Abstract
Background:
While gay and bisexual men (GBM) represent the largest group of HIV-infected individuals in the United States (U.S.), nearly all evidence on their HIV risk and prevention outcomes derive from non-probability samples.
Setting:
A probability-based cohort of GBM (N=502) from 45 states and Washington, D.C.
Methods:
Cross-sectional survey.
Results:
Among HIV negative/unknown/untested GBM, only 6.7% reported using pre-exposure prophylaxis (PrEP) in the past 6 months. Two thirds (63.3%) of PrEP users reporting daily adherence in the last week. Over half (54.2%) of GBM reported not using a condom during anal sex with their most recent male partner; of these men, 93.8% were not on PrEP. Most GBM had been tested for HIV (80.7%) and other sexually transmitted infections (STI) (67.1%) in their lifetime, with 45.2% having tested for HIV during the past year. Among those ever tested, 14.1% reported being HIV infected, while an additional 8.9% reported testing positive for at least one other STI following their most recent test. All HIV positive GBM reported being currently on antiretroviral treatment, and 94.7% reported an undetectable viral load, but nearly one-third (30.4%) reported not taking their medication every day during the last month. A majority of HIV negative/unknown/untested GBM (64.3%) reported that they had never discussed HIV prevention with their primary healthcare provider.
Conclusion:
Our findings present a decidedly mixed picture regarding the success of the U.S. National HIV/AIDS Strategy in meeting its stated goals of addressing HIV risk among the general population of GBM.
Keywords: HIV, pre-exposure prophylaxis (PrEP), gay men, bisexual men, probability sample, United States
Introduction
Gay and bisexual men (GBM), and other men who have sex with men (MSM), are substantially impacted by the HIV epidemic in the United States (U.S.), with male-to-male sexual contact representing the vast majority of new HIV diagnoses.1,2 Because this paper focuses on self-identified gay- and bisexual-identified men, we hereafter use the term GBM, unless citing studies that specifically refer to MSM. While GBM and other MSM represent approximately 4% of the U.S. male population, they constitute over 75% of new HIV infections among men.3,4 It is estimated that approximately 1 in 6 MSM will be diagnosed with HIV in their lifetime.5,6
Previous research on HIV risk and prevention behaviors among GBM in the U.S. has almost exclusively relied on non-probability sampling strategies, often targeting a small segment of the GBM population who are relatively connected to broader lesbian, gay and bisexual (LGB) communities and who frequent gay-identified venues. While these studies provide critical data, sexuality-related stigma, access to care, and other factors may differentially affect individuals who are less connected to and engaged in local LGB communities and venues, including sub-populations of GBM that are at disproportionately high risk for HIV infection. Given these concerns about possible sampling bias, researchers have indicated that the lack of nationally representative samples has limited our ability to generalize the findings of prior studies to the general population, and to devise a comprehensive strategy for the prevention of HIV and other sexually transmitted infections (STI) in particularly vulnerable sub-groups of the population.7,8
Probability studies of HIV risk and preventative behaviors among GBM in the U.S. are important for tracking key biomedical and other sexual health indicators, understanding demographic trends, and informing clinical practice.9,10 Given the public health significance of HIV, and the highly disproportionate burden among GBM since the earliest days of the epidemic, it is remarkable that relatively little research has examined HIV risk and prevention outcomes among more representative samples of these men in the U.S. Several issues likely prevent researchers from obtaining probability-based samples of GBM, including cost, availability of funding, and feasibility.11
Despite these challenges, recent innovations have facilitated the possibility of collecting data from samples of self-identified GBM in the U.S. that are reflective of the general population. These studies, few in number, have included measures of HIV risk and prevention behaviors, such as the National Survey of Sexual Health and Behavior (NSSHB),12 the Generations Study,13 the Behavioral Risk Factor Surveillance System (BRFSS), the National Health and Social Life Survey (NHSLS),14 and the Urban Men’s Study (UMS).15 These studies have provided important insights into HIV risk and prevention outcomes among GBM in the U.S., but they either were conducted over two decades ago (i.e., NHSLS in 1992),14 included a small number of sites (n=4 cities in UMS, and n=19 states in the BRFSS) or relatively few GBM (e.g., N=76 in the 2009 NSSHB),16 or else assessed a limited number of HIV prevention outcomes (e.g., PrEP use in the Generations Study).13
We present baseline data from a new large probability-based sample of 502 GBM that overcomes some of the limitations of prior probability-based studies. We examine a comprehensive range of HIV risk and prevention outcomes among HIV-negative GBM, including pre-exposure prophylaxis (PrEP) use and adherence, and post-exposure prophylaxis (PEP) use, condom use with male partners at last sexual event, and testing for HIV and other STI. We also evaluate HIV risk and prevention outcomes that are relevant for HIV positive GBM, including HIV viral load and antiretroviral treatment length and adherence.
