Impact of frozen section on long-term outcomes in robot-assisted laparoscopic prostatectomy.

OBJECTIVES: To compare 1-year functional and 5-year oncological outcomes of men undergoing robot-assisted laparoscopic prostatectomy (RALP) with neurovascular structure-adjacent frozen-section examination (NeuroSAFE) with those in men undergoing RALP without NeuroSAFE (standard of care [SOC]). SUBJECTS AND METHODS: Men undergoing RALP in our centre between 1 January 2009 and 30 June 2018 were enrolled from a prospectively maintained database. Patients were excluded if they had undergone preoperative therapy or postoperative adjuvant therapy or were enrolled in clinical trials. Patients were grouped based on use of NeuroSAFE. Follow-up was censored at 5 years. The primary outcome was difference in time to biochemical recurrence (BCR) on multivariable analysis, defined as prostate-specific antigen (PSA) >0.2 ng/L on two consecutive measurements. Secondary outcomes were difference in 1-year erectile dysfunction and incontinence. RESULTS: In the enrolment period, 1199 consecutive men underwent RALP, of whom 1140 were eligible, including 317 with NeuroSAFE and 823 with SOC. The median PSA follow-up was 60 months in both groups. Rates of 5-year BCR were similar on Kaplan-Meier survival curve analysis (11% vs 11%; P = 0.9), as was time to BCR on multivariable Cox proportional hazards modelling (hazard ratio 1.2; P = 0.6). Compared with the SOC group at 1 year, the NeuroSAFE group had similar unadjusted rates of incontinence (5.1% vs 7.7%) and lower unadjusted impotence (57% vs 80%). On multivariable analysis, NeuroSAFE patients had equivalent risk of incontinence (odds ratio [OR] 0.59, 95% CI 0.17-1.6; P = 0.4) but significantly reduced risk of erectile dysfunction (OR 0.37, 95% CI 0.22-0.60; P < 0.001). CONCLUSIONS: For men undergoing RALP, compared with SOC, NeuroSAFE patients had equivalent time to BCR and risk of 1-year incontinence, and significantly lower risk of 1-year erectile dysfunction.

Robot-assisted vs open radical cystectomy for bladder cancer in adults.

