To the Editor:
A number of biomedical interventions to prevent HIV acquisition and transmission are currently being tested in the United States for safety and, for some, efficacy. Three strategies being tested among men who have sex with men (MSM) include preventive HIV vaccines,1 suppression of herpes simplex virus type 2 (HSV-2) infection,2 and use of antiretrovirals for prevention of infection.3
The first approach, preventive HIV vaccines, has been under development in the United States since 1988, and phase 1 and 2 trials are ongoing. Two efficacy trials completed to date have not demonstrated efficacy of test vaccines.4,5 The second approach, suppression of HSV-2 infection with acyclovir, is based on evidence that HSV-2 infection increases the risk of HIV infection at least 2-fold.6,7 A recently completed trial testing the efficacy of suppressive therapy with acyclovir in preventing HIV acquisition among MSM in the United States and Peru and women in Africa did not show efficacy of this prevention strategy.8 Lastly, recommendations for nonoccupational postexposure prophylaxis (nPEP) using antiretrovirals were published by the Centers for Disease Control and Prevention (CDC) in 2005, although clinicians and health departments have recommended use of nPEP since 1998.9 One study of pre-exposure prophylaxis (PrEP) among MSM is underway in the United States and is examining the safety of PrEP, biologically and with regard to potential increases in risk behaviors.3
Information on awareness of potential interventions within at-risk communities can be useful in preparing for the dissemination of effective approaches in the future. Furthermore, there is concern that some strategies, such as PrEP, are already being used within at-risk populations before they are proven to be effective.3 Information on the level of awareness of these potential prevention strategies in the MSM community is limited. Using data from the New York City HIV Behavioral Surveillance Study, we assessed the awareness of HIV vaccines and of the association between herpes and HIV in a venue-based community sample of MSM. We also inquired about the use of nPEP and PrEP in this study sample, as a measure of awareness of this strategy.
The National HIV Behavioral Surveillance survey in New York City (NHBS-NYC) was part of a national survey conducted in 17 cities.10 This cross-sectional survey, using time-space sampling methods,11 was designed to estimate the frequency of risk behaviors among MSM who attend public venues. HIV antibody testing was also included in 5 cities. The methods for the NHBS-NYC have been described previously.12 For the NHBS-NYC, HIV antibody testing was also included, although not offered to the first 101 participants because of late institutional review board (IRB) approval of the testing component.
The questionnaire collected data on demographics, history of HIV antibody testing, and sexual risk behaviors and drug and alcohol use in the prior 12 months. For awareness of preventive HIV vaccines, men were asked “Have you heard about vaccines that could be used to prevent getting infected with HIV?” and where they had heard about HIV vaccines. For the HIV-herpes association, participants were asked “If someone has genital herpes, do you think that their risk of getting HIV is the same, greater or less than someone without genital herpes?” The men were also asked if they ever had a blood test for herpes. For nPEP or PrEP, the men were asked “Have you ever used anti-HIV medications to prevent HIV infection either before or after a high-risk sexual or drug use exposure?” The study was approved by the IRBs of the participating institutions.
These analyses were based on the 503 men recruited in 2004 to 2005 who reported having had a male partner (MSM) in the previous 12 months. Approximately half (51.1%) of the men were younger than 30 years of age, 27.4% were Latino, and 23.3% were African American. Approximately half of the sample (53.7%) was recruited at bars and 11.3% at dance clubs, with the remaining men recruited at street locations, retail businesses, cafes/restaurants, events, social organizations, parks, and gyms. Most men (74.2%) had at least some college education. Of the 402 men offered HIV antibody testing, 349 accepted testing and 18.3% were found to be infected. In the previous 12 months, 53.1% of men reported having unprotected anal intercourse: 32.4% with main partners and 42.2% with nonmain partners.
Overall, 46.2% of men had heard of preventive HIV vaccines. Of those, 33.6% had heard about HIV vaccines from local newspapers, 25.8% from television reports, 22.3% from the Internet, 21.4% from local magazines, and 6.1% from community presentations. Close to one third (32.8%) of men had heard about HIV vaccines from multiple places. The youngest men (aged 18 to 24 years) were less likely to have heard about HIV vaccines compared with older men (30.0% vs. 53.6%; P < 0.0001), as were less educated men (high school degree or less) compared with more educated men (35.4% vs. 50.4%; P = 0.003) and HIV-uninfected men compared with HIV-infected men (44.9% vs. 64.1%; P = 0.006). Men who reported unprotected insertive anal intercourse with a main partner were significantly more likely to be aware than men who did not (57.5% vs. 44.6%; P = 0.041). Awareness of HIV vaccines was not related to race/ethnicity, venue of recruitment, sexual identity, other sexual risk behaviors, or use of specific drugs.
