Examining Levels of Risk Behaviors among Black Men Who Have Sex with Men (MSM) and the Association with HIV Acquisition

Seroadaptation is defined as the practice of modifying sexual behavior based on one's own HIV serostatus, the perceived HIV serostatus of sexual partners, and differences in risk of HIV transmission by sexual acts. Because this definition implies intent, we use the term "seroprotection" to describe HIV negative participants reporting condomless anal sex (CAS) either exclusively with seronegative partners, or only as the insertive partner with HIV positive or unknown serostatus partners. Little is known about seroprotection in Black men who have sex with men (MSM). We evaluated the independent association of seroprotection and HIV acquisition among the 1144 HIV-negative Black MSM enrolled in HPTN 061 using Cox models; we stratified by city of enrollment, and controlled for number of partners, age, and drug use. Behaviors reported at 0, 6, and 12 months were assigned to three mutually exclusive categories: (1) No CAS; (2) Seroprotection; and (3) CAS without seroprotection. In 2,861 six-month intervals; 28 HIV seroconversions occurred. No CAS was reported at 33.3% of visits, seroprotection at 46.6% of visits, and CAS without seroprotection at 20.1% of visits. The seroconversion rate per 100 person-years for no CAS was 0.98 (95% CI: 0.27, 2.51), compared with 2.39 (95% CI: 1.03, 4.71) and 13.33 (95% CI: 7.62, 21.66) for seroprotection and CAS without seroprotection, respectively. Compared to CAS without seroprotection, intervals without CAS were associated with an 87% reduction (aHR: 0.13, 95% CI: 0.03-0.46) in HIV acquisition and intervals with seroprotection with a 78% reduction (aHR: 0.22, 95% CI: 0.09-0.57). No CAS is the safest behavior to prevent HIV acquisition. Seroprotective behaviors significantly reduced risk, but HIV incidence was still >2/100 person-years, suggesting that additional strategies, such as pre-exposure prophylaxis, are warranted for this population.