BACKGROUND: It has been suggested that, in comparison with open radical cystectomy (ORC), robot-assisted radical cystectomy (RARC) results in less blood loss, shorter convalescence and fewer complications, with equivalent short-term oncological and functional outcomes; however, uncertainty remains as to the magnitude of these benefits. OBJECTIVES: To assess the effects of RARC vs ORC in adults with bladder cancer. SEARCH METHODS: We conducted a comprehensive search, with no restrictions on language of publication or publication status, for randomized controlled trials (RCTs) that compared RARC with ORC. The date of the last search was 1 July 2018. Databases searched included the Cochrane Central Register of Controlled Trials, MEDLINE (1999 to July 2018), PubMed Embase (1999 to July 2018), Web of Science (1999 to July 2018), Cancer Research UK (www.cancerresearchuk.org/), and the Institute of Cancer Research (www.icr.ac.uk/). We also searched the following trial registers: ClinicalTrials.gov (clinicaltrials.gov/); BioMed Central International Standard Randomized Controlled Trials Number (ISRCTN) Registry (www.isrctn.com); and the World Health Organization International Clinical Trials Registry Platform. The review was based on a published protocol. Primary outcomes of the review were recurrence-free survival and major postoperative complications (Clavien grade III to V). Secondary outcomes were minor postoperative complications (Clavien grades I and II), transfusion requirement, length of hospital stay (days), quality of life, and positive surgical margins (%). Three review authors independently assessed relevant titles and abstracts of records identified by the literature search to determine which studies should be assessed further. Two review authors assessed risk of bias using the Cochrane risk-of-bias tool and rated the quality of evidence according to GRADE. We used Review Manager 5 to analyse the data. RESULTS: We included in the review five RCTs comprising a total of 541 participants. Total numbers of participants included in the ORC and RARC cohorts were 270 and 271, respectively. We found that RARC and ORC may result in a similar time to recurrence (hazard ratio 1.05, 95% confidence interval [CI] 0.77 to 1.43; two trials, low-certainty evidence). In absolute terms at 5 years of follow-up, this corresponds to 16 more recurrences per 1000 participants (95% CI 79 fewer to 123 more) with 431 recurrences per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in similar rates of major complications (risk ratio [RR] 1.06, 95% CI 0.76 to 1.48; five trials, low-certainty evidence). This corresponds to 11 more major complications per 1000 participants (95% CI 44 fewer to 89 more). We downgraded the certainty of evidence because of study limitations and imprecision. We were very uncertain whether RARC reduces minor complications (very-low-certainty evidence). We downgraded the certainty of evidence because of study limitations and very serious imprecision. RARC probably results in substantially fewer transfusions than ORC (RR 0.58, 95% CI 0.43 to 0.80; two trials, moderate-certainty evidence). This corresponds to 193 fewer transfusions per 1000 participants (95% CI 262 fewer to 92 fewer) based on 460 transfusion per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations. RARC may result in a slightly shorter hospital stay than ORC (mean difference -0.67, 95% CI -1.22 to -0.12; five trials, low-certainty evidence). We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in a similar quality of life (standardized mean difference 0.08, 95% CI 0.32 lower to 0.16 higher; three trials, low-certainty evidence). We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in similar positive surgical margin rates (RR 1.16, 95% CI 0.56 to 2.40; five trials, low-certainty evidence). This corresponds to eight more (95% CI 21 fewer to 67 more) positive surgical margins per 1000 participants, based on 48 positive surgical margins per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations and imprecision. CONCLUSIONS: We conclude that RARC and ORC may have similar outcomes with regard to time to recurrence, rates of major complications, quality of life, and positive surgical margin rates (all low-certainty evidence). We are very uncertain whether the robotic approach reduces rates of minor complications (very-low-certainty evidence), although it probably reduces the risk of blood transfusions substantially (moderate-certainty evidence) and may reduce hospital stay slightly (low-certainty evidence). We were unable to conduct any of the preplanned subgroup analyses to assess the impact of patient age, pathological stage, body habitus, or surgeon expertise on outcomes. This review did not address issues of cost-effectiveness.

Sexual violence experiences among black gay, bisexual, and other men who have sex with men and transgender women in South African townships: contributing factors and implications for health.

This study examined experiences with sexual violence among Black African gay, bisexual, and other men who have sex with men (GBMSM) and transgender women (TGW) in townships surrounding Pretoria, South Africa. Of 81 GBMSM and TGWs interviewed, 17 reported to have experienced sexual violence perpetrated by other men. Qualitative analysis of interviews revealed the social and relational context of these experiences as well as their psychological and health consequences. The described context included single- and multiple-perpetrator attacks in private and public spaces, bias-motivated attacks, and violence from known partners. Several participants reported refusing propositions for sex as a reason for being victimized. HIV-positive individuals were overrepresented among survivors compared to the sample as a whole. Following victimization, participants described feelings of pain, fear, anger and self-blame. The results demonstrate the need for interventions designed to (a) prevent sexual violence against GBMSM and TGW in this population, and (b) reduce the negative psychological and health outcomes of sexual victimization. The discussion also highlights the need to examine more closely the link between experiences of sexual violence and risk for HIV infection.

The role of extended venous thromboembolism prophylaxis for major urological cancer operations.

