence could be achieved. Delivering PrEP to MSM at high risk for HIV acquisition can augment population-level impact up to 1.8-fold. CONCLUSIONS: If highly ambitious targets for coverage and adherence can be achieved, PrEP can substantially reduce HIV incidence in the short-term. Although the reduction in HIV incidence largely reflects the proportion of person-years protected, the efficiency of PrEP delivery can be enhanced by targeting high-risk populations.

Individual-Level and Partner-Level Predictors of Newly Diagnosed HIV Infection Among Black and White Men Who Have Sex with Men in Baltimore, MD.

Black MSM continue to be the group most disproportionately impacted by HIV in the United States. This study assesses the relationship between partner-level and respondent-level characteristics and newly diagnosed HIV infection among a sample of MSM. Ego-centric data were gathered using venue-based time-space sampling on 335 men who reported on a total of 831 male anal sex partners. In multivariate analyses, age of partner, HIV status of partner, and respondent having had an STD in the past twelve months were associated with a newly diagnosed HIV infection among black MSM. Efforts for black MSM are needed that aim to increase HIV and STD testing, foster open communication between partners about HIV status, and address social determinants of health.

HIV risk among men who have sex with men only (MSMO) and men who have sex with men and women (MSMW) in Baltimore.

Men who have sex with men and women (MSMW) are at high risk for HIV. However, the majority of research on populations of men who have sex with men (MSM) combines MSMW and men who have sex with men only (MSMO) samples, which limits our understanding of HIV risk behaviors and factors associated with HIV risk among MSMW populations. We used the BESURE-MSM2, a venue-based cross-sectional study of HIV risk behaviors among MSM in Baltimore, MD, to examine HIV risk among MSMW. MSMW were less likely to report unprotected receptive anal intercourse than MSMO (6.8% vs. 19.6%, p = .0024). Among MSMW, 43.0% reported unprotected sex with a woman in the past year, but only 19.4% reported unprotected sex with both men and women, representing only 5.0% of the total MSM sample. In multivariate analyses, we found that among MSMW having unprotected sex with women in the past year, disclosing same sex behavior and having a main female partner were associated with unprotected anal intercourse with male partners. HIV prevention programs for MSMW are needed that address the complex partnerships of MSMW and the social contextual factors within which relationships and behaviors are embedded.

Differences and Similarities in HIV Testing Among Men Who have Sex with Men and Women (MSMW) and Men Who Have Sex with Men Only (MSMO).

The study examined differences in HIV testing between men who have sex with men only (MSMO) (n=300) and men who have sex with men and women (MSMW) (n=105) and assessed associations with HIV testing among MSMW. A venue-based cross-sectional HIV surveillance study in 2008 (BESURE-MSM2) was examined. Prevalence of HIV testing was similar for MSMO and MSMW. One-on-one counseling (excluding counseling that is part of HIV testing) and having seen a health care provider in the past twelve months were associated with HIV testing in the past six months among MSMW in multivariate analyses. One-on-one counseling interventions may increase rates of HIV testing among MSMW.

Partner characteristics and undiagnosed HIV seropositivity among men who have sex with men only (MSMO) and men who have sex with men and women (MSMW) in Baltimore.

This study examined the relationship between HIV risk behaviors, partner characteristics, and undiagnosed seropositivity among men who have sex with men and women (MSMW) and men who have sex with men only (MSMO). BESURE-MSM2 is a venue-based cross-sectional HIV surveillance study conducted among MSM in 2008. Stratified log-binomial regression was used to assess adjusted prevalence ratios of undiagnosed seropositivity among 103 MSMW and 296 MSMO (N = 399). Among MSMO, race/ethnicity, age, having had a sexually transmitted infection, concurrency, and having a black/African American male partner were associated with undiagnosed seropositivity. Among MSMW, having five or more male partners, having a main male partner, and having a main female partner were associated with undiagnosed seropositivity. Our findings underscore the importance of partner characteristics in understanding HIV transmission. HIV programs for men with both male and female partners are needed to address the unique partnership dynamics of MSMW.

