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Men who have sex with men (MSM) often change sexual behaviors following HIV diagnosis. This systematic review examined such changes, including sero-adaptive behaviors (i.e., deliberate safer-sex practices to reduce transmission risk) to better understand the magnitude of their association with HIV diagnosis. We searched four databases (1996-2017) and reviewed references from other systematic reviews. We included studies conducted in the United States that compared sexual behavior among HIV-infected "aware" versus "unaware" MSM. We meta-analytically pooled RRs and associated 95% confidence intervals (CI) using random-effects models, and assessed risk of bias and evidence quality. Twenty studies reported k = 131 effect sizes on sexual practices outcomes, most of which reported changes in unprotected sex (k = 85), and on sex with at-risk partners (k = 76); 11 reported sero-adaptive behaviors. Unprotected anal intercourse with an HIV-uninfected/unknown-status partner was less likely among aware MSM (insertive position: k = 2, RR 0.26, 95% CI 0.17, 0.41; receptive position: k = 2, RR 0.53, 95% CI 0.37, 0.77). Risk of not always serosorting among aware MSM (k = 3) was RR = 0.92 (0.83, 1.02). Existing evidence, although low-quality, suggests that HIV-infected MSM tend to adopt safer sexual practices once aware of their diagnosis. Variation in reporting of outcomes limits their comparability. Sero-adaptive behavior data are sparse.

BackgroundDespite significant public health implications, the extent to which community-based condom distribution interventions (CDI) prevent HIV infection in the United States is not well understood.MethodsWe systematically reviewed research evidence applying Cochrane Collaboration methods. We used a comprehensive search strategy to search multiple bibliographic databases for relevant randomized controlled trials (RCTs) and non-RCTs published from 1986-2017. We focused on CDI that made condoms widely available or accessible in community settings. Eligible outcomes were HIV infection (primary), sexually transmitted infections, condom use, and multiple sexual partnership. Two reviewers independently screened citations to assess their eligibility, extracted study data, and assessed risk of bias. We calculated risk ratios (RR) with 95% confidence intervals (CI) and pooled them using random-effects models. We assessed evidence quality using GRADE.ResultsWe reviewed 5,110 unique records. Nine studies (including one RCT) met eligibility criteria. Studies were conducted in 10 US states between 1989 and 2011. All studies were at high risk of bias. Interventions were categorized into three groups: "Ongoing" (unlimited access to condoms), "Ongoing-plus" (unlimited access to condoms, with co-interventions), and "Coupon-based" (coupons redeemed for condoms). No studies reported incident HIV. Ongoing CDI (four non-RCTs) modestly reduced condomless sex (RR 0.88, 95% CI 0.78 to 0.99). Ongoing-plus CDI (two non-RCTs) significantly reduced multiple sexual partnership (RR 0.37, 95% CI 0.16 to 0.87). Of two coupon-based studies, one (non-RCT) showed reduction in condomless sex in female participants (Odds Ratio 0.67, 95% CI 0.47 to 0.96), while the other one (RCT) showed no effect on STI incidence (RR 0.91, 95% CI 0.63 to 1.31). Evidence quality was "very low" for all outcomes.ConclusionsCDI may reduce some risky sexual behaviors, but the evidence for any reduction is limited and of low-quality. Lack of biological outcomes precludes assessing the link between CDI and HIV incidence.

Men who have sex with men (MSM) can reduce their risk of acquiring human immunodeficiency virus (HIV) by using various prevention strategies and by understanding the effectiveness of each option over the short- and long-term. Strategies examined were: circumcision; insertive anal sex only; consistent, 100% self-reported condom use; and pre-exposure prophylaxis (PrEP). PrEP efficacy was based on three levels of adherence. The cumulative HIV acquisition risk among MSM over periods of 1 year and 10 years were estimated with and without single and combinations of prevention strategies. A Bernoulli process model was used to estimate risk. In the base case with no prevention strategies, the 1-year risk of HIV acquisition among MSM was 8.8%. In contrast, the 1-year risk associated with circumcision alone was 6.9%; with insertive sex only, 5.5%; with 100% self-reported condom use, 2.7%; and with average, high, and very high PrEP adherence, 5.1%, 2.5%, and 0.7%, respectively. The 10-year risk of HIV acquisition among MSM with no prevention strategy was 60.3%. In contrast, that associated with circumcision alone was 51.1%; with insertive sex only, 43.1%; with 100% self-reported condom use, 24.0%; and with average, high, and very high PrEP adherence, 40.5%, 22.2%, and 7.2%, respectively. While MSM face substantial risk of HIV, there are now a number of prevention strategies that reduce risk. Very high adherence to PrEP alone or with other strategies appears to be the most powerful tool for HIV prevention. [ABSTRACT FROM AUTHOR]

Introduction: HIV testing is an essential prerequisite for accessing treatment with antiretroviral therapy or prevention using pre‐exposure prophylaxis. Internet distribution of HIV self‐tests is a novel approach, and data on the programmatic cost of this approach are limited. We analyse the costs and cost‐effectiveness of a self‐testing programme. Methods: Men who have sex with men (MSM) reporting unknown or negative HIV status were enrolled from March to August 2015 into a 12‐month trial of HIV self‐testing in the United States. Participants were randomly assigned either to the self‐testing arm or the control arm. All participants received information on HIV testing services and locations in their community. Self‐testing participants received up to four self‐tests each quarter, which they could use themselves or distribute to their social network associates. Quarterly follow‐up surveys collected testing outcomes, including number of tests used and new HIV diagnoses. Using trial expenditure data, we estimated the cost of implementing a self‐testing programme. Primary outcomes of this analysis included total programme implementation costs, cost per self‐test completed, cost per person tested, cost per new HIV diagnosis among those self‐tested and cost per quality adjusted life year (QALY) saved. Results: A total of 2665 men were assigned either to the self‐testing arm (n = 1325) or the control arm (n = 1340). HIV testing was reported by 971 self‐testing participants who completed a total of 5368 tests. In the control arm, 619 participants completed 1463 HIV tests. The self‐testing participants additionally distributed 2864 self‐tests to 2152 social network associates. Testing during the trial identified 59 participants and social network associates with newly diagnosed HIV infection in the self‐testing arm; 11 control participants were newly diagnosed with HIV. The implementation cost of the HIV self‐testing programme was $449,510. The cost per self‐test completed, cost per person tested at least once, and incremental cost per new HIV diagnosis was $61, $145 and $9365 respectively. We estimated that self‐testing programme potentially averted 3.34 transmissions, saved 14.86 QALYs and nearly $1.6 million lifetime HIV treatment costs. Conclusions: The HIV self‐testing programme identified persons with newly diagnosed HIV infection at low cost, and the programme is cost saving. [ABSTRACT FROM AUTHOR]