Temporal trends and transmission dynamics of pre-treatment HIV-1 drug resistance within and between risk groups in Kenya, 1986-2020.

BACKGROUND: Evidence on the distribution of pre-treatment HIV-1 drug resistance (HIVDR) among risk groups is limited in Africa. We assessed the prevalence, trends and transmission dynamics of pre-treatment HIVDR within and between MSM, people who inject drugs (PWID), female sex workers (FSWs), heterosexuals (HETs) and perinatally infected children in Kenya. METHODS: HIV-1 partial pol sequences from antiretroviral-naive individuals collected from multiple sources between 1986 and 2020 were used. Pre-treatment reverse transcriptase inhibitor (RTI), PI and integrase inhibitor (INSTI) mutations were assessed using the Stanford HIVDR database. Phylogenetic methods were used to determine and date transmission clusters. RESULTS: Of 3567 sequences analysed, 550 (15.4%, 95% CI: 14.2-16.6) had at least one pre-treatment HIVDR mutation, which was most prevalent amongst children (41.3%), followed by PWID (31.0%), MSM (19.9%), FSWs (15.1%) and HETs (13.9%). Overall, pre-treatment HIVDR increased consistently, from 6.9% (before 2005) to 24.2% (2016-20). Among HETs, pre-treatment HIVDR increased from 6.6% (before 2005) to 20.2% (2011-15), but dropped to 6.5% (2016-20). Additionally, 32 clusters with shared pre-treatment HIVDR mutations were identified. The majority of clusters had R0 ≥ 1.0, indicating ongoing transmissions. The largest was a K103N cluster involving 16 MSM sequences sampled between 2010 and 2017, with an estimated time to the most recent common ancestor (tMRCA) of 2005 [95% higher posterior density (HPD), 2000-08], indicating propagation over 12 years. CONCLUSIONS: Compared to HETs, children and key populations had higher levels of pre-treatment HIVDR. Introduction of INSTIs after 2017 may have abrogated the increase in pre-treatment RTI mutations, albeit in the HET population only. Taken together, our findings underscore the need for targeted efforts towards equitable access to ART for children and key populations in Kenya.

URCHOICE: Preferences for Pre-Exposure Prophylaxis (PrEP) Options for HIV Prevention Among Kenyan men who have sex with men and Transgender Women in Nairobi, Kisumu and the Coast.

HIV prevention method preferences were evaluated among Kenyan men who have sex with men (MSM) and transgender women (TW) from three sites: Kisumu, Nairobi and the Coast. Information sessions detailing the attributes, duration of protection, route of administration and probable visibility were attended by 464 HIV negative participants, of whom 423 (median age: 24 years) agreed to be interviewed. Across pairwise comparisons daily PrEP was by far the least preferred (1%); quarterly injections (26%) and monthly pills (23%) were most preferred, followed by yearly implant (19%) and condoms (12%). When participants were "forced" to choose their most preferred PrEP option, only 10 (2.4%) chose the daily pill; more (37.1%) chose the quarterly injection than the monthly pill (34.8%) and the yearly implant (25.8%). TW preferred the yearly implant over the quarterly injection. To achieve the rates of PrEP uptake and adherence necessary for protecting large proportions of vulnerable MSM and TW, a variety of long-acting products should be developed and made accessible to appeal to a diversity of preferences.

Challenges with PrEP Uptake and Adherence Among Gay, Bisexual, and Other Men Who Have Sex with Men in Kisumu, Kenya.

Data on challenges with pre-exposure prophylaxis (PrEP) uptake and adherence among Kenyan gay, bisexual, and other men who have sex with men (GBMSM) are limited. In this mixed-methods sequential explanatory design study, our quantitative phase followed 157 at-risk, HIV-negative GBMSM who accepted PrEP and enrolled in a cohort with 12-month follow-up. Stored dried blood spots collected at two intervals were batch tested for tenofovir diphosphate (TFV-DP) concentrations at study end. Despite high self-reported adherence, only 14.6% of individuals had protective TFV-DP levels at any visit. Protective TFV-DP levels were positively associated with injection drug use and a self-assessed moderate risk of acquiring HIV, and negatively associated with time since enrolment. In our subsequent qualitative phase, an intensive workshop was conducted with the GBMSM community to identify barriers and facilitators to PrEP uptake and adherence. These data revealed numerous challenges with traditional PrEP programs that must be addressed through community collaborations.

