You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.


Reported 86% effectiveness for MSM PrEP by PROUD study makes this intervention a viable option for UK health services

25 Mar, 15 | by Leslie Goode, Blogmaster

The Conference on Retroviruses and Opportunistic Infections has recently taken place.  At that event the UK PROUD (PRe-exposure Option for reducing HIV in the UK: immediate or Deferred) study of pre-exposure prophylaxis (PrEP) for MSM reported its results, prior to publication in the coming months.  The headline figure is an astonishing 86% for the reduction of risk of infection in the intervention group.  Hitherto, results of PrEP trials, largely conducted in Africa, have often been disappointing.  This is probably on account of poor adherence (VOICE D( STI/blog); Haberer & Bangsberg (STI/blog); Hendrix & Bumpus (STI/blog)).  The good result achieved here is no doubt attributable to good adherence.  It demonstrates, as these earlier trials have not, the true effectiveness of PrEP.

The UK trial included 545 participants at 13 practices. 276 were randomized to receive PrEP immediately, while the remaining 269 received it after a year.  Earlier PrEP trials have been blind and placebo-controlled.  But this design had the advantage of demonstrating the effectiveness of PrEP in real life. The participants were aware if they were taking the active drug and could have changed their sexual behaviour accordingly.  Given one of the major concerns around PrEP is that of risk compensation – i.e. taking advantage of the protection of PrEP to engage in more risky behaviour than they would otherwise (Marcus & Grant (STI/blog); Baeten & Celum (STI/blog)) – this was a valuable aspect of the trial.

In the period to October 2014, there were 22 HIV infections – 3 in the immediate, and 19 in the deferred group.  This gives us the headline figure of 86%.  At this point, ethical considerations dictated that the study design be changed so all participants received PrEP from then on.  Initially, this study was intended to be a pilot, and to be followed by a larger scale trial.  The decisiveness of the interim findings, however, led to cancellation of that further study.  (For an interesting commentary on the need for researchers to keep pace with changing ethical parameters, see Cohen & Sugarman (STI/blog)).  Cost-effectiveness analyses are apparently underway.  No details are given in the report.  But evidently the high effectiveness observed in the study will allow investigators to present a far more positive case for PrEP than has been warranted by earlier trials (see Borquez & Hallett (STI); Gomez & Hallett (STI/blog); Cremin & Garnett (STI)).  They are also working with stakeholders on how PrEP services could be commissioned across NHS and local authorities.

Should bisexuals be considered a population with specific sexual health needs?

28 Jul, 14 | by Leslie Goode, Blogmaster

Across many cultural contexts, men who have sex with both men and women (MSMW) have levels of STIs/HIV comparable to those we find in men who have sex only with men (MSM); but MSMW have often proved particularly hard for health services to access.  Mercer & Cassell (M&C) (UK) and STIs/Beyrer & Baral (B&B) (South Africa) refer to poor rates of HIV testing as compared to MSM (RR 0.31 and 0.62 respectively). Both studies stress the need to find ways of targeting safe-sex messages for MSMW who do not identify as gay.

In an intriguingly entitled reivew of the literature on MSMW sexual health in the US 2008-2013 (“Beyond the bisexual bridge”)  Jeffries  corroborates this general picture of high STI risk and poor accessibility.  But he seeks to get beyond what he considers an obsession on the part of researchers with the role of MSMW as a “bridging” population with women.  He claims this “characterization” is not justified by the research – at least where the US is concerned (Chu & Curran; Satcher & Dean; Kahn & Catania).  He also views it as ultimately detrimental to the sexual health of MSMW, which needs to be founded on the “recognition of MSMW’s unique sexual and social experiences”.

The article reviews both the sexual health, and socio-cultural challenges to MSMW’s health.  Sexual health challenges include: levels of STIs other than HIV equalling and exceeding MSM levels, alongside levels of HIV lower than MSM, yet higher than MSW (as in the UK (see M&C)); also enormously higher levels of injection drug use, sex in exchange for money or drugs, and drug and alcohol use during sex than in MSM; also sex within female networks (as well as male) that imperil sexual health, with a high proportion of female partners having injected drugs, being under influence of drugs during sex, and having concurrent partners.  Socio-cultural challenges include biphobia in society at large, and fairly extreme socio-economic marginalization, as indicated by lack of education, poverty, homelessness and incarceration.

