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

Technical Notes

NHBS conducts rotating cycles of bio-behavioral surveys among MSM, PWID, and heterosexually active persons at increased risk of HIV infection [4]; data are collected in annual cycles from one population per year so that each population is surveyed once every 3 years. The same general eligibility criteria are used in each cycle: age 18 years or older, current residence in a participating city, no previous participation in NHBS during the current survey cycle, ability to complete the survey in either English or Spanish, and ability to provide informed consent. In addition to these basic NHBS eligibility criteria, participation in the 2021 NHBS cycle was limited to persons who (1) were male at birth, (2) reported their gender as male, and (3) reported oral or anal sex with a male partner during their lifetime. Only participants who reported having oral or anal sex with another man in the past 12 months were counted toward the sample size of current MSM.

A standardized questionnaire is used to collect information about behavioral risk factors for HIV infection, HIV testing, and use of HIV prevention services. The anonymous survey is administered by a trained interviewer using a portable computer. All participants are offered an anonymous HIV test, which is linked to the survey data though a unique survey identifier.

Activities for NHBS were approved by CDC [21, 22] and by applicable institutional review boards (IRBs) in each participating city.

Participating Cities

State and local health departments eligible to participate in NHBS are among those whose jurisdictions include an MSA or a specified division with high number of HIV infections diagnosed. In 2021, NHBS was conducted in 23 MSAs (see list at the end of the report), which represented approximately 59% of all persons living with HIV in urban areas with a population of at least 500,000 at year’s end 2016 [23]; however, this report includes data from 13 MSAs that met the threshold for sufficient sample size (see Data Analysis section).

Throughout this report, MSAs and divisions are referred to by the name of the principal city.

Sampling Method

Participants in the 2021 NHBS cycle were recruited using either respondent-driven sampling (RDS) [24] or virtual venues sampling (VVS) [25]). RDS begins with the non-random selection of a small number of initial recruiters or “seeds.” These seeds recruit project participants who in turn recruit other participants. This chain of recruiters and recruits then continues for multiple “waves” of recruitment. VVS participants were recruited through active outreach on geospatial social networking apps, online advertisements, and local social organization outreach on social media. Project sites used different recruitment methods tailored to their local community. Among the 13 project sites, 11 used RDS methods and 2 used VVS methods (San Diego, San Francisco). For the purposes of this report, these methods are presented in aggregate.

Data Collection

Persons recruited for the interview were screened for eligibility. For those who met eligibility requirements, trained interviewers obtained informed consent and conducted a remote interview, which took approximately 24 minutes and consisted of questions concerning participants’ demographic characteristics, HIV testing history, sexual and drug use behaviors, STI testing and diagnosis, and use of HIV prevention services and programs. In exchange for the time spent taking part in the interview, participants received compensation equivalent to $20–$50 (amount determined locally).

HIV testing was performed for participants who consented; blood specimens were collected for rapid testing in the field or laboratory-based testing, or participants completed oral-based testing. For participants who consented to the testing for HIV, STI, or hepatitis, local testing procedures were followed, and an additional incentive was provided.

Participants received $10–$50 for HIV testing (amount determined locally). Participants who agreed to recruit others received an additional incentive of $10–$20 for each recruit (up to 5) who completed the interview (amount determined locally). Each participating city’s goal was to interview 500 eligible men who reported having sex with another man in the 12 months before the interview.

Data Analysis

This surveillance report presents descriptive data; no statistical tests were performed. In addition, these data are cross-sectional; we did not attempt to infer causal relationships. Reported numbers fewer than 12, and percentages based on these numbers, should be interpreted with caution because the numbers are considered unreliable.

Data for this report are not weighted. The purpose of this report is to provide a detailed summary of surveillance data collected as part of the NHBS 2021 cycle; unweighted data provide an efficient and transparent way to do so. Further, unweighted analysis allows for detailed reporting of outcomes among small subgroups of the population of interest.

Inclusion for this report is limited to participants who (1) were eligible for and consented to the interview and (2) reported having sex with another man in the 12 months before interview.

In 2021, 23 MSAs participated in NHBS among MSM; however, this report includes data from 13 MSAs that met the threshold for sufficient sample size of 50 or more interviews of non-seeds. Among the 13 included MSAs, 2,846 men were recruited for participation; 2,536 persons were screened to participate in NHBS. Of those, 82 persons did not meet NHBS eligibility criteria or did not provide consent and were excluded from the survey. An additional 52 interviews were excluded from this report due to incomplete survey data, survey responses of questionable validity, being recruited using a non RDS/VVS method, or data lost during electronic upload. Further, 161 eligible persons who completed interviews but did not report having sex with a male partner in the 12 months before interview were excluded from this report. The full analysis sample for this report includes 2,241 participants from the 2021 NHBS cycle. Additional inclusion criteria were applied for certain analyses of HIV infection and of HIV-associated behaviors; details of each analysis sample can be found in the footnotes of each table.