Additionally, we focus on specific subgroups, since current HIV/AIDS data show the highest incidence rates in the South, among men of color, and among those ages 35 and younger.1 We therefore explore whether these key demographic characteristics (region, race/ethnicity, and age) relate to HIV risk and prevention outcomes in our sample of GBM. Probability data are uniquely suited to this question, as they provide insights into diverse demographic subgroups that are representative of the general population of the U.S., in contrast to those samples most often recruited from “high risk” venues.7 Together, these data provide a unique opportunity to evaluate whether, and to what extent, the current U.S. National HIV/AIDS Strategy3 have been successful in meeting their stated goals of addressing HIV risk among high-risk samples, including GBM. These data can also be used for establishing population-level baseline data for tracking the success of the recently proposed End the HIV Epidemic Initiative.2
Methods
Study Design
Our data come from the Ipsos (formerly GfK) KnowledgePanel®, the largest online panel that is representative of the U.S. adult population. Starting in 2009, KnowledgePanel® began employing an address-based sampling (ABS) methodology, which allows probability-based sampling of addresses from the Delivery Sequence File of the United States Postal Service, a database with full coverage of all delivery points in the U.S. ABS provides a statistically-valid sampling method with a published sample frame of residential addresses that covers approximately 97% of U.S. households. This probability-based sampling methodology maximizes population coverage, particularly for hard-to-reach individuals such as young adults and minority subgroups. Ipsos, which maintains KnowledgePanel®, provides a web-enabled device, such as a tablet computer, and free Internet service for adults recruited from households without Internet access. As such, samples from KnowledgePanel® cover households regardless of their connectivity status, enhancing representativeness of the sample.
Participants
KnowledgePanel consists of about 50,000 adult members (ages 18 and older), of which about 900 identify as GBM (based on a response to 1 screener item: “Do you consider yourself to be: (1) heterosexual or straight, (2) gay/lesbian, (3) bisexual, (4) other?”). We partnered with Ipsos to recruit a sample of adult GBM (age 18+, English- and/or Spanish-language speakers) from KnowledgePanel to become part of a 2-year longitudinal cohort study, the National Study of Stigma and Sexual Health (NSASH). Based on their prior experience with response and survey completion rates for panelists, Ipsos estimated a final sample size of 500 GBM men at baseline; our final sample size was 502.
Sampling Plan
Once the sampling frame is established, KnowledgePanel® members receive a notification email letting them know that there is a new survey available for them to take. This email notification contains a custom link that sends members to the survey questionnaire. After reading a brief description of the survey, participants completed a consent form, followed by the questionnaire, which asked about their sexual, physical, mental, and behavioral health, as well as psychosocial factors unique to GBM (e.g., stigma experiences). To maximize diversity among Hispanic/Latino participants, participants were given the option of completing the survey in English or Spanish. The median length for survey completion was approximately 30 minutes. Participants were paid $25 in Ipsos incentives as compensation for their time (KnowledgePanel® members receive incentives in the form of cash or points for merchandise for occasional survey completion).
Measures
We present baseline data on five key HIV risk and preventive behaviors among GBM in the NSASH sample: (1) (pre- and post-exposure prophylaxis use (PrEP and PEP, respectively); (2) condom use during anal sex with the last male partner; (3) HIV/STI testing; (4) discussions with primary healthcare providers.antiretroviral medication adherence; and (5) HIV plasma RNA level (also known as “viral load”17) among HIV-positive respondents. Items measuring these behaviors come from the following sources: HIV/STI testing (NHBS);18 condom use at last event;19 PrEP and PEP use;20,21 and antiretroviral medication adherence and viral load (NHBS).18 These five indicators of HIV risk and prevention behaviors were selected based on their relevance to the goals outlined in the National HIV/AIDS Strategy.3
Statistical Analysis
We first present prevalence rates for the five study outcomes in the full sample of GBM, and for HIV positive men separately. Given high HIV incidence rates in the South, among men of color, and among those ages 35 and younger,1 we also stratified our analyses by these three key demographic characteristics (race, age, and geographic region). We applied the survey weights provided by Ipsos to adjust for selection probabilities and nonresponse, and to generate nationally representative estimates. Due to the very small number of participants who reported currently being 1) HIV negative/unknown/untested and on PrEP and 2) HIV positive with a detectable viral load, we used nonparametric tests with unweighted data for these two analyses.
Results
Demographic Characteristics
Between June and July 2018, 502 GBM (M age=45.3, SE=0.99) from the general population of the United States, ages 18–91, responded to our survey. Table 1 presents the demographic characteristics of the sample. Nearly three-fourths of the men (74.7%) identified as gay. The majority of men were currently employed (68.5%), single (53.6%), white (62.0%), non-Hispanic (81.3%), and residing in a metro area (92.2%). Over a third (35.3%) had a bachelor’s degree or higher, and nearly half (47.0%) reported an annual household income of $75,000+.
