HIV Behavioral Surveillance Survey Research Articles

Grindr, Scruff, and on the Hunt: Predictors of Condomless Anal Sex, Internet Use, and Mobile Application Use Among Men Who Have Sex With Men.

In 2016, gay, bisexual, and other men who have sex with men (MSM) comprise more than half of all new HIV diagnoses in the United States, with the primary mode of infection being condomless anal sex (CAS). While studies report an association between use of Internet-based social networking sites and increased CAS, the research on the relationship between cell phone mobile applications (e.g., Grindr, Scruff, Jack’d) and CAS is much less developed. The present study examines whether the manner in which gay, bisexual, and other MSM find sexual partners predicts an increase in likelihood of engaging in CAS in an urban, noncoastal U.S. city. Conducting a secondary data analysis of the 2011 National HIV Behavioral Surveillance survey for Denver (N = 546), the authors performed binary logistic regression analyses to assess the models that predict how MSM find sexual partners, and the odds of engaging in CAS. While the results suggest that age and race are associated with the mode of finding sexual partners, using the Internet or a mobile app to find sexual partners was not predictive of CAS (ZWald = .41, p = .52; ZWald = .80, p = .37). In terms of HIV prevention, these findings suggest a need for intervention to address HIV prevention on multiple levels (e.g., individual, group, community).

Closing the Gap? The HIV Continuum in Care for African-American Men Who Have Sex with Men, San Francisco, 2004-2014.

We examined trends in the HIV continuum in care in the National HIV Behavioral Surveillance surveys for MSM in San Francisco from 2004 to 2014. In 2004, HIV-positive African-American MSM were less likely to be diagnosed (42.9 vs. 87.5%, p=0.003), linked to care (42.9 vs. 85.7%, p=0.007), or to have ever used antiretroviral treatment (ART) (28.6 vs. 69.6%, p=0.032) compared to white MSM. By 2014, these gaps had narrowed but not closed, including diagnosis (85.7 vs. 100%, Fisher's exact p=0.106), linkage to care (85.7 vs. 96.8%, Fisher's exact p=0.290), and ART use (85.7 vs. 94.9%, Fisher's exact p=0.369).

HIV test offers and acceptance: New York State findings from the behavioral risk factor surveillance system and the National HIV behavioral surveillance, 2011-2012.

The New York State HIV testing law requires that patients aged 13-64 years be offered HIV testing in health care settings. We investigated the extent to which HIV testing was offered and accepted during the 24 months after law enactment. We added local questions to the Behavioral Risk Factor Surveillance System (BRFSS) and the National HIV Behavioral Surveillance (NHBS) surveys asking respondents aged 18-64 years whether they were offered an HIV test in health care settings, and whether they had accepted testing. Statewide prevalence estimates of test offers and acceptance were obtained from a combined 2011-2012 BRFSS sample (N = 6,223). Local estimates for 2 high-risk populations were obtained from NHBS 2011 men who have sex with men (N = 329) and 2012 injection drug users (N = 188) samples. BRFSS data showed that 73% of New Yorkers received care in any health care setting in the past 12 months, of whom 25% were offered an HIV test. Sixty percent accepted the test when offered. The levels of test offer increased from 20% to 29% over time, whereas acceptance levels decreased from 68% to 53%. NHBS data showed that 81% of men who have sex with men received care, of whom 43% were offered an HIV test. Eighty-eight percent accepted the test when offered. Eighty-five percent of injection drug users received care, of whom 63% were offered an HIV test, and 63% accepted the test when offered. We found evidence of partial and increasing implementation of the HIV testing law. Importantly, these studies demonstrated New Yorkers' willingness to accept an offered HIV test as part of routine care in health care settings.

Evidence for risk reduction among amphetamine-injecting men who have sex with men; results from national HIV behavioral surveillance surveys in the Seattle area 2008-2012.

In the Seattle area men who have sex with men and also inject amphetamines (amphetamine-injecting MSM/IDU) are disproportionately likely to be infected with HIV. To characterize their distinctive characteristics, we combined data from two Seattle-area surveys of men who have sex with men (MSM) and two surveys of injection drug users (IDU). Amphetamine-injecting MSM/IDU were compared with: male IDU, MSM and other MSM/IDU. Amphetamine-injecting MSM/IDU were older than MSM but younger than IDU, more likely to be white than either group, and had an educational level higher than IDU but below MSM. They had the highest HIV prevalence (56 vs. 4-19 %). However, reported HIV cases among them fell from 92 in 1990 to 25 in 2012. They were most likely to report ten or more sex partners (49 vs. 4-26 %), an STD diagnosis (22 vs. 1-7 %) and be tested for HIV (odds ratio 1.00 vs. 0.34-0.52), and least likely to share needles (odds ratio 1.00 vs. 6.80-10.50). While sexual risk remains high, these data suggest measurable and effective risk reduction with respect to sharing injection equipment and HIV testing among Seattle-area amphetamine-injecting MSM/IDU.

