Discussions about sex and sexuality are taboo in Lesotho, which complicates an already delicate situation given that the HIV pandemic feeds off this conservatism and the lack of education around prevention. According to Populations Services International, an organization working on the social marketing of condoms, many Basotho would rather support HIV positive people than talk to them about safe sex as a means of HIV prevention (Population Services International - Lesotho, 2012). Many HIV/AIDS education programs are not as effective as they could be because of the difficulty in discussing culturally-taboo subjects. (UNAIDS; UNESCO, 2002) According to Asthana, an African man‟s success was defined by how many women he could sleep with, and the more powerful you became, the more wives and children you should have (Asthana, 2005). As in India, (Thomas, Mimiaga, Mayer, Perry, Swaminathan, & Safren, 2013) cultural expectations of the Basotho are that each man will marry a woman, placing future female partners at an increased risk of acquiring HIV. Not surprisingly, menwho choose to follow a path that differs from this traditional expectation are often shunned from society. Men in this predicament have two logical choices: 1) Stay true to their identity without regard to
The finding that anticipated HIVstigma from the public and depressive symptoms was mediated by less use of peers to control distressing thoughts (Social thought control) is contrary to our prediction which was based on previous inconsistent relationships between Social thought control and psychological distress (Barahmand, 2009; Wells and Davies, 1994). However, Social thought control has gener- ally been identified as more of an adaptive strategy (Coles and Heimberg, 2005; Wells and Carter, 2009). This is con- sistent with Wells and Carter’s (2009) finding that patients with GAD and patients with depression used Social thought control significantly less than non-patient controls. As such, some MSM living with HIVwho anticipate HIVstigma from the public may be less likely to discuss these thoughts with peers in an attempt to suppress their distress and in turn may be more likely to experience depressive symptoms. Social thought control may offer a unique understanding of the link between the anticipation of HIVstigma from the public and depressive symptoms in some MSM living with HIV and is consistent with previous research findings that social support mediates the impact of HIVstigma on both depressive symptoms and quality of life in PLWH (Rao et al., 2012). Also, inconsistent with prediction, Punishment was not a significant mediator of anxiety and this may be a unique characteristic of this pop- ulation that requires further research.
offer social support. The high prevalence of HIV and STIs reported in Abuja suggest a high HIVrisk within the sex- ual network [14, 31]. At the public policy level, laws crim- inalizing MSM organizations create a barrier to peer HIV/ STI prevention programmes and peer support pro- grammes for adherence to TasP. Finally, a very high level of enacted human rights violations were found in this study, stressing that factors at the community level poses a barrier for MSM to access needed HIV/STI services. Thereby we also find structural stigma towards MSM em- bedded in all ecological layers, including the individual, social network, community and public policy level. A re- cent study among MSM in Togo stressed further that the network, community and policy level factors was associ- ated with HIV infection .
Also, the unfavorable legal environment for MSM through the introduction of the Same Sex Prohibition Act  mitigates access of MSM to HIV prevention services: the law drove MSM into hiding with deleteri- ous impact on access to HIV prevention and treatment services in a peer-led facility . Although Staff in se- lected public and private hospitals across Nigeria are trained to provide key population friendly services , concerns about stigma, discrimination, privacy and con- fidentiality had limited use of these facilities by MSM . Drop-in-centers were established through the USAID funded ‘ Strengthening HIV Prevention Services for Most-at-Risk Populations ’ project  to facilitate access of MSM to HIV testing and STI syndromic man- agement. There is however no formal evaluation of MSM ’ s perspective on challenges with HIV prevention service access in the public, private and peer-led facil- ities; and how to improve access of MSM to HIV pre- vention services.