RESUMEN: La evidencia respecto a desafíos existentes con aceptación y adherencia de la profilaxis previa a la exposición (PrEP) de VIH, entre los hombres homosexuales, bisexuales y otros hombres que tienen sexo con hombres (GBMSM) en Kenia es limitada. Condujimos un estudio de métodos mixtos y diseño explicativo secuencial. En la fase cuantitativa seguimos a 157 GBMSM VIH-negativos en riesgo que aceptaron PrEP y se inscribieron en una cohorte con un seguimiento de 12 meses. Analizamos, por lotes y al final del estudio, gotas de sangre seca recolectada a dos intervalos de tiempo y previamente almacenada, para determinar las concentraciones de difosfato de tenofovir (TFV-DP). A pesar de la alta adherencia autoinformada, solo el 14,6% de las personas tenían niveles protectores de TFV-DP en alguna visita. Los niveles protectores de TFV-DP se asociaron positivamente con el uso de drogas inyectables y un riesgo moderado autoevaluado de contraer el VIH, y negativamente con el tiempo transcurrido desde la inscripción. En la fase cualitativa posterior, conversamos con GBMSM de la comunidad para identificar las barreras y los facilitadores para la concientización, aceptación, adherencia y retención a PrEP. Estos datos revelaron numerosos desafíos con los programas tradicionales de PrEP que deben abordarse mediante colaboraciones comunitarias.

Transgender women in Kenya experience greater stigma, depressive symptoms, alcohol and drug use and risky sexual practices than cis-gendered men who have sex with men.

BACKGROUND: Worldwide, sexual and gender minority individuals have disproportionate burden of HIV. There are limited quantitative data from sub-Saharan Africa on the intersection of risks experienced by transgender women (TGW) in comparison to cis-men who have sex with men (MSM). This analysis addresses this gap by comparing reported stigma, psychosocial measures of health, and sexual risk practices between TGW and cis-MSM in Kenya. METHODS: We analyzed data from the baseline visit of an ongoing prospective cohort study taking place in three diverse metropolitan areas. Eligible participants were HIV-negative, assigned male at birth, ages 18-29 years, and reported anal intercourse in the past 3 months with a man or TGW. Data collected by audio computer assisted self-interview included sociodemographic measures, and sexual practices occurring in the past 3 months. Multivariable regressions assessed differences between TGW and cis-MSM in selected sexual practices, depressive symptoms, alcohol and drug use, and stigma. RESULTS: From September, 2019, through May, 2021, 838 participants were enrolled: 108 (12.9%) TGW and 730 (87.1%) cis-MSM. Adjusting for sociodemographic variables, TGW were more likely than cis-MSM to report: receptive anal intercourse (RAI; adjusted prevalence ratio [aPR] = 1.59, 95% CI: 1.32 - 1.92), engaging in group sex (aPR = 1.15, 95% CI: 1.04 - 1.27), 4 or more male sex partners (aPR = 3.31, 95% CI: 2.52 - 4.35), and 3 or more paying male sex partners (aPR = 1.58, 95% CI: 1.04 - 2.39). TGW were also more likely to report moderate to severe depressive symptoms (aPR = 1.42, 95% CI: 1.01 - 1.55), and had similar alcohol and drug abuse scores as cis-MSM. In sensitivity analysis, similar to TGW, male-identifying individuals taking feminizing gender affirming therapy had an increased likelihood of reporting RAI and group sex, and greater numbers of male sex partners and paying male sex partners relative to cis-MSM. CONCLUSIONS: Across three metropolitan areas in Kenya, TGW were more likely to report depressive symptoms and increased sexual risk taking. We identified a need for research that better characterizes the range of gender identities. Our analysis affirms the need for programmatic gender-affirming interventions specific to transgender populations in Kenya and elsewhere in Africa.

Vaginal and Penile Microbiome Associations With Herpes Simplex Virus Type 2 in Women and Their Male Sex Partners.

BACKGROUND: We determined how the vaginal and penile microbiomes contribute to herpes simplex virus type 2 (HSV-2) serostatus within sexual partnerships. METHODS: Microbiomes were characterized in cervicovaginal lavage and penile meatal swab specimens through high-throughput 16s ribosomal RNA gene amplicon sequencing. HSV-2 antibody was detected in serum specimens. We modeled vaginal and penile taxa and covariates contributing to HSV-2 status in women and men using bivariate probit analysis. RESULTS: Among 231 couples, HSV-2 was detected in both partners in 78 couples (33.8%), in the woman only in 52 (22.5%),in the man only in 27 (11.7%), and in neither in 74 (32.0%). Among the women (median age, 22 years) 10.9% had human immunodeficiency virus (HIV), and 21.4% had Bacterial vaginosis. Among men (median age, 26 years), 11.8% had HIV, and 55.0% circumcised. In an analysis with adjustment for sociodemographics and Bacterial vaginosis, enrichment of vaginal Gardnerella vaginalis and Lactobacillus iners was associated with increased likelihood of HSV-2 in both partners. Penile taxa (including Ureaplasma and Aerococcus) were associated with HSV-2 in women. CONCLUSIONS: We demonstrate that penile taxa are associated with HSV-2 in female partners, and vaginal taxa are associated with HSV-2 in male partners. Our findings suggest that couples-level joint consideration of genital microbiome and sexually transmitted infection or related outcomes could lead to new avenues for prevention.