Comparison of HIV Behavioral Indicators Among Men Who Have Sex With Men Across Two Survey Methodologies, San Francisco, 2004 and 2008

Our goal was to examine whether community-based behavioral surveys can augment data collected for the National HIV Behavioral Surveillance System (NHBS) among men who have sex with men (MSM) in San Francisco. We compared estimates of sexual risk behaviors among MSM using data from two cycles of NHBS (2004 and 2008) and outreach surveys conducted by STOP AIDS Project (SAP) during the same years. We compared estimates of unprotected anal intercourse (UAI) and other indicators to assess concordance of estimates across methodologies. Of the 3248 interviews conducted, the NHBS sample included more nonwhite and older MSM, more self-reported HIV positive, and less sexually active men than the SAP sample. Estimates of UAI in the last 6 months were slightly higher in the NHBS survey than in the SAP surveys (2004: 40% vs. 36%, P = 0.03; 2008: 44% vs. 38%, P = 0.08). In 2008, where respondent-partner HIV-discordant status could be measured, estimates of UAI with a potentially discordant partner were similar (12% vs. 12%, P = 0.87). Also, the NHBS and SAP surveys observed similar estimates of UAI by high-risk positioning with potentially discordant partners (HIV-positive men reporting insertive UAI with a potentially HIV-negative partner: 13% vs. 11%, P = 0.45; HIV-negative men reporting receptive UAI with a potentially HIV-positive person: 5% vs. 4%, P = 0.85). Behavioral estimates drawn from convenience sampling methods can provide informative surveillance estimates of key behavioral indictors that can augment data from more rigorous national HIV behavioral surveillance surveys.

Comparing Study Populations of Men Who Have Sex with Men: Evaluating Consistency Within Repeat Studies and Across Studies in the Seattle Area Using Different Recruitment Methodologies

There is no gold standard for recruiting unbiased samples of men who have sex with men (MSM). To assess differing recruitment methods, we compared Seattle-area MSM samples from: venue-day-time sampling-based National HIV Behavioral Surveillance (NHBS) surveys in 2008 and 2011, random-digit-dialed (RDD) surveys in 2003 and 2006, and STD clinic patient data 2001-2011. We compared sociodemographics, sexual and drug-associated behavior, and HIV status and testing. There was generally good consistency between the two NHBS surveys and within STD clinic data across time. NHBS participants reported higher levels of drug-associated and lower levels of sexual risk than STD clinic patients. RDD participants differed from the other study populations in sociodemographics and some risk behaviors. While neither NHBS nor the STD clinic study populations may be representative of all MSM, both appear to provide consistent samples of MSM subpopulations across time that can provide useful information to guide HIV prevention.

Respondent Driven Sampling for HIV Biological and Behavioral Surveillance in Latin America and the Caribbean

Since 2005, respondent driven sampling (RDS) has been widely used for HIV biological and behavioral surveillance surveys (BBSS) in Latin America and the Caribbean (LAC). In this manuscript, we provide a focused review of RDS among hard-to-reach high-risk populations in LAC and describe their principal operational, design, and analytical considerations. We reviewed published and unpublished reports, protocols, and manuscripts for RDS studies conducted in LAC between January 1, 2005 and December 31, 2011. We abstracted key operational information and generated summary statistics across all studies. Between 2005 and 2011, 87 RDS studies were conducted in 15 countries in LAC (68% in South America, 18% in Mexico and Central America, and 14% in the Caribbean). The target populations were primarily men who have sex with men (43%), sex workers (29%), and drug users (26%). Study considerations included establishing clear eligibility criteria, measuring social network sizes, collecting specimens for biological testing, among others. Most of the reviewed studies are the first in their respective countries to collect data on hard-to-reach populations and the first attempt to use a probability-based sampling method. These RDS studies allowed researchers and public health practitioners in LAC to access hard-to-reach HIV high-risk populations and collect valuable data on the prevalence of HIV and other infections, as well as related risk behaviors.