The strengths of our study include large sample size, diverse geography, and multiple recruitment venues. This study also has limitations. First, behavioral data were collected via interviewer-administered question- naire survey, which might lead to underreporting of commercial sex due to stigma. We took several mea- sures to minimize this information bias, including pro- viding standardized trainings for all interviewers, not collecting any personal identifiable information from participants, and explaining to participants about the study purpose and anonymity nature prior to conducting the interviews. Second, the number of MSM with commercial sex experience was moderate, which lim- ited the statistical power for MSM subgroup compari- sons. Third, while the refusal rate in our study was low, we cannot assess the proportion of MSM who heard about the study but did not come for eligibility screening. Last, since our study sample represents MSM in urban China only, we cannot generalize find- ings to rural or small township residents. We specu- late that MSM in rural or small town venues may have more clandestine social networks with stronger local stigma against homosexuality, with attendant dif- ferences in sexual behaviors and HIV/STI prevalence. As our study is the first study comparing the risk of HIV/STIs among Chinese MSM with different com- mercial sex activities, the findings provide valuable in- formation for HIV/STI prevention interventions among these high-risk subgroups.
While most previous studies have explored PrEP acceptability among individuals involved in clinical trials, i.e. those already taking PrEP, the present study set out to understand perceptions of PrEP amongHIV-negative MSM who had never used it and amongHIV-positive MSM who would not per- sonally benefit from PrEP as a chemoprophylaxis but who may nevertheless be affected socially and psychologically by its availability. Interviewees strove to construct a social representation of PrEP that could enable them to think and communicate about it. AmongHIV-negative MSM, these repre- sentations were characterized by socialstigma that focused largely around HIVstigma, sexual risk- taking, and shame surrounding unprotected sex. HIV-positive interviewees also reproduced socialstigma in relation to PrEP but unanimously acknowledged the potential social psychological benefits of implementing the preventive tool, particularly for improving interpersonal relations between peo- ple of serodiscordant status (Grant & Koester, 2016). Therefore, it is possible to refer to two distinct social representations: (1) amongHIV-negative individuals, there was a representation of PrEP as a risky solution for “high risk” individuals, and (2) amongHIV-positive individuals, there was a repre- sentation of PrEP as potentially enhancing interpersonal relations. These representations guided interviewees’ engagement with PrEP.
In order to further inform best counseling practices, future research building on the current study’s findings should focus on both the negative as well as the positive lived experiences of this population. There is limited qualitative data on the relationship between internalized homophobia, trauma (such as childhood sexual abuse, racism, verbal and physical abuse), and HIVrisk behaviors. Follow up qualitative research should also explore the often overlooked aspects of resiliency among Black MSM as discussed in chapter 2. Mays, Cochran & Zamudio (2004) have identified resiliency as a critical area for future research among Black MSM. It would be helpful for counselors to understand how aspects that influence resiliency, such as natural supports, protective factors, affirmation, and social support (Consolacion, Russell, & Sue, 2004; CDC, 2003; Mays & Cochran, 2001) could be utilized to help buffer the negative and often homophobic experiences of Black MSM. Future research should work to uncover these homophobic experiences, when and how they start, how they may change over time, and how these factors affect mental health and how it may become internalized. This would help counselors to design and improve interventions and therapeutic counseling practices that would enhance resiliency and buffer against the negative experiences of homophobia.
the seven seeds that had not produced any participants. The next wave of survey participants was recruited by the seeds. Each interviewed participant, including the seeds, was told by the research staff about the process for recruiting new participants and was given three recruitment coupons for recruiting his peers into the survey. Each coupon had the address, office hours, and contact details of the study office and a unique code linking the recruiter with those recruited by him. In order to protect privacy, the coupon had no information that might imply that coupon bearers were MSM or were at elevated risk of HIV infection. Men given the coupon by a previous respondent could contact the study office to learn more about the study, make an appointment or come directly to the study office for the interview. The coupons were valid for one month from the date of the interview at which they were given to a respondent. The participant making the referral retained a portion of the coupons he distributed for use in collecting his recruitment incentive payment. Participants received a small incentive (VND 50,000, worth approximately USD 3 at that time) for their interview plus an additional VND 50,000 per participant whom they recruited.
