The Impact of Sexual Behaviours, Risk Perceptions and the Criminalization of HIV Non-Disclosure on HIV Transmission among HIV-Negative and HIV-Positive Men Who Have Sex With Men in Toronto

Background: Men who have sex with men (MSM) continue to have disproportionately high rates of human immunodeficiency virus (HIV), even though risk factors for HIV acquisition are known and antiretroviral treatment has reduced transmission. Objectives: To characterize the sexual behaviours and risk perceptions of HIV transmission among HIV-negative and HIV-positive MSM. Methods: 150 HIV-negative and 292 HIV-positive MSM participated in the STI/HIV Co-Infection Study between September 2010 and June 2012. Participants were recruited from the Maple Leaf Medical Clinic, a primary and HIV-related care centre in Toronto. Multivariable logistic regression (MLR) models quantified the relationships between actualsexual HIV risk, HIV incidence risk index for MSM (HIRI-MSM), perceived HIV risk and willingness to take pre-exposure prophylaxis (PrEP) among HIV-negative MSM. MLR and flow chart models were used to estimate the potential impact of HIV non-disclosure laws on HIV testing rates and transmission among HIV-negative MSM, and on condom use, HIV status disclosure and proportion at risk for criminal prosecutions among HIV-positive MSM. Results: As condom use frequency with HIV-positive regular partners decreased, perceived HIV risk (Odds Ratio (OR):18.33, 95% Confidence Interval (CI):1.65-203.45) and willingness to take PrEP (OR:27.11, 95% CI:1.33-554.43) increased. Condom use frequency with casual or HIV-unknown status regular partners and the HIRI-MSM index were not associated with perceived HIV risk or PrEP willingness. The 7% (9/124) reduction in HIV testing due to fear of prosecution found in this study could increase community HIV transmission by 18.5%; the majority of transmission being driven by the unmet needs of undiagnosed HIV-positive MSM. Almost half of HIV-positive MSM were more likely to use condoms and/or disclose their HIV-positive status due to fear of prosecution and 8.6% (25/292) could be at risk for non-disclosure prosecutions given their condom use, viral load and disclosure rates. Conclusions: HIV-negative MSM using condoms less frequently with HIV-positive partners but not with HIV-unknown status or casual partners accurately gauged their sexual risk behaviour and were willing to take PrEP. HIV non-disclosure laws may incentivize safer sex practices among HIV-positive MSM; however, they may also deter HIV testing which impedes HIV prevention efforts and increases community HIV transmission .Ph.D