Table 1.
Demographic Characteristics of Gay and Bisexual Male Respondents in the National Study of Stigma and Sexual Health (N=502).
| Demographic Characteristics | N (%) | |||
|---|---|---|---|---|
| Age | Full Sample | HIV+ |
HIV−/ Unknown |
|
| 18-25 | 27 (5.4%) | 0 (0%) | 11 (3.2%) | |
| 26-35 | 138 (27.5%) | 8 (14.0%) | 92 (26.4%) | |
| 36-45 | 88 (17.5%) | 2 (3.5%) | 68 (19.5%) | |
| 46-55 | 113 (22.5%) | 20 (35.1%) | 82 (23.6%) | |
| 56-65 | 91 (18.1%) | 23 (40.4%) | 59 (17.0%) | |
| 65+ | 45 (9.0%) | 4 (7.0%) | 36 (10.3%) | |
| Race | ||||
| Non-white | 191 (38.0%) | 25 (43.9%) | 137 (39.5%) | |
| White | 311 (62.0%) | 32 (56.1%) | 210 (60.5%) | |
| Hispanic Ethnicity | ||||
| Hispanic | 94 (18.7%) | 12 (20.7%) | 66 (19.0%) | |
| Non-Hispanic | 408 (81.3%) | 46 (79.3%) | 282 (81.0%) | |
| Education | ||||
| Less than high school or high school | 144 (28.7%) | 15 (26.3%) | 81 (23.3%) | |
| Some college | 181 (36.0%) | 24 (42.1%) | 128 (36.9%) | |
| Bachelor degree or higher | 177 (35.3%) | 18 (31.6%) | 138 (39.8%) | |
| Sexual identity | ||||
| Bisexual | 127 (25.3%) | 6 (10.5%) | 95 (27.4%) | |
| Gay/homosexual | 375 (74.7%) | 51 (89.5%) | 252 (72.6%) | |
| Relationship Status | ||||
| Single | 269 (53.6%) | 32 (56.1%) | 168 (48.4%) | |
| In a relationship | 119 (23.7%) | 18 (31.6%) | 86 (24.8%) | |
| Married | 114 (22.7%) | 7 (12.3%) | 93 (26.8%) | |
| Region | ||||
| Midwest | 87 (17.3%) | 11 (19.3%) | 54 (15.5%) | |
| Northeast | 86 (17.1%) | 9 (15.8%) | 61 (17.5%) | |
| South | 185 (36.9%) | 26 (45.6%) | 132 (37.9%) | |
| West | 144 (28.7%) | 11 (19.3%) | 101 (29.0%) | |
| MSA/urbanicity | ||||
| Metro | 463 (92.2%) | 55 (94.8%) | 321 (92.2%) | |
| Non-Metro | 39 (7.8%) | 3 (5.2%) | 27 (7.8%) | |
| Household Income | ||||
| <$25,000 | 91 (18.1%) | 9 (15.8%) | 43 (12.4%) | |
| $25,000-$49,999 | 91 (18.1%) | 13 (22.8%) | 64 (18.4%) | |
| $50,000-74,999 | 84 (16.7%) | 5 (8.8%) | 61 (17.5%) | |
| $75,000+ | 236 (47.0%) | 30 (52.6%) | 180 (51.7%) | |
| Employment status | ||||
| Not working (due to layoff or looking for work) | 58 (11.6%) | 3 (5.3%) | 32 (9.2%) | |
| Not working (retired, disabled, or other) | 100 (19.9%) | 17 (29.8%) | 63 (18.2%) | |
| Working | 344 (68.5%) | 37 (64.9%) | 252 (72.6%) | |
| Total N | 502 | |||
Notes. MSA=Metropolitan Statistical Area.
In items where the N does not add up to the Total N (502), this represents instances where all participants did not answer the question due to survey routing and/or skip patterns.
Risk Categorization
In terms of risk categorization in the current era of biomedical prevention, rates of condomless anal sex must be considered in the context of one’s HIV status, PrEP use, and (among HIV positive individuals) viral suppression and ART use. Accordingly, we created risk categories, based on classifications used in recent research.22 Categories classified as indicators of potential HIV risk transmission include condomless anal sex among: 1) HIV negative/unknown/untested respondents not currently using PrEP; and 2) HIV positive participants who report being not virally suppressed or not currently adherent to ART.
