However, these findings are preliminary and there are several limitations in this analysis. Although the use of venue- day-time sampling provides a systematic sample of a hard-to- reach population, this recruitment method is still subject to sampling bias. Venue-day-time-sampling recruits participants found in venues during high traffic periods and thus the findings of this analysis may not reflect the experiences of all MSM and TG in Chiang Mai, particularly those who do not attend venues. As many of the sampled venues are locations where MSM and TG attend to seek sexual partners, the prevalence of HIV risk behaviors may be overestimated compared to the general population of MSM and TG. Our findings may also be subject to social desirability bias, which may have led to an overestimate of PrEP acceptability despite the use of hand- held computers to maximize privacy and anonymity. This survey also measured intent-to-use PrEP and thus may not reflect actual behaviors once PrEP becomes more widely available, especially if PrEP is combined with other
Background Without a vaccine, the only ways to halt the global HIV epidemic are prevention strategies that reduce transmission of the HIV virus. Up until recently, behavioral strategies such as condom use and reduction of sexual partners have been at the center of HIV prevention. In the past few years, several biological prevention measures have also been shown to be effective in reducing (though not completely preventing) HIV transmission. These include male circumcision, treatment for prevention (giving antiretroviral drugs to HIV-infected people, before they need it for their own health, to reduce their infectiousness) andpre-exposureprophylaxis (or PrEP), in which HIV-negative people use antiretroviral drugs to protect themselves from infection. One PrEP regimen (a daily pill containing two different antiretrovirals) has been shown in a clinical trial to reduce new infections by 44% inofmenwhohavesexwithmen (MSM). In July 2012, the US Food and Drug Administration approved this PrEP regimen to reduce the risk of HIV infection in uninfected menandwomenwho are at high risk of HIV infection andwho may engage in sexual activity with HIV-infected partners. The approval makes it clear that PrEP needs to be used in combination with safe sex practices. Why Was This Study Done? Clinical trials have shown that PrEP can reduce HIV infections among participants, but they have not examined the consequences PrEP could have at the population level. Before decision-makers can decide whether to invest in PrEP programs, they need to know about the costs and benefits at the population level. Besides the price of the drug itself, the costs include HIV testing before starting PrEP, as well as regular tests thereafter. The health benefits of reducing new HIV infections are calculated in ‘‘disability-adjusted life years’’ (or DALYs) averted. One DALY is equal to one year of healthy life lost. Other benefits include future savings in lifelong HIV/AIDS treatment for every person whose infection is prevented by PrEP.
tenofovir disoproxil fumarate (FTC/TDF) . Efficacy correlated closely with drug adherence and drug levels. Pill use on 90% or more of days was associated with 73% efficacy, while detectable drug levels were associated with 92% efficacy. Early in 2011, the US Centers for Disease Control published interim guidance for the use of PrEP in MSM . PrEP was also shown to be effective in other at-risk populations. Two studies of daily PrEP with either FTC/TDF or TDF alone in HIV serodiscordant couples andin young menandwomenin sub-Saharan Africa found that daily FTC/TDF or TDF alone reduced HIV incidence by 62–73% (Baeten J, Celum C. (2011) Antiretroviral Pre-Exposure Prophy- laxis for HIV-1 prevention among heterosexual African menandwomen: the Partners PrEP Study [Abstract MOAX0106]. 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention; 17– 20 July 2011; Rome, Italy. Available: http://pag.ias2011.org/ flash.aspx?pid = 886. Accessed 14 March 2012. Thigpen MC, Kebaabetswe PM, Smith DK, Segolodi TM, Soud FA, et al. Daily oral antiretroviral use for the prevention of HIV infection in heterosexually active young adults in Botswana: results from the TDF2 study. [Abstract WELBC01]. 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention; 17–20 July 2011; Rome, Italy. Available: http://pag.ias2011.org/abstracts.aspx?aid=4631. Accessed 14 March 2012.)
Violence by an intimate partner affects nearly one in three women globally, ranging from 16.3% in East Asia to 65.6% in central sub-Saharan Africa [1–3]. The associated adverse health consequences for female victims include depression, anxiety, post- traumatic stress disorder, eating disorders [4,5], and sexual and reproductive health problems [6,7]. However, intimate partner violence (IPV) is not exclusive to opposite-sex relationships, and there is a growing body of research highlighting the prevalence of IPV in same-sex relationships [8–14]. Recent reviews suggest that the prevalence in same-sex couples, in particular male–male couples, is as high as or higher than it is for womenin opposite-sex relationships [15–18]. The reported lifetime experience of IPV in gay male relationships lies between 15.4% and 51% [9,11,15,18], depending on the population studied [11,17], the definition of ‘‘partner’’ or ‘‘relationship’’ , and the type of measures used . Most reviews addressing of IPV in the LGBT (lesbian, gay, bisexual, andtransgender) population focus on the prevalence of IPV, with limited research on the health associations of IPV . The two existing reviews that explored this association [11,17] used a narrative approach, which summarises and explains results in words rather than pooling quantitative results, and concluded that further research was needed to understand the range of health conditions associated with IPV among MSM.
