Interventions to Reduce Sexual Risk Behaviors or Increase Protective Behaviors to Prevent Acquisition of HIV in Men Who Have Sex with Men: Individual-, Group-, and Community-Level Behavioral Interventions

Research Gaps

What are Research Gaps?

Prior to and during the literature review and data analysis, the review team and the Community Preventive Services Task Force attempt to address the key questions of what interventions work, for whom, under what conditions, and at what cost. Lack of sufficient information often leaves one or more of these questions unanswered. The Community Guide refers to these as "research gaps." Research gaps can be pulled together in the form of a basic set of questions to inform a research agenda for those in the field.

Informational Approaches Identified Research Gaps

Results from the Community Guide reviews of the effectiveness of individual-, group-, and community-level HIV behavioral risk-reduction interventions for adult men who have sex with men (MSM) indicate that a number of interventions are effective in reducing HIV risk behaviors among MSM. Yet, important research issues remain. Research gaps are provided for the following categories:

Subgroups and settings. Although available results suggest robustness in effectiveness across populations and contexts, differences in effectiveness among subgroups of MSM have not been ruled out.

• Only three studies conducted in the U.S. focused exclusively on nonwhite MSM,^{1, 2, 3} and the majority of participants in only one international study94 were nonwhite.
• Because African-American and Hispanic MSM are disproportionately affected by the HIV epidemic in the U.S.,⁴ the need for research on these subgroups of MSM is urgent.⁵
• None of the studies identified in this review specifically targeted non–gay-identified MSM, who may have different HIV prevention needs than gay-identified men.^{6, 7} Several reports have linked increased recreational or "club" drug use (e.g., cocaine and crystal methamphetamine) to increased risky sex behavior in adult MSM.^{8, 9, 10 ,11}
• For example, combination of methamphetamines with erectile dysfunction drugs has become increasingly popular, and has raised serious concerns in both the gay and public health communities.
• Only two studies^{12, 13} included in this systematic review evaluated interventions targeting substance-using MSM. The findings of these two studies were inconsistent in the direction of change and not significant. Further research is needed.

The interventions in this systematic review were evaluated among participants in a variety of settings, including gay bars, community-based organizations, health clinics, and research study sites. However, according to Fenton and Imrie,¹⁴ a new "sexual marketplace" has emerged that provides greater opportunities for MSM to acquire potential partners in settings not well represented in this body of evidence (e.g., the Internet and "circuit parties"). These high-risk settings, which facilitate access to not only homosexual men but to non–gay-identified and bisexual MSM, increase the potential for rapid spread of STDs.¹⁵ Future research is needed to evaluate behavioral interventions in high-risk venues.

Outcome assessment. Continued improvement is also needed in the quality of behavioral assessment in HIV intervention evaluations.

• These Task Force recommendations are based on self-reported change in sex behavior that can be potentially biased by faulty recall and social desirability.
  • Studies in this review used different strategies to minimize the bias of self-report, including assurances of confidentiality, the use of self-administered questionnaires, and shorter recall periods.
  • One study¹⁶ used the new technology of audio computer-assisted self interviewing (ACASI) to enhance the quality of behavioral assessment. ACASI has been shown to increase reporting of sexual contacts of MSM, while providing an acceptable method for collecting self-reports of HIV risk behavior in clinical trials.^{17, 18}
  • Because self reported behaviors are subject to potential biases, many investigators have called for the use of biological outcomes (e.g., STDs and HIV) to assess the overall effectiveness of an intervention.¹⁹ Few studies measure biological outcomes because of the extensive costs and large sample sizes required to assess disease acquisition over a long period of time.^{20, 21, 22, 23}
• Like behavioral outcomes, biological outcomes are also subject to potential biases in measurement.
  • STD incidence may be an invalid "surrogate" for HIV incidence²⁴ because STD acquisition is not only dependent on behaviors such as consistent condom use or frequency of unprotected sex, but also on correct condom use, effectiveness of condoms in preventing different types of STDs, partner selection, acceptance and adherence to STD treatment, and STD prevalence rates within a particular community.^{25, 26, 27, 28}
  • To assess an intervention’s impact on HIV incidence more thoroughly, as well as to understand the complex relationship between behavior and biological outcomes, future intervention evaluations not only need to measure biological endpoints such as STD and HIV incidence, but also develop and use more precise and validated behavioral and biological measures.²⁹

Intervention components. The person-to-person HIV behavioral risk reduction approach, as defined in this review, includes a broad class of interventions that work across various groups and settings. What remains to be determined is the identification of intervention components considered to be most effective, least effective, and cost effective. Most behavioral intervention research to date involved a variety of populations, outcome measures, content, duration, and sessions, making it difficult to replicate findings.³⁰ Results of a recent review³¹ indicate that interventions for MSM promoting interpersonal skills training (i.e., negotiation or communication of safer sex) showed positive effects. Among the group-level interventions in this review, effectiveness may have been enhanced by the provision of multiple sessions, the use of MSM deliverers, and the inclusion of role plays, live demonstrations, or practice of skills. Further research is necessary to determine what works best, in what context, and with whom.