Prevalence of HIV Risk and Preventative Behaviors
Among the full sample of HIV negative/unknown/untested GBM, only 30 (6.7%) reported using PrEP in the past 6 months (Table 2). Of these men, 19 (63.3%) reported that they took PrEP every day in the past 7 days. The majority of GBM (80.7%) had been tested for HIV and other STI (67.1%) at some point in their lives. Nearly half (45.2%) of GBM who had been tested for HIV were tested in the past year. Among those who reported STI testing, 8.9% tested positive for at least one STI other than HIV during their most recent test. Very few HIV negative/unknown/untested GBM (1.6%) reported that they had used post-exposure prophylaxis (PEP) in the past 6 months.
Table 2.
Prevalence of HIV Risk and Prevention Behaviors in the National Study of Stigma and Sexual Health (N=502).
| HIV Risk/Prevention Behavior | N (%) | 95% CI of Prevalence |
|---|---|---|
| PrEP Use in Past 6 Months1 | ||
| No | 415 (93.3%) | |
| Yes | 30 (6.7%) | (2.6%, 10.9%) |
| PrEP Adherence in Past 7 Days1 | ||
| Every day | 19 (63.3%) | (30.0%, 98.1%) |
| Not every day | 11 (36.7%) | |
| PEP Use in Past 6 Months1 | ||
| No/unknown | 438 (98.4%) | |
| Yes | 7 (1.6%) | (0.1%, 2.9%) |
| Tested for HIV in past year | ||
| No | 221 (54.8%) | |
| Yes | 182 (45.2%) | (38.0%, 52.3%) |
| Ever STI Tested | ||
| No | 127 (25.3%) | (19.5%, 31.1%) |
| Unsure | 38 (7.6%) | (4.1%, 11.2%) |
| Yes | 337 (67.1%) | (60.8%, 73.3%) |
| Most Recent STI Test Result | ||
| Negative | 301 (89.3%) | (84.9%, 93.9%) |
| Positive | 30 (8.9%) | (4.6%, 13.1%) |
| Don’t know/waiting for result | 6 (1.8%) | (0.2%, 3.3%) |
| Feels Comfortable Discussing Sex with Men with a Provider | ||
| No | 170 (38.4%) | |
| Yes | 273 (61.6%) | (54.8%, 68.3%) |
| Has Discussed Ways to Prevent HIV with a Provider | ||
| No | 285 (64.3%) | |
| Yes | 158 (35.7%) | (29.0%, 42.5%) |
Notes: STI = Sexually transmitted infections (other than HIV); PrEP = pre-exposure prophylaxis; PEP = post-exposure prophylaxis. In items where the N does not add up to the Total N (502), this represents instances where all participants did not answer the question due to survey routing and/or skip patterns.
These analyses were conducted among HIV negative/unknown/untested participants.
Over half of GBM (54.2%) reported not using a condom during anal sex with their most recent male partner; among these men, 93.8% were not on PrEP. Among participants who were HIV negative/unknown/untested, those on PrEP reported a higher proportion of condomless anal sex, as compared to those not on PrEP (81.8% vs 43.7%, p=0.0005 per unweighted chi-square test). However, these findings must be considered in light of the fact that among those who had engaged in recent condomless anal sex, only a very small proportion used PrEP.
Fifty-seven GBM (14.1%) reported testing positive for HIV. Among these HIV positive respondents (Table 3), all reported currently being on antiretroviral treatment, and the vast majority (96.5%) had been on treatment for more than a year. Fifty-four (94.7%) reported an undetectable level of viral load. Among the 3.5% of HIV positive GBM who reported being on treatment less than a year, all reported that their most recent HIV test was less than a year ago, suggesting they may have been recently diagnosed. Despite the high rates of reported antiretroviral treatment, however, nearly one third (30.4%) of HIV positive GBM reported not taking their antiretroviral medication every day during the last month. Overall, 5.26% of HIV positive GBM reported a detectable viral load. Among these men, three percent (3.19%) reported condom use during anal sex with their most recent male partner, as compared to 7.95% who reported not using a condom. The difference, however, did not reach the level of statistical significance, possibly due to the small number of HIV positive men with detectable viral loads in the study sample. The finding, therefore, must be interpreted with caution.
Table 3.