This study has several limitations. First, in both ACS and MACS the interval of six months between study visits was relatively long. Questionnaires in both cohorts included questions on symptoms and risk behavior in the preceding six months. These were reported at sero- conversion visits, but it is unclear whether symptoms occurred during AHI. Twenty-nine percent of serocon- verters in the ACS did not report any symptom in the preceding six months (data not shown). AHI might have been asymptomatic , associated with nonspecific symptoms [18, 37] or symptoms might have been under- reported due to recall bias. A multicenter study from Af- rica showed that prevalence of reported AHI symptoms of patients evaluated within six weeks following infection was higher as compared to patients who were evaluated later . This may also explain the relatively low sensi- tivity observed in the present study. Thus, this relatively long interval between study visits may have led to an underestimation of the performance of the risk scores. Furthermore, the period of acute infection might have been occurring at the previous study visit, when anti- bodies were not yet detectable, rather than at the sero- conversion visit. However, in the ACS, fewer symptoms
Furthermore, there were several limitations to this study that are important to mention. First, there was a difference between the exposure and outcome measure- ments with regard to the time period included; financial hardship was measured at the time of the survey, while drug use was measured based on the past 3 months. Therefore, participants may have reported financial hardship during any period of their lives, including current or past hardships, or hardships spanning the lifetime. In addition, no causal inferences can be drawn due to the cross-sectional design of the study. Reverse causality and a potential bidirectional relationship cannot be ruled out (e.g., consumption of drugs may contribute to financial hardship). Also, our study relies on a single item to measure of financial hardship as conducted by other previous studies [26, 33]. Future studies involving multiple scales/indicators of financial hardship are warranted. Moreover, self-reporting was used to collect data, which could have introduced social desirability bias, reporting bias, or recall bias, particu- larly among MSM . Therefore, for example, we may have underestimated the exact prevalence of drug use. Because some of study variables were not collected with the aim of maximizing the participation rate, there may have been residual confounding from other unmeas- ured covariates (e.g., income, education status, race/ ethnicity and binge drinking) related to substance use. Finally, we focused on MSM in the Paris metropolitan area who used a single geo-social networking applica- tion. The relatively low response rate precludes generalization of our results.
The health- and behavioral characteristics of MSM who reported frequently buying sex in the past year differed from those of both MSM frequently selling sex and those neither buying nor selling. In most re- spects, buyers reported less risk than men selling sex but more than men reporting no TS. It is worth not- ing that, relative to MSM sellers, buyers reported more bisexual activity, lower engagement in condom- less anal sex, but a higher proportion reported some- times feeling lonely, and not testing for HIV and STIs. After adjusting for number of partners, age, and education, buying sex was only borderline associated with having HIV- and STI diagnoses, and injection drug use, but, as discussed above, buying sex was sig- nificantly associated with higher likelihood of using benzodiazepines. Related, a higher proportion con- sumed alcohol, which also lowers social inhibition and anxiety. Our findings on bisexual behavior, alco- hol use, and rates of HIV and STIs are in line with past research [14, 22, 23], but the health profile and risks of menwho buy sex from other men require
Administration approval of PrEP for minors $35 kg, 19 it is critical that AMSM at high risk for HIV acquisition not only have access to routine HIV testing but also access to PrEP and other HIV prevention services. AMSM, particularly African American AMSM, have had consistently low PrEP uptake relative to their rate of new HIV diagnoses. 20 Although PrEP access and uptake may be beyond the scope of the original article, many of the strategies and recommendations needed to improve limited access to testing for AMSM are equally needed to improve access to PrEP and mitigate HIV acquisition risk in this population.
A community-based cross-sectional study among MSM was conducted in Changsha and Tianjin cities from No- vember to December 2011. Potential participants were recruited through venue-based convenience sampling and peer-referral. Peer recruiters were the volunteers from local MSM community-based organizations (i.e. ‘Tianjin Deep Blue Voluntary working group’ in Tianjin; ‘Changsha Zonda-Sunlight Working Party’ and ‘Zuo An Cai Hong’ in Changsha). Ten volunteers were trained for outreach to recruit participants in well-known MSM hotspots including gay bars, clubs, saunas and bath- houses. Each volunteer spent three to four hours on out- reach recruitment on every weekend evening throughout the 2-month period. In addition, peer recruiters and par- ticipants were also asked to refer their peers to partici- pate in this study. Participants were eligible if they were (i) aged 15 or over and had engaged in anal or oral sex with men in the past 12 months; and (ii) able to recall whether they had ever been tested for HIV in their life- time. Participants were asked to complete an anonymous questionnaire of approximately 15–20 minutes duration through face-to-face interviews. All participants, if ne- cessary, were invited or referred to the voluntary coun- selling and testing (VCT) service that offered by the local community-based organizations.
