Behavioral, not just medical, strategies are needed to curb transmission from HIV-positive adolescent boys and young men who have sex with men, according to a report published online Dec. 7 in JAMA Pediatrics.
Condom use, together with treatment to suppress viral load, drastically reduce the likelihood that HIV-positive teens and men will transmit the virus to their sexual partners. But it is “challenging” to keep this patient group engaged in health care and adherent to antiretroviral treatment (ART), said Patrick A. Wilson, Ph.D., of the department of sociomedical sciences, Mailman School of Public Health, Columbia University, New York, and his associates.
© Dr. A. Harrison; Dr. P. Feorino / CDC
This thin-section transmission electron micrograph shows the ultrastructural details of a number of HIV particles.
They performed a cross-sectional survey involving 991 HIV-positive males who reported having recent oral or anal intercourse with other males. They were aged 12-26 years and received at least some care at 20 specialty clinics in major cities across the United States. They completed 45- to 90-minute computer-assisted self-interviews assessing substance use, mental health, and sexual behavior. Their medical records provided information regarding treatment and viral load.
A little more than half (52.1%) of the respondents said they were currently prescribed ART, and a majority – 69.4% – had a detectable viral load. “It was particularly troubling” that fewer than 3 in 10 (29.1%) of these sexually active young men had an undetectable viral load. Clinicians should be aware of the stark disparities in viral suppression among men who have sex with men, Dr. Wilson and his associates said.
Just as alarming was the high incidence of engaging in anal intercourse without a condom: 46.2%. Moreover, fully 31.3% of the respondents said they had condomless anal intercourse with male partners who were not HIV positive.
Several factors were strongly and independently linked with both unprotected anal sex and unprotected anal sex with an HIV-negative partner, including problematic substance use, unemployment, previous incarceration, and nonblack race. Previous research has found that substance use both escalates high-risk sexual behavior and disrupts adherence to ART, so this study result demonstrates that “substance use must continue to be a target of health promotion interventions [aimed at] HIV-infected youth,” the investigators said (JAMA Pediatrics 2015 Dec 7. doi: 10.1001/jamapediatrics.2015.3333).
Previous research has revealed a paradox: Among young men who have sex with men, those who are black are less likely to engage in high-risk sexual behavior than are those of other races, yet black men are the population group most affected by HIV in the United States. “This finding underscores the role that social network and structural factors [such as unemployment and incarceration] play in explaining enhanced HIV vulnerability among young black men who have sex with men,” Dr. Wilson and his associates wrote.
One factor in particular correlated with safe sexual practice in this study population: transgender gender identity. This constitutes another paradox that deserves further research, since HIV-infected transgender individuals are at uniquely high risk for poor health outcomes, the researchers added.
Overall, the study findings clearly demonstrate that behavioral interventions are critical to addressing HIV transmission in this patient population, they said.
The National Institute of Child Health and Human Development, the National Institute on Drug Abuse, and the National Institute on Mental Health funded the study. Dr. Wilson and his associates reported having no financial conflicts.