Prevalence of HIV Risk and Prevention Behaviors among HIV-Positive Gay and Bisexual Men in the National Study of Stigma and Sexual Health (N=57).
| HIV Risk/Prevention Behavior |
N (%) | 95% CI of Prevalence |
|---|---|---|
| HIV Viral Load | ||
| Detectable | 3 (5.3%) | (0.0%, 13.5%) |
| Undetectable | 54 (94.7%) | |
| On Antiretroviral Treatment | ||
| No | 0 (0.0%) | |
| Yes | 57 (100.0%) | (98.8%,100.0%) |
| Length of Antiretroviral Treatment | ||
| <= 1 year | 2 (3.5%) | |
| > 1 year | 55 (96.5%) | (89.7%, 100.0%) |
| Antiretroviral Treatment Adherence in Last 30 days | ||
| Missed 0 days | 39 (69.6%) | (52.9%, 85.5%) |
| Missed 1 day | 8 (14.3%) | (2.4%, 27.3%) |
| Missed 2+ days | 9 (16.1%) | (3.0%, 29.0%) |
Demographic Associations with HIV Risk and Preventative Behaviors
In analyses stratified by three key demographic characteristics associated with the highest incidence of the HIV/AIDS epidemic in the U.S. (i.e., being non-White, younger, and/or living in the South) (Table 4), we observed few significant differences in HIV risk and preventive behaviors. Instead, our data show similar rates of condom use during anal sex with last male partner, HIV/STI testing, testing positive for STI, and PEP use across race, age and region. Only three statistically significant differences emerged. GBM ages 35 and older were more likely to have ever been tested for HIV compared to GBM under 35 (86.9% vs 67.5%; p<0.01). Although we found no differences in past 6 month PrEP use across age and region, non-white GBM were significantly more likely to have used PrEP than white GBM (12.1% vs. 3.6%, p<0.05). However, white GBM reported a significantly higher proportion of taking PrEP everyday as compared to non-white GBM (100.0% vs. 50%, p<0.01).
Table 4.
Prevalence of HIV Risk and Prevention Behaviors in the National Study of Stigma and Sexual Health, Stratified by Key Demographic Characteristics (N=502).
| Race | Age | U.S. Region | ||||
|---|---|---|---|---|---|---|
| HIV Risk/Prevention Behavior |
Non-White (N=191) |
White (N=311) |
18-35 (N=165) |
36+ (N=337) |
South (N=185) |
All Other Regions (N=317) |
| Condom Used During Anal Sex With Most Recent Male Partner | 74 (45.4%) | 129 (46.2%) | 59 (46.5%) | 144 (45.6%) | 73 (41.5%) | 129 (48.5%) |
| Ever Tested for HIV | 162 (84.8%) | 243 (78.1%) | 112 (67.5%) | 293 (86.9%)** | 158 (85.4%) | 247 (77.9%) |
| Tested Positive for HIV | 25 (15.4%) | 32 (13.2%) | 8 (7.2%) | 49 (16.7%) | 26 (16.5%) | 31 (12.6%) |
| Ever Tested for STI | 129 (67.5%) | 207 (66.6%) | 108 (65.1%) | 229 (68.0%) | 130 (70.3%) | 207 (65.3%) |
| Tested Positive for an STI | 16 (12.3%) | 14 (6.8%) | 8 (7.4%) | 22 (9.6%) | 17 (13.1%) | 13 (6.3%) |
| Used PrEP in Past 6 Months | 20 (12.1%) | 10 (3.6%)* | 15 (9.6%) | 15 (5.2%) | 12 (7.6%) | 18 (6.3%) |
| Took PrEP Every day for 7 Days | 10 (50.0%) | 9 (100.0%)** | 10 (62.5%) | 9 (64.3%) | 5 (41.7%) | 15 (83.3%) |
| Used PEP in Past 6 Months | 3 (1.8%) | 3 (1.1%) | 1 (0.6%) | 5 (1.7%) | 3 (1.9%) | 4 (1.4%) |
p<0.001;
p<0.01;
p<0.05
Note: Chi-squared tests were performed for all variables. P-values less than 0.05 were considered statistically significant. Comparisons were made between two levels of each category (e.g., within race/ethnicity non-white was compared to white)
HIV Risk and Prevention Discussions with Primary Healthcare Provider
In terms of interactions with primary healthcare providers, many GBM in our sample did not feel comfortable discussing HIV-related risk with their healthcare providers. Specifically, over a third of our overall sample of GBM (38.4%) reported that they did not feel comfortable discussing that they had anal sex with men with their primary healthcare providers. Additionally, the majority of HIV-negative/unknown/untested GBM (64.3%) reported that they had never discussed ways to protect themselves from HIV with their primary healthcare provider.
Discussion
The National HIV/AIDS Strategy, recently updated through the year 2020, highlights several goals, including reducing new infections; increasing access to care and improving health outcomes among individuals living with HIV; reducing HIV-related health disparities; and achieving a more coordinated national response to HIV.3 The current study assessed the prevalence of HIV risk and prevention behaviors in a current probability-based sample of gay and bisexual men in the U.S., with the primary aim of evaluating the success of the U.S. National HIV/AIDS Strategy3 in meeting these goals. Data can also serve as a starting point for tracking the success of the End the HIV Epidemic Initiative.2
Overall, our findings present a decidedly mixed picture. We were encouraged that over three quarters of the sample (80.7%) had been tested for HIV in their lifetime. That all HIV positive participants reported using and, for the most part, adhering to ART suggests that messages surrounding treatment as prevention for HIV positive men are reaching the general population. Further, over two thirds (67.1%) had been tested for STI other than HIV, and of these men, over 80% reported testing negative. It is also encouraging that all HIV positive participants not only reported currently being on antiretroviral therapy but nearly all (94.7%) reported being virally undetectable and had been on treatment for more than one year. Given the current emphasis on treatment-as-prevention,3 these findings are particularly noteworthy and promising, suggesting that the number of individuals who could potentially transmit HIV is diminishing.
