Strategies used by gay male HIV serodiscordant couples to reduce the risk of HIV transmission from anal intercourse in three countries

Abstract

Introduction There are few data about the range of strategies used to prevent sexual HIV transmission within gay male serodiscordant couples. We examined HIV prevention strategies used by such couples and compared differences between countries. Methods Opposites Attract was a cohort study of male serodiscordant couples in Australia, Brazil and Thailand, from May 2014 (Australia) or May 2016 (Brazil/Thailand) to December 2016. At visits, HIV‐positive partners had viral load (VL) tested; HIV‐negative partners reported sexual behaviour and perceptions of their HIV‐positive partner's VL results. Within‐couple acts of condomless anal intercourse (CLAI) were categorized by strategy: condom‐protected, biomedically protected (undetectable VL and/or pre‐exposure prophylaxis [PrEP]), or not protected by either (HIV‐negative partners engaging in insertive CLAI, receptive CLAI with withdrawal, or receptive CLAI with ejaculation). Results A total of 343 couples were included in this analysis (153 in Australia, 93 in Brazil and 97 in Thailand). Three‐quarters of HIV‐positive partners were consistently virally suppressed (<200 copies/mL) during follow‐up, and HIV‐negative partners had correct perceptions of their partner's VL result for 76.5% of tests. One‐third of HIV‐negative partners used daily PrEP during follow‐up. Over follow‐up, 73.8% of couples had CLAI. HIV‐negative partners reported 31,532 acts of anal intercourse with their HIV‐positive partner. Of these, 46.7% were protected by condoms, 48.6% by a biomedical strategy and 4.7% of acts were not protected by these strategies. Australian couples had fewer condom‐protected acts and a higher proportion of biomedically protected acts than Brazilian and Thai couples. Of the 1473 CLAI acts where the perceived VL was detectable/unknown and were not protected by PrEP (4.7% of all acts), two‐thirds (n = 983) were when the HIV‐negative partner was insertive (strategic positioning). Of the 490 acts when the HIV‐negative partner was receptive, 261 involved withdrawal and 280 involved ejaculation. Thus, <1% of acts were in the highest risk category of receptive CLAI with ejaculation. Conclusions Couples used condoms, PrEP or perceived undetectable VL for prevention in the majority of anal intercourse acts. Only a very small proportion of events were not protected by these strategies. Variation between countries may reflect differences in access to HIV treatment, education, knowledge and attitudes.

Estimation of Potential HIV Transmission Risk in Recent Anal Intercourse Events among Men Who Have Sex with Men and Transgender Women in Bali, Indonesia

“…Overall, 29.2% reported a monthly income of < 2 million Indonesian rupiah (IDR; approximately USD $140), 31.0% of 2-3 million IDR, 30.8% of 3-5 million IDR, and 9.0% of 5+ million IDR; the Bali-born were more likely to earn < 2 million IDR (p = 0.011). In the previous 6 months, 16.9% had done some incidental sex work, while 11.1% reported sex work as their main source of income. Over 90% of the respondents were recruited to the study via HIV outreach workers, and 89.4% and 77.7% had had contact with these workers face-to-face or online, respectively.…”

“…Greater familiarity with romantic partners, as well as the desire for increased intimacy, may be key motivators [14]. Often, CLAI in the context of primary romantic relationships can be safe with respect to HIV transmission, such as when using a non-condom-based risk reduction strategy such as 'negotiated safety' in HIV-negative seroconcordant relationships [15], or relying on an undetectable viral load in serodiscordant relationships [16]. However, it is important to note that HIV infections in the context of relationships may still be prevalent in many countries, especially in settings where non-condom-based risk reduction strategies have not been openly promoted, as is the case in Bali where HIV prevention education has essentially focused only on condoms.…”

Fatores associados ao conhecimento e utilização de estratégias de prevenção do HIV entre mulheres trabalhadoras do sexo em 12 cidades brasileiras

“…Quanto às trabalhadoras do sexo portadoras de HIV, encontramos cerca de 29% que relataram não realizar tratamento e/ou tê-lo interrompido. Atualmente existem evidências irrefutáveis (estudos HPTN 052 22 , Partner 23 e Opposites Attract 24 ), que demonstram que PVHIV em tratamento e com boa adesão à terapia antirretroviral (TARV), atingem rapidamente a supressão viral, representando um impacto extremamente positivo na redução da transmissão do HIV, embasando as atuais recomendações de tratamento como prevenção [21][22][23][24][25] .…”

Changing Characteristics of HIV-Positive Gay and Bisexual Men's Relationships in the Era of Biomedical Prevention

“…There is some evidence to suggest that people living with HIV with undetectable viral loads (UVLs) report more positive health and social outcomes, including greater equity and satisfaction in romantic and sexual relationships. 22 Among HIV-positive GBM in serodiscordant relationships, those with UVL tend to report higher levels of condomless sex with their partners, 23 although this may be less common than within HIV-negative seroconcordant relationships. 24 Australian research suggests that relying on TasP may at first be daunting for GBM in serodiscordant relationships, but confidence builds over time, particularly with clear communication, evidence of sustained viral suppression and repeated HIV-negative test results for the HIV-negative partner.…”