The HSS in India was carried out in representative popula- tions among various subgroups, including female sex workers (FSWs), MSM, IDUs, and patients attending STI clinics. Although the first HSS was conducted in the year 1985 by the Indian Council of Medical Research, the formal annual survey among high-risk groups started in 1998, after the National AIDS Control Organization (NACO) implemented it as part of monitoring the national level program. MSM sites were first included in the HSS in the year 2003 at three dif- ferent locations. These surveillance sites were increased to 98 by the year 2010. The target sample size for the surveillance was set at 250 MSMs at each sentinel site (usually held during June to August every year). Respondents for the surveillance are usually drawn from one of the following service points located in each of the sites: deaddiction centers, drop-in cen- ters, and nongovernmental organization (NGO) clinics. With coverage of over 85% of the MSM population by the year 2006–07, little may be the bias with regard to generalization of the MSM epidemic using HSS data. However, for cor- roboration of HIV prevalence estimated using annual HSS, other data sources such as external surveys involving HIV testing, mapping of the populations, and factors associated with HIVriskamong MSM are crucial.
NVIVO7 was used as an analysis tool for the data. Each participant was assigned to a case, with attribute data for the case coded as a case node (Bazeley, 2007) including key demographics such as age, ethnicity and educational qualification. An initial coding scheme was developed following transcription of the first five interviews with initial tree nodes created. These nodes were both inductive and deductive: my own prior professional practice and reading of the PrEP literature ensured I was attentive to certain issues that I wanted to examine in more detail, however I remained entirely open to the possibility of new and interesting issues emerging (which indeed they did). In order to ensure complex and divergent data was not lost in the process of establishing the coding tree, a number of free nodes were created and used during this initial analysis for data that did not initially sit within the tree nodes. These tree nodes included men’s accounts of SWC; delivery method of PrEP – with each of the five potential methods as branch nodes; and risk reduction strategies. These themes were discussed with my supervisor and then verified with him following further transcriptions of interviews. These themes were discussed further with support of the advisory committee, and a framework was constructed to illustrate their connectivity.
The study began on 21-Sep-2010 at a single site, with opening times differing for MSM and FSW, as they preferred not to share the same waiting room. Sampling started with initial participants, referred to as seeds, which were identified during an initial mapping exercise, carried out by an international consultant on social mapping to explore the situation, sensitize the populations of interest and identify their most active representatives as potential seeds. The criteria we used to select the seeds included clear understanding of the study goal and enthusiasm for it; good communication skills, a large personal network size and enjoying great respect among peers were assets. Because some of the seeds failed to successfully initiate recruitment chains due to the highly stigmatizing environment, we had to recruit a total of 14 MSM and 13 FSW seeds. The intensive outreach work continued even after the start of the survey. We made every effort to include seeds of diverse sociodemographic background and serostatus, as well as places of gathering. After undergoing the survey process them- selves, the seeds initiated the recruitment chains by distributing up to three recruitment coupons to their peers and referring them to
Most parameter values were taken from the existing literature (Supplementary Table 1, http://links.lww.- com/QAD/B377). Behavioral parameters were esti- mated from data. The average number of new partners per year was determined from sexual behavior data on the self-reported number of sexual partners in the last 6 months for MSM in the Netherlands by Rutgers World Population , using the method described in detail in Rozhnova et al. . In this method, we used the actual number of partners for respondents who reported inconsistent condom use. The respondents who always used condoms were assumed to have zero sexual partners. We used population stratification by risk from Rozhnova et al.  in which three groups with highest risk were grouped into one. The resulting percentages of MSM in the four risk groups were 45.1, 35.3, 12.5 and 7.1%. The average numbers of new partners per year (range) were 0.13 (0–0.45), 1.43 (0.45–3.35), 5.44 (3.35–8.88) and 18.21 (8.88–500), respectively.