Behavior Change and Sexually Transmitted Incidence in Relation to PREP Use Among Men Who Have Sex with Men in Kenya.

We measured change in sexual practices and the incidence of C. trachomatis (CT) and N. gonorrhoeae (NG) within a prospective cohort of Kenyan MSM taking PrEP in Kenya. Over the one year of study participation, CT and NG were diagnosed in urine at baseline, 6- and 12- months. Multivariable Cox regression identified factors associated with incident infection. Sexual practices were assessed at baseline and every 3 months. We evaluated changes over time and in relation to PrEP adherence via generalized estimating equation analysis. From October 2017-January 2018, 158 participants initiated PrEP, having 10.3% baseline CT/NG prevalence (either or both). The incidence was 17.2 cases per 100 person-years (95% CI 11.7-25.5). Incident CT/NG increased with report of: transactional male sex partner (adjusted Hazard Ratio (aHR) = 2.46, p = 0.016, z = 2.40), regular female sex partner (aHR = 2.22, p = 0.051, z = 1.96), greater social support (highest vs. lowest quartile, aHR = 6.24, p = 0.012, z = 2.51), and CT/NG infection prior to enrollment (aHR = 2.90, p = 0.002, z = 3.03). Multiple sex partners, condomless sex, and transactional sex decreased over time and were not associated with PrEP adherence. Urethral CT/NG incidence remained high and there was no evidence of PrEP-related behavioral change. There is need for ongoing etiologic testing, improved understanding of risk from female sex partners, and development of more effective risk reduction interventions.

Revisiting COVID-19 policies: 10 evidence-based recommendations for where to go from here.

BACKGROUND: Strategies to control coronavirus 2019 disease (COVID-19) have often been based on preliminary and limited data and have tended to be slow to evolve as new evidence emerges. Yet knowledge about COVID-19 has grown exponentially, and the expanding rollout of vaccines presents further opportunity to reassess the response to the pandemic more broadly. MAIN TEXT: We review the latest evidence concerning 10 key COVID-19 policy and strategic areas, specifically addressing: 1) the expansion of equitable vaccine distribution, 2) the need to ease restrictions as hospitalization and mortality rates eventually fall, 3) the advantages of emphasizing educational and harm reduction approaches over coercive and punitive measures, 4) the need to encourage outdoor activities, 5) the imperative to reopen schools, 6) the far-reaching and long-term economic and psychosocial consequences of sustained lockdowns, 7) the excessive focus on surface disinfection and other ineffective measures, 8) the importance of reassessing testing policies and practices, 9) the need for increasing access to outpatient therapies and prophylactics, and 10) the necessity to better prepare for future pandemics. CONCLUSIONS: While remarkably effective vaccines have engendered great hope, some widely held assumptions underlying current policy approaches call for an evidence-based reassessment. COVID-19 will require ongoing mitigation for the foreseeable future as it transforms from a pandemic into an endemic infection, but maintaining a constant state of emergency is not viable. A more realistic public health approach is to adjust current mitigation goals to be more data-driven and to minimize unintended harms associated with unfocused or ineffective control efforts. Based on the latest evidence, we therefore present recommendations for refining 10 key policy areas, and for applying lessons learned from COVID-19 to prevent and prepare for future pandemics.

Integration of voluntary male medical circumcision for HIV prevention into norms of masculinity: findings from Kisumu, Kenya.

While it is clear that in many communities ideas about masculinity and circumcision are connected, it is still unclear how young Kenyan men in the former Nyanza province from the traditionally non-circumcising Luo people perceive voluntary medical male circumcision as connected to masculinity and the role of voluntary medical male circumcision in the transition from boyhood to manhood. The objective of this study was to explore norms of masculinity and the decision-making process among Luo young men to provide a better understanding of how circumcision and masculinity relate to cultural norms within this community. The methodology consisted of eight FGDs with male peer groups and 24 in-depth interviews to elicit young men's perceptions of masculinity and voluntary medical male circumcision. Findings from thematic analysis reveal that young men described several key characteristics of masculinity including responsibility, bravery and sexual attractiveness. For some young men, voluntary medical male circumcision has embedded itself into cultural norms of masculinity by being a step in the transition from boyhood to manhood and by being a marker of some of these masculine characteristics. In the case of voluntary medical male circumcision, there may be opportunities to integrate other programming that helps men transition into healthy adulthood.

Incident gonorrhoea and chlamydia among a prospective cohort of men who have sex with men in Kisumu, Kenya.