References

1. National HIV/AIDS strategy for the United States 2022–2025. https://files.hiv.gov/s3fs-public/NHAS-2022-2025.pdf. Published August 2022. Accessed January 12, 2023.
2. CDC. High-Impact HIV Prevention: CDC’s approach to reducing HIV infections in the United States. https://www.cdc.gov/hiv/policies/hip/hip.html. Published August 2011. Accessed January 12, 2023.
3. Fauci AS, Redfield RR, Sigounas G, Weahkee MD, Giroir BP. Ending the HIV Epidemic: A Plan for the United States. JAMA. 2019;321(9):844–845. doi:10.1001/jama.2019.1343
4. Gallagher KM, Sullivan PS, Lansky A, Onorato IM. Behavioral surveillance among people at risk for HIV infection in the U.S.: The National HIV Behavioral Surveillance System. Public Health Rep 2007;122(suppl 1):32–38. doi:10.1177/00333549071220S106
5. DiNenno EA, Oster AM, Sionean C, Denning P, Lansky A. Piloting a system for behavioral surveillance among heterosexuals at increased risk of HIV in the United States. Open AIDS J 2012;6(suppl 1):169–176. doi:10.1177/00333549071220S106
6. CDC. HIV Surveillance Report, 2020; vol. 33. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published May 2022. Accessed January 12, 2023.
7. CDC. [Sanchez T, Finlayson T, Drake A, et al] Human immunodeficiency virus (HIV) risk, prevention, and testing behaviors—United States, National HIV Behavioral Surveillance System: Men who have sex with men, November 2003–April 2005. MMWR 2006;55(6):1–16. Erratum in: MMWR 2006;55(27):752.
8. CDC. [Finlayson T, Le B, Smith A, et al]. HIV risk, prevention, and testing behaviors among men who have sex with men—National HIV Behavioral Surveillance System, 21 U.S. cities, United States, 2008. MMWR 2011;60(SS-14):1–34.
9. CDC. HIV risk, prevention, and testing behaviors— National HIV Behavioral Surveillance System: men who have sex with men, 20 U.S. cities, 2011. HIV Surveillance Special Report 8. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published September 2014. Accessed January 12, 2023.
10. CDC. HIV infection risk, prevention, and testing behaviors among men who have sex with men—National HIV Behavioral Surveillance System, 20 U.S. cities, 2014. HIV Surveillance Special Report 15. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published January 2016. Accessed January 12, 2023
11. CDC. HIV infection risk, prevention, and testing behaviors among men who have sex with men—National HIV Behavioral Surveillance, 23 U.S. cities, 2017. HIV Surveillance Special Report 22. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published February 2019. Accessed January 12, 2023.
12. DiNenno EA, Prejean J, Irwin K, et al. Recommendations for HIV screening of gay, bisexual, and other men who have sex with men—United States, 2017. MMWR 2017;66(31):830–832. doi:10.15585/mmwr.mm6631a3
13. CDC: US Public Health Service: Preexposure prophylaxis for the prevention of HIV infection in the United States—2021 update: A clinical practice guideline. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2021.pdf. Published 2021. Accessed January 12, 2023.
14. Smith DK, Herbst JH, Zhang X, Rose CE. Condom effectiveness for HIV prevention by consistency of use among men who have sex with men in the United States. J Acquir Immune Defic Syndr 2015;68(3):337–344. doi:10.1097/QAI.0000000000000461
15. Johnson WD, O’Leary A, Flores SA. Per-partner condom effectiveness against HIV for men who have sex with men. AIDS 2018;32(11):1499–1505. doi:10.1097/QAD.0000000000001832
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18. Vosburgh HW, Mansergh G, Sullivan PS, Purcell DW. A review of the literature on event-level substance use and sexual risk behavior among men who have sex with men. AIDS Behav 2012;16(6):1394–1410. doi:10.1007/s10461-011-0131-8
19. Moyer VA, U. S. Preventive Services Task Force. Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med 2013;159(1):51–60. doi:10.7326/0003-4819-159-1-201307020-00645
20. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents with HIV. Department of Health and Human Services. https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/whats-new-guidelines. Updated September 21, 2022. Accessed January 12, 2023.
21. CDC. “Distinguishing Public Health Research and Public Health Nonresearch” Policy. https://www.cdc.gov/os/integrity/docs/cdc-policy-distinguishing-public-health-research-nonresearch.pdf . Published July 2010. Accessed October 24, 2022.
22. Protection of Human Subjects, CFR 45, Part 46. https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-46. Last amended January 12, 2023. Accessed January 12, 2023.
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Appendix: Measurement Notes

