HIV Infection Risk, Prevention, and Testing Behaviors Among Men Who Have Sex With Men—National HIV Behavioral Surveillance, 13 U.S. Cities, 2021: Commentary

Lowering the annual number of new HIV infections is a major HIV prevention goal [1]. This goal can be achieved by implementing three important strategies for reducing HIV infections: (1) intensifying HIV prevention efforts among populations with high burden of HIV, including gay, bisexual, and other men who have sex with men (hereafter referred to as MSM); Black or African American people (hereafter referred to as Black); Hispanic or Latino people; and people who inject drugs (PWID); (2) expanding efforts to prevent HIV infection by using a combination of effective, evidence-based, scalable approaches; and (3) educating the general public about HIV infection and how to prevent it. State and local health departments, as well as federal agencies, are expected to monitor progress toward HIV prevention goals [1].

National HIV Behavioral Surveillance (NHBS) provides data for monitoring behaviors among populations at risk of acquiring or transmitting HIV infection and identifies the populations for whom scientifically proven, cost-effective, and scalable interventions are most appropriate. Monitoring key indicators among members of populations disproportionally affected by HIV is critical to achieving the goals of the Ending the HIV Epidemic in the U.S. (EHE) Initiative [2] and the Centers for Disease Control and Prevention (CDC)’s high-impact prevention (HIP) approach [3]. The EHE Initiative is aimed at reducing new HIV infections by 90% by 2030 by implementing evidence-based strategies for specific populations in geographic areas most affected by HIV. NHBS has previously proven effective at monitoring key indicators, such as behavioral risk factors, HIV testing, and linkage to care; access to and use of prevention interventions, including preexposure prophylaxis (PrEP) and syringe services programs (SSPs); and prevalence of HIV in areas with high HIV prevalence among 3 populations at high risk of HIV infection: MSM, PWID, and heterosexually active persons at increased risk for HIV infection [4, 5].

Male-to-male sexual contact continues to be the most common route of HIV transmission in the United States among adults and adolescents, accounting for approximately 72% of the HIV infections diagnosed in 2020, including those attributed to the combination of male-to-male contact and injection drug use [6]. This report summarizes findings from the 2021 NHBS data collection cycle among MSM. Data from previous MSM cycles of NHBS have been published elsewhere [7–11].

The report provides descriptive, unweighted data that can be used to describe HIV infection among MSM and the percentages reporting specific behavioral risk factors, HIV testing, and participation in prevention programs. Monitoring these outcomes is useful for assessing behavioral risk factors and the use of prevention efforts over time and for identifying new HIV prevention opportunities for this population.

Report Changes

CDC routinely assesses NHBS reports to ensure the content and methods best meet the information needs of the nation. The following reporting changes were made from the previous NHBS report on MSM [11]:

• In 2021, 23 metropolitan statistical areas (MSAs) participated in NHBS among MSM; however, this report includes data from 13 MSAs that met the threshold for sufficient sample size (Figure 1; see Data Analysis section).
• In previous MSM cycles a venue-based sampling (VBS) method was used to collect data. As a result of the COVID-19 pandemic, 2 sampling methods were used in the 2021 cycle: respondent-driven sampling (RDS) and virtual venues sampling (VVS). The results in this report combine data from both sampling methods.
• Due to the impact of the COVID-19 pandemic, in addition to the standard NHBS HIV testing protocol (i.e., blood specimens collected for rapid HIV testing with rapid or laboratory-based supplemental testing), the NHBS HIV testing protocol could be modified locally to include testing without in-person contact, such as offering only one rapid oral HIV self-test. As a result, rapid or laboratory-based supplemental testing was not always performed to confirm infection. Therefore, HIV status in this report (Table 1) is reported using the following 4 categories: HIV-negative, HIV-positive, presumed HIV-positive, and no valid HIV test result.
• Tables are not stratified by participants’ HIV status determined from the NHBS HIV test results (i.e., HIV-positive, HIV-negative, and no valid NHBS HIV test results); instead, some tables include a new row ‘self-reported HIV-positive (Yes/No)’, which serves as a proxy for the traditional stratification by HIV status.
• A new indicator, ‘unprotected sex with an HIV-discordant partner at last sex’, was developed and presented for the first time in this report. This indicator accounts for sex without the participant’s use of either condoms or HIV medications (i.e., PrEP among those without HIV or antiretrovirals among those with HIV) with a sex partner of different or unknown HIV status.

Some modifications to “measure definitions” are made routinely to more accurately, or more precisely, describe the outcome or characteristic of interest; measure definitions are described in the appendix of this report.

Highlights

Demographic Characteristics, HIV Testing, and Preexposure Prophylaxis

This report describes data from 2,241 MSM who participated in NHBS in 2021, of whom 26% were aged 29 years or younger (Figure 2), 38% were Black, 27% were White, and 25% were Hispanic or Latino (Figure 3; Table 1). Overall, 71% of MSM had more than a high school education and 71% had a household income above the federal poverty level; 86% of MSM had health insurance and 89% had visited a health care provider in the 12 months before interview; 30% of MSM reported having a disability and 18% reported being unemployed; 14% experienced homelessness and 6% were incarcerated in the 12 months before interview (Figure 4).

CDC recommends that persons with risk factors for HIV infection, including sexually active MSM, undergo HIV testing at least annually [12]. Among MSM who (1) did not report a previous HIV-positive test result or (2) had received their first HIV-positive test result less than 12 months before interview, 76% reported that they had been tested for HIV in the 12 months before interview (Figure 5), and 95% reported that they had ever been tested (Table 2).