At the same time, there is clear cause for concern. In recent years, significant resources have been invested in promoting PrEP use among GBM as a primary prevention strategy, including in a recent U.S. Preventive Services Task Force recommendation report.23 Our data indicate that such efforts have not reached the vast majority of GBM in the general population, with only 6.7% of HIV negative/unknown/untested men in our sample using PrEP in the last 6 months. This remarkably low rate of PrEP use is similar to that found by Hammack and colleagues (4.1%) across three age cohorts in another recent probability-based study of GBM in the U.S.13 Further, there were strikingly low rates of condom use among men not currently taking PrEP. Specifically, over half of GBM reported not using a condom during anal sex with their most recent male partner, and of these, 93.8% were not on PrEP. If we found lower rates of condom use alongside higher rates of PrEP use, suggesting that this biomedical prevention strategy was replacing condom use, there might be less cause for concern regarding potential for HIV transmission. That PrEP use in the general population of gay and bisexual men is not nearly prevalent enough to warrant such high rates of condomless anal sex highlights the need to further focus on this critical pillar of the recent End the HIV Epidemic Initiative.2
Additional causes for concern were evident in low rates of other HIV prevention practices, including STI testing and discussions of HIV prevention with primary healthcare providers. Nearly one third of GBM had not been tested for an STI other than HIV, despite the high prevalence (approximately 8.9%) of STI in our sample at most recent testing among those who had been tested. Early diagnosis and treatment of STI reduces transmission and risk of HIV acquisition, and these infections are also useful measures of behavioral risk for providers and patients because of the shared mode of transmission.24 While many of the participants (61.6%) reported that they may feel comfortable discussing same-sex behavior with their primary healthcare provider, the majority of HIV unknown/negative/untested GBM (64.3%) had never actually discussed HIV prevention with their provider.
As with all research, this study has strengths and shortcomings. Our most notable strength is the rare use of a probability sample to identify GBM study participants, thus allowing findings to be generalized to GBM living in the United States at the time of the study. Our survey was also accessible in both English and Spanish, which was particularly important given that nearly one-fifth of the sample identified as Latino. However, by design, the present study was limited to those at least 18 years old who were not living in institutions or without an address. Sexual minority individuals are over-represented in homeless25 and incarcerated populations;26 to the extent that HIV risk factors are higher in these populations, their absence from our sample means that we likely underestimated these outcomes among GBM in the U.S.
In addition, while the use of probability-based samples offers certain advantages, these designs typically result in relatively small sample sizes of subgroups of sexual minority respondents (e.g., racial/ethnic and gender minorities), as was the case in the current study. These smaller sample sizes likely precluded our ability to observe statistically significant subgroup differences by key demographic characteristics that are important to understanding the HIV/AIDS epidemic in the U.S. (i.e., race, age, and U.S. region). Moreover, these smaller sample sizes can create estimates among population subgroups that may not be generalizable, despite the use of a population-based design. For instance, recent evidence suggests that among HIV-positive patients in care, the rate of virological suppression is 77%.27 The higher rate of reported virological suppression in our study (95%) may suggest that those who agree to answer surveys are more adherent than those in the general clinical population, or could reflect a reporting bias. However, with 38,000 new infections occurring per year, a substantial number of HIV positive people coming in and out of care, and 14% of those with chronic HIV unaware of their infection, the true prevalence of people who are not virologically suppressed is not known.
Finally, we recruited our sample based on a measure of sexual identity because Ipsos currently uses this question—rather than a question on sexual behavior—to ascertain the sexual minority sample. This sampling approach was appropriate for the main aims of the parent study, which are focused on assessing relationships between identity-based stressors and health outcomes, including HIV risk. This approach is limited in that our focus is on GBM, and we do not capture heterosexually-identified MSM. However, population-based data from the NSSHB indicate that only approximately 1% of heterosexually-identified men report having sex with men in the last 12 months7, a sample size that would be too small to create reliable estimates in our study.