OBJECTIVES: Venous thromboembolism (VTE), consisting of both pulmonary embolism (PE) and deep vein thromboses (DVT), remains a well-recognised complication of major urological cancer surgery. Several international guidelines recommend extended thromboprophylaxis (ETP) with LMWH, whereby the period of delivery is extended to the post-discharge period, where the majority of VTE occurs. In this literature review we investigate whether ETP should be indicated for all patients undergoing major urological cancer surgery, as well procedure specific data that may influence a clinician's decision. METHODS: We performed a search of six databases (PubMed, Cochrane, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and British Nursing Index (BNI)) from inception to June 2019, for studies looking at adult patients who received VTE prophylaxis after surgery for a major urological malignancy. RESULTS: Eighteen studies were analysed. VTE risk is highest in open and robotic Radical Cystectomy (RC) (2.6-11.6%) and ETP demonstrates a significant reduction in risk of VTE, but not a significant difference in Pulmonary Embolism (PE) or mortality. Risk of VTE in open Radical Prostatectomy (RP) (0.8-15.7%) is comparable to RC, but robotic RP (0.2-0.9%), open partial/radical nephrectomy (1.0-4.4%) and robotic partial/radical nephrectomy (0.7-3.9%) were lower risk. It has not been shown that ETP reduces VTE risk specifically for RP or nephrectomy. CONCLUSION: The decision to use ETP is a fine balance between variables such as VTE incidence, bleeding risk and perioperative morbidity/mortality. This balance should be assessed for each specific procedure type. While ETP still remains of net benefit for open RP as well as open and robotic RC, the balance is closer for minimally invasive RP as well as radical and partial nephrectomy. Due to a lack of procedure specific evidence for the use of ETP, adherence with national guidelines remains poor. Therefore, we advocate further studies directly comparing ETP vs standard prophylaxis, for specific procedure types, in order to allow clinicians to make a more informed decision in future.

'My Tablets are on Top of the Fridge': The Roles of Relationship Desire and Medical Mistrust in ART Adherence for HIV-Positive MSM and Transgender Women Living in Rural South Africa.

Given the high HIV prevalence for men who have sex with men (MSM) and transgender women in South Africa, there is limited understanding of social determinants that influence antiretroviral treatment (ART) adherence. Although universal testing and treatment (UTT) is available, ART adherence remains suboptimal. We conducted focus groups with MSM and transgender women in order to understand factors influencing their ART adherence in Mpumalanga, South Africa. All focus groups were audio-recorded, transcribed and translated for analysis using a constant comparison approach, guided by the concept of Therapeutic Citizenship. We found there is medical mistrust of ART based on differing interpretations of HIV cure that may influence treatment adherence behaviors within social networks, and relationship desire had a significant influence on optimal ART adherence. Our findings suggest that clinics must provide interventions that integrate HIV disclosure and relationship skill-building to support optimal ART adherence for MSM and transgender women under UTT.

Robotic versus open radical cystectomy for bladder cancer in adults.

