Brief Report: Sexual Risk Behaviors of HIV Seroconverters in the US Army, 2012–2014

The United States (US) Army implemented a comprehensive HIV characterization program in 2012 following repeal of the Don't Ask, Don't Tell policy banning openly homosexual individuals from serving in the US military. Program staff administered a standardized case report form to soldiers newly diagnosed with HIV from 2012 to 2014 in compliance with new program requirements. The case report form documented sociodemographic, sexual, and other risk behavior information elicited from US Army regulation-mandated epidemiologic interviews at initial HIV notification. A majority of HIV-infected soldiers were male and of black/African American racial origin. In the HIV risk period, male soldiers commonly reported male–male sexual contact, civilian partners, online partner-seeking, unprotected anal sex, and expressed surprise at having a positive HIV result. Don't Ask, Don't Tell repeal allows for risk screening and reduction interventions targeting a newly identifiable risk category in the US Army. At-risk populations need to be identified and assessed for possible unmet health needs.

… These findings mirror a description of the HIV epidemic in the United States; in 2010, 63% of all new HIV infections and 78% of new HIV infections among men were attributable to male–male sexual contact, whereas 44% of all new HIV infections were among blacks/African Americans.1 Both groups constitute a minority of the US population: Purcell et al11 estimated that 3.5%–4.4% of the adult male US population were MSM, which represented approximately 2% of the 2008 US population; Blacks/African Americans formed 13.6% of the 2010 US population. Although it is unknown what proportion of the active US Army engage in male–male sexual contact, in fiscal year 2012 black/African Americans were one of the minority race and ethnic groups in the US Army comprising 20% of soldiers on active service, whereas soldiers of white, non-Hispanic race and ethnic origin made up 61% of the active US Army.12

Several factors that increase HIV acquisition and transmission reportedly explain the racial disparity in HIV infection status in the general population. Structural factors such as social and income inequalities and lack of economic opportunity were correlated significantly with a higher HIV risk among blacks/African Americans.2 Black/African American MSM are more likely to have sexual partners of unknown HIV status13,14 and perceive their risk of HIV acquisition to be lower with intraracial sexual partners.13 Linkage to care within 3 months of HIV diagnoses and antiretroviral therapy use, both effective risk-reduction interventions among persons positive for HIV, were less prevalent among black/African American MSM.13,15 Reductions in community viral load levels from large-scale antiretroviral therapy use have been associated with a decrease in new HIV diagnoses.16 Despite universal health care and periodic HIV testing, racial and risk disparities persist in the US Army and seem to be influenced by drivers of the national HIV epidemic among black/African American MSM.

One in 2 soldiers had a negative HIV result within a year of diagnosis. Among MSM, 1 in 2 had an HIV test outside the MHS. Although service-related reasons predominated, risk-based reasons for HIV testing were frequent, especially among MSM. Almost all syphilis infections were reported by MSM and not MSW. Together, these findings indicate that soldiers at high risk for HIV and STIs may need more frequent testing, and more services, such as provision of PrEP, targeted to their health needs. National guidelines recommend that sexually active MSM get annual screening for HIV, syphilis, chlamydia, and gonorrhea, and MSM with multiple or anonymous sexual partners get quarterly or biannual screening.17 Testing more frequently provides an opportunity for earlier access to treatment, and utilization of services such as behavior counseling, thus reducing onward transmission risks. As a means of HIV prevention, national clinical practice guidelines recommend health care providers consider offering PrEP to eligible patients, including MSM, exceeding a threshold risk score.18

MSM commonly described having nonservice members, casual partners, or strangers (versus service members or a spouse or main partner) as sexual partners in their period at risk. They frequently met these temporary partners (37%) on the Internet rather than bars/clubs or other venues. Furthermore, among those who reported a location where they likely acquired HIV, most of them believed that the exposure occurred in southern US states, which is consistent with the epidemiology of HIV in the United States. Although the prevalence of HIV was highest in northeastern United States and the rate of new HIV diagnoses decreased from 2008 to 2011 in all regions except the Midwest, the southern United States continued to have the highest rate of diagnoses among all regions in the United States.19 Seeking partners on the Internet and higher sexual risk behavior associated with online partner seeking have been reported among HIV-infected MSM. A meta-analysis conducted in 2006 found that among MSM recruited offline, online partner-seeking was more prevalent among HIV-infected MSM (49.6%) than uninfected MSM (41.2%).20 In a meta-analysis conducted in 2014, unprotected anal intercourse was common among MSM who sought partners on the Internet (versus those who did not) especially among HIV-infected MSM irrespective of the HIV serostatus of their partners.21 Risk reduction interventions among people living with HIV have reduced secondary transmission risk. In 2 large intervention trials conducted at 20 US-based clinics, a significant reduction in unprotected vaginal or anal intercourse was seen among HIV positive participants who received counseling from medical providers compared with those who received standard care.22,23 These risk reduction programs may reduce HIV transmission and acquisition risks in the US Army.

Consistent with the US HIV epidemic, men who had male–male sexual contact and of black/African-American racial origin comprised a majority of active-duty soldiers who acquired HIV in the US Army. HIV-infected soldiers frequently reported nonservice member partners, online partner-seeking, unprotected anal intercourse, surprise at testing HIV positive, and seeking HIV or STI testing outside the MHS. Prevention programs ascertaining the needs of and targeting MSM and other populations at high risk are now possible after DADT repeal. Adopting and adapting best practices in the civilian community for HIV prevention and risk reduction to the US Army should be a priority.

TABLE 1

Characteristics of Male Soldiers in Active Service and Newly Diagnosed as HIV-Infected, 2012-2014

Full article at:  http://goo.gl/eY2uAd

By:  Shilpa Hakre, DrPH, MPH,* Stephanie L. Scoville, DrPH,† Laura A. Pacha, MD, MPH,† Sheila A. Peel, MSPH, PhD,‡Jerome H. Kim, MD, PhD,‡ Nelson L. Michael, MD, PhD,‡ Steven B. Cersovsky, MD, MPH,† and Paul T. Scott, MD, MPH‡

^*US Military HIV Research Program, Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD;

^†US Army Public Health Command, Aberdeen Proving Ground, MD; and

^‡US Military HIV Research Program, Walter Reed Army Institute of Research, Bethesda, MD.

Corresponding author.

Correspondence to: Shilpa Hakre, DrPH, MPH, Department of Epidemiology and Threat Assessment, US Military HIV Research Program, 6720-A Rockledge Drive, Suite 400, Bethesda, MD 20817 (e-mail: gro.hcraeservih@erkahs).

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