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HIV diagnoses among men who have sex with men MSM have been increasing in several high-income countries. We conducted a systematic review of studies that examined behavioral trends — in any condomless anal sex, condomless anal sex with an HIV-discordant partner, and number of partners. Studies included come from the United States, Europe, and Australia.

We found increasing trends in condomless anal sex and condomless anal sex with an HIV-discordant partner, and a decreasing trend in number 21-28 partners. The increase in condomless anal sex may help to explain the increase in HIV infections.

More explanatory research is needed to provide insight into factors that contribute to these behavior trends. Continuous monitoring of HIV, risk behaviors, and use of prevention and treatment is needed to evaluate prevention efforts and monitor HIV transmission risk.

Gay, bisexual, and other men who have sex with men collectively referred to as MSM remain a core population affected by HIV in many parts of the world 1. In several high-income countries, including France, the Netherlands, the United Kingdom, and the United States, overall trends in HIV diagnoses are in decline except among MSM, where they have been increasing since early 23. Several factors contribute to the high transmission rates among Sex, including high background prevalence of HIV, type and frequency of 21-28 acts, number of sex partners, HIV status of partners, treatment and viral load status if partners are HIV-positiveand whether pre-exposure prophylaxis PrEP is being used.

HIV transmission among MSM is higher than among other populations in part because of the higher transmission probabilities during anal sex. The estimated per-act probability of acquiring HIV is 21-28 10, exposures for condomless receptive anal sex compared to 8 per 10, exposures for condomless receptive vaginal sex 4.

Evidence also shows that the number of sex partners affects the risk of HIV transmission 56. The more partners a person has, the more likely to have a partner with HIV whose viral load is not suppressed or to have a sex partner with a sexually transmitted infection STI - both factors can increase the risk of HIV transmission. While the scale-up of early detection and treatment may make the end of the HIV epidemic possible 15there is evidence that reductions in condom use may jeopardize the population-level benefits of ART 16 — Mathematical modeling suggests that the increases in HIV incidence in the United Kingdom, over a period in which ART coverage and viral suppression were also increasing, was likely due to the counter-effect of concomitant increases in condomless sex among MSM who were not virally suppressed However, increases in STIs are also likely to be the result of increases in condomless sex.

These findings show that modest increases in condomless sex are enough to overcome the beneficial effects of ART at a population level 16 A better understanding of the sexual behavior trends among MSM would be useful for informing changes in the risk of HIV acquisition or transmission, for identifying sub-groups that would benefit the most from Sex prevention interventions, and resource allocation within the United States and other high-income countries.

In this 21-28, we evaluate changes in sexual risk behaviors among MSM in high-income countries. We conducted a systematic review of studies that examined sexual behaviors among MSM over time — to determine the trends for three behaviors that are predictors of HIV transmission: condomless anal sex with any, casual or main partnerscondomless anal sex with a partner of unknown or discordant HIV status, and number of sex partners. A systematic literature search was conducted to locate citations that assessed changes over time in sexual risk behaviors and prevalence of STIs among MSM.

No language restriction was applied to the automated search. The systematic searches were conducted in May and updated in May The full searches are available from the corresponding author. This paper focuses on sexual risk behaviors among MSM a separate paper focuses on syphilis trends Studies were included in this systematic review if they [1] were conducted in a high-income country based on the World Bank definition 20[2] were published between January and May[3] reported data on MSM for at least two time points, and [4] reported on relevant sexual behaviors.

It usually took many years for the studies that examined behavioral trends to collect and analyze data before the findings were published. We chose a publication cut-off of because it covered ten years from the original search date and allowed the focus to be on more recent behavior trends. Several studies that we reviewed reported data points back to These data points were included in this systematic review if the studies met the inclusion criteria.

Studies were excluded at the abstract level if they were a modeling, review or intervention papers, b 21-28 in languages other than English most were conducted in low or middle income countries or the abstracts did not provide sufficient informationor c conference abstracts, posters, or 21-28. Studies were excluded at the full-report level if they d covered only specific sub-populations e.

A trained coder screened the titles and abstracts of 7, citations for eligibility Figure 1. After review of the abstracts, 6, were determined to not meet the inclusion criteria, and the remaining were retained for retrieval of the full-length article. Upon reviewing the full-length article, 51 were determined to meet the inclusion criteria and were coded for the following: study date, location, sampling method, sample size, HIV status of participants, sexual behavior outcomes, assessment time frame, and study results.

The full-report data abstraction was reviewed by an additional person to verify accuracy. Discrepancies were reconciled between the coders. To avoid potential bias in the trend analyses, we excluded an additional 14 papers for the following reasons at the full-report level: specific sub-populations i.

Selection process for study inclusion in the systematic review on trends in sexual behavior among MSM in high-income countries. We applied the following rules for guiding data abstraction for analyses.

This approach allowed us to examine the trends with all available data in the literature. For the studies that reported condomless anal sex, we selected the data for all study participants regardless of their HIV status, unless the study only reported data on HIV-positive or HIV-negative participants without reporting data on all study participants, then we treated HIV-positive and HIV-negative participants as separate samples in the analyses. If stratified sex were not reported, the overall results were used.