BACKGROUND: It has been suggested that in comparison with open radical cystectomy, robotic-assisted radical cystectomy results in less blood loss, shorter convalescence, and fewer complications with equivalent short-term oncological and functional outcomes; however, uncertainty remains as to the magnitude of these benefits. OBJECTIVES: To assess the effects of robotic-assisted radical cystectomy versus open radical cystectomy in adults with bladder cancer. SEARCH METHODS: Review authors conducted a comprehensive search with no restrictions on language of publication or publication status for studies comparing open radical cystectomy and robotic-assisted radical cystectomy. The date of the last search was 1 July 2018 for the Cochrane Central Register of Controlled Trials, MEDLINE (1999 to July 2018), PubMed Embase (1999 to July 2018), Web of Science (1999 to July 2018), Cancer Research UK (www.cancerresearchuk.org/), and the Institute of Cancer Research (www.icr.ac.uk/). We searched the following trials registers: ClinicalTrials.gov (clinicaltrials.gov/), BioMed Central International Standard Randomized Controlled Trials Number (ISRCTN) Registry (www.isrctn.com), and the World Health Organization International Clinical Trials Registry Platform. SELECTION CRITERIA: We searched for randomised controlled trials that compared robotic-assisted radical cystectomy (RARC) with open radical cystectomy (ORC). DATA COLLECTION AND ANALYSIS: This study was based on a published protocol. Primary outcomes of the review were recurrence-free survival and major postoperative complications (class III to V). Secondary outcomes were minor postoperative complications (class I and II), transfusion requirement, length of hospital stay (days), quality of life, and positive margins (%). Three review authors independently assessed relevant titles and abstracts of records identified by the literature search to determine which studies should be assessed further. Two review authors assessed risk of bias using the Cochrane risk of bias tool and rated the quality of evidence according to GRADE. We used Review Manager 5 to analyse the data. MAIN RESULTS: We included in the review five randomised controlled trials comprising a total of 541 participants. Total numbers of participants included in the ORC and RARC cohorts were 270 and 271, respectively.Primary outomesTime-to-recurrence: Robotic cystectomy and open cystectomy may result in a similar time to recurrence (hazard ratio (HR) 1.05, 95% confidence interval (CI) 0.77 to 1.43); 2 trials; low-certainty evidence). In absolute terms at 5 years of follow-up, this corresponds to 16 more recurrences per 1000 participants (95% CI 79 fewer to 123 more) with 431 recurrences per 1000 participants for ORC. We downgraded the certainty of evidence for study limitations and imprecision.Major complications (Clavien grades 3 to 5): Robotic cystectomy and open cystectomy may result in similar rates of major complications (risk ratio (RR) 1.06, 95% CI 0.76 to 1.48); 5 trials; low-certainty evidence). This corresponds to 11 more major complications per 1000 participants (95% CI 44 fewer to 89 more). We downgraded the certainty of evidence for study limitations and imprecision.Secondary outcomesMinor complications (Clavien grades 1 and 2): We are very uncertain whether robotic cystectomy may reduce minor complications (very low-certainty evidence). We downgraded the certainty of evidence for study limitations and for very serious imprecision.Transfusion rate: Robotic cystectomy probably results in substantially fewer transfusions than open cystectomy (RR 0.58, 95% CI 0.43 to 0.80; 2 trials; moderate-certainty evidence). This corresponds to 193 fewer transfusions per 1000 participants (95% CI 262 fewer to 92 fewer) based on 460 transfusion per 1000 participants for ORC. We downgraded the certainty of evidence for study limitations.Hospital stay: Robotic cystectomy may result in a slightly shorter hospital stay than open cystectomy (mean difference (MD) -0.67, 95% CI -1.22 to -0.12); 5 trials; low-certainty evidence). We downgraded the certainty of evidence for study limitations and imprecision.Quality of life: Robotic cystectomy and open cystectomy may result in a similar quality of life (standard mean difference (SMD) 0.08, 95% CI 0.32 lower to 0.16 higher; 3 trials; low-certainty evidence). We downgraded the certainty of evidence for study limitations and imprecision.Positive margin rates: Robotic cystectomy and open cystectomy may result in similar positive margin rates (RR 1.16, 95% CI 0.56 to 2.40; 5 trials; low-certainty evidence). This corresponds to 8 more (95% CI 21 fewer to 67 more) positive margins per 1000 participants based on 48 positive margins per 1000 participants for ORC. We downgraded the certainty of evidence for study limitations and imprecision. AUTHORS' CONCLUSIONS: Robotic cystectomy and open cystectomy may have similar outcomes with regard to time to recurrence, rates of major complications, quality of life, and positive margin rates (all low-certainty evidence). We are very uncertain whether the robotic approach reduces rates of minor complications (very low-certainty evidence), although it probably reduces the risk of blood transfusions substantially (moderate-certainty evidence) and may reduce hospital stay slightly (low-certainty evidence). We were unable to conduct any of the preplanned subgroup analyses to assess the impact of patient age, pathological stage, body habitus, or surgeon expertise on outcomes. This review did not address issues of cost-effectiveness.

The neurovascular structure-adjacent frozen-section examination (NeuroSAFE) approach to nerve sparing in robot-assisted laparoscopic radical prostatectomy in a British setting - a prospective observational comparative study.

