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Ending Epidemic??? - HIV+ MSM Condomless Sex/Detectable Viral Load Behavior USA - Blind Spot ? For Ending the Epidemic....efforts not good enough
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"Characteristics of Sexual Partnerships Among Men With Diagnosed HIV Who Have Sex With Men, United States and Puerto Rico-2015-2019"
We described sexual partnerships among HIV-positive men who have sex with men (MSM), including partnerships with a high risk for sexual HIV transmission.
Recently, the Ending the HIV Epidemic initiative was announced, in which the primary goal was to reduce new HIV infections by 90% in 10 years; reaching this goal will require increasing promotion of various risk reduction strategies, including viral suppression, condom use, sexual HIV concordance, and PrEP use.
In this analysis, we used nationally representative person-level and dyad-level data to describe characteristics of sexual partnerships of MSM with diagnosed HIV. We described high-risk sex within HIV-serodiscordant partnerships among MSM, overall and by selected characteristics, including race/ethnicity.
We also reported that the prevalence of high-risk sex among sexually active HIV-positive MSM was 11%, and was 9% among HIV-discordant partnerships. However, among persons who were not virally suppressed, 30% were engaging in high-risk sex. .....when accounting for a combination of sustained viral suppression and risk reduction strategies, only 11% of sexually active MSM with diagnosed HIV engaged in high-risk sex, thereby illustrating the importance of PrEP, condom use, and HIV treatment as HIV prevention strategies.
Among MSM with diagnosed HIV who were not virally suppressed, 66% had condomless sex, 71% had sex with an HIV-negative or HIV-unknown partner, 62% had sex with an HIV-negative partner not known to be using PrEP or an HIV-unknown partner, and 30% engaged in high-risk sex (Fig. 2). There were significant differences in condomless sex by race/ethnicity among persons who did not have sustained viral suppression (P < 0.0001), where 56% of blacks had condomless sex, compared with 80% of whites and 64% of Hispanics/Latinos. In addition, the prevalence of high-risk sex varied by race/ethnicity (P < 0.0001), with 22% of blacks engaging in high-risk sex, compared with 39% of whites and 28% of Hispanics/Latinos.
Among HIV-discordant partnerships, 67% included an HIV-positive person who did not have sustained viral suppression, 45% involved condomless sex, and 82% involved sex with an HIV-negative partner not known to be using PrEP or an HIV-unknown partner. Nine percent of HIV-discordant partnerships involved high-risk sex in the past 12 months.
partnerships with a white HIV-positive participant had a higher prevalence of high-risk sex compared with those with black [aPR: 0.56 (95% CI: 0.39 to 0.80)] or Hispanic/Latino [aPR: 0.46 (95% CI: 0.31 to 0.68)] HIV-positive participants
There were significant differences in sustained viral suppression by race/ethnicity (P < 0.0001); specifically, 44% of blacks had a detectable viral load in the past 12 months, compared with 31% of whites and 32% of Hispanics/Latinos.
Among sexually active MSM, 36% did not have sustained viral suppression, 66% had condomless sex, 73% had sex with an HIV-negative or HIV-unknown partner, 64% had sex with an HIV-negative partner not known to be using PrEP or an HIV-unknown partner, and 11% engaged in high-risk sex (Fig. 1).
77% of whites had condomless sex, compared with 57% of blacks and 60% of Hispanics/Latinos. Overall, 73% had sex with an HIV-negative or HIV-unknown partner; estimates differed by race/ethnicity (P = 0.0014) (whites: 73%; blacks: 70%; Hispanics/Latinos: 78%). There were no significant differences in high-risk sex by race/ethnicity.
Abstract
Background:
Understanding sexual partnerships of HIV-positive persons, particularly at the dyad level, can help in quantifying HIV transmission risk. We described sexual partnerships among HIV-positive men who have sex with men (MSM), including partnerships with a high risk for sexual HIV transmission.
Setting:
The Medical Monitoring Project is an annual, cross-sectional study that reports representative estimates on U.S. HIV-positive adults.
Methods:
During 2015-2019, we assessed sexual behaviors by interview, and viral load results from medical records. Among sexually active HIV-positive MSM (n = 4923), we described prevalence of high-risk sex, defined as: (1) not having sustained viral suppression, and (2) having condomless sex with an HIV-negative partner not known to be taking pre-exposure prophylaxis or an HIV-unknown partner. We described sexual partnerships among HIV-positive MSM (n = 13,024 partnerships among 4923 MSM). For HIV-discordant partnerships (n = 7768), we reported the proportion involved in high-risk sex, and associations with high-risk sex using prevalence ratios with predicted marginal means, controlling for age of the HIV-positive partner (P < 0.05).
Results:
More than half (66%) of sexually active HIV-positive MSM had condomless sex; 11% had high-risk sex. Blacks were more likely to have detectable viral loads, but less likely to have condomless sex, making prevalence of high-risk sex comparable between racial/ethnic groups. Dyad-level analyses among HIV-discordant partnerships indicated that prevalence of high-risk sex was higher among partnerships with HIV-positive white MSM, which was not observed using person-level data alone.
Conclusions:
In the context of ending the HIV epidemic, behavioral and clinical surveillance data can help monitor HIV transmission risk and target prevention efforts to reduce transmission among populations at disproportionate risk.
