Sexual Positioning among Men Who Have Sex with Men: A Narrative Review

Sexual positioning practices among men who have sex with men (MSM) have not received a thorough discussion in the MSM and HIV literature, given that risks for acquiring or transmitting HIV and STIs via condomless anal sex vary according to sexual positioning. MSM bear a disproportionate burden of HIV compared to the general population in the United States; surveillance efforts suggest that HIV and STIs are increasing among domestic and international populations of MSM. 

We conducted a narrative review, using a targeted literature search strategy, as an initial effort to explore processes through which sexual positioning practices may contribute to HIV/STI transmission. Peer-reviewed articles were eligible for inclusion if they contained a measure of sexual positioning identity and/or behavior (i.e., "top", "bottom," etc.) or sexual positioning behavior (receptive anal intercourse or insertive anal intercourse), or assessed the relationship between sexual positioning identity withHIV risk, anal sex practice, masculinity, power, partner type, or HIV status. 

A total of 23 articles met our inclusion criteria. This review highlights dynamic psychosocial processes likely underlying sexual decision making related to sexual positioning identity and practices among MSM and MSM who have sex with women (MSMW), and ways these contexts may influence HIV/STI risk. 

Despite limited focus in the extant literature, this review notes the important role the contextual factors (masculinity stereotypes, power, partner type, and HIV status) likely to play in influencing sexual positioning identity and practices. Through this review we offer an initial synthesis of the literature describing sexual positioning identities and practices and conceptual model to provide insight into important areas of study through future research.

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By:  Dangerfield DT 2nd1, Smith LR2, Williams J3, Unger J3, Bluthenthal R3.

• 1Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90032, USA. ddangerf@usc.edu.
• 2Division of Global Public Health, University of California, San Diego, La Jolla, CA, USA.
• 3Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90032, USA.
• Arch Sex Behav. 2016 May 13. 

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Acceptability & Willingness to Use HIV Pre-Exposure Prophylaxis among HIV-Negative Men Who Have Sex with Men in Switzerland

Pre-exposure prophylaxis (PrEP) is discussed as an additional HIV prevention method targeting men who have sex with men (MSM). So far, PrEP has not been approved in Switzerland and only little is known about the acceptability of PrEP among MSM living in Switzerland. Given the slow uptake of PrEP among MSM in the USA, the objectives of the study were to investigate the acceptability for PrEP and to identify factors influencing the acceptability for this prevention method and the willingness to adopt it. 

During a 4-month period we conducted five focus group discussions with 23 consecutively sampled HIV-negative MSM aged 22-60 years living in Switzerland. We analyzed the data according to qualitative content analysis. The acceptability of PrEP varied considerably among the participants. 

Some would use PrEP immediately after its introduction in Switzerland because it provides an alternative to condoms which they are unable or unwilling to use. Others were more ambivalent towards PrEP but still considered it 

1. an additional or alternative protection to regular condom use, 
2. an option to engage in sexual activities with less worries and anxieties or 
3. a protection during receptive anal intercourse independently of the sexual partner's protective behaviour. 

Some participants would not consider using PrEP at all: they do not see any benefit in PrEP as they have adopted safer sex practices and did not mention any problems with condom use. Others are still undecided and could imagine using an improved form of PrEP. The results provide a valuable basis for a model explaining the acceptability of PrEP among MSM and suggest including the personal HIV protection strategy in the considerations adopted.

Full article at:   http://goo.gl/Bjn9An

By:   Gredig D1, Uggowitzer F1, Hassler B1, Weber P1, Nideröst S1.

• 1 School of Social Work , University of Applied Sciences and Arts Northwestern Switzerland , Olten , Switzerland. 
• AIDS Care. 2016 Mar 13:1-4.

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Economic, Legal, and Social Hardships Associated with HIV Risk among Black Men Who Have Sex with Men in Six US Cities

We assessed whether economic, legal, and social hardships were associated with human immunodeficiency virus (HIV) risk among a sample of Black men who have sex with men (MSM) and whether associations were moderated by city of residence. 