OBJECTIVES: To evaluate the neurovascular structure-adjacent frozen-section examination (NeuroSAFE) technique in a British setting in men undergoing robot-assisted laparoscopic radical prostatectomy (RALP) . PATIENTS AND METHODS: We retrospectively analysed our prospectively maintained database of patients who underwent RALP between November 2008 and February 2017. We examined preoperative pathological and functional parameters, intraoperative nerve sparing (NS), postoperative histology, as well as functional and oncological follow-up. We compared those who had a NeuroSAFE approach and those who had NS without NeuroSAFE. We also compared all the RALPs before and after the introduction of NeuroSAFE. Statistical analysis was done using the two-tailed t-test and chi-squared analysis. RESULTS: This single surgeon series included 417 RALPs, including 120 NeuroSAFEs. The NeuroSAFE cohort had a greater proportion of D'Amico high-risk disease (30.8% vs 9.6%, P < 0.001), higher Gleason scores and higher pT stage compared to the non-NeuroSAFE NS cohort. After the introduction of NeuroSAFE, more preoperatively potent men underwent bilateral NS with pT2 disease (84.6% vs 66.3%, P = 0.002) and more overall NS were performed in patients with pT3 disease (65.1% vs 36.7%, P = 0.012). Overall positive surgical margin (PSM) rates were lower in the NeuroSAFE cohort compared to those who had NS without NeuroSAFE (9.2% vs 17.8%, P = 0.04). The 12-month potency rates were also higher in the NeuroSAFE cohort for both bilateral (77.3% vs 50.9%, P = 0.009) and unilateral (70.6% vs 40%, P = 0.04) NS. Pad-free continence was also higher in the NeuroSAFE group (85.7% vs 70.9%, P = 0.019), but there was no significant difference between those who were wearing ≤1 safety pad. Although we only had short-term oncological follow-up, it did not significantly differ between the two groups. CONCLUSION: Adoption of NeuroSAFE allowed us to offer NS in higher risk patients, whilst reducing PSM rates and at the same time improving potency at 12 months.

Modelling the UNAIDS 90-90-90 treatment cascade for gay, bisexual and other men who have sex with men in South Africa: using the findings of a data triangulation process to map a way forward.

A data triangulation exercise was carried out between 2013 and 2015 to assess the HIV epidemic and response among gay, bisexual and other men who have sex with men (GBMSM) in South Africa. We used the findings to assess progress in achieving the UNAIDS 90-90-90 goals for GBMSM in the country. Three scenarios were developed using different GBMSM population factors (2.0, 3.5 and 5.0% of males aged ≥15) to estimate the population size, HIV prevalence of 13.2-49.5%, and 68% of GBMSM knowing their status. Due to data gaps, general population data were used as estimates of GBMSM on antiretroviral therapy (ART) and virologically suppressed (25.7 and 84.0%, respectively). The biggest gap is access to ART. To address the data gap we recommend developing data collection tools, indicators, and further quantification of HIV cascades. Targeted testing, linkage to services and scaled-up prevention interventions (including pre-exposure prophylaxis) are also required.

Bisexual and Bidirectional: Assessing the Potential for HIV Bridging in Mozambique.

African men who have sex with men (MSM) frequently, and often concurrently, have female partners, raising concerns about HIV sexual bridging. We explored potential HIV transmission in Mozambique from and to female partners of MSM focusing on preferred anal sex role and circumcision status. Data collected in a respondent-driven sampling study of MSM in 2011 in Maputo and Beira. Men who had oral or anal sex with other men 12 months prior completed a questionnaire and consented for HIV testing. Statistical analysis explored demographic/risk characteristics and associations among circumcision status, anal sex with men, sexual positions during anal sex with men and vaginal or anal sex with women. We identified 326 MSM in Maputo and 237 in Beira with both male and female partners 3 months before the study. Of these, 20.8% in Maputo and 36.0% in Beira had any receptive anal sex with men 12 months prior, including 895 unprotected sexual acts with males in Maputo and 692 in Beira. Uncircumcised and exclusively insertive males, 27.7% of the sample in Maputo and 33.6% in Beira, had the most unprotected sex with females: 1159 total acts in Maputo and 600 in Beira. Sexual bridging between MSM and women likely varies geographically and is probably bi-directional, occurring within a generalized epidemic where HIV prevalence is higher among reproductive-age women than MSM. Prevention strategies emphasizing correct and consistent condom use for all partners and circumcision for bisexual men should be considered.