Overall, 59.0% of men knew that infection with genital herpes increases the risk of HIV infection. One third (33.7%) of men thought that the risk was the same whether or not someone had genital herpes, 5.6% did not know, and 1.6% thought that the risk was lower compared with the risk in someone without genital herpes. Approximately half (47.3%) of the men had ever been tested for herpes infection. Men who had previously been tested for herpes were not significantly more likely to know that herpes increases the risk of HIV compared with men who had never been tested for herpes (62.7% vs. 55.7%; P = 0.11). Men who were younger (18 to 24 years of age) were less likely to know of the increased risk of HIV associated with herpes compared with older men (51.3% vs. 62.4%; P = 0.022), as were less educated men (high school degree or less) (51.5% vs. 61.7%; P = 0.043). No other demographic, sexual risk behavior, or drug use was associated with knowledge of the herpes-HIV association. Only 10 (2.0%) men reported that they had ever used nPEP or PrEP.
The NHBS-NYC survey provided an opportunity to assess the awareness of potential prevention strategies within the MSM community in New York City. The men were recruited at public venues and included only those who chose to participate; thus, they do not necessarily represent all MSM in New York City. Furthermore, the questionnaires were interviewer administered; thus, some behaviors may have been underreported.
Almost half of these MSM were aware of an important strategy being tested in New York City and around the world-preventive HIV vaccines. This is of particular interest, because recruitment for a large HIV vaccine efficacy trial was going on during the same time as the NHBS-NYC survey. Because of the wording of the question, we were not able to distinguish men who believe, incorrectly, that a licensed HIV vaccine exists and is available from men who were aware of HIV vaccines under development. Thus, the proportion aware of HIV vaccines under development may have been overestimated. HIV-infected men were significantly more likely to be aware of HIV vaccines for prevention of HIV infection than HIV-uninfected men. Although it is important to include all persons in building support for HIV vaccine trials, the results emphasize the need to continue and expand community education about HIV vaccine trials among HIV-uninfected men to increase participation of eligible MSM.
Only 59% of these MSM knew that infection with genital herpes increases the risk of HIV infection. Furthermore, less than half of the men had ever been tested for herpes, and those tested were not significantly more likely to know about the herpes-HIV association. Previous studies have shown that symptoms of genital ulcers are neither sensitive nor specific for HSV-2 infection and that the increase in HIV infection is present for those who have HSV-2 infection, regardless of symptoms.7 Thus, this raises another important area for community education efforts to underscore the importance for MSM to take precautions against acquiring infection with HSV-2, to increase the knowledge of the herpes-HIV association, and to test for HSV-2 infection when indicated. Community outreach efforts for HIV vaccines and herpes need to focus on younger men and less educated men, 2 groups with particularly low levels of knowledge.
As has been observed in another survey,13 few men reported using nPEP or PrEP. For nPEP, we do not know if this is a result of lack of awareness of this intervention or other factors, such high cost or personal preferences. For PrEP, this is not a proven intervention; thus, it was not expected that many men would have reported PrEP use. If PrEP is shown to be effective in reducing HIV acquisition, it would be important to monitor trends in use and any subsequent changes in HIV risk behaviors.
The authors thank the NHBS-NYC field staff (Christine Borges, Juan Carlos Guerrero, Joshua Hinkson, Kerri O'Meally, Kenny Torres, Alex Nemirovsky, and Terrance Precord) for their work and devotion in conducting this study, the Project ACHIEVE Community Advisory Board for their advice and contributions, and the study participants who gave their time and effort.
Beryl A. Koblin, PhD*
Christopher Murrill, PhD†
Guozhen Xu, BS*
Michael Camacho, BA‡
Kai-lih Liu, PhD†
Shavvy Raj-Singh, MPH†
Lucia Torian, PhD†
*Laboratory of Infectious Disease Prevention New York Blood Center New York, NY
†New York City Department of Health and Mental Hygiene New York, NY
‡Mt. Sinai Medical Center New York, NY
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