Clinical effectiveness of pre-exposure prophylaxis (PrEP) for preventing HIV acquisition in menwhohavesex with men (MSM) at high HIVrisk is established. A static decision analytical model was constructed to inform policy prioritisation in England around cost-effectiveness and budgetary impact of a PrEP programme covering 5,000 MSM during an initial high- risk period. National genitourinary medicine clinic surveillance data informed key HIVrisk assumptions. Pragmatic large-scale implementation scenarios were explored. At 86% effectiveness, PrEP given to 5,000 MSM at 3.3 per 100 person-years annual HIV incidence, assuming risk compensation (20% HIV incidence increase), averted 118 HIV infections over remaining lifetimes and was cost saving. Lower effectiveness (64%) gave an incremental cost-effectiveness ratio of + GBP 23,500 (EUR 32,000) per quality-adjusted life year (QALY) gained. Investment of GBP 26.9 mil- lion (EUR 36.6 million) in year-1 breaks even anywhere from year-23 (86% effectiveness) to year-33 (64% effectiveness). PrEP cost-effectiveness was highly sensitive to year-1 HIV incidence, PrEP adherence/ effectiveness, and antiretroviral drug costs. There is much uncertainty around HIV incidence in those given PrEP and adherence/effectiveness, especially under programme scale-up. Substantially reduced PrEP drug costs are needed to give the necessary assurance of cost-effectiveness, and for an affordable public health programme of sufficient size.
and GAG2), one in pol (POL), and three in env (ENV1, ENV2, and ENV3) [13,17]; HXB2 coordinates of these six regions and the primers used for HRM analysis are described in a pre- vious report . Briefly, each HRM region was amplified using a nested polymerase chain reaction in the presence of a fluorescent, intercalating, duplex-dependent dye . A Light- Scanner instrument (Model HR 96, BioFire Diagnostics Inc., Salt Lake City, UT) was used to melt the resulting DNA amplicons. Release of the fluorescent dye was quantified from melting curves produced by the LightScanner software (plotted as -d[fluorescence]/d[temperature]) . The melting range of the DNA amplicons (i.e., the number of degrees over which melting occurred, HRM score) was calculated from each melting curve using an automated R software package (DivMelt, version 1.02) . ARV drug testing and HIV genotyping were performed in a previous study for HIV-infected menwho had viral loads >400 copies/mL . ARV drug testing was performed using a qualitative, high-throughput assay based on high-resolu- tion mass spectrometry; this assay detects 15 ARV drugs: four nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs: emtricitabine, lamivudine, tenofovir, and zidovudine), two non-nucleoside reverse transcriptase inhibitors (NNRTIs: efavirenz and nevirapine), and nine protease inhibitors (PIs: atazanavir, amprenavir, darunavir, indinavir, lopinavir, nelfinavir, saquinavir, tipranavir, and ritonavir) [28,30]. HIV genotyping was performed using the Viro- Seq HIV-1 Genotyping System, v2.8 (Celera Diagnostics, Alameda, CA), which predicts HIV drug resistance to NRTIs, NNRTIs, and PIs. Samples were classified as having drug resistance using the ViroSeq Algorithm advisor .
Polydrug use may be indicative of high-risk personality profile that is typified by high levels of sensation-seeking and negative self-perception, and low levels of impulse control (Patterson, Semple, Zians, & Strathdee, 2005). These traits have been observed in polydrug- using MSM who engage in high rates of HIVrisk behaviors. Alternatively, other scholars suggest that MSM engage in polydrug use as a means to cope with loneliness or psychological distress (McCarty-Caplan, Jantz, & Swartz, 2014). Finally, social and environmental context may play a substantial role in polydrug use. Historically, YMSM have congregated in physical (e.g. bars, night clubs) and virtual (geosocial networking application) venues where substance use is common and accepted. In this type of environment, YMSM may experiment with different drugs as they are being used by other MSM in the environment, which can lead to risk-taking behavior such as inconsistent condom use or sex with multiple partners (Halkitis et al., 2011).