OBJECTIVE: STIs disproportionately affect men who have sex with men (MSM) in sub-Saharan Africa. We identified factors associated with incident Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections among MSM in the Anza Mapema cohort study in Kisumu, Kenya. METHODS: We enrolled 711 MSM who underwent HIV testing and counselling, medical history and examination, and collection of demographic and behavioural information. They also provided urine and rectal swab specimens for CT and NG testing by qualitative PCR at baseline and at months 6 and 12. Separate multivariable Cox regression models identified factors associated with first incident urethral or rectal infection. RESULTS: Among the 619 men aged 18-54 years included in this analysis, there were 83 first incident urethral CT/NG infections (14.4 cases per 100 person-years (PY)) and 40 first incident rectal infections (6.84 cases per 100 PY), and an overall incidence of 18.0 cases per 100 PY (95% CI 14.8 to 21.8). Most urethral (84%) and rectal (81%) infections were asymptomatic. In the adjusted model, the risk of first incident urethral CT/NG decreased by 4% for each 1-year increase in age and was 41% lower for men who reported their partner used condom at last sexual encounter. Men who were HIV-positive had a 68% less risk of urogenital CT/NG compared with those who were negative. Men who reported being usually receptive or versatile as compared with usually insertive had an 81% increased risk of incident urogenital CT/NG. CONCLUSION: Our study demonstrated a high incidence of urethral CT/NG infection, with somewhat lower incidence of rectal CT/NG infection, despite repeated testing and treatment, highlighting the need for preventive interventions to decrease the burden of CT/NG among Kenyan MSM. Most infections were asymptomatic, and routine aetiological screening for STIs is recommended.

Characteristics of Women and Their Male Sex Partners Predict Bacterial Vaginosis Among a Prospective Cohort of Kenyan Women With Nonoptimal Vaginal Microbiota.

BACKGROUND: Up to 50% of women with nonoptimal vaginal microbial community state type (CST) have bacterial vaginosis (BV). Little is known about what distinguishes women with and without BV diagnosis within nonoptimal CST. We identified features of women and their male sex partners associated with BV among women with nonoptimal vaginal CST. METHODS: In this prospective study, 252 heterosexual couples were observed at 1, 6, and 12 months after baseline. Microbiomes were characterized in cervicovaginal lavage and penile meatal swabs through high-throughput 16s ribosomal RNA gene amplicon sequencing. Nonoptimal CST was defined as CST-IV. Bacterial vaginosis was defined as a Nugent score of 7 to 10. Generalized estimating equation analysis estimated adjusted odds ratios (aORs) for BV among women with nonoptimal CST. RESULTS: At baseline, women with nonoptimal CST were a median age of 22 years, 44% had BV, 16% had HIV, and 66% had herpes simplex virus (HSV) type 2. Male partners were a median age of 27 years, 12% had HIV, 48% had HSV-2, and 55% were circumcised. Within nonoptimal CST, Sneathia sanguinegens, Prevotella species, Prevotella amnii, and Clostridiales, BV-associated bacteria-2 were statistically significantly enriched in observations with BV. In multivariable generalized estimating equation controlling for CST, HIV, and HSV-2, BV was increased among women with CST-IVA (aOR, 1.91; P = 0.087), HIV (aOR, 2.30; P = 0.051), HSV-2 (aOR, 1.75; P = 0.065), and enrichment of male partner penile taxa: Dialister (aOR, 1.16; P = 0.034), Megasphaera (aOR, 1.22; P = 0.001), and Brevibacterium (aOR, 1.13; P = 0.019).These results provide insights into factors differentiating women with BV among those with nonoptimal vaginal CST. Interrupting the sexual exchange of penile and vaginal taxa may be beneficial for preventing pathologic state of vaginal microbiome.

Prevalence and correlates of and a risk score to identify asymptomatic anorectal gonorrhoea and chlamydia infection among men who have sex with men in Kisumu, Kenya.

OBJECTIVES: In settings where laboratory capacity is limited, the WHO recommends presumptive treatment for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in asymptomatic men who have sex with men (MSM) at high risk for these infections. However, little is known about how best to target this intervention. We aimed to identify correlates of anorectal NG/CT infection in Kenyan MSM with and without anorectal symptoms and evaluate the performance of an empirical, model-based risk score to identify cases in asymptomatic men. METHODS: Anorectal NG/CT infections were diagnosed by the Abbott RealTime NG/CT nucleic acid amplification testamong 698 MSM at enrolment into the Anza Mapema study. Multivariable logistic regression was used to identify correlates of anorectal NG/CT infection in men with and without anorectal symptoms. Using coefficients from the final multivariable model for asymptomatic men, we calculated a risk score for each participant. Risk score performance was determined by calculating the sensitivity, specificity and number needed to treat (NNT) to identify one NG/CT infection. RESULTS: Overall anorectal NG/CT infection prevalence was 5.2% (n=36), of which 58.3% (n=21) were asymptomatic. Factors associated with anorectal NG/CT infection in asymptomatic men were aged 18-24 years (aOR=7.6; 95% CI: 1.7 to 33.2), HIV positive serostatus (aOR=6.9; 95% CI: 2.2 to 21.6) and unprotected anal sex in the past 3 months (aOR=3.8; 95% CI: 1.2 to 11.9). Sensitivity and specificity were optimal (81.0% and 66.1%, respectively) at a model-derived risk score cut-point ≥3, and the NNT was 12. CONCLUSIONS: A model-derived risk score based on correlates of anorectal NG/CT infection in asymptomatic participants would be sensitive and efficient (i.e, low NNT) for targeting presumptive treatment. If validated in other settings, this risk score could improve on the WHO algorithm and help reduce the burden of asymptomatic anorectal NG/CT infections among MSM in settings where diagnostic testing is not available.