Sampling strategies such as respondent-driven sampling (RDS) and time- location sampling (TLS) offer unique opportunities to access key popula- tions such as menwhohavesexwithmen (MSM) andtransgenderwomen. Limited work has assessed implementation challenges of these methods. Overcoming implementation challenges can improve research quality and increase uptake of HIV services among key populations. Drawing from studies using RDS in Brazil and TLS in Peru, we summarize challenges encountered in the field and potential strategies to address them. In Bra- zil, study site selection, cash incentives, and seed selection challenged RDS implementation with MSM. In Peru, expansive geography, safety concerns, and time required for study participation complicated TLS implementa- tion with MSM andtransgenderwomen. Formative research, meaningful participation of key populations across stages of research, and transpar- ency in study design are needed to link HIV/AIDS research and practice. Addressing implementation challenges can close gaps in accessing services among those most burdened by the epidemic.
Globally, the HIV epidemic affects key populations, such as female sex workers (FSW), menwho had sexwithmen (MSM), people who inject drugs (PWID) andtransgenderwomen, dis- proportionately [1–5]. Legal and social barriers can prevent key population members from seeking health-related and social services. These barriers, upheld by stigma and discrimination, and systemic indifference or discomfort to discuss the behaviors that both define these popula- tions epidemiologically and sociologically, combine to drive these populations underground. UNAIDS estimated that PWID, MSM, sex workers had 28, 19 and 12 times higher HIV preva- lence levels than that among adults in the general population in countries which reported prev- alence data for both the general population and key populations. This pattern appears not only in countries with concentrated epidemics but also in countries with generalized epidemics . To be successful, public health interventions for a robust HIV response require monitoring key population members’ interactions with prevention, care and treatment services. A strong response, that will halt the HIV epidemic among key populations, must reach at least 80% of key population members with services .
MSMW were more likely to engage in the sexual risk behaviors, while the rates of health care utilization were low. As expected, the VCT acceptability was verified to be related to the physical health and environment domains. Those who accepted VCT services have mostly test- ed for HIV. The negative results of HIV testing may reduce the psychological pressure of HIV infection and then better participate in recreation or leisure. The counselling procedure, as a part of VCT services, may increase the participants’ HIV knowledge and reduce sexual risk be- haviors. This may explain the mechanism of how VCT acceptability affects physical domain rated by MSMW. Rates of attending VCT clinics were lower among MSMW than MSMO, with 10/77 of MSMW and over two-thirds of MSMO (62.96%) reporting ever having attended VCT clinics. This acceptability rate among MSMW was consistent with previous studies conducted in Beijing and Urumqi, China , but is significantly lower than that in Hong Kong . The Chinese government's ‘Plan for HIV/AIDS Prevention and Control amongMenWhoHaveSexwithMenin China, 2007–2010’ set an ambitious target of achieving a 50% or higher HIV testing rate among MSM by 2010, recommending that MSM receive HIV testing at least once per year . Despite the ongoing expansion of the national ‘Four Frees and One Care’ pro- gram and support of the Gates Foundations which provides free voluntary HIV screening and HIV testing, the HIV testing rate remains as low as 36.36% among MSMW which is lower among MSMO (70.58%), suggesting that efforts to expand the scopes of HIV testing among MSMW still need to be intensified. The rate of HIV testing (36.36%) is higher than that of at- tending VCT clinics (12.99%). This may be resulted from that most MSMW remain unaware of where and how to seek VCT services. Among MSMW who had ever tested for HIV, more than 2 in 3 were tested in places other than VCT clinics, despite the fact that Chinese govern- ment policy mandates free HIV testing throughout the VCT system.