In 2021, CDC released an update to clinical guidance recommending the use of PrEP for persons at an increased risk of HIV acquisition, including MSM [13]. Among participants who did not report a previous HIV-positive test result and participants who received their first HIV-positive test result less than 12 months before interview, the majority reported previously hearing about PrEP (89%) and 42% reported taking PrEP in the past 12 months (Figure 5); 57% of White MSM reported taking PrEP compared with 44% of Hispanic or Latino MSM and 24% of Black MSM.

Among MSM who were tested for HIV in the past 12 months, 72% reported their most recent test was performed in a clinical setting (Figure 6), while 25% reported being tested in a nonclinical setting such as an HIV counseling and testing site, an HIV street outreach program or mobile unit, a syringe services program, or at home (Table 3). Testing in nonclinical settings varied by race and ethnicity: 32% of Black MSM and 29% of Hispanic or Latino MSM reported their most recent HIV test was conducted in a nonclinical setting, while 15% of White MSM reported a nonclinical setting for their most recent HIV test.

Sexual Behaviors

Condomless anal sex with male partners was reported by 77% of MSM regardless of self-reported HIV status (Figure 7; Table 4). Condomless vaginal or anal sex with female sex partners was higher among MSM who did not self-report HIV-positive (10% and 6%, respectively) than among MSM who self-reported HIV-positive (4% and 2%, respectively). MSM who self-reported HIV-positive reported condomless anal sex with main and casual male partners (44% and 55%, respectively) at a similar percentage to MSM who did not self-report HIV-positive (50% and 53%, respectively) (Table 5). Among MSM, 19% reported having a male last sex partner but not having had anal sex with him during their last sexual encounter, and this did not differ by self-reported HIV status (Table 6).

Despite the existence of other HIV prevention options, correct and consistent condom use is one of the primary means of protection from HIV and other infections [14, 15]. The high percentages of MSM who engaged in condomless sex underscore the importance of using effective, evidence-based scalable combination HIV prevention strategies among MSM at increased risk for HIV infection that include access to and use of condoms, PrEP, risk-reduction counseling, and HIV testing [3, 13].

Sexually Transmitted Infections

Sexually transmitted infections (STIs) can increase the likelihood of acquiring and transmitting HIV [16]. The percentage of MSM who reported a diagnosis of any bacterial STI (chlamydia, gonorrhea, or syphilis) during the 12 months before interview was 23% overall (Figure 8) and was higher among MSM who self-reported HIV-positive (33%) than among MSM who did not self-report HIV-positive (19%). Percentages of lifetime diagnosis of genital warts (18%) and genital herpes (13%) among MSM who self-reported HIV-positive were also higher than among MSM who did not self-report HIV-positive (8% for genital warts and 8% for genital herpes) (Table 7).

Since 2000, rates of primary and secondary syphilis have increased among men, likely attributable to increases in cases among MSM; however, increases among MSM have slowed in recent years and during 2019-2020, the number of cases of primary and secondary syphilis among MSM decreased 2.2%. Still, MSM are disproportionately impacted, accounting for a majority (53%) of all male primary and secondary syphilis cases in 2020 [17]. In the current NHBS cycle, 20% of MSM who self-reported HIV-positive reported receiving a syphilis diagnosis during the 12 months before interview compared with 5% of MSM who did not self-report HIV-positive.

Drug and Alcohol Use

Drug and alcohol use, particularly binge drinking, injection drug use, and methamphetamine use, have been associated with sexual risk behavior among MSM [18]. Among MSM, 17% reported binge drinking in the past 30 days, while 59% reported using marijuana, 18% reported using cocaine, 16% reported using ecstasy, and 14% reported using methamphetamine in the 12 months before interview (Figure 9; Table 8). Non-injection use of any drug in the 12 months before interview was reported by 65% of MSM while any injection drug use was reported by 6% of MSM.

Additional Outcomes

Table 9 presents data on additional outcomes related to the risk of HIV transmission and acquisition among MSM. Outcomes reported in Table 9 are of cu­rrent relevance to HIV among MSM and may not be reported in future reports.

The median number of male sex partners reported in the 12 months before interview was 4 (Q1–Q3: 2–10) among MSM regardless of self-reported HIV-positive status.

Giving or receiving money or drugs in exchange for sex is a recognized risk factor for HIV infection [19]. In 2021, 13% of MSM reported giving or receiving things like money or drugs in exchange for sex with a male casual partner in the 12 months before interview (Figure 10). The percentage of MSM reporting exchange sex with a male casual partner was higher among MSM who self-reported HIV-positive (18%) than among MSM who did not self-report HIV-positive (11%).

Overall, 8% of MSM reported unprotected sex with an HIV-discordant partner at last sex (Figure 7); this percentage was lower among MSM who self-reported HIV-positive (1%) compared with MSM who did not self-report HIV-positive (11%).

Overall, 51% of MSM reported receiving free condoms and 27% reported participating in an HIV behavioral intervention (Figure 11). The percentage of MSM who received condoms were higher among MSM who self-reported HIV-positive (61%) compared with MSM who did not self-report HIV-positive (47%). The percentage of MSM who reported participating in an HIV behavioral intervention was highest for MSM who self-reported HIV-positive (34%) and, among all MSM, for the youngest age group (32% of MSM aged 18–24 years).

Receipt of HIV Care and Treatment

Achieving viral suppression through antiretroviral treatment improves clinical outcomes and reduces the likelihood of transmitting HIV to others [20]. The national goal is to link a person with a new HIV diagnosis to care within one month of diagnosis [1]. In 2021, among MSM who self-reported HIV-positive, 98% reported having ever visited a health care provider for HIV, 69% reported that they did so within one month after diagnosis, and 88% reported visiting a health care provider for HIV care in the six months before interview (Table 10). Current use of antiretroviral treatment was reported by 95% of MSM who self-reported HIV-positive (Figure 12).