Some corroboration of the role that Jeffries attributes to settled identities in moderating at risk behaviour is provided by the success of a number of ongoing initiatives aimed at black or Latino MSMW.  These all appear to address MSMW’s masculinity concerns and heterosexual identities in a non-judgmental and culturally sensitive manner.  Men of African American Legacy Empowering Self (MAALES) has been evaluated in a RCT discussed in an earlier blog (STI/blog/Are bisexuals well served by interventions that assume gay identity?).  Jeffries also mentions: Hombres Sanos; the Bruthas Project; the Enhanced Sexual health Intervention for Men (ES-HIM).

A puzzle remains in the lower susceptibility of MSMW, as against MSM, to HIV – alongside equivalent or higher susceptibility to other STIs .  Jeffries discusses this, but offers no explanation.  Could the less than expected levels of HIV in MSMW be the result of an association between MSM identity and sexual networks that carry particular risk of HIV transmission?

Are bisexuals well served by HIV interventions that assume gay identity?

30 Oct, 13 | by Leslie Goode, Blogmaster

Studies published in STI journal have examined the impact of bisexual concurrency on HIV epidemiology in South Africa (Behrer & Baral) (B&B) and China (Yun & Shang) (Y&S), where it is reckoned at 53.7% and 31.2% of the MSM population, respectively.  However, a recent randomized control study of an educational intervention in Los Angeles (Harawa & Cunningham) claims to be among the first studies addressing bisexual concurrency among black MSM in the US.

US black MSM who have sex with women (MSMW) are less likely than white MSM to identify gay, and more concerned to fulfil traditional gender expectations.  Consequently, say the authors, they may be less well served by interventions based on contemporary conceptualizations of sexual behaviour in terms of fixed sexual identities.  This raises a number of interesting questions, among them, how far the situation of US black MSM resembles that of MSM in traditional societies (e.g. South Africa or China), and how far influential contemporary conceptualizations about sexual identity, based on the cultural experience of white MSM, constitute an appropriate model for interventions outside that specific social context.   The authors see potential benefits for MSMW of interventions based on more fluid and context-dependent models of sexual behaviour.

The intervention that is the object of this study – Men of African American Legacy Empowering Self (MAALES) – is an HIV education and risk-reduction course addressed specifically to the needs of this group (Williams & Harawa).  It consists in six two-hour sessions delivered over a three week period (with booster sessions at six and 18 weeks), and aims, above all, to be “culturally congruent”.  It is conducted by black MSM facilitators, and its content is theoretically grounded in a teaching model developed in African American communities (the critical thinking model), as well as in reasoned action theory and empowerment theory.

The study itself compares sexual behaviours, at base-line and three and six months after the intervention, of 437 black MSMW randomly assigned to either the MAALES intervention or a twenty-minute HIV education and risk-reduction session based on a standard HIV test counselling approach. Adjusted results indicate the achievement of significantly less unprotected sex acts with male or female over prior ninety days at six months in the intervention arm as against the control arm (RR 0.61), significantly less unprotected sex acts with females (RR 0.5), and a near-significant reduction in sex acts with males (RR 0.63).  Given the time and resources dedicated to the MAALES as compared to the control intervention, one wonders how much of this behavioural modification is owed to the greater investment in the patients in the intervention arm of the study, and how much to the superiority of its culturally congruent methodology over the conventional alternative.

In their conclusions Harawa and Cunningham tend to corroborate the emphasis of Behrer and Baral, Yun and Shang and others on the influence of societal and cultural factors.  There have even been attempts to quantify the impact of psychosocial constructs on MSM sexual behaviour (Konda & Kegeles).  Yet, Harawa and Cunningham differ somewhat from these other studies in the greater stress they place on the role of participants as responsible agents.  They also recommend on the basis of the more frequent reporting of unprotected sex with females in their study, and the relatively low levels of sex with males, that interventions aiming to “responsibilise” MSMW should prioritize the reduction of risky behaviour which involves females, rather than males.

Sexually Transmitted Infections blog

Sexually Transmitted Infections

Discussion and suggestion space for readers of STIs.
Visit site

Creative Comms logo

Latest from Sexually Transmitted Infections

Latest from Sexually Transmitted Infections