Among the same participants, we also conducted an as-treated analysis that accounted for study drug use among participants receiving FTC/TDF. Because drug level testing was only conducted in a subset of participants and visits, drug levels were imputed for participants in both arms at any monthly visit missing drug level data using chained equations and predictive means matching. Predictors in the imputations included study week, study site, baseline number of sexual partners, baseline ncRAI, transgender identity, body mass index, weight, report of an STI in the six months before screening, secondary education, circumci- sion, baseline HSV-2 infection, age, and number of drinks on days when the participant drank in the prior month. Covariates were used to predict the probability of having detectable drug and the probability that the level of tenofovir diphosphate (TFV-DP) in PBMCs was .16 fmol per million viable cells, the concentration associated with an estimated 90% reduction in HIV acquisition.  Drug levels were multiply imputed  for visits at which drug level testing was not conducted but the participant was still taking study drug, with 200 imputations per observation.  We then used site-stratified Cox regression to estimate HRs for HSV-2 seroincidence associated with being randomized to the FTC/TDF arm and having detectable drug with TFV-DP #16 or being randomized to the FTC/TDF arm and having detectable drug with TFV-DP .16. Unadjusted models included only a time- dependent covariate for drug detection, while adjusted models also included age, level of education, transgender identity, number of alcoholic drinks on days when drinking in the past month, and sexual behaviors in the past three months (number of anal sex partners, cRAI, ncRAI, cIAI, and ncIAI). Sexual behavior variables were time-updated at approximately three-month intervals.
We anticipate the following objection to these conclusions: Why would evolved mechanisms take on the complexity necessary to distinguish context when more simple (e.g., perceiver based) mechanisms could confer the same benefits? This objection really contains two presumptions: that simpler mechanisms can explain the observed differences, and that nature preferentially selects for simplicity. The first objection can be—and has been—answered empirically. Simpler models cannot adequately account for the data. The answer to the second objection is more complex, but in general, we want to contend that evolutionary explanations should be wary of arguments of parsimony. Natural selection is a tinkerer, making use of existing adaptations and architectures but also being constrained by them—it saticfices rather than optimizes. The massive complexity and interactivity of brain systems at all levels certainly does not preclude complex solutions to adaptive problems. The simple act of moving through a room requires a number of parallel informational inputs to be successful, and this coordination has evolved because of the recurrent nature of the problem (see DeKay and Buss, 1992). Indeed, the Ecological perspective in psychology (e.g. Gibson, 1979; Reed, 1996) is founded on the premise that it is often complex, higher- order ratios of environmental variables which enable us to execute seemingly simple actions, and that neural systems have been selected to be attuned to these complexities.
The surveys were carried out through a questionnaire that was completed by the conscripts themselves at the time they presented themselves to the Army authorities. Illiter- ate conscripts and functional illiterates in other words, young menwho would have been unable to respond co- herently to the written questionnaires have always been ex- cluded, constituting one of the limiting factors of the study. Considering that informed consent could lead to refusals and be a source of bias, the self-reported and anonymous questionnaires were deposited directly into a container as a way of guaranteeing confidentiality for the interviewee.
Eligible participants were 18 years old or older, had a history of ever having had anal intercourse with another man, and were able to give verbal informed consent for HIV screening in local languages. Inclusion criteria were not based on sexual orientation or identity, frequency of sexual contacts, previous HIV testing, or known HIV serostatus. Given the hidden nature of MSM in these communities, participants were recruited by in-country commu- nity-based organizations (CBO) with experience working with gay, bisexual, and other MSM. In-country technical support was provided as requested by the CBOs. In Namibia, investigators from the University of Namibia HIV/AIDS unit played a central role in providing ongoing support for this work. Similarly, researchers from the Malawi College of Medicine supported the Malawian CBO. The study staff was provided on–site training in outreach and recruitment, obtaining informed consent, andin interviewing techniques. The study was anonymous, confidential, and no written communications were shared with participants to minimize the risk of disclosure of MSM status. Sample size calculations were based measuring risk associated with unprotect- ed anal intercourse (UAI). Assuming that UAI increases risk of HIV transmission by approximately 80% with a significance level of 0.05 and a power of 80%, the minimum necessary sample size was 150 men. Rounding up, the planned sample size was 200 for each of the three sites for a total of 600 men.
Electronic literature searches were conducted from 1 January 2003 to 31 December 2013 in the following da- tabases: EBSCO, Gale, NLM (PubMed Central, PMC, Medline), Oxford University Press, Ex Libris, Web of Knowledge, Elsevier, SpringerLink, Taylor & Francis On- line, PLoS and SAGE. The search engine b-on—Online Knowledge Library 1 was used to conduct database searches. The last search was run on 16 June 2014. Studies were excluded if they did not include study participants (e.g., studies that make theoretical assumptions only) and were systematic or non-systematic reviews, letters, edito- rials or commentaries. We also excluded clinical trials due to the very specific methods used to recruit participants, publications that did not mention the recruitment method and all publications that required additional payment for access.