Persistently high prevalence and unrecognized HIV infection among men who have sex with men in Baltimore: the BESURE study.

BACKGROUND: Given high rates of HIV among Baltimore men who have sex with men (MSM), we examined characteristics associated with HIV prevalence and unrecognized HIV infection among Baltimore MSM at two time points. METHODS: Cross-sectional behavioral surveys and HIV testing in 2004-2005 and 2008 using venue-based sampling among adult Baltimore men at MSM-identified locations. MSM was defined as sex with a male partner in the past year. Bivariate and backward stepwise regression identified characteristics associated with HIV and unrecognized infection. RESULTS: HIV prevalence was 37.7% overall in 2004-2005 (n = 645) and 37.5% in 2008 (n = 448), 51.4% and 44.7% among black MSM and 12.9% and 18.3% among non-Hispanic white MSM. Compared with non-Hispanic white MSM, black MSM were 4.0 times (95% confidence interval, 2.3-7.0) more likely to be HIV-positive in 2004-2005 and 2.5 times (95% confidence interval, 1.5-4.0) more likely in 2008. Prevalence of unrecognized HIV infection was 58.4% overall in 2004-2005 and 74.4% in 2008, 63.8% and 76.9% among black MSM and 15.4% and 47.4% among non-Hispanic white MSM. In adjusted models, unrecognized infection was significantly associated with minority race/ethnicity, younger age, and no prior year doctor visits in 2004-2005 and with younger age and no prior year doctor visits in 2008. CONCLUSION: High rates of HIV infection and substantial rates of unrecognized HIV infection among Baltimore MSM, particularly men of color and young men, require urgent public and private sector attention and increased prevention response.

Two independent epidemics of HIV in Maryland.

BACKGROUND: HIV-1 subtype B virus is the predominant subtype in HIV-infected individuals in the United States. However, increasing evidence suggests that prevalence of non-B subtypes may be on the rise in the West, and this may have implications for HIV-1 disease surveillance and treatment. The state of Maryland currently has the fourth highest AIDS case report rate in the United States. The goal of this study was to evaluate the prevalence of HIV-1 non-B subtypes in Maryland. The study population included individuals diagnosed with HIV in 2007 through the voluntary counseling and testing sites at the Maryland Department of Health and Mental Hygiene and HIV-infected patients who had genotyping performed at the University of Maryland Medical Center. RESULTS: At the Department of Health and Mental Hygiene sites, 47 unique non-B subtype strains were identified representing a non-B prevalence of 12.9%. These non-B subtypes included CRF02_AG (n = 20), C (n = 11), A (n = 7), G (n = 5), D (n = 1), and unique recombinant forms (n = 3). The non-B patients were predominantly non-Hispanic black (95.7%) with 63.8% female. Although the majority of the HIV subtype B cases (65.3%) were identified from the Baltimore metropolitan area, most (80.9%) of the non-B cases were from the Maryland suburbs of Washington, DC. Among University of Maryland Medical Center patients, there were 30 non-B subtypes, representing a non-B prevalence of 1.9%. The non-B subtypes detected were CRF02_AG (n = 14), C (n = 6), A (n = 6), G (n = 2), D (n = 1), and unique recombinant forms (n = 1). Phylogenetic analysis of the non-B subtypes revealed that viral sequences from both sources were intermixed, confirming that both sampling frames were drawing from the same overall population. CONCLUSIONS: Multiple HIV-1 subtypes exist in the Baltimore-Washington metropolitan area with a significant non-B-infected population in the Maryland suburbs of Washington, DC, suggesting 2 independent epidemics of HIV in Maryland. Population-based surveillance inclusive of groups at higher risk of non-B strains is essential to monitor the prevalence and variations of HIV subtypes in Maryland and the United States.