Sociodemographic Characteristics

• Age: Calculated from the reported date of birth; age categories were chosen for epidemiologic relevance and consistency of reporting across all 3 National HIV Behavioral Surveillance (NHBS) populations.
• Race/ethnicity: Participants reported 1 or more race categories (American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or other Pacific Islander, and White). Hispanic or Latino ethnicity was asked separately; participants reporting Hispanic or Latino ethnicity were considered Hispanic or Latino, regardless of reported race. Participants reporting multiple races (but not Hispanic or Latino ethnicity) were classified as multiple races.
• Education: Highest level of education completed.
• Household income: Participants were asked about their combined monthly or yearly household income (in US$) from all sources for the calendar year before interview. Poverty was determined by using the U.S. Department of Health and Human Services poverty guidelines for 2021. These guidelines are issued yearly for the United States and are one of the indicators used for determining eligibility for many federal and state programs. The 2021 guidelines [1] were used for participants interviewed in 2021. Because the poverty guidelines are not defined for Puerto Rico, the guidelines for the 48 contiguous states and Washington, D.C., were used for this jurisdiction. Participants were asked to identify the range of their income by selecting from a list of income ranges and the number of dependents on that income. If the participant’s income range and household size resulted in an ambiguous determination of poverty level, the participant’s household income was assumed to be the low point of the income range.
• Unemployment: Participants who reported their employment status as “unemployed”.
• Disability: Participants who reported difficulty with hearing, seeing, cognition, ambulation, self-care, or independent living, based on responses to the questions that comprise the US Department of Health and Human Services data standard for disability status [2,3].
• Health insurance: Currently having some form of health insurance.
• Visited a health care provider: Having visited a healthcare provider during the 12 months before interview.
• Homeless: Living on the street, in a shelter, in a single-room–occupancy hotel, or in a car at any time during the 12 months before interview.
• Incarcerated: Having been held in a detention center, jail, or prison for more than 24 hours during the 12 months before interview.
• City: Throughout this report, eligible metropolitan statistical areas (MSAs) and divisions are referred to by the name of the principal city. State and local health departments eligible to participate in NHBS are those in jurisdictions that include an MSA (or a specified division within an MSA) with high prevalence of HIV. This report presents 2021 data in 13 MSAs (see list at the end of the report), that met the threshold for sufficient sample size.

HIV Status

HIV testing was performed for participants who consented to testing. Due to 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), local NHBS HIV testing procedures could be modified 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 is reported using the following four categories:

• HIV-negative: Participants with a negative NHBS HIV test result who did not self-report a previous HIV-positive test result.
• HIV-positive: Participants who had a reactive rapid NHBS HIV test result that was supported by a second rapid test, supplemental laboratory-based testing, or self-report of a previous HIV-positive test result.
• Presumed HIV-positive: Participants who had a reactive NHBS HIV test result that was not supported by a second rapid test, supplemental laboratory-based testing, or self-report of a previous HIV-positive test result, as well as participants who self-reported a previous HIV-positive test result and had a non-reactive NHBS HIV test result. Of participants in this category, 79% received only one oral-based test.
• No valid NHBS HIV test result: All participants not classified as HIV-positive, presumed HIV-positive, or HIV-negative, including those who did not consent to the NHBS HIV test and those who had only one rapid test result that was invalid.

HIV Testing and Preexposure Prophylaxis (PrEP)

• Ever tested: Having had an HIV test during one’s lifetime.
• Tested in past 12 months: Having had an HIV test during the 12 months before interview.
• PrEP awareness: Ever heard of PrEP, an antiretroviral medicine taken for months or years by a person who is HIV-negative to reduce the risk of getting HIV.
• PrEP use: Took PrEP at any point during the 12 months before interview to reduce the risk of getting HIV.
• Clinical setting: Participants reported the location of their most recent HIV test as private doctor’s office (including health maintenance organization), emergency department, hospital (inpatient), public health clinic or community health center, family planning or obstetrics clinic, correctional facility (jail or prison), or drug treatment program.
• Nonclinical setting: Participants reported the location of their most recent HIV test as HIV counseling and testing site, HIV street outreach program or mobile unit, needle exchange program, or home.