Biomedical, technologic, and social changes. HIV behavioral interventions for adult MSM must continue to evolve to address the challenges of HIV prevention in this population.³² One way this can be accomplished is by considering and incorporating into interventions biomedical advances, technologic innovations, and social changes in HIV transmission.

• Advances in technology and medicine over the past decade have drastically altered the social and behavioral landscape of the MSM community.
• The introduction of HAART in the mid-1990s resulted in expanded treatment options for HIV/AIDS and a dramatic decrease in AIDS mortality.³³
• As HIV is increasingly considered to be a chronic and often manageable disease, commitment to reducing sex risk behaviors, as observed in the first decade of the epidemic, may have declined among many MSM after the introduction of HAART.³⁴
• A recent metaanalysis³⁵ showed that MSM who believed that receiving HAART protects against transmitting HIV had reduced concerns of engaging in unsafe sex, and had engaged in higher rates of unprotected intercourse. This association was seen in HIV-seropositive, HIV-seronegative, and never-tested men.
• While attitudes toward unsafe sex may have changed due to the availability of HAART, the overall efficacy of HIV behavioral interventions for MSM in reducing sex risk behavior has not diminished after the introduction of HAART.³⁶
• As we now move into an era of greater understanding of HAART treatment optimism, HIV risk-reduction interventions for MSM must continue to refocus beliefs and perceptions on HIV risk behavior.^{37, 38, 39}

Accompanying the dramatic medical advances in treating HIV/AIDS are changes in computer technology (e.g., the Internet, chat rooms, e-mail) that allow for increased social interaction among members of the MSM community.

• Studies conducted in the U.S., Europe, and Australia have indicated elevated levels of sex risk behavior among MSM seeking and meeting sex partners through the Internet.^{40, 41, 42, 43}
• Internet chat rooms provide a venue through which MSM, who may be HIV seropositive or at high risk for STDs, can seek casual sex partners while avoiding face-to-face rejection.^{44, 45}
• Although the Internet increases the opportunities for MSM to meet potential sex partners, this communication web also provides expanded opportunities for the broad dissemination of risk-reduction information and the recruitment of diverse MSM subgroups into HIV prevention programs.^{46, 47, 48}

For MSM, HIV behavioral interventions must also consider the rapidly changing social context in which MSM engage in risky unprotected anal sex. The phenomenon of "barebacking," or intentional anal sex without a condom with someone other than a primary partner, has been recently reported in the literature.^{49, 50, 51} Although HIV-seropositive men typically engage in this behavior with other HIV-seropositive men, one study reported a sizeable proportion of men having partners of negative or unknown serostatus.⁵²

In a survey of MSM in New York City,⁵³ the barebacking phenomenon was attributed to the increased availability of willing partners identified through Internet chat rooms and websites, confidence in effective treatments for HIV, emotional fatigue regarding HIV prevention messages, and the increased popularity of "club" drugs. Further, MSM who engage in this behavior dramatically increase their risk of acquiring STDs, which in turn increase the risk of HIV acquisition among seronegative MSM.⁵⁴

Evidence Review

Herbst JH, Beeker C, Mathew A, et al. The effectiveness of individual-, group-, and community-level HIV behavioral risk-reduction interventions for adult men who have sex with men: A systematic review. Am J Prev Med 2007;32(4S):S38–S67.

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³Peterson JL, Coates TJ, Catania J, et al. Evaluation of an HIV risk reduction intervention among African-American homosexual and bisexual men. AIDS 1996;10:319 –25.

⁴Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2003. Vol. 15. Atlanta GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2004.

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²⁷Pequegnat W, Fishbein M, Celentano D, et al. NIMH/APPC workgroup on behavioral and biological outcomes in HIV/STD prevention studies: a position statement. Sex Transm Dis 2000;27:127–32.

²⁸Shain RN, Perdue ST, Piper JM, et al. Behaviors changed by intervention are associated with reduced STD recurrence: the importance of context in measurement. Sex Transm Dis 2002;29:520 –9.

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⁵³Halkitis PN, Parsons JT, Wilton L. Barebacking among gay and bisexual men in New York City: explanations for the emergence of intentional unsafe behavior. Arch Sex Behavior 2003;32:351–7.

⁵⁴Fenton KA, Imrie J. Increasing rates of sexually transmitted diseases in homosexual men in Western Europe and the United States: why? Infect Dis Clin N Am 2005;19:311–31.