Substance use and sexual risk behavior in HIV-positive men who have sex with men: an episode-level analysis

Descriptive study on substance uses and risk of sexually transmitted infections in the practice of Chemsex in Spain

Background

In recent years, there has been an increasing use of sex-related substances (known as "Chemsex") to facilitate, intensify, and prolong the sexual experience of men who have sex with men. This phenomenon poses a public health problem, increasing the risk of sexually transmitted infections (STIs) and mental disorders.

Objective

The primary aim of this study was to delve into the correlation between substance use and sexual health, specifically examining the association between different substances used and the risk of sexually transmitted infections (STIs) in the context of Chemsex in Spain.

Methods

An observational, descriptive, cross-sectional study was conducted among 563 Spanish participants between January and April 2023. Non-probabilistic purposive sampling was used by the investigators. The researchers administered a questionnaire to men who have sex with men who use substances, especially in the sexual sphere, in all the autonomous communities of Spain.

Results

14.7% reported having practiced slamsex in the last year, and 17.94% were diagnosed with a Sexually Transmitted Infection in the previous 6 months. Of these, 21% were on PREP treatment, with the main STIs being gonorrhea (p < 0.001), chlamydia (p < 0.001), genital herpes (p = 0.020), and syphilis (p < 0.001). The 63.7% used methamphetamines as the main drug in the practice of chemsex.

Discussion

Chemsex in Spain is linked to a high prevalence of STIs, especially gonorrhea and chlamydia, even among those on PrEP treatment. The use of various drugs during chemsex, such as amyl nitrite, GHB, ecstasy, and others, correlates with higher rates of STIs, highlighting the need for interventions to reduce risk and harm. The drugs most associated with slamsex include ketamine, mephedrone, and methamphetamine, underscoring the importance of addressing the risk behaviors associated with this activity.

Conclusion

This study shows that chemsex appears to be associated with a high prevalence among men who have sex with men. Who use multiple substances in a sexual context, and are particularly exposed to sexually transmitted infections (STIs), indicating a particular need for STI prevention and care in this group.

Prevalence and Predictors of Psychoactive Drug Use among Chinese Men Who Have Sex with Men: A Longitudinal and Mediation Study

Few longitudinal studies have examined the prevalence of psychoactive drug use and its related predictors among Chinese men who have sex with men (MSM) in Hong Kong. This longitudinal study aimed to investigate the prevalence of psychoactive drug use in this population and the relationships of background characteristics, health status, MSM-related self-stigma, and perceived stress with psychoactive drug use. Furthermore, the study tested the mediation effect of perceived stress in the relationship between MSM-related self-stigma and psychoactive drug use based on the minority stress model and the general strain model. A total of 600 MSM were recruited through multiple sources and completed a telephone interview at baseline, and 407 completed the 6-month follow-up survey. Prevalence of using any type of psychoactive drugs in the past 12 months at baseline and in the past six months at follow-up was 16.8% and 9.1% respectively. History of sexually transmitted infection (STI), self-stigma and perceived stress significantly predicted psychoactive drug use at 6-month follow-up. Bootstrapping analysis showed that self-stigma could, directly and indirectly, predict psychoactive drug use at 6-month follow-up through perceived stress. The results highlighted the need for interventions to reduce psychoactive drug use among local MSM and its potential modifiable factors.

The Relationship Between Alcohol and Drug Use, Compulsive Sexual Behavior, and Condomless Anal Sex in Men Who have Sex with Men: Analysis of Retrospectively-Reported Sexual Behavior

Men who have sex with men (MSM) are disproportionately impacted by HIV in the United States, and substance use and compulsive sexual behavior (CSB) are contributors to HIV risk behavior. This study sought to examine the direct and interactive effects of concurrent substance use and CSB on condomless anal sex (CAS) in a community sample of MSM (N = 200) utilizing a 90-day timeline follow-back assessment. Results indicated CSB did not directly increase risk for CAS when controlling for substance use and age. There was limited evidence for a direct effect of concurrent alcohol use on CAS, and no evidence for an interaction effect with CSB. The relationship between concurrent drug use and CAS was moderated by CSB, such that concurrent drug use was positively associated with CAS for those who screened positive for CSB, while the association was non-significant for those who screened negative. Implications and limitations of these findings are discussed.

Barriers and Facilitators to HIV Pre-Exposure Prophylaxis Uptake Among Men Who have Sex with Men Who Use Stimulants: A Qualitative Study

The HIV epidemic disproportionately impacts men who have sex with men (MSM), particularly those who use stimulants. We explored barriers and facilitators to pre-exposure prophylaxis (PrEP) uptake among this population. From June 2018 through February 2019, we conducted semi-structured interviews in Providence, Rhode Island, and New Haven, Connecticut, with 21 MSM who reported recent (past six months) stimulant use. We identified individual, interpersonal, and structural barriers to PrEP, including: (1) high awareness but mixed knowledge of PrEP, resulting in concerns about side effects and drug interactions; (2) interest that was partly determined by substance use and perceived HIV risk; (3) fragmented and constrained social networks not conducive to disseminating PrEP information; and (4) PrEP access, such as insurance coverage and cost. Our findings suggest potential approaches to increase PrEP uptake in this group, including promotion through mainstream and social media, clarifying misinformation, and facilitating increased access through structural interventions.

Effect of the COVID-19 Pandemic on Stimulant Use and Antiretroviral Therapy Adherence Among Men Who Have Sex With Men Living With HIV: Qualitative Focus Group Study

BACKGROUND

Evidence suggests that economic, social, and psychological circumstances brought about by the COVID-19 pandemic may have a serious impact on behavioral health. Men who have sex with men (MSM) are disproportionally impacted by HIV and stimulant use, the co-occurrence of which heightens HIV transmission risk and undermines nationwide treatment strategies as prevention efforts for ending the HIV epidemic. There is a paucity of information regarding the potential impact of the COVID-19 pandemic on the substance use and HIV medication adherence in this key vulnerable population-MSM who use stimulants and are living with HIV.

OBJECTIVE

The aim of this qualitative study was to identify ways in which the COVID-19 pandemic has affected stimulant use and antiretroviral therapy (ART) adherence among a sample of MSM living with HIV.

METHODS

Two focus groups were conducted in