Sexual Behaviors

• Sex of any type: Includes oral or anal sex.
• Anal sex: Penis inserted into a partner’s anus or butt.
• Vaginal sex: Penis inserted into a partner’s vagina.
• Oral sex: Penis inserted into a partner’s mouth, or mouth on a partner’s penis.
• Insertive anal sex: Participant’s penis inserted into a partner’s anus.
• Receptive anal sex: Partner’s penis inserted into the participant’s anus.
• Both insertive and receptive anal sex, condomless: participant reported both insertive and receptive anal sex at last sex and reported not using a condom during either or both of those anal sex acts.
• Condomless sex: Vaginal or anal sex during which a condom either is not used or is not used throughout the sex act.
• Main partner: Person with whom the participant has sex and to whom he feels most committed (e.g., boyfriend, husband, significant other, or life partner).
• Casual partner: Person with whom the participant has sex, but to whom he does not feel committed or whom he does not know very well.

Sexually Transmitted Infections (STI)

• Any bacterial STI: Having received a diagnosis of chlamydia, gonorrhea, or syphilis during the 12 months before interview.
• Chlamydia: Having received a diagnosis of chlamydia during the 12 months before interview.
• Gonorrhea: Having received a diagnosis of gonorrhea during the 12 months before interview.
• Syphilis: Having received a diagnosis of syphilis during the 12 months before interview.
• Genital warts: Having received a diagnosis of genital warts during one’s lifetime.

Substance Use

Participants were asked about their use of drugs (excluding those prescribed for them) during the 12 months before interview and their use of alcohol during the 30 days before interview. Participants were not limited in the number of substances they could report. Participants were considered to have used a substance if they reported using that substance with any frequency other than “never.”

• Binge drinking: Consumed 5 or more drinks at one sitting during the 30 days before interview.
• Any injection drug: Used any injection drug (excluding those prescribed for him) during the 12 months before interview.
• Any non-injection drug: Used any non-injection drug, excluding alcohol, including marijuana, during the 12 months before interview.
• Cocaine: Used powder cocaine during the 12 months before interview.
• Crack: Used crack cocaine during the 12 months before interview.
• Downer: Used downers (benzodiazepines), such as Klonopin, Valium, Ativan, or Xanax, during the 12 months before interview.
• Ecstasy: Used X or ecstasy during the 12 months before interview.
• Heroin: Used heroin (smoked or snorted) during the 12 months before interview.
• Marijuana: Used marijuana during the 12 months before interview.
• Methamphetamine: Used methamphetamines, including meth, crystal meth, speed, or crank, during the 12 months before interview.
• Prescription opioids: Used pain killers, such as OxyContin, Vicodin, morphine, or Percocet, during the 12 months before interview.

Additional Outcomes

Table 9 includes outcomes that were of particular interest at the time of publication, but that were not included in other tables.

• Number of male sex partners: Median number of male sex partners in the 12 months before interview; first and third quartiles (25th and 75th percentiles) are also reported.
• Exchange sex: Refers to giving or receiving money or drugs from a male casual partner in exchange for sex.
• Unprotected sex with HIV-discordant partner at last sex: “Unprotected sex” refers to 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). “HIV-discordant partner” refers to a sex partner of different or unknown HIV status.
• Free condoms: Having received free condoms during the 12 months before interview, not including those given by a friend, relative, or sex partner.
• Individual-or group-level intervention: Individual-level intervention defined as a one-on-one conversations with an outreach worker, a counselor, or a prevention program worker about ways to prevent HIV. Group-level intervention defined as a small group discussion that is part of an organized session about ways to prevent HIV; excludes informal discussions with friends. Conversations that were part of obtaining an HIV test were excluded.

Receipt of HIV Care

Participants who self-reported HIV-positive were asked about their receipt of HIV care. Specifically, participants were asked the date of their first HIV-positive test result; if they had ever visited a doctor, nurse, or other health care provider for a medical evaluation or care related to their HIV infection; the date of their first visit to a health care provider for HIV care after learning they had HIV; the date of their most recent visit to a health care provider for HIV care; and whether they were currently taking any antiretroviral medicines.

• Visited health care provider about HIV, ever: Having ever visited a health care provider for HIV care.
• Visited health care provider about HIV, within 1 month after diagnosis: Having visited a health care provider for HIV care within 1 month after the date of their first HIV-positive test result.
• Visited health care provider about HIV, in the past 6 months: Having visited a health care provider for HIV care during the 6 months before date of interview.

Currently taking antiretroviral HIV medicines: Taking antiretroviral medicines at the time of interview.

References

1. U. S. Department of Health and Human Services. 2021 poverty guidelines. http://aspe.hhs.gov/2021-poverty-guidelines. Published 2021. Accessed January 12, 2023.
2. Office of Minority Health. Data collection standards for race, ethnicity, sex, primary language, and disability status. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=23. Published October 2011. Accessed January 12, 2023.
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Participating Metropolitan Statistical Areas, 2021

^*Included in report