| |
Trends in condom use among men who have sex with men in the united states: the role of antiretroviral therapy and sero-adaptive strategies.....Condomless sex increasing
|
| |
| |
Download the PDF here
"Among HIV-positive MSM, condomless sex at last sex increased from 34% in 2005 to 44% in 2014 (p<0.001). There were increases in both concordant (p<0.001) and discordant condomless sex (p<0.001), although the former was more common (Table 1). These increases did not differ significantly by age, race or ART use (Supplemental Figure, http://links.lww.com/QAD/A926). However, in 2014 most HIV-positive MSM were on ART (90%) and of those reporting discordant condomless sex, 88% were on ART (258/293).
Among 5,371 HIV-positive MSM, there were increases in concordant (19% in 2005 to 25% in 2014, p < 0.001) and discordant condomless sex (15% to 19%, p < 0.001).
The increases were not different by ART use. Among 30,547 HIV-negative MSM, concordant (21% to 27%, p < 0.001) and discordant condomless sex increased (8% to 13%, p < 0.001)."
"Conclusions: Our data suggest that condom use decreased among MSM and that the trends are not explained by serosorting or ART. Promotion of condoms and increased access to PrEP, are vital to ensure that the benefits of ART in reducing transmission of HIV are not undermined."
"Our data suggests that condom use has decreased among MSM and that the trends are not explained by serosorting, seropositioning, PrEP use or HIV treatment, and should continue to be monitored. The promotion of condom use among HIV-negative as well as HIV-positive MSM remains vital to ensure the benefits of ART in reducing transmission of HIV are not undermined. However, MSM comprise diverse populations that vary in socio-demographic and behavioral characteristics and have different prevention needs and preferences. In this new era of HIV prevention, MSM have more tools available to them than ever before. There are new strategies, such as PrEP for those who are negative and at high risk and treatment as prevention for HIV-positive men, and previously recognized methods which can substantially reduce risk such as using condoms consistently and correctly. Since no single strategy provides complete protection in real-world use, multiple approaches are needed to reduce new HIV infections.
This analysis explored whether documented increases in condomless sex among MSM were associated with adoption of other prevention strategies. We found that among HIV-negative MSM condomless sex increased with both concordant and discordant partners and there was no indication that sero-adaptive behaviors were associated with the increases. In the years studied, PrEP use was too low to contribute to the increases in condomless sex, and excluding MSM on PrEP from the analyses did not change the results. Although discordant condomless receptive anal sex was rare among HIV-negative MSM, our data suggest that this practice has increased. While we found increases in concordant and discordant condomless sex among HIV-positive MSM, we also found evidence of sero-adaptive behaviors among HIV-positive MSM; the increase in discordant condomless anal sex was only statistically significant for receptive sex but not insertive sex, which carries higher risk of HIV transmission. The data also suggest that HIV treatment does not explain the increase in condomless sex among HIV-positive MSM, however, most HIV-positive MSM were on ART."
---------
Trends in condom use among men who have sex with men in the united states: the role of antiretroviral therapy and sero-adaptive strategies.
AIDS May 5 2016
Paz-Bailey, Gabriela; Mendoza, Maria; Finlayson, Teresa; Wejnert, Cyprian; Le, Binh; Rose, Charles; Raymond, Henry Fisher; Prejean, Joseph; for the NHBS Study Group
1. Centers for Disease Control and Prevention, Atlanta, GA; 2. San Francisco Department of Public Health, San Francisco, CA; 3. University of California, San Francisco, CA
Abstract
Objective: Evaluate changes in condomless anal sex at last sex among MSM and assess if these changes are associated with the adoption of serosorting and biomedical prevention.
Design: The National HIV Behavioral Surveillance (NHBS)is a cross-sectional survey done in up to 21 cities in 2005, 2008, 2011 and 2014.