"Booze is the main factor that got me where I am today": alcohol use and HIV risk for MSM in rural South Africa.

Excessive alcohol consumption has been shown to increase HIV risk for men who have sex with men (MSM) and compromise HIV prevention behaviors. However, there is limited contextual understanding of alcohol use for MSM in rural sub-Saharan African settings, which can inform and direct HIV interventions. Applying an adaptation of PhotoVoice, we worked with 35 HIV-positive MSM who created photo-essays about alcohol and HIV in Mpumalanga. A semi-structured protocol was used in focus group discussions that were audio-recorded, translated and transcribed. Transcript data and visual data of 24 photo-essays were analyzed using a constant comparison approach. We found that participants used alcohol to build and sustain social networks, meet sexual partners, and enhance sexual experience. Excessive alcohol use was common, which was associated with increased HIV risk behaviors within a community of MSM who maintained multiple partnerships. Our study suggests that HIV interventions need to address excessive alcohol use to mitigate the associated HIV risk at both the individual and community levels.

Exploring dual disclosures for men who have sex with men in Mpumalanga, South Africa: a report from the field.

We explored to whom rural men who have sex with men (MSM) disclose their sexual identity and HIV status in Mpumalanga, South Africa. Participants were recruited using a modified snowball sampling method in order to complete a questionnaire. Descriptive and logistic regression analyses were conducted. There were 47 participants of whom 22 self-reported as HIV-positive. Most participants disclosed their sexuality and HIV status to immediate family members and gay-identified friends. We found that the longer someone had identified as MSM, the more likely they were to be HIV-positive and not go to clinic. Education and employment modified these findings. This study presents a broader picture of MSM in this rural African setting: that they do disclose their sexuality and HIV status to others in their community. However, more research is needed to develop these measures. We need to assess how long participants identify as MSM, how long they have been HIV-positive, and to whom they have disclosed these aspects of their lives to inform HIV prevention and treatment interventions for MSM in rural settings.

Substance Use and Sexual Risk Behavior Among Black South African Men Who Have Sex With Men: The Moderating Effects of Reasons for Drinking and Safer Sex Intentions.

Research studies suggest an association between substance use and sexual risk behavior, but are not completely consistent. The moderating effects of other psychosocial factors might help explain these inconsistencies. The current study therefore assessed whether substance use is associated with sexual risk behavior, and whether this relationship is modified by expectancies about the effects of alcohol, reasons for consuming alcohol, or intentions to engage in safe sex. A cross-sectional survey was conducted among 480 black South African men who have sex with men recruited using respondent-driven sampling. In multivariable analyses, the effect of alcohol use on unprotected receptive anal intercourse (URAI) was modified by drinking to enhance social interaction (R2 change = 0.03, p < 0.01). The effect of drug use on URAI was modified by safe sex intentions (R2 change = 0.03, p < 0.001). Alcohol use was positively associated with URAI only among those who drink to enhance social interaction (ß = 0.08, p < 0.05). Drug use was positively associated with URAI only among those with high safe sex intentions (ß = 0.30, p < 0.001). Our findings suggest that efforts to minimize the impact of substance use on HIV risk behavior should target men who drink to enhance social interaction and men who intend to engage in safer sex. Efforts made to increase safer sex intentions as a way to reduce HIV risk behavior should additionally consider the effects of substance use.

Breakage is the norm: use of condoms and lubrication in anal sex among Black South African men who have sex with men.