INTRODUCTION
During 2017, 70% of diagnosed HIV infections in the United States were attributed to male-to-male sexual contact.1 Disparities in HIV diagnoses within selected populations of men who have sex with men (MSM) exist, particularly by race/ethnicity. For example, during 2014, the rate of new HIV diagnoses among black MSM were over 5 times as high compared with that among white MSM; these racial/ethnic disparities have persisted over time.2,3
Sexual HIV transmission risk is a function of sexual behaviors and viral load.4 Use of prevention strategies, such as pre-exposure prophylaxis (PrEP) and condom use, have been shown to decrease sexual HIV transmission risk.5-7 In addition, multiple studies have shown that persons with HIV who are virally suppressed have effectively no risk of transmitting HIV to sexual partners,8-10 leading to the development of the undetectable equals untransmittable (U = U) campaign in 2016.10 Because of the availability of multiple HIV prevention strategies and their relevance across partnerships with varying levels of sexual risk, estimating sexual HIV transmission risk and targeting interventions to reduce risk have become increasingly complex. In addition to clinical HIV surveillance data on HIV viral load, behavioral surveillance data describing the characteristics of sexual partnerships, including sexual behaviors within partnerships, are essential for monitoring patterns of high-risk sex associated with HIV transmission risk. These data can also help to target prevention efforts for reducing HIV transmission among populations with disproportionate HIV risk.
In addition to person-level data, using dyad-level data can provide more granular detail for assessing partnership characteristics, including components of high-risk sex associated with HIV transmission. Although previous studies have assessed sexual HIV transmission risk among MSM, these analyses have mostly focused on smaller populations or on persons at risk for HIV (i.e., from a risk acquisition standpoint), or have been restricted to persons currently in HIV care or certain geographic areas.3,11-15 In this analysis, we used nationally representative person-level and dyad-level data to describe characteristics of sexual partnerships of MSM with diagnosed HIV. We described high-risk sex within HIV-serodiscordant partnerships among MSM, overall and by selected characteristics, including race/ethnicity.
RESULTS
Person-Level Analysis
Demographic Characteristics and Sexual Behaviors
Among MSM with diagnosed HIV who had vaginal or anal sex in the past 12 months, 38% were white, 29% were black, and 26% were Hispanic/Latino (Table 1). Overall, 84% self-identified as gay, but there were differences in sexual orientation by race/ethnicity (P < 0.0001), with 74% of black MSM identifying as homosexual or gay, compared with 89% of white and 87% of Hispanic/Latino MSM. The median number of sex partners in the past 12 months was 2 (min: 1, max: 960) and 3% of MSM exchanged sex for money or goods. Most (95%) persons had only male partners, but gender of sex partners differed significantly by race/ethnicity (P < 0.0001); 92% of black MSM had only male partners, compared with 98% of white and 95% of Hispanic/Latino MSM.
Components of High-Risk Sex Among Sexually Active MSM
Among sexually active MSM, 36% did not have sustained viral suppression, 66% had condomless sex, 73% had sex with an HIV-negative or HIV-unknown partner, 64% had sex with an HIV-negative partner not known to be using PrEP or an HIV-unknown partner, and 11% engaged in high-risk sex (Fig. 1). There were significant differences in sustained viral suppression by race/ethnicity (P < 0.0001); specifically, 44% of blacks had a detectable viral load in the past 12 months, compared with 31% of whites and 32% of Hispanics/Latinos. There were also differences in condomless sex by race/ethnicity (P < 0.0001); 77% of whites had condomless sex, compared with 57% of blacks and 60% of Hispanics/Latinos. Overall, 73% had sex with an HIV-negative or HIV-unknown partner; estimates differed by race/ethnicity (P = 0.0014) (whites: 73%; blacks: 70%; Hispanics/Latinos: 78%). There were no significant differences in high-risk sex by race/ethnicity.
Prevalence of different combinations of the high-risk sex components among sexually active HIV-positive MSM are also presented in Appendix Table 1, Supplemental Digital Content, http://links.lww.com/QAI/B471.
Dyad-Level Analysis
Overall, 61% of partnerships in the past 12 months among HIV-positive MSM were HIV-discordant, of which 53% included an HIV-negative partner and 47% included an HIV-unknown partner (Table 2). Racial/ethnic partnerships were diverse, although racial/ethnic assortativity was more common among black MSM (73%) compared with white (61%) or Hispanic/Latino (58%) MSM. Most partnerships were male/male (98%). Among HIV-discordant partnerships, 67% included an HIV-positive person who did not have sustained viral suppression, 45% involved condomless sex, and 82% involved sex with an HIV-negative partner not known to be using PrEP or an HIV-unknown partner. Nine percent of HIV-discordant partnerships involved high-risk sex in the past 12 months.
Table 3 presents factors associated with high-risk sex in HIV-discordant partnerships, controlling for age of the HIV-positive participant. Although we did not find significant differences in high-risk sex by race/ethnicity in person-level analyses, we did observe differences by racial/ethnic partnerships in dyad-level analyses. Specifically, partnerships with a white HIV-positive participant had a higher prevalence of high-risk sex compared with those with black [aPR: 0.56 (95% CI: 0.39 to 0.80)] or Hispanic/Latino [aPR: 0.46 (95% CI: 0.31 to 0.68)] HIV-positive participants.
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