The study analyzed baseline and follow-up data from HIV Prevention Trials Network 061 (N = 1553). Binary logistic regression assessed associations between hardships and HIV risk indicators. Multivariate regressions were used to test if city of residence had a moderating effect for hardships and HIV risks. Adjusted analyses showed that Black MSM with recent job loss were more likely to engage in condomless insertive anal intercourse and that those with recent financial crisis were more likely to have had two or more male sexual partners in the past 6 months. Black MSM with recent convictions were more likely to have a sexually transmitted infection at 6 months, while those who were unstably housed were more likely to have a sexually transmitted infection at 12 months. 

There were no city of residence and hardship interaction effects on HIV risks. Hardships are important factors that influence HIV risk for Black MSM. Integrating strategies that address structural factors that influence HIV risk may enhance HIV prevention interventions implementation efforts.

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By:  Nelson LE1,2, Wilton L3,4, Moineddin R5, Zhang N6, Siddiqi A7,8, Sa T6, Harawa N9,10, Regan R11,12, Dyer TP13, Watson CC14, Koblin B15, Del Rio C16,Buchbinder S17, Wheeler DP18, Mayer KH19; HPTN 061 Study Team.

• 1School of Nursing, University of Rochester, Rochester, NY, USA. laron_nelson@urmc.rochester.edu.
• 2Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada. laron_nelson@urmc.rochester.edu.
• 3College of Community and Public Affairs, State University of New York at Binghamton, Binghamton, NY, USA.
• 4Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa.
• 5Faculty of Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.
• 6Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
• 7Dalla Lana School of Public Health, Divisions of Epidemiology and Social & Behavioural Health Sciences, University of Toronto, Toronto, ON, Canada.
• 8Gillings School of Public Health, Department of Health Behavior, University of North Carolina Chapel Hill, Chapel Hill, NC, USA.
• 9College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA.
• 10David Geffen School of Medicine, General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA.
• 11David Geffen School of Medicine, Department of Family Medicine, University of California Los Angeles, Los Angeles, CA, USA.
• 12School of Medicine, Division of Infectious Diseases, Emory University, Atlanta, GA, USA.
• 13School of Public Health, Department of Epidemiology and Biostatistics, University of Maryland College Park, College Park, MD, USA.
• 14School of Public Health, George Washington University, Washington, DC, USA.
• 15New York Blood Center, New York, NY, USA.
• 16Rollins School of Public Health, Hubert Department of Global Health and School of Medicine, Department of Medicine, Emory University, Atlanta, GA, USA.
• 17San Francisco Department of Public Health, HIV Research Section, San Francisco, CA, USA.
• 18School of Social Welfare, State University of New York Albany, Albany, NY, USA.
• 19Fenway Health, The Fenway Institute, Boston, MA, USA. 
• J Urban Health. 2016 Feb 1.

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Characteristics Associated with Urethral and Rectal Gonorrhea and Chlamydia Diagnoses in a US National Sample of Gay and Bisexual Men

BACKGROUND:

Gay and bisexual men are at elevated risk for Neisseria gonorrhoeae and Chlamydia trachomatis (GC/CT). Rectal GC/CT symptoms may be less obvious than urethral, increasing opportunities for undiagnosed rectal GC/CT.

METHODS:

A US national sample of 1071 gay and bisexual men completed urethral and rectal GC/CT testing and an online survey.

RESULTS:

In total, 6.2% were GC/CT positive (5.3% rectal, 1.7% urethral). We calculated adjusted (for education, race, age, relationship status, having health insurance, and income) odds ratios for factors associated with rectal and urethral GC/CT diagnoses. Age was inversely associated with urethral and rectal GC/CT. Compared with white men, Latinos had significantly greater odds of rectal GC/CT. Among men who reported anal sex, those reporting only insertive sex had lower odds of rectal GC/CT than did men who reported both insertive and receptive. There was a positive association between rectal GC/CT and number of male partners (<12 months), the number of anal receptive acts, receptive condomless anal sex (CAS) acts, and insertive CAS acts. Compared with those who had engaged in both insertive and receptive anal sex, those who engaged in only receptive anal sex had lower odds of urethral GC/CT. The number of male partners (<12 months) was associated with increased odds of urethral GC/CT.

CONCLUSIONS:

Rectal GC/CT was more common than urethral and associated with some demographic and behavioral characteristics. Our finding that insertive CAS acts was associated with rectal GC/CT highlights that providers should screen patients for GC/CT via a full range of transmission routes, lest GC/CT go undiagnosed.

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By:  Grov C1, Cain D, Rendina HJ, Ventuneac A, Parsons JT.

• 1From the Center for HIV/AIDS Educational Studies and Training, New York, NY. 
• Sex Transm Dis. 2016 Mar;43(3):165-71. doi: 10.1097/OLQ.0000000000000410.

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Enema Use among Men Who Have Sex with Men: A Behavioral Epidemiologic Study with Implications for HIV/STI Prevention

Enema use or douching is a risk factor for HIV/STI in men who have sex with men (MSM). However, few studies have explored enema use practices. 

We examined the frequency of enema use, type of products used, and reasons to use and not to use before and after receptive anal sex in a large sample of MSM (N = 4,992) recruited from 16 U.S. cities. Through online surveys, we examined personal, behavioral, and environmental factors associated with enema use. 

Most (52 %) participants reported having douched at least once and 35 % reported douching within the last 3 months. While most (88 %) reported enema use before receptive anal sex, 28 % douched after receptive anal sex. Most participants (65 %) used water to douche, 24 % added salt, soap, and/or antibacterial products to water, and 30 % reported using commercially available products. 

Being a man of color, HIV-positive, diagnosed with an STI, identifying as "versatile" in sex, and having more than two unprotected sex partners were significantly associated with recent enema use. 

Douching behavior appears closely associated with HIV/STI risk. Douching with water may be a concern since it may increase HIV/STI infection by damaging the epithelium. 

Development and promotion of a non-damaging, non-water based enema specifically for use in anal sex are recommended. 

In addition, the seemingly contradictory recommendations that water-based lubricant is recommended for anal sex but water-based enemas are dangerous need to be reconciled into a single consistent message.

Reasons not to use enema before anal sex (N=4301)

Reasons not to douche before anal sex	n	%
I do not have receptive anal sex	866	20.1
I do not like douche, find it painful or uncomfortable	256	5.9
No need, I prefer it to be spontaneous/not planned	1975	45.9
I do not mind/prefer anal sex being “dirty”/“natural”	424	9.8
HIV/STI prevention	156	3.6
I don’t know about douching or haven’t thought about it	1141	26.5
Other	264	6.1

Full article at:   http://goo.gl/mIb0UC

By:  Noor SW1, Rosser BR.

• 1Division of Epidemiology and Community Health, University of Minnesota School of Public Health (http://www.sph.umn.edu/), WBOB-300, 1300 2nd St. South, Minneapolis, MN, 55454, USA, snoor@umn.edu. 
• Arch Sex Behav. 2014 May;43(4):755-69. doi: 10.1007/s10508-013-0203-0. Epub 2013 Dec 18.

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Poppers Use & Risky Sexual Behaviors among Men Who Have Sex with Men in Beijing, China

BACKGROUND:

Although poppers are increasingly popular among MSM in China, little is known about the patterns of poppers use. The objectives of this study were to describe the patterns of poppers use and examine its association with sexual behaviors and HIV infection among MSM in Beijing, China.

METHODS:

As part of a multi-component HIV intervention trial, 3588 MSM were surveyed between March 2013 and March 2014 in Beijing, China. Blood samples were collected and tested for HIV and syphilis. The questionnaire collected information about socio-demographic and behavioral characteristics. Univariate and multivariable logistic regression analyses were performed to evaluate the correlates of poppers use.

RESULTS:

Over a quarter of men (27.5%) reported having used at least one type of drugs in the past three months. Poppers were the most popular one (26.8%). Poppers use was correlated with a higher HIV prevalence. Demographic and sexual behavioral factors associated with poppers use included: younger age, higher education, alcohol use, seeking male partners mainly via the internet, multiple male sex partnership, and unprotected receptive anal intercourse.

CONCLUSIONS:

In this study, poppers use was positively associated with HIV infection and unprotected anal intercourse. Intervention efforts should be devoted to promote safer sex and HIV testing and counseling among MSM who use poppers.

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By:  Zhang H1, Teng T1, Lu H2, Zhao Y2, Liu H3, Yin L4, Sun Z1, He X5, Qian HZ4, Ruan Y1, Shao Y1, Vermund SH4.

• 1State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China.
• 2Beijing Center for Disease Control and Prevention (http://www.chinacdc.cn/en/), Beijing, China.
• 3Department of Epidemiology and Biostatistics, School of Public Health, University of Maryland, College Park, USA.
• 4Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, TN, USA.
• 5Beijing Center for Disease Control and Prevention, Beijing, China. Electronic address: hexiong@vip.163.com. 

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"This Will Not Enter Me": Painful Anal Intercourse among Black Men Who Have Sex with Men in South African Townships

Little is known about painful receptive anal intercourse (RAI) and its relationship to HIV risk and protective behaviors among men who have sex with men (MSM). The purpose of this study was to identify attributions for and responses to painful RAI among Black MSM in South African townships. In-depth interviews were conducted with 81 Black MSM (ages 20-39 years) who were purposively recruited from four townships. The semi-structured interviews addressed sexual behavior and identity, alcohol use, and safer sex. 

Pain during RAI was brought up by many participants without specific prompting from the interviewer. Analysis of the interview transcripts revealed that pain was a common feature of first RAI experiences but was not limited to first-time experiences. The participants attributed pain during RAI to partner characteristics, interpersonal dynamics, lack of lubricant, and alcohol use or non-use. The main strategies participants used to address pain during RAI were setting sexual boundaries and lubricant use; a small number of participants reported purposefully consuming alcohol to prevent the pain associated with RAI. 

Black South African MSM can be supported to reduce pain during RAI in ways that reduce their HIV/STI risk. Culturally specific sexual health education, supportive sexual health services, and improved access to condom-compatible lubricants are important components of HIV/STI interventions for this population.

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By: Collier KL1, Sandfort TG, Reddy V, Lane T.

• 1Division of Gender, Sexuality, & Health and HIV Center for Clinical and Behavioral Studies,, New York State Psychiatric Institute and Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA.  

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Individual-Level, Partnership-Level, and Sexual Event-Level Predictors of Condom Use During Receptive Anal Intercourse among HIV-Negative Men Who Have Sex with Men in Los Angeles

We examined individual-level, partnership-level, and sexual event-level factors associated with condom use during receptive anal intercourse (RAI) among 163 low-income, racially/ethnically diverse, HIV-negative men who have sex with men (MSM) in Los Angeles (2007-2010). 

At baseline, 3-month, and 12-month visits, computer-assisted self-interviews collected information on ≤3 recent male partners and the last sexual event with those partners. Factors associated with condom use during RAI at the last sexual event were identified using logistic generalized linear mixed models. 

Condom use during RAI was negatively associated with reporting ≥ high school education and methamphetamine use, specifically during RAI events with non-main partners and those that included lubricant use. 

Condom use during RAI varies according to individual-level, partnership-level, and sexual event-level factors that should be considered in the development of risk reduction strategies for this population.

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By: Pines HA1, Gorbach PM2, Weiss RE3, Reback CJ4,5, Landovitz RJ6, Mutchler MG7,8, Mitsuyasu RT6.

• 1Division of Global Public Health, Department of Medicine, University of California, San Diego, 9500 Gilman Dr., MC 0507, La Jolla, CA, 92093-0507, USA. hpines@ucsd.edu.
• 2Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA.
• 3Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, CA, USA.
• 4Friends Research Institute, Inc., Los Angeles, CA, USA.
• 5Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA.
• 6Center for Clinical AIDS Research & Education, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
• 7AIDS Project Los Angeles, Los Angeles, CA, USA.
• 8Department of Sociology, California State University, Dominguez Hills, Carson, CA, USA.  

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