This paper explores condom use and lubrication practices among Black men who have sex with men in South African townships. Results are from 81 in-depth individual interviews conducted among a purposive sample from four townships surrounding Pretoria as part of a larger qualitative study. Awareness that condoms should be used to have safer anal sex was ubiquitous. Fewer men reported that lubricants should be used to facilitate anal intercourse. Partner pressure and partner distrust were the most common barriers cited for not using condoms and lubricants. Knowledge about condom-lubricant compatibility was rare. Condom problems were a norm, with widespread expectations of condom failure. Men's subjectivities - their perceptions of and preferences for specific brands, types and flavours of condoms and lubricants - influenced engagement with such safer-sex technologies. However, what was available in these settings was often neither what men needed nor preferred. Findings show the need to enhance access to appropriate and comprehensive: safer-sex supplies, health services and health education, and underline the importance of efforts to develop targeted programmes relevant to experiences of men who have sex with men in the South African context.

Risk Factors Associated with HIV Among Men Who Have Sex Only with Men and Men Who Have Sex with Both Men and Women in Three Urban Areas in Mozambique.

Using respondent-driven sampling (RDS), an integrated biological behavioral survey among men that have sex with men (MSM) enrolled 457 participants in Maputo [63.0 % were MSM who had sex with women (MSMW)], 538 in Beira (36.2 % MSMW) and 330 in Nampula-Nacala (54.8 % MSMW) in 2011. Analysis suggests that MSM who have sex only with men (MSMO) had increased odds of having HIV (aOR 2.7) compared to MSMW. HIV among MSMO associated with age, self-reported STI (aOR 4.2), having a single male anal partner (aOR 3.8) and having transactional sex with a man (aOR 3.5) in the past year. Among MSMW, HIV associated with age, lower education (aOR 32.5), being uncircumcised (aOR 3.1) and having transactional sex with a woman (aOR 6.0) in the past year. Findings confirm that MSMO and MSMW have distinct HIV risks in Mozambique; HIV programs for MSM in Southern Africa should take such differences into consideration.

Gender Expression and Risk of HIV Infection Among Black South African Men Who Have Sex with Men.

To explore demographic, behavioral and psychosocial risk factors for HIV infection in South African MSM we recruited 480 MSM (aged 18 and 44 years) using respondent-driven sampling. Data were collected through individual computer-assisted face-to-face interviews. Participants were tested for HIV. RDS-adjusted HIV prevalence is 30.1 % (unadjusted 35.6 %). Few participants had ever engaged in both receptive and insertive anal sex; sex with women was frequently reported. Independent demographic and behavioral correlates of HIV infection include age, education, number of male sexual partners, ever having been forced to have sex, and ever having engaged in transactional sex; engagement in sex with women was a protective factor. Psychosocial risk factors independently associated with HIV infection were feminine identification, internalized homophobia, and hazardous drinking. Our findings confirm what has been found in other studies, but also suggest that the dynamics and context of sexual transmission among MSM in South Africa differ from those among MSM in Western countries.

HIV testing practices of South African township MSM in the era of expanded access to ART.

While men who have sex with men (MSM) in Africa are at high risk for HIV infection, few of those already infected know their status. Effectively promoting frequent HIV testing-of increasing importance with the expanding accessibility of antiretroviral treatment-requires an understanding of the testing practices in this population. To understand men's HIV testing practices, including their behavior, experiences, and perceptions, we conducted in-depth interviews with 81 black South African MSM (ages 20-39), purposively recruited from four townships. Many men in the sample had tested for HIV. While ever having tested seemed to facilitate repeat testing, men still expressed a high level of discomfort with testing. It was common to test after having engaged in risky behavior, thus increasing anxiety about testing that was already present. Fear that they might test HIV positive caused some men to avoid testing until they were clearly sick, and others to avoid testing completely. HIV testing may increase in this population if it becomes a routine practice, instead of being driven by anxiety-inducing incidents. Mobilization through social support might facilitate frequent testing while education about current treatment options is needed.

Correlates of HIV Testing Among Men Who have Sex with Men in Three Urban Areas of Mozambique: Missed Opportunities for Prevention.