Virological Non-suppression and Its Correlates Among Adolescents and Young People Living with HIV in Southern Malawi.

We examined virological non-suppression (VLN) among youth ages 13-24 years receiving HIV treatment in public health facilities in six southern Malawi districts. We also tested three ART adherence measures to determine how well each identified VLN: pill counts, a Likert scale item, and a visual analogue scale. VLN was defined as HIV RNA > 1000 copies/ml. Of the 209 youth, 81 (39%) were virally non-suppressed. Male gender and stigma were independently associated with VLN; social support and self-efficacy were independently protective. Pill count had the highest positive predictive value (66.3%). Using a pill count cut-off of < 80% nonadherence, 36 (17%) of the youth were non-adherent. Of the adherent, 120 (69%) were viral suppressed. Results indicate the need to address HIV-related stigma and to bolster social support and selfefficacy in order to enhance viral suppression. In the absence of viral load testing, pill count appears the most accurate means to assess VLN.

Adolescent Male Circumcision for HIV Prevention in High Priority Countries: Opportunities for Improvement.

Global experts recognize the need to transform conventional models of healthcare to create adolescent responsive health systems. As countries near 80% coverage of voluntary medical male circumcision (VMMC) for those aged 15-49 years, prioritization of younger men becomes critical to VMMC sustainability. This special supplement reporting 9 studies focusing on adolescent VMMC programming and services comes at a critical time. Eight articles report how well adolescents are reached with the World Health Organization's minimum package for comprehensive human immunodeficiency virus (HIV) prevention in South Africa, Zimbabwe, and Tanzania, analyzing motivation, counseling, wound healing, parental involvement, female peer support, quality of in-service communication, and providers' perceptions, and one presents models for achieving high VMMC coverage by 2021. One important finding is that adolescent boys, especially the youngest, experience gaps in their comprehension of key elements in the World Health Organization's minimum package. Although parents, counselors, and providers are involved and supportive, they are inadequately prepared to counsel youth, partly owing to discomfort with adolescent sexuality. At the country level, deliberately prioritizing young adolescents (aged 10-14 years) is likely to achieve national coverage targets more quickly and cost-effectively than continuing to focus on older, harder-to-reach men. The studies in this supplement point to areas where VMMC programs are achieving successes and they reveal areas for improvement. Given that prioritizing adolescents will be the best means of achieving sustainable VMMC for HIV prevention for the foreseeable future, applying the lessons learned here will increase the effectiveness of VMMC programs.

Sexual Quality of Life and Association With HIV and Sexually Transmitted Infections Among a Cohort of Heterosexual Couples in Kenya.