Infectious and Parasitic Diseases, So ﬁa, Bulgaria); Ulrich Marcus, Susanne Barbara Schink (Robert Koch Institute, Berlin, Germany); Barbara Suligoi, Vincenza Regine (Centro Operativo AIDS, Istituto Superiore di Sanità, Rome, Italy); Saulius Caplinskas, Irma Caplinskiene (Centre for Communicable Diseases and AIDS, Vilnius, Lithuania); Magdalena Rosińska, Marta Nied źwiedzka-Stadnik (NIZP-PZH, Warsaw, Poland); Sónia Ferreira Dias (Global Health and Tropical Medicine, GHTM, Instituto de Higiene e Medicina Tropical, IHMT, Universidade Nova de Lisboa, Portugal); Alexandru Raﬁla, Daniela Pitigoi (National Institute for infectious Diseases), Matei Bals (Carol Davila University of Medicine and Pharmacy, Bucharest, Romania); Danica Staneková, Monika Hábeková (Slovak Medical University, Bratislava, Slovakia); Irena Klavs (NIJZ - Nacionalni Institut za Javno Zdravje, Ljubljana, Slovenia); Cinta Folch, Laia Ferrer (Centre for Epidemiological Studies on HIV/STI in Catalonia CEEISCAT, Agència de Salut Pública de Catalunya, Barcelona, Spain); Inga Velicko, Sharon Kühlmann-Berenzon (Public Health Agency of Sweden, Stockholm, Sweden); Igor Toskin (Department of Reproductive Health & Research World Health Organization, Geneva, Switzerland); Nigel Sherriff (School of Health Sciences, University of Brighton, Brighton, UK).
Furthermore, in multivariate analysis, older age ( 40 years) was another risk factor of HIV infection in both samples. This finding is consistent with previous studies that showed older MSM to be more at risk for HIV infection than young MSM . Many older MSM were unaware of high-risk sexual behaviours, or they thought that their beha- viours were of no risk. A study showed that the knowledge level regarding the specific behaviours leading to the trans- mission of HIV among older adults was significantly lower than among younger adults . Without HIV/AIDS educa- tional and prevention programmes tailored to older audi- ences, it is likely that many older adults are unwilling to attend or accept HIV education, prevention and intervention activities. Therefore, older MSM perceive themselves to be at low risk for HIV infection, which leads them to have a greater chance of becoming infected with HIV.
There were a few important challenges experienced during implementation of the pilot. The first was managing accurate enumeration of MSM reached through social media. During the first several months of the pilot, the CLOs and SHARPER team tested a number of different approaches to accurately measure unique contacts until a method was devised that was both sound and acceptable to the CLOs (as described in the program description). The second challenge involved the difficulty of verifying service utilisation among MSM contacted by the CLOs. Peer educators use carbon copy referral slips that are collected by implementing partners at service delivery sites once a month. With social media outreach, it was not possible for CLOs to provide MSM with referral slips, or to verify from the service provider that the service was accessed given the long list of public and private providers utilised by MSM across the three pilot cities. We were only able to collect self-reports as part of this pilot.
Study limitations are based primarily on the focused population and enrollment criteria. First, as the sample is based in Los Angeles, it is possible that participants from other locations might not share the same population characteristics. However, high HIV rates in Los Angeles make Los Angeles an important area for HIV prevention research. Second, although sexual risk behaviors presented in this study are associated with HIV transmission, knowing the specific type of sexual behavior would help to more accurately determine the associated risk. For example, while exchanging sex for food and drugs is associated with sexual risk, engaging in unprotected anal intercourse in exchange for drugs would be associated with greater risk than engaging in protected intercourse. This study presents a first look at associations between social networking use and sexual risk behavior, and future studies that identify the specific sexual behaviors (such as protected versus unprotected sexual intercourse) may help to provide a more definitive link to HIV transmission. Next, participants were not asked to report how they were recruited to the study. Future research can address this question to provide data on best recruitment methods. Finally, it is possible that the present results might not generalize to groups other than MSM, or early technology adopters. Although social networking use is being studied among broader racial and ethnic populations of people living in the Untied States[10,13], research on the link between social networking and HIV risk has only recently been studied and has focused on populations at high-risk for HIV, such as MSM [19,24]. Future research is encouraged to test whether these findings extend to other at-risk populations.