Our findings suggest that clinical practice, programmatic, and policy-related changes are needed to achieve the goals set forth in the U.S. National HIV/AIDS Strategy, as well as in the recent End the HIV Epidemic Initiative, as they relate to GBM.2,3 For example, in clinical settings across the nation, the assessment of sexual orientation and behavior at intake is critically important to understand potential risk for HIV infection.28 Our findings have implications for training providers to proactively address their GBM patients’ orientation and behavior openly and, as relevant, communicate about risk and prevention. This is particularly true in terms of reaching sexual minority individuals who may not have access to, or who may not feel comfortable receiving care in specialized lesbian, gay, bisexual and transgender (LGBT) community centers or clinics (which tend to be located in large, relatively progressive urban areas of the U.S.).
Additionally, our findings suggest that public health and HIV care providers clearly have much work to do to address the lack of widespread dissemination of PrEP in the GBM population, as well as routine testing for HIV and other STI.29,30 Thus, our findings further highlight the importance of promoting and disseminating HIV prevention strategies, including condom use and PrEP, beyond high risk samples. Finally, our results underscore the importance of the inclusion of more comprehensive assessments of HIV prevention outcomes among general population samples of GBM in order to more accurately evaluate the effectiveness of the national strategy for reducing HIV infections among GBM and other MSM in the U.S.
Acknowledgments
Funding:
The National Institute of Mental Health (R01 MH112384, MPI: Hatzenbuehler/Dodge) funded this study. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Contributor Information
Brian Dodge, Indiana University School of Public Health, Center for Sexual Health Promotion, Bloomington, Indiana
Jessie Ford, Columbia University Mailman School of Public Health, Department of Sociomedical Sciences, New York, New York
Na Bo, Indiana University School of Medicine, Department of Biostatistics, Indianapolis, Indiana
Wanzhu Tu, Indiana University School of Medicine, Department of Biostatistics, Indianapolis, Indiana
John Pachankis, Yale University School of Public Health, Social and Behavioral Sciences, New Haven, Connecticut
Debby Herbenick, Indiana University School of Public Health, Center for Sexual Health Promotion, Bloomington, Indiana.
Kenneth Mayer, The Fenway Institute/Harvard University School of Medicine, Boston, Massachusetts
Mark L. Hatzenbuehler, Columbia University Mailman School of Public Health, Department of Sociomedical Sciences, New York, New York
References
- 1.Centers for Disease Control and Prevention. Diagnoses of HIV infection in the United States and dependent areas, 2014. HIV Surveillance Report. 2015;26. [Google Scholar]
- 2.Fauci AS, Redfield RR, Sigounas G, Weahkee MD, Giroir BP. Ending the HIV Epidemic: A Plan for the United StatesEnding the HIV EpidemicEditorial. JAMA. 2019;321(9):844–845. [DOI] [PubMed] [Google Scholar]
- 3.Office of National AIDS Policy. National HIV/AIDS Strategy for the United States: Updated to 2020. Washington, DC: The White House Office of National AIDS Policy;2015. [Google Scholar]
- 4.Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data - United States and 6 dependent areas - 2013. HIV Surveillance Report - Supplement Report. 2015;20(2). [Google Scholar]
- 5.Centers for Disease Control and Prevention. 2016 Conference on Retroviruses and Opportunistic Infections. 2016; http://www.cdc.gov/nchhstp/newsroom/2016/croi-2016.html#Graphics.
- 6.Hess KL, Hu X, Lansky A, Mermin J, Hall HI. Lifetime risk of a diagnosis of HIV infection in the United States. Annals of epidemiology. 2017;27(4):238–243. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Dodge B, Herbenick D, Fu TC, et al. Sexual Behaviors of U.S. Men by Self-Identified Sexual Orientation: Results From the 2012 National Survey of Sexual Health and Behavior. The journal of sexual medicine. 2016;13(4):637–649. [DOI] [PubMed] [Google Scholar]
- 8.Meyer IH, Wilson PA. Sampling lesbian, gay, and bisexual populations. Journal of counseling psychology. 2009;56(1):23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Chandra A, Mosher WD, Copen C, Sionean C. Sexual behavior, sexual attraction, and sexual identity in the United States: data from the 2006–2008 National Survey of Family Growth. National health statistics reports. 2011(36):1–36. [PubMed] [Google Scholar]
- 10.Sell RL. Challenges and Solutions to Collecting Sexual Orientation and Gender Identity Data. American journal of public health. 2017;107(8):1212–1214. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Sell RL, Holliday ML. Sexual Orientation Data Collection Policy in the United States: Public Health Malpractice. American journal of public health. 2014;104(6):967–969. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Reece M, Herbenick D, Schick V, Sanders SA, Dodge B, Fortenberry JD. Background and considerations on the National Survey of Sexual Health and Behavior (NSSHB) from the investigators. The journal of sexual medicine. 2010;7(S5):243–245. [DOI] [PubMed] [Google Scholar]
