Conclusions & Implications Factors associated with out-of-care or undiagnosed HIV infection at baseline among men who have sex with men—The Anza Mapema Study Colin Kunzweiler1, Robert Bailey1, Supriya Mehta1, Susan Graham2, Duncan Okall3, Fredrick Otieno3 1University of Illinois at Chicago, Epidemiology and Biostatistics, Chicago, IL, USA; 2University of Washington, Medicine, Epidemiology, and Global Health, Seattle, WA, USA; 3Nyanza Reproductive Health Society, Kisumu, Kenya Introduction Results Results The UNAIDS 90-90-90 targets have prioritized HIV testing and awareness of infection status among persons living with HIV. Men who have sex with men (MSM) are disproportionately burdened by HIV infection compared to men of the general population, and 15% of all new HIV infections in Kenya are attributed to male-male sex. However, recent estimates suggest only ~33% of MSM know that they are infected with HIV. There is an urgent need for programs that assist MSM to accept testing, to know their status, and to become engaged in treatment and care.   Sociodemographic and psychosocial characteristics Median age: 24 years (IQR: 21-28 years) 79.1% had completed >9 years of education 50.1% of all men reported harmful alcohol use (Alcohol Use Disorders Identification Test >8) Most (71.9%) had ever had sex with a female partner Most (63.9%) had transactional sex in the past 3 months Clinical characteristics of HIV-positive men 23 were virally suppressed (plasma viral load <1,000 copies/mL) 2 (both PDOC) reported previously taking antiretrovirals (ARVs) Median CD4 count: 486 (IQR: 338-664) 15 (20.6%) had advanced beyond WHO clinical stage 1 at baseline Multivariable multinomial logistic regression Adjusted relative risk ratio (aRRR) of PDOC status, relative to HIV-negative status, greater for men who experienced MSM trauma (aRRR=3.59), who did not report harmful alcohol use (aRRR=3.46), and who experienced upsetting sexual experiences during childhood (aRRR=3.42) NDOC infection status associated with older men (>30 years: aRRR=3.90), completing <8 years of education (aRRR=2.23) Figure 1: Study recruitment and enrollment. Figure 2: Clinical characteristics of HIV-positive men. Newly diagnosed out of care (n=54; 72%) Screened 1,012 Previously diagnosed out of care (n=21; 28%) 248 Ineligible 3 doubly enrolled 5 declined Consented 756 45 withdrawn Enrolled 711 Objectives To report the prevalence of HIV infection at baseline among all participants To identify sociodemographic characteristics and sexual behaviors associated with known and newly diagnosed HIV infections (relative to HIV-negative) at enrolment HIV-negative 636 (89.5%) PDOC 21 (3.0%) NDOC 54 (7.6%) Figure 3: Prevalence of HIV infection by predictor. Table 1: Distribution of participant characteristics by category of HIV infection status (*p<0.05). Age (years) Education (years) Harmful alcohol use MSM trauma Childhood sex. abuse Variable Total n (%) Negative PDOC NDOC Sample 711 (100.0) 636 (89.5) 21 (3.0) 54 (7.6) Age (years)* 18-19 77 (10.8) 72 (11.3) 2 (9.5) 3 (5.6) 20-24 321 (45.1) 296 (46.5) 7 (33.3) 18 (33.3) 25-29 177 (24.9) 159 (25.0) 5 (23.8) 13 (24.1) >30 136 (19.1) 109 (17.1) 20 (37.0) Education (years) 0 to 8 149 (21.0) 124 (19.5) 6 (28.6) 19 (35.2) 9 to 12 354 (49.8) 324 (50.9) 10 (47.6) 13 or more 208 (29.3) 188 (29.6) 15 (27.8) Harmful alcohol use (AUDIT>8) No 354 (49.9) 316 (49.8) 13 (61.9) 25 (46.3) Yes 356 (50.1) 319 (50.2) 8 (38.1) 29 (53.7) Harmful substance use (DAST>3) 169 (23.8) 150 (23.6) 12 (22.2) 542 (76.2) 486 (76.4) 14 (66.7) 42 (77.8) Social support (range: 0-100%) (median/IQR) 50 (34-64) 50 (36-64) 48 (32-66) 48 (32-55) Upsetting sexual experiences during childhood (childhood sexual abuse)* 220 (30.9) 189 (29.7) 491 (69.1) 447 (70.3) 36 (66.7) Physical abuse or verbal threats (MSM trauma)* 258 (39.1) 224 (37.7) 15 (71.4) 19 (42.2) 402 (60.9) 370 (62.3) 26 (57.8) Ever had sex with a female partner 511 (71.9) 458 (72.0) 12 (57.1) 41 (75.9) 200 (28.1) 178 (28.0) 9 (42.9) Transactional sex (last 3 months) 454 (63.9) 401 (63.1) 38 (70.4) 257 (36.1) 235 (36.9) 16 (29.6) Always protected anal intercourse with a man (last 3 months)* 421 (60.6) 367 (59.1) 17 (81.0) 37 (69.8) 274 (39.4) 254 (40.9) 4 (19.1) 16 (30.2) Methods Limitations Eligibility and Recruitment Aged >18 years Oral or anal sex with a man in the past 6 months Not enrolled in HIV care Not taken ART in the past 3 months Outcome variable HIV infection status—3 categories: HIV-negative Previously diagnosed HIV-positive and out of care (PDOC) Newly diagnosed HIV-positive and out of care (NDOC) Serial testing algorithm: two rapid tests (tie-breaker if necessary) Predictor variables Sociodemographic characteristics (6 variables) Sexual behaviors (9 variables) Psychosocial scales (9 variables), including alcohol use (Alcohol Use Disorders Identification Test-AUDIT), substance use (Drug Abuse Screening Test-DAST), and social support Clinical characteristics (4 variables among HIV-positive men) Statistical analyses Multinomial logistic regression analysis: Index categories: PDOC; NDOC Referent (base) category: HIV-negative Manual, backwards multivariable model building included predictors where p<0.05 for at least one comparison Unadjusted and adjusted relative risk ratios (RRR) and 95% confidence intervals (CI) are presented Cross-sectional analysis prohibits causal interpretation Participants not representative of MSM population in Kisumu Participation bias: MSM who participated may be different from those who declined or who were not assessed for eligibility Misclassification is possible: While validated in other populations, psychosocial scales are not validated specifically among Kenyan MSM Conclusions & Implications Table 2: Results of multivariable multinomial logistic regression analyses (n=660). Among 711 men enrolled, prevalence of HIV was 10.6% (n=75) and the majority of HIV-positive MSM (72%) were unaware of their infection. Greater efforts are necessary to reach MSM and engage them in HIV testing, care, and treatment. Histories of childhood sexual abuse and same-sex related trauma were more likely to be PDOC. Researchers and clinicians must screen and provide supportive counseling for these histories in order to improve engagement and retention of MSM in HIV care and treatment. Variable PDOC aRRR (95% CI) NDOC Age (years) (ref: 18-19) >30 2.71 (0.54-13.61) 3.90 (1.01-15.04) 25-29 1.59 (0.28-9.15) 1.33 (0.34-5.16) 20-24 0.98 (0.20-4.93) 1.27 (0.35-4.60) Education (years) (ref: >13) 0 to 8 1.32 (0.36-4.81) 2.23 (1.00-4.97) 9 to 12 1.02 (0.34-3.10) 1.00 (0.46-2.18) Harmful alcohol use (AUDIT>8) (ref: Yes) No 3.46 (1.63-7.37) 1.13 (0.58-2.22) Physical abuse or verbal threats (MSM trauma) (ref: No) Yes 3.59 (1.43-9.00) 0.97 (0.50-1.90) Childhood sexual abuse (ref: No) 3.42 (1.44-8.12) 1.31 (0.67-2.54) Acknowledgements The authors thank the study participants, the Nyanza Reproductive Health Society Team, the University of Illinois at Chicago, the University of Washington, the Centers for Disease Control and Prevention, and the Kenya Ministry of Health. The authors also thank Dr. Ross Slotten and the UIC Slotten Scholarship in Global Health for their support of this research.