STIs through an RDS survey of five suspected high risk groups, including MSM . Full description on the Crane Survey including sampling methods and findings related to each population, have been described previously . Briefly, with respect to MSM, survey participants were recruited using RDS . Inclusion criteria were male sex, age $18 years, residence in Kampala, and self-reported anal sexwith another man in the preceding 3 months. Demographic and HIV-related behavioral data were collected through audio computer-assisted self-admin- istered interviews. The Crane survey found that MSM in Kampala are at markedly higher risk for HIV than the general adult male population and that MSM reporting a lifetime history of homophobic abuse are at increased risk of being HIV infected. Population estimates were adjusted for the non-random sampling frame using RDSAT and STATA. The median age of 300 MSM was 25 years. Overall HIV prevalence was 13.7% (95% confidence interval [CI] 7.9%–20.1%), and was higher among MSM. = 25 years (22.4%) than among MSM aged 18–24 years (3.9%, odds ratio [OR] 5.69, 95% CI 2.02–16.02). In multivariate analysis, MSM. = 25 years (adjusted OR [aOR] 4.32, 95% CI 1.33–13.98. In conjunction with the MSM survey, we conducted a nested qualitative study to explore the social and behavioral contexts of HIV risk, gender identity, stigma and violence with a sub-set of 16 survey participants who reported higher-risk sexual behaviors in their survey responses.
I would like to participate for the sake of the women that I have been working with so far. I have been working for the last six or seven years. I am satisfied that I have worked with these women for a noble cause. I feel proud thinking that I have influenced many women so as to change their life. I have helped many women to have a good life. And I am even ready to offer myself in case any additional responsibilities are given to me. (ORW, NGO, Belgaum) [T]hese womenhave been suffering from so many issues. We need to support them . . .. [E] arlier I had misconceptions regarding these women; I was thinking that she is not good, she has no other jobs to do, she always does sex work. I [felt] irritated to look at them. A wrong notion was there. As I have been working with them for a long time, I can now understand each and every facet of their life. I also understand ways to encourage them, to motivate them, and what kind of support they need . . .. I am always ready to help them though I have per- sonal work to do. I consider it as a service. (Program manager, CBO, Bellary)
young adults, as the age group of ‘26 – 40 years’ accounted for most cases, followed by the ‘18 – 25 years’ group. Considering the patients’ countries of origin, although most cases corresponded to Portuguese MSM, our sample included also several foreigners, living in or visiting Lisbon. This is also a noteworthy finding, reminding that population movements (migration, travelling, etc.) may influence the dynamics of infectious diseases, particularly STIs, and pose challenges to prevention and control efforts, particularly in major urban areas. Walk-in STI clinics like ours are very useful to facilitate people’s access to healthcare, including STI testing and treatment, with no appointment required. Exclusive extragenital gonorrhoea without concurrent urogenital infection accounted for the majority of cases. This means that we identified a considerable number of gonococcal infections that would have been undiagnosed if urethral screening alone had been performed. Furthermore, in most cases (54%) the patients did not present with any extragenital symptoms, including 26 (30%) cases of completely asymptomatic infection. Considering that we found local complaints possibly associated with gonococcal infection at extragenital sites only in 52% of the anorectal andin 14% of the oropharyngeal infections, 48% of the anorectal and 86% of the oropharyngeal infections would have been missed if only the patients reporting local symptoms had been tested for N. gonorrhoeae at these sites. In fact, it is known that anorectal and oropharyngeal gonococcal infections are usually asymptomatic. 2,7,9,20 According to
Study subjects returned to the clinic 3 times per week for a total of 18 weeks. Swabbing of the anal and genital regions for viral pathogens was performed by two methods. Rectal mucosal swabbing was performed via anoscopy by placing a sterile Dacron-tipped plastic applicator (Puritan Medical Products, Guilford, ME) against the rectal mucosa 3 to 4 cm above the squamocolumnar junction and rotating for approximately 20 seconds. Surface swabbing of the anogenital region was performed by rubbing the swab over the glans and full length of the penis, the scrotum, perianal skin and completed by inserting the swab in the anus and rotating once (360 degrees). Rectal and anogenital swabbing was performed at each clinic visit. To characterize viral shedding between visits, anogenital swabbing was also self-performed by participants at home. Applicator tips were placed in vials containing 1.0 ml proteinase K digestion buffer (100 mM KCl, 25 mM EDTA, 10 mM Tris-HCl pH 8.0, 1% IGEPAL) and stored at 220uC until processing by the laboratory. Home swabs were maintained at room temperature until the nearest clinic visit and then stored as above.