INTRODUCTION: Sexual quality of life (SQoL) is a critical component of sexual health and is understudied in Sub-Saharan African settings with endemic HIV and sexually transmitted infection (STI). AIM: We sought to assess SQoL among heterosexual couples in Kisumu, Kenya, and how this was associated with HIV status, STIs, and sexual practices. METHODS: This was a prospective cohort study of community-recruited couples. SQoL, HIV status, herpes simplex virus (HSV)-2 status, bacterial vaginosis (BV), sexual practices, and sociodemographics were measured at baseline, 6 months, and 12 months. Multivariable linear regression with random intercept was fitted separately for females and males, accounting for partner characteristics. MAIN OUTCOME MEASURE: SQoL was assessed with an 18-item female and 11-item male survey. RESULTS: From April 2014 through July 2016, 252 couples were enrolled, and followed up through September 2017. At baseline, women were median age 23 years, 10% HIV positive, 53% HSV-2 seropositive, and 22% with BV. At baseline men were median age 26 years, 12% HIV positive, 47% HSV-2 seropositive, and 56% circumcised. Mean SQoL was higher for men (88) than women (78), with consistent scores over time. In multivariable analysis (P < .05 each), SQoL Questionnaire-Female (SQoL-F) score was reduced with: male partner report that sex felt rougher than he would have liked (9.5-point decrease), female HSV-2 seropositivity (5.15-point decrease), female reported having dry vaginal sex (5.27-point decrease); among women with BV, SQoL-F score declined with recent sexual activity (8.27-point decrease) and increasing age (0.75-point decrease per 1 year increase in age). Age and recent sex did not affect SQoL-F for women without BV. SQoL Questionnaire-Male score was decreased 4.99 points if male was employed, 4.52 points if male reported multiple recent sex partners, and 29.5 points for HIV positive men whose female partner reported having sex when not in the mood. Men's SQoL increased by 0.84 points for each 1-U increase in female partner body mass index and 17.6 points for HIV positive men whose female partner reported recent sex with him. CLINICAL IMPLICATIONS: Within sexual partnerships, men had greater SQoL than women, and the adverse impact of BV and STIs on SQoL was greater for women than men. STRENGTH & LIMITATIONS: Research is needed to ensure relevant domains are measured in settings where measure of SQoL has not been validated, along with robust measures of physiologic and psychologic correlates. CONCLUSION: More attention to SQoL as an outcome may strengthen interventions aimed at preventing HIV and STIs and improving sexual health holistically. Mehta SD, Nordgren RK, Agingu W, et al. Sexual Quality of Life and Association With HIV and Sexually Transmitted Infections Among a Cohort of Heterosexual Couples in Kenya. J Sex Med 2018;15:1446-1455.

Depressive Symptoms, Alcohol and Drug Use, and Physical and Sexual Abuse Among Men Who Have Sex with Men in Kisumu, Kenya: The Anza Mapema Study.

Men who have sex with men (MSM) are disproportionately burdened by depressive symptoms and psychosocial conditions including alcohol and substance abuse as well as physical and sexual abuse. We examined sociodemographic and psychosocial factors associated with depressive symptoms at baseline among a cohort of MSM in Kisumu, Kenya. Depressive symptoms were assessed via the Personal Health Questionnaire 9 instrument and examined dichotomously. We performed multivariable modified Poisson regression with robust standard errors for the binary outcome. Among 711 participants: 11.4% reported severe depressive symptoms; 50.1% reported harmful alcohol abuse; 23.8% reported moderate substance abuse; 80.9% reported any childhood physical or sexual abuse; and 39.1% experienced recent trauma due to same-sex behaviors. In the final multivariable model, severe depressive symptoms were more common for men who were ≥ 30 years old, had completed ≤ 8 years of education, had experienced childhood physical or sexual abuse, and had recently experienced trauma due to same-sex behaviors. Our results demonstrate that comprehensive services capable of identifying and addressing depressive symptoms, alcohol and substance abuse, and physical and sexual abuse must be expanded within this sample of MSM.

Factors associated with viral suppression among HIV-positive Kenyan gay and bisexual men who have sex with men.

The UNAIDS 90-90-90 target has prioritized achieving high rates of viral suppression. We identified factors associated with viral suppression among HIV-positive gay, bisexual, and other men who have sex with men (GBMSM) in Kisumu, Kenya. HIV-positive participants in the Anza Mapema study were offered antiretroviral therapy (ART) regardless of CD4 count. HIV viral load was assessed at baseline and after 6 and 12 months of follow-up. Viral suppression was defined as <1,000 copies/mL. Sociodemographic, sexual behaviors, and psychosocial characteristics were assessed via audio computer-assisted self interview. We used generalized estimating equations to estimate the associations between baseline and time-dependent predictors and viral suppression at 6 and 12 months. Seventy-five HIV-positive men were enrolled in the Anza Mapema study, of which 63 had at least one viral load measured during follow-up. Among 52 men with a viral load measure at month 6, 37 (71%) were on ART and virally suppressed. Among 59 men with a viral load measure at month 12, 37 (63%) were on ART and virally suppressed. In the final multivariable model, men who reported receptive or versatile sexual position during anal intercourse with a male partner had reduced odds of viral suppression (aOR = 0.20; 95% CI: 0.08-0.50). Greater levels of coping self-efficacy were associated with increased odds of viral suppression (aOR = 1.10; 95% CI: 1.03-1.16). Despite extensive initiation, retention, and adherence support, the rate of viral suppression in this population did not meet the UNAIDS 90-90-90 target (81% for individuals aware of their HIV status). Pervasive stigma against male-male sex, especially men who practice receptive anal sex, may underlie our findings, which highlight the need for advocacy and stigma reduction efforts. Because coping self-efficacy was a protective factor, efforts to promote resilience in addition to healthy sexual identity development may lead to improved care outcomes among GBMSM in this area.

Circumcision status at HIV infection is not associated with plasma viral load in men: analysis of specimens from a randomized controlled trial.