Methods: MSM were recruited through venue-based sampling. Among men reporting >=1 male partner we evaluated changes in condomless anal sex at last sex with a partner with: 1) HIV-concordant (proxy for sero-sorting), or 2) HIV-discordant (discordant/unknown) status. We hypothesized that if concordant condomless sex was increasing while discordant was stable/declining, the increases could be driven by more men attempting to serosort. We used generalized estimating equations assuming a Poisson distribution and robust variance estimator to explore whether temporal changes in the outcomes varied by selected characteristics. We also assessed changes in condomless anal sex by antiretroviral therapy (ART) use among HIV-positive MSM.
Results:
Among 5,371 HIV-positive MSM, there were increases in concordant (19% in 2005 to 25% in 2014, p < 0.001) and discordant condomless sex (15% to 19%, p < 0.001).
The increases were not different by ART use. Among 30,547 HIV-negative MSM, concordant (21% to 27%, p < 0.001) and discordant condomless sex increased (8% to 13%, p < 0.001).
Conclusions: Our data suggest that condom use decreased among MSM and that the trends are not explained by serosorting or ART. Promotion of condoms and increased access to PrEP, are vital to ensure that the benefits of ART in reducing transmission of HIV are not undermined.
Background
Condom use affects the likelihood of HIV sexual transmission when a contact is made between an infected and susceptible individual [1], and is one of the key indicators measured in behavioral surveillance and prevention research. While condoms can reduce the risk of HIV transmission, they do not eliminate risk and are often not used consistently[2]. Some men who have sex with men (MSM) attempt to decrease their HIV risk by engaging in seroadaptive practices such as serosorting and seropositioning [3]. Seroadaptive practices have been shown to reduce the risk of HIV acquisition compared to having no strategy but increase the risk of infection compared to consistent condom use [3] . Other biomedical prevention strategies are now available, such as treatment as prevention and pre-exposure prophylaxis (PrEP) [4]. Some men may also choose these strategies instead of using condoms.
Previous analyses from CDC's National HIV Behavioral Surveillance (NHBS) showed that condom use among MSM declined 20% from 2005 to 2011[5]. This follow-up analysis includes new data (2014) and investigates if the increases in condomless sex were associated with use of other perceived prevention strategies. We investigated trends in concordant condomless sex at last sex as a proxy for serosorting and trends in the adoption of the insertive or receptive role when having condomless sex as an indication of seropositioning. We compared the trends in condomless sex among HIV-positive men on antiretroviral treatment (ART) versus not on ART to investigate if the overall increases were mainly due to reliance among HIV-positive MSM on the protective role of ART. Finally, we investigated the association of PrEP use and condomless sex.
Results
The percent of black participants and those recruited at bars and clubs increased from 2005 to 2014. Other characteristics of the sample remained unchanged (Supplemental Table,
Concordant and discordant sex
Among HIV-positive MSM, condomless sex at last sex increased from 34% in 2005 to 44% in 2014 (p<0.001). There were increases in both concordant (p<0.001) and discordant condomless sex (p<0.001), although the former was more common (Table 1). These increases did not differ significantly by age, race or ART use (Supplemental Figure, http://links.lww.com/QAD/A926). However, in 2014 most HIV-positive MSM were on ART (90%) and of those reporting discordant condomless sex, 88% were on ART (258/293).
Overall (all years), 41% of HIV-negative MSM reported a discordant partner (37% with a partner of unknown status and 4% with an HIV-positive partner). Among HIV-negative MSM condomless sex at last anal sex increased from 29% in 2005 to 41% in 2014 (p<0.001) (Table). Both concordant and discordant condomless sex increased (both p<0.001). The increases did not vary by race. The increase did vary by age (p=0.003), and was greatest among MSM ages 18-24 years. (Figure).
Insertive and receptive sex
Among HIV-positive MSM an increase was noted for discordant receptive condomless sex (p<0.001) while the percent engaging in discordant insertive sex (p=0.34) remained unchanged. Among HIV-negative MSM both insertive and receptive anal sex with a discordant partner increased from 2005 to 2014 (both p<0.001).
PREP use
PREP use among HIV-negative MSM was 0.5% in 2011 and 3.5% in 2014. When excluding men on PREP from the analyses the increasing trend in any, concordant and discordant condomless anal sex remained unchanged.