Estimating HIV Prevalence and HIV-Related Risk Behaviors Among Heterosexual Women Who Have Multiple Sex Partners Using Respondent-Driven Sampling in a High-Risk Community in South Africa

Repeated surveillance surveys are important for monitoring trends in HIV and risk behaviors over time. In countries most adversely affected by HIV and AIDS, community-level HIV biological and behavioral surveillance surveys are needed among subpopulations who engage in high-risk sexual behaviors. To describe the effectiveness of respondent-driven sampling (RDS) to recruit heterosexual women who have multiple concurrent sexual partnerships, to report HIV prevalence and describe key characteristics among them, and to assess whether RDS-accessed women not usually recruited during routine sentinel surveillance surveys. We conducted a HIV biological and behavioral surveillance surveys using RDS among women. Participants completed an audio-computer-assisted survey interview, voluntarily provided dried blood spots for HIV testing, and were offered rapid HIV testing. The analytical sample comprised 845 women whose mean age was 23.9 years. About 6.4% were married, 49.6% lived in informal dwellings, and 31.8% reported not to have enough money for food. HIV prevalence was 28.8% (95% confidence intervals: 24.3 to 33.4). Being between 20 and 29 years was significantly related to HIV infection. Women who had never attended a public health facility (10.1%) compared with those who had were more likely to be 16-19 years (P = 0.008), reported sexual debut at 10-14 years (P = 0.044), were more likely to have experienced a symptom of a sexually transmitted infection (P = 0.031), and to have taken illegal drugs (P = 0.007). RDS effectively recruited women who reported 2 or more male sexual partners in the past 3 months. HIV prevalence and HIV-related risk behaviors were high among women who have multiple concurrent partners.

If the permanent deferral were lifted would men who have sex with men want to donate blood, and if so, who would be eligible?

The deferral of men who have sex with men (MSM) from blood donation is controversial worldwide, with national policies varying from no explicit deferral to permanent deferral. This study assesses whether MSM have donated and would be interested in donating if the US exclusion policy were removed and who would be eligible to donate if the policy were modified to a temporary or lower-risk deferral criterion. Questions about previous blood donation and interest in future donation were added to the National HIV Behavioral Surveillance survey questionnaire, which periodically gathers risk behavior information from MSM in San Francisco. Overall, 77.3% of 475 MSM respondents expressed interest in donating. By lower-risk criteria, 10.1% had no sexual contact in the past 6 months (2.3% in the past 12 months) and 1.9% had only lower-risk sexual contact in the past 6 months (1.5% in the past 12 months). Of the 23.4% who answered yes to having donated in the past, at least 25.2% did not comply with the current deferral of no male-male sex since 1977. The majority of MSM are interested in donating blood. Depending on how the policy would be changed (i.e., either a temporary or a behavior-based deferral criterion), substantial numbers of MSM would be eligible.

International travel among HIV-positive and HIV-negative men who have sex with men, San Francisco, USA

We measured the prevalence of international travel, the demographic and risk profile of international travellers and risk and preventive behaviours of travellers among HIV-negative and HIV-positive men who have sex with men (MSM), based in San Francisco, CA, USA, through the addition of questions to the local implementation of the National HIV Behavioral Surveillance survey in 2008. Of 270 MSM participating in the survey, slightly more than one-quarter (26.3%) had travelled internationally in the last year. Those with a history of international travel were more likely to be foreign born, of a higher socioeconomic status and HIV uninfected. Of eight HIV-positive MSM who travelled internationally (11.3% of HIV-positive MSM), all were on antiretroviral therapy and only three recalled being vaccinated for hepatitis A and B. Human papillomavirus infection was also higher among international travellers. Travel health services must be improved to address special needs of this population of international travellers.

Variations in Patterns of Sexual Risk Behavior among Seattle-Area MSM Based on their HIV Status, the HIV Status of their Partner and Partner Type

We evaluated sexual risk behavior in 368 Seattle-area MSM recruited in the 2008 National HIV Behavioral Surveillance survey. We found significant concordance between participants' self-reported HIV status and that of their sexual partners. Persons unaware of partners' HIV status were more likely to report only oral sex. Those aware were less likely to report non-concordant unprotected anal intercourse (UAI). Participants reporting themselves HIV-positive were more likely than those self-reporting HIV-negative status to report non-concordant UAI and several other sexual risk behaviors. The level of non-concordant UAI did not materially differ by whether their partner was a main or casual partner.