BACKGROUND: Male circumcision provides men with approximately 60% protection from acquiring HIV infection via heterosexual sex, and has become a key component of HIV prevention efforts in sub-Saharan Africa. Possible mechanisms for this protection include removal of the inflammatory anaerobic sub-preputial environment and the high concentration of Langerhans cells on the inside of the foreskin, both believed to promote local vulnerability to HIV infection. In people who do acquire HIV, viral load is partially determined by infecting partner viral load, potentially mediated by size of infecting inoculum. By removing a portal for virion entry, prior male circumcision could decrease infecting inoculum and thus viral load in men who become HIV-infected, conferring the known associated benefits of slower progression to disease and decreased infectiousness. METHODS: We performed an as-treated analysis of plasma samples collected under a randomized controlled trial of male circumcision for HIV prevention, comparing men based on their circumcision status at the time of HIV acquisition, to determine whether circumcision is associated with lower viral load. Eligible men were seroconverters who had at least one plasma sample available drawn at least 6 months after infection, reported no potential exposures other than vaginal sex and, for those who were circumcised, were infected more than 6 weeks after circumcision, to eliminate the open wound as a confounder. Initial viral load testing indicated that quality of pre-2007 samples might have been compromised during storage and they were excluded, as were those with undetectable or unquantifiable results. Log viral loads were compared between groups using univariable and multivariable linear regression, adjusting for sample age and sexually transmitted infection diagnosis with 3.5 months of seroconversion, with a random effect for intra-individual clustering for samples from the same man. A per-protocol analysis was also performed. RESULTS: There were no viral load differences between men who were circumcised and uncircumcised at the time of HIV infection (means 4.00 and 4.03 log10 copies/mL respectively, p = .88) in any analysis. CONCLUSION: Circumcision status at the time of HIV infection does not affect viral load in men. TRIAL REGISTRATION: The original RCT which provided the samples was ClinicalTrials.gov trial NCT00059371 .

Medical Male Circumcision Is Associated With Improvements in Pain During Intercourse and Sexual Satisfaction in Kenya.

BACKGROUND: Two cohort studies using data from randomized controlled trials in Africa offer the best evidence to date on the effects of voluntary medical male circumcision (VMMC) on male sexual function and satisfaction, suggesting no significant impairments in sexual function or satisfaction and some improvements in sexual function after male circumcision. AIM: To assess the effects of VMMC on sexual function and satisfaction in a large population-based cohort of men circumcised as adults and uncircumcised controls in Kenya. METHODS: Sexual function and satisfaction of young (median age = 20 years) sexually active men (1,509 newly circumcised men and 1,524 age-matched uncircumcised controls after 5% loss to follow-up) were assessed at baseline and 6, 12, 18, and 24 months, with data collected in 2008 to 2012. Self-reported data on lack of sexual interest or pleasure, difficulty getting or maintaining erections, orgasm difficulties, premature ejaculation, pain during intercourse, and satisfaction with sexual intercourse were analyzed with mixed-effect models to detect differences between circumcised and uncircumcised men and changes over time. OUTCOMES: Changes over time in sexual interest, desire and pleasure, erectile and ejaculatory function, and pain during intercourse (dyspareunia) in circumcised and uncircumcised men; group differences in time trends; satisfaction with sexual performance; and enjoyment of sex before and after circumcision. RESULTS: Sexual dysfunctions decreased in the two study groups from 17% to 54% at baseline to 11% to 44% at 24 months (P < .001), except dyspareunia, which decreased only in circumcised men (P < .001). Sexual satisfaction outcomes increased in the two study groups from 34% to 82% at baseline to 66% to 93% at 24 months (P < .001), with greater improvements in circumcised men (P < .001). On average, 97% of circumcised men were satisfied with sexual intercourse and 92% rated sex as more enjoyable or no different after circumcision compared with before circumcision. CLINICAL TRANSLATION: Results are applicable to VMMC programs seeking to increase the acceptability of male circumcision as part of comprehensive HIV prevention. STRENGTHS AND LIMITATIONS: Large-scale population-based longitudinal data restricted to sexually active individuals and adjusted for differences in baseline levels of outcomes and potential confounders are used. The questionnaire used, although not a standardized survey instrument, includes all major domains of male sexual function and satisfaction used in the most common standardized tools. CONCLUSIONS: Results are consistent with large cohort studies of VMMC using data from randomized controlled trials and indicate that VMMC has no significant detrimental effect or might have beneficial effects on male sexual function and satisfaction for the great majority of men circumcised as adults. Nordstrom MPC, Westercamp N, Jaoko W, et al. Medical Male Circumcision Is Associated With Improvements in Pain During Intercourse and Sexual Satisfaction in Kenya. J Sex Med 2017;14:601-612.