This is the first study to identify levels of recent HIV testing and associated factors among men who have sex with men (MSM) in Mozambique. Using data from Maputo (n = 493), Beira (n = 572), and Nampula/Nacala (n = 347), collected via respondent-driven sampling in 2011, and excluding those with prior known infection, we found that 30.4 % [95 % confidence interval (CI) 25.0-36.3 %], 42.1 % (95 % CI 36.8-47.3 %) and 29.8 % (95 % CI 22.9-36.9 %), respectively, had recently tested for HIV (≤12 months), while between three and five out of 10 MSM had never tested. A range of factors was associated with recent HIV testing such as familiarity with the modes of transmission, knowledge of antiretroviral treatment for HIV, contact with peer educators and awareness of partner serostatus; yet, surprisingly recent healthcare utilization was not associated with recent testing. Findings provide evidence that structural and behavioral interventions among MSM may play an important role in increasing HIV testing.

Men who have sex with men in Mozambique: identifying a hidden population at high-risk for HIV.

The population of men who have sex with men (MSM) has been largely ignored in HIV-related policies and programming in Mozambique and there is little information about the contribution of MSM to the HIV epidemic. An integrated biological and behavioral study among MSM using respondent-driven sampling was conducted in 2011 in Maputo, Beira and Nampula/Nacala. Men who reported engaging in oral or anal sex with other men in the last 12 months answered a questionnaire and provided a blood sample for HIV testing. The prevalence of HIV was 8.2 % (Maputo, n = 496), 9.1 % (Beira, n = 584) and 3.1 % (Nampula/Nacala, n = 353). Prevalence was higher among MSM ≥ 25 vs. 18-24 years: 33.8 % vs. 2.4 % (p < 0.001), 32.1 vs. 2.8 % (p < 0.001), and 10.3 vs. 2.7 % (p < 0.06), in each city respectively. The difference in prevalence demonstrates the need to increase prevention for younger MSM at risk for HIV and ensure care and treatment for older HIV-infected MSM.

"This will not enter me": painful anal intercourse among Black men who have sex with men in South African townships.

Little is known about painful receptive anal intercourse (RAI) and its relationship to HIV risk and protective behaviors among men who have sex with men (MSM). The purpose of this study was to identify attributions for and responses to painful RAI among Black MSM in South African townships. In-depth interviews were conducted with 81 Black MSM (ages 20-39 years) who were purposively recruited from four townships. The semi-structured interviews addressed sexual behavior and identity, alcohol use, and safer sex. Pain during RAI was brought up by many participants without specific prompting from the interviewer. Analysis of the interview transcripts revealed that pain was a common feature of first RAI experiences but was not limited to first-time experiences. The participants attributed pain during RAI to partner characteristics, interpersonal dynamics, lack of lubricant, and alcohol use or non-use. The main strategies participants used to address pain during RAI were setting sexual boundaries and lubricant use; a small number of participants reported purposefully consuming alcohol to prevent the pain associated with RAI. Black South African MSM can be supported to reduce pain during RAI in ways that reduce their HIV/STI risk. Culturally specific sexual health education, supportive sexual health services, and improved access to condom-compatible lubricants are important components of HIV/STI interventions for this population.

'They think that gays have money': gender identity and transactional sex among Black men who have sex with men in four South African townships.

Transactional sex has not been studied much among men who have sex with men in Africa. Consequently, little is understood about attitudes towards the practice, the circumstances that give rise to it or how transactional sex relationships are managed. We conducted in-depth interviews with 81 Black men aged 20-44 from four low-resourced townships in Tshwane, South Africa. We found that transactional sex was a widely used strategy for initiating and sustaining relationships with regular and casual partners, and was motivated by both the need for subsistence and for consumption. Alcohol-based exchanges in particular provided men in the townships with a covert and safe platform to communicate erotic, sexual and romantic attraction to other men, and bars and other drinking places were a popular venue for meeting potential sexual partners. The majority of 'feminine-identifying' men had engaged in transactional sex as the providers of money and material goods compared to men who identified as either 'masculine' or as 'both masculine and feminine'. Surprisingly, however, this did not necessarily give them greater control in these relationships. Our study provides an initial foray into a complex sociosexual phenomenon and suggests that gender identity is an important construct for understanding transactional sex relationships among men in Africa.