- 13.Hammack PL, Meyer IH, Krueger EA, Lightfoot M, Frost DM. HIV testing and pre-exposure prophylaxis (PrEP) use, familiarity, and attitudes among gay and bisexual men in the United States: A national probability sample of three birth cohorts. PloS one. 2018;13(9):e0202806. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Laumann EO. The social organization of sexuality: Sexual practices in the United States. Chicago, Illinois: University of Chicago Press; 1994. [Google Scholar]
- 15.Stall R, Mills TC, Williamson J, et al. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. American journal of public health. 2003;93(6):939–942. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Herbenick D, Reece M, Schick V, Sanders SA, Dodge B, Fortenberry JD. Sexual behavior in the United States: results from a national probability sample of men and women ages 14–94. The journal of sexual medicine. 2010;7(S5):255–265. [DOI] [PubMed] [Google Scholar]
- 17.Mayer KH, Safren SA, Elsesser SA, et al. Optimizing Pre-Exposure Antiretroviral Prophylaxis Adherence in Men Who Have Sex with Men: Results of a Pilot Randomized Controlled Trial of “Life-Steps for PrEP”. AIDS and behavior. 2017;21(5):1350–1360. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Centers for Disease Control and Prevention. HIV testing among men who have sex with men−−21 cities, United States, 2008. MMWR Morbidity and mortality weekly report. 2011;60(21):694. [PubMed] [Google Scholar]
- 19.Celentano DD. Editorial response: it’s all in the measurement: consistent condom use is effective in preventing sexually transmitted infections. Sexually transmitted diseases. 2004;31(3):161–162. [DOI] [PubMed] [Google Scholar]
- 20.Wheeler DP, Fields SD, Beauchamp G, et al. Pre-exposure prophylaxis initiation and adherence among Black men who have sex with men (MSM) in three US cities: results from the HPTN 073 study. Journal of the International AIDS Society. 2019;22(2):e25223. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Jain S, Krakower DS, Mayer KH. The Transition From Postexposure Prophylaxis to Preexposure Prophylaxis: An Emerging Opportunity for Biobehavioral HIV Prevention. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2015;60 Suppl 3:S200–204. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Holt M, Lea T, Mao L, et al. Community-level changes in condom use and uptake of HIV pre-exposure prophylaxis by gay and bisexual men in Melbourne and Sydney, Australia: results of repeated behavioural surveillance in 2013–17. The lancet HIV. 2018;5(8):e448–e456. [DOI] [PubMed] [Google Scholar]
- 23.Owens DK, Davidson KW, Krist AH, et al. Preexposure Prophylaxis for the Prevention of HIV Infection: US Preventive Services Task Force Recommendation Statement. Jama. 2019;321(22):2203–2213. [DOI] [PubMed] [Google Scholar]
- 24.Farley TA, Cohen DA, Wu SY, Besch CL. The value of screening for sexually transmitted diseases in an HIV clinic. Journal of acquired immune deficiency syndromes (1999). 2003;33(5):642–648. [DOI] [PubMed] [Google Scholar]
- 25.Corliss HL, Goodenow CS, Nichols L, Austin SB. High burden of homelessness among sexual-minority adolescents: findings from a representative Massachusetts high school sample. American journal of public health. 2011;101(9):1683–1689. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Javanbakht M, Murphy R, Harawa NT, et al. Sexually transmitted infections and HIV prevalence among incarcerated men who have sex with men, 2000–2005. Sexually transmitted diseases. 2009;36(2):S17–S21. [DOI] [PubMed] [Google Scholar]
- 27.Bradley H, Althoff KN, Buchacz K, et al. Viral suppression among persons in HIV care in the United States during 2009–2013: sampling bias in Medical Monitoring Project surveillance estimates. Annals of epidemiology. 2019;31:3–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Haider A, Adler RR, Schneider E, et al. Assessment of Patient-Centered Approaches to Collect Sexual Orientation and Gender Identity Information in the Emergency Department: The EQUALITY StudyCollection of Sexual Orientation and Gender Identity Information in the Emergency DepartmentCollection of Sexual Orientation and Gender Identity Information in the Emergency Department. JAMA Network Open. 2018;1(8):e186506–e186506. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Cáceres CF, O’Reilly KR, Mayer KH, Baggaley R. PrEP implementation: moving from trials to policy and practice. Journal of the International AIDS Society. 2015;18(4 Suppl 3):20222. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Underhill K, Operario D, Skeer M, Mimiaga M, Mayer K. Packaging PrEP to Prevent HIV: An Integrated Framework to Plan for Pre-Exposure Prophylaxis Implementation in Clinical Practice. Journal of acquired immune deficiency syndromes (1999). 2010;55(1):8–13. [DOI] [PMC free article] [PubMed] [Google Scholar]