“Are You Iffy?”: A Social Marketing Campaign to Address Uncertainty in HIV Status Communication Among Men Who Have Sex With Men

To The Editor: Recent data show that 44% of HIV- positive men who have sex with men (MSM) in the United States were unaware of their infection.1 Having inaccurate information about one's HIV status along with increasing practice of serosorting may increase risk of HIV infection among MSM.2,3 Yet, the continued use of the language “HIV-negative” to describe one's HIV status, regardless of recent sexual risk and HIV testing history, suggests that new language is needed for self assessment and communication of HIV status. We launched a social marketing campaign “Are You Iffy?” to encourage MSM in San Francisco to reassess their HIV-negative status. Focus groups and community field-testing were conducted to design the campaign, introducing the concept of being “iffy” about one's HIV status (Fig. 1). Between May and July 2008, 10,000 palm cards, 140 posters, 7 large billboards, and 10 newspaper advertisements were distributed at various locations, including bars/clubs, bathrooms, subway and bus terminals, and newspaper kiosks, in neighborhoods where MSM are known to congregate. A post-test evaluation was conducted between July and October 2008 to assess the effects of the campaign as a part of the National HIV Behavioral Surveillance survey. Details of National HIV Behavioral Surveillance sampling and recruitment procedures have been described elsewhere.4,5 Participants were asked how sure they were about their HIV status on a scale of 1 (not sure at all) to 5 (very sure), and if they had rethought how certain they were about their HIV status after they saw the campaign. The study was approved by the Centers for Disease Control and Prevention Institutional Review Board and the Committee for Human Research of the University of California, San Francisco.Figure 1.: “Are You Iffy?” campaign palm card.Study population: N = 316; 53% white, 24% Latino, 7% Asian, and 7% black; mean age = 37.6 (standard deviation = 11.3); 54% with a bachelor degree or higher, 33% completed some college, and 13% with a high school degree. In all, 61 (19%) participants self reported being HIV positive and were thus not asked the evaluation questions. Of the remaining 255 MSM, 114 (45%) reported having seen the campaign. About 73 (64%) correctly identified the campaign as being about reassessing one's HIV status. Overall, of those who saw the campaign, 41 (36%) indicated that they rethought their own HIV status after seeing/reading the messages in the campaign (Table 1). It is noteworthy that 31% of those who were “Very sure” of their HIV status at the time of the survey also reported to have reconsidered their status, suggesting that the campaign concepts and messages resonated with men across varying levels of certainty around their HIV status.TABLE 1: Effects of the “Are You Iffy?” Campaign in San Francisco: Proportions of MSM Participants Who Have Reconsidered Their HIV Status Due to Exposure to the CampaignThe campaign was moderately successful in reaching non-HIV-positive MSM, and encouraging them to reassess their HIV status. This effort suggests that such campaigns may help reinforce MSM who are unsure of their HIV status to think critically about how confident to be in their HIV-negative status. Future campaigns built on this one can explicitly focus on how to appropriately communicate uncertainty around HIV status to one's partners and how to overcome barriers to HIV testing so that MSM will be better aware of their HIV status. Jennifer Hecht, MPH Jason Riggs, BA Hunter Hargraves, BA STOPAIDS Project San Francisco, CA Chongyi Wei, DrPH Behavioral and Community Health Sciences Graduate School of Public Health University of Pittsburgh Pittsburgh, PA H. Fisher Raymond, MPH San Francisco Department of Public Health San Francisco, CA hfisher.[email protected]

A Major HIV Risk Factor for Young Men Who Have Sex With Men Is Sex With Older Partners

A Major HIV Risk Factor for Young Men Who Have Sex With Men Is Sex With Older Partners

Differences in HIV-related behaviors at Lugufu refugee camp and surrounding host villages, Tanzania