Discussion
This analysis explored whether documented increases in condomless sex among MSM were associated with adoption of other prevention strategies. We found that among HIV-negative MSM condomless sex increased with both concordant and discordant partners and there was no indication that sero-adaptive behaviors were associated with the increases. In the years studied, PrEP use was too low to contribute to the increases in condomless sex, and excluding MSM on PrEP from the analyses did not change the results. Although discordant condomless receptive anal sex was rare among HIV-negative MSM, our data suggest that this practice has increased. While we found increases in concordant and discordant condomless sex among HIV-positive MSM, we also found evidence of sero-adaptive behaviors among HIV-positive MSM; the increase in discordant condomless anal sex was only statistically significant for receptive sex but not insertive sex, which carries higher risk of HIV transmission. The data also suggest that HIV treatment does not explain the increase in condomless sex among HIV-positive MSM, however, most HIV-positive MSM were on ART.
These findings corroborate previous reports of increases in condomless sex among MSM in the United States[9]. We cannot establish if these trends are contributing to the documented increase in HIV incidence among MSM. However, the increase in concordant condomless sex among HIV-negative MSM was highest among the youngest age group, among whom the greatest increase in the number of new HIV infections has occurred [10]. Men may perceive themselves and their partners to be HIV-negative, however, many men who are HIV-positive are not aware of their infection, and awareness is lowest among the youngest age groups [11]. Although men could be choosing other prevention strategies such as PrEP, this strategy was uncommon and did not explain the increases in condomless sex. Men with discordant partners could be choosing not to use condoms if their HIV-positive partner is on ART. However, most discordant partnerships among HIV-negative MSM in this analysis were with a partner of unknown status as opposed to an HIV-positive partner. There may be other reasons for the increases in condomless sex that were not explored such as changing social norms around condom use [12].
Similar increases in condomless sex have been reported from other developed countries[13-17]. Mathematical modeling from the United Kingdom [18] and the Netherlands [19] suggests that reductions in HIV incidence due to ART and earlier HIV diagnosis have been offset by increases in condomless sex among MSM.
The findings in this report are subject to limitations. NHBS data are from MSM who were recruited at venues in cities with high AIDS burden. Thus, results may not be generalizable to all MSM. Further, analyses were based on self-reported data and may be subject to social-desirability bias. Several studies have previously documented misreporting of HIV status [20]. However, trends by HIV-status were similar and we do not believe the potential biased introduced by this would affect the conclusion of our analyses. It is not possible to fully exclude a methodological change in NHBS contributing to our findings. One major change in NHBS methods was the inclusion of sexual behavior questions during eligibility screening starting in 2011. Requiring disclosure of sexual behaviors at the time of screening could have differentially selected participants who were more comfortable with disclosing their sexuality. Another possible explanation for our findings is that MSM may be more willing to disclose their risk behaviors in later years if stigma associated with HIV infection or homosexuality is decreasing, for which some evidence exists[21, 22]. Finally, data are not weighted to account for the complex sampling methodology used to recruit MSM. Point estimates may therefore be biased by over-or under-represented subgroups of the population. We did not present behaviors by partner type, because condomless sex with regular partners is also risky [23].
Our data suggests that condom use has decreased among MSM and that the trends are not explained by serosorting, seropositioning, PrEP use or HIV treatment, and should continue to be monitored. The promotion of condom use among HIV-negative as well as HIV-positive MSM remains vital to ensure the benefits of ART in reducing transmission of HIV are not undermined. However, MSM comprise diverse populations that vary in socio-demographic and behavioral characteristics and have different prevention needs and preferences. In this new era of HIV prevention, MSM have more tools available to them than ever before. There are new strategies, such as PrEP for those who are negative and at high risk and treatment as prevention for HIV-positive men, and previously recognized methods which can substantially reduce risk such as using condoms consistently and correctly. Since no single strategy provides complete protection in real-world use, multiple approaches are needed to reduce new HIV infections.
|
|
| |
| |
|
|
|
