1. 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 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: 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: )
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45 withdrawn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 ( )
3.90 ( )
25-29
1.59 ( )
1.33 ( )
20-24
0.98 ( )
1.27 ( )
Education (years) (ref: >13)
0 to 8
1.32 ( )
2.23 ( )
9 to 12
1.02 ( )
1.00 ( )
Harmful alcohol use (AUDIT>8) (ref: Yes) No
3.46 ( )
1.13 ( )
Physical abuse or verbal threats (MSM trauma) (ref: No)
Yes
3.59 ( )
0.97 ( )
Childhood sexual abuse (ref: No)
3.42 ( )
1.31 ( )
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.