Sexual Pleasure and Function, Coital Trauma, and Sex Behaviors After Voluntary Medical Male Circumcision Among Men in the Dominican Republic.

BACKGROUND: Voluntary medical male circumcision (VMMC) is effective in decreasing the risk of HIV acquisition. As men resume sexual activity after circumcision, it will be important to study their satisfaction with the procedure, sexual pleasure and function, coital trauma, and risk compensation (RC), which can hamper or facilitate the long-term success of VMMC programs. AIM: To assess men's satisfaction with VMMC, sexual pleasure and function, coital trauma, and RC after VMMC. METHODS: This is a cohort study of circumcised men who presented for follow-up 6 to 24 months after VMMC. Logarithmic binomial regression was performed to explore factors associated with any increase in the number of sex partners after VMMC as a measurement of RC. MAIN OUTCOME MEASURES: (i) Men's satisfaction with their VMMC; (ii) sexual pleasure and function after VMMC; (iii) coital trauma; and (iv) RC. RESULTS: Of 454 circumcised men, 362 (80%) returned for a follow-up visit 6 to 24 months after VMMC. Almost all (98%) were satisfied with the outcome of their VMMC; most (95%) reported that their female partners were satisfied with their circumcision. Two thirds (67%) reported enjoying sex more after VMMC and most were very satisfied or somewhat satisfied (94%) with sexual intercourse after VMMC. Sexual function improved and reported sex-induced coital injuries decreased significantly in most men after VMMC. There was an increase in the proportion of men who reported at least two sexual partners after VMMC compared with baseline. In multivariate analysis, having sex with a woman they met the same day (adjusted relative risk = 1.7, 95% CI = 1.2-2.4) and having at least two sexual partners at baseline (adjusted relative risk = 0.5, 95% CI = 0.3-0.8) were associated with the outcome of any increase in the number of partners after VMMC. CLINICAL IMPLICATIONS: VMMC can be offered to Dominican men for HIV prevention without adversely affecting sexual pleasure or function. The procedure substantially reduces coital trauma. STRENGTHS & LIMITATIONS: This is the first report of long-term overall satisfaction, sexual pleasure/function and sex behaviors in the context of VMMC outside of Africa. Limitations of the study included the reliance on self-reported sex behaviors, the lack of physiologic measurement of penile sensitivity and the lack of follow up data beyond 24 months, which precludes the assessment of longer term RC. CONCLUSION: The study confirmed men's long-term satisfaction with the outcome of their VMMC. VMMC improved sexual pleasure and function for most men and significantly decreased coital injuries. There was mixed evidence of RC. Brito MO, Khosla S, Pananookooln S, et al. Sexual Pleasure and Function, Coital Trauma, and Sex Behaviors After Voluntary Medical Male Circumcision Among Men in the Dominican Republic. J Sex Med 2017;14:526-534.

Higher HPV16 and HPV18 Penile Viral Loads Are Associated With Decreased Human Papillomavirus Clearance in Uncircumcised Kenyan Men.

BACKGROUND: Whether higher penile human papillomavirus (HPV) viral load is associated with a lower rate of HPV clearance remains unknown. OBJECTIVES: We examined the association between penile HPV16 and HPV18 viral load and subsequent HPV clearance in uncircumcised Kenyan men. STUDY DESIGN: Participants were human immunodeficiency virus (HIV)-seronegative, sexually active, 18- to 24-year-old men randomized to the control arm of a male circumcision trial in Kisumu, Kenya. Men provided exfoliated penile cells from two anatomical sites (glans/coronal sulcus and shaft) every 6 months for 2 years. GP5+/6+ polymerase chain reaction was used to identify 44 HPV-DNA types. Human papillomavirus viral load testing was conducted using a LightCyler real-time polymerase chain reaction assay; viral load was classified as high (>250 copies/scrape) or low (≤250 copies/scrape), for nonquantifiable values. The Kaplan-Meier method and Cox regression modeling were used to examine the association between HPV viral load and HPV clearance. RESULTS: A total of 1097 men, with 291 HPV16 and 131 HPV18 cumulative infections over 24 months were analyzed. Human papillomavirus clearance at 6 months after first HPV detection was lower for high versus low viral load HPV16 infections in the glans (adjusted hazard ratio [aHR], 0.65; 95% confidence interval [CI], 0.46-0.92)] and shaft (aHR, 0.44; 95% CI, 0.16-0.90), and HPV18 infections in the glans (aHR, 0.05; 95% CI, 0.01-0.17). DISCUSSION: High versus low HPV viral load was associated with a reduced HPV clearance for HPV16 infections in the glans and shaft, and for HPV18 infections in the glans, among young uncircumcised men. Reduced clearance of high viral load HPV16 and HPV18 infections in men may increase HPV transmission to their female partners as well as enhance the development of penile lesions in comparison to men with low viral load HPV infections.