BackgroundAn HIV behavioral surveillance survey was undertaken in November 2005 at Lugufu refugee camp and surrounding host villages, located near western Tanzania's border with the Democratic Republic of Congo (DRC).MethodsThe sample size was 1,743 persons based on cluster survey methodology. All members of selected households between 15–49 years old were eligible respondents. Questions included HIV-related behaviors, population displacement, mobility, networking and forced sex. Data was analyzed using Stata to measure differences in proportions (chi-square) and differences in means (t-test) between gender, age groups, and settlement location for variables of interest.ResultsStudy results reflect the complexity of factors that may promote or inhibit HIV transmission in conflict-affected and displaced populations. Within this setting, factors that may increase the risk of HIV infections among refugees compared to the population in surrounding villages include young age of sexual initiation among males (15.9 years vs. 19.8 years, p = .000), high-risk sex partners in the 15–24 year age group (40% vs. 21%, χ2 33.83, p = .000), limited access to income (16% vs. 51% χ2 222.94, p = .000), and the vulnerability of refugee women, especially widowed, divorced and never-married women, to transactional sex (married vs. never married, divorced, widowed: for 15–24 age group, 4% and 18% respectively, χ2 8.07, p = .004; for 25–49 age group, 4% and 23% respectively, χ2 21.46, p = .000). A majority of both refugee and host village respondents who experienced forced sex in the past 12 months identified their partner as perpetrator (64% camp and 87% in villages). Although restrictions on movements in and out of the camp exist, there was regular interaction between communities. Condom use was found to be below 50%, and expanded population networks may also increase opportunities for HIV transmission. Availability of refugee health services may be a protective factor. Most respondents knew where to go for HIV testing (84% of refugee respondents and 78% of respondents in surrounding villages), while more refugees than respondents from villages had ever been tested (42% vs. 22%, χ2 63.69, p = .000).ConclusionThis research has important programmatic implications. Regardless of differences between camp and village populations, study results point to the need for targeted activities within each population. Services should include youth education and life skills programs emphasizing the benefits of delayed sexual initiation and the risks involved in transactional sex, especially in the camp where greater proportions of youth are affected by these issues relative to the surrounding host villages. As well, programs should stress the importance of correct and consistent condom use to increase usage in both populations. Further investigation into forced sex within regular partnerships, and programs that encourage male involvement in addressing this issue are needed. Program managers should verify that current commodity distribution systems ensure vulnerable women's access to resources, and consider additional program responses.

Assessment of Respondent Driven Sampling for Recruiting Female Sex Workers in Two Vietnamese Cities: Reaching the Unseen Sex Worker

Respondent driven sampling (RDS) is a relatively new method to sample hard-to-reach populations. Until this study, female sex workers (FSWs) in Vietnam were sampled using a variety of methods, including time location sampling (TLS), which may not access the more hidden types of FSWs. This paper presents an analysis from an HIV biological and behavioral surveillance survey to assess the feasibility and effectiveness of RDS to sample FSWs, to determine if RDS can reach otherwise inaccessible FSWs in Vietnam and to compare RDS findings of HIV risk factors with a theoretical TLS. Through face-to-face interviews with FSWs in Ho Chi Minh City (HCMC) and Hai Phong (HP), data were collected about the venues where they most often solicit their clients. These data were used to create three variables to assess whether FSWs solicit their clients in locations that are visible, semi-visible and non-visible. For this analysis, the visible group simulates a sample captured using TLS. Survey results in HIV prevalence and related risk factors and service utilization, adjusted for sampling methodology, were compared across each of the three FSW visibility groups to assess potential bias in TLS relative to RDS. The number of self-reported visible FSWs (HCMC: n=311; HP: n=162) was much larger than those of the semi-visible (HCMC: n=65; HP: n=43) and non-visible (HCMC: n=37; HP: n=10) FSWs in HCMC and HP. Non-visible FSWs in both cities were just as likely as visible and semi-visible FSWs to be HIV positive (HCMC: visible 14.5%, semi-visible 13.8%, non-visible 13.5%, p value = 0.982; HP: visible 35.2%, semi-visible 30.2%, non-visible 30.0%, p value = 0.801), to practice behaviors that put them at risk for contracting and transmitting HIV (injecting drug use—HCMC: visible 13.8%, semi-visible 12.3%, non-visible 5.4%, p value = 0.347; HP: visible 38.9%, semi-visible 23.3%, non-visible 30.0%, p value = 0.378, to have no condom use in the past month —HCMC only: visible 52.7%, semi-visible 63.1%, non-visible 48.6%, p value = 0.249) and to have symptoms of a sexually transmitted infection (STI) in the past year (HCMC: visible 16.1%, semi-visible 12.3%, non-visible 16.2%, p value = 0.742; HP: visible 13.6%, semi-visible 18.6%, non-visible 20.0%, p value = 0.640). There was a difference found among the visible, semi-visible and non-visible groups in HP for no past month condom use (visible 53.1%, semi-visible 79.1%, non-visible 60.0%, p value = 0.009). This study found that RDS was successful at recruiting hidden types of FSWs in Vietnam. Past reports of FSWs in Vietnam have assessed the more visible FSWs as being the most vulnerable and at risk for HIV. Although the number of visible FSWs is much higher than those of the semi and non-visible groups, this study found that the non-visible FSWs are very vulnerable to HIV infection. If prevention programs are targeting and responding to those who are most likely to be assessed (e.g., more visible types of FSWs) then this analysis indicates that a significant proportion of the FSW population at risk for HIV may not be receiving optimal HIV information and services.