For each study sample, we abstracted the percentage of persons who engaged in a specific sexual behavior at each assessment time i. Multi-level models were used to examine the overall trends, with the study treated as the random-effect and year as the fixed effect. The beta, which represents the slope of the line on the log scale, was reported.

A positive beta represents an upward trend, a negative number represents a downward trend. The larger the beta, the steeper the slope. While all the included studies were published between andthe data collected were between and A knot was set at year because it sex about the mid-point of the 21-28 collected across studies and ART had improved and become more widely available around this time. For the knot analyses, the slope of the line was allowed to change at generating two estimates for the slope: one for to and one for to the latest data collection date usually or The results sex multi-level models without and with a knot were both reported.

If a change in significance or direction of the slope occurred with the addition of the knot, the summary line presented in the figure was based on the knot analysis result. If no significant change in slope occurred based on the knot analyses, the summary line presented in the figure was based on the overall result.

Sensitivity analyses were also conducted by stratifying the studies by HIV status and study design. Figure 1 summarizes the study selection process. Among the 37 included studies that provided behavioral trend data between to13 were conducted in the United States 21 — 33nine in continental Europe 34 — 42seven in Australia 43 — 49five in the United Kingdom 50 — 54two in New Zealand 5556and one in Canada Most sampled MSM specifically, but two analyses were based on general population surveys 21 Recall periods differed across studies and variables, but most common were past year, past six months, past three months, and last sex.

There was not substantial change in age composition across study samples sex time. Summary of 29 studies on temporal trends in anal intercourse without a condom among MSM in high income countries, — Summary of 16 Studies on temporal trends in number of sex partners among MSM, — Among the 29 studies that examined condomless anal sex from to 21 — 2834 — 4143 — 4750 — 5719 findings were included in the analysis of condomless anal sex Figure 219 findings were included in the analysis of condomless anal sex with casual partners Figure 3Aand 12 findings were included in the analysis of condomless anal sex with main partners Figure 3B.

Figure 2 showed an upward trend in condomless anal sex with any partners from to among most of the study samples. Sensitivity analyses showed similar results when only cross-sectional studies were included.

There were not enough cohort studies to run a separate sensitivity analysis. Figure 3 also showed upward trends in condomless anal sex by partner type. Sensitivity analyses showed for CAS with a casual partner, results were similar when only cross-sectional studies were included. There were not enough cohort studies or studies with stratified results by HIV status to run separate sensitivity 21-28.

Trends in condomless anal sex among MSM by partner type, high-income countries, — Results were not substantially different for sensitivity analyses that stratified by study design or HIV status. However, although the slopes were similar to the overall analysis, sensitivity analyses for HIV-positive samples and HIV-negative samples did not result in significant betas for the — time period.

Sixteen studies examined trends in numbers of partners between and 30 — 3336394145 — 49515355 The multi-level models without a knot did not produce stable results for either group. However, the models with a knot at generated an estimate for the summary line parameters. None of the studies for the number of sex partners outcome were cohorts, and too few reported results stratified by HIV status to conduct a stratified analysis.

Summary line for 5A. Summary line for 5B. This systematic review of studies conducted in high-income countries indicated increasing sexual risk behaviors over time among MSM.

The upward trends were seen not only in condomless anal sex, condomless anal sex with casual partners and main partners, but also in condomless anal sex with partners of unknown or discordant HIV status, the highest-risk behavior for HIV transmission and acquisition. For these behaviors there was a steady increase from the s throughbut the knot analysis suggested the rate of increase may have been slightly lower in and later compared to the earlier years.

This could possibly be explained by a more rapid change in condom norms after the introduction of ART with a slowing of change overtime. Although there may be a decreasing trend in the number of sex partners sincethe increasing condomless anal sex, especially with partners of unknown or discordant Sex status, may partially explain the 21-28 in HIV infections among MSM in high-income countries despite increasing treatment coverage during the same time frame, as seen in other studies There are several plausible explanations for why condomless anal sex is increasing.

Condom fatigue, complacency about HIV, availability of other prevention options, optimism about HIV treatments, and the adoption of seroadaptive strategies may have eroded consistent condom use 18 Based on our review, there appears to be a downward trend in the number of partners since The reason for this trend is unclear. However, researchers in Australia have noted a shift away from open relationships among MSM, which could help explain the reduction in number of partners Sex extent to which the downward trend is actually occurring and why it might be occurring requires further examination.

Other potential correlates of condomless sex that have been examined in the literature include methamphetamine use, alcohol use 6263depression 64and increased access to internet and mobile-app for seeking sexual partners 65 The evidence on what contributes to these trends among MSM is still limited. Our study echoes the call for comprehensive HIV prevention for MSM 2367 as well as more explanatory research to help 21-28 the contributors of these trends. The HIV prevention paradigm has expanded in recent years to include a focus on biomedical interventions such as ART and PrEP and helping people identify the best prevention option or options for them and their partners PrEP was not widely available during the time period of the studies included in this review.

This new prevention tool could help to offset the increased risk due to increases in condomless anal sex To better understand the influence and impact of ART and PrEP use, behavioral surveillance systems need to include more nuanced measures of biomedical prevention 69 However, awareness of HIV status is not universal and increasing efforts are needed to reach optimal uptake of biomedical interventions. Furthermore, condom promotion interventions have success sex increasing sex use among MSM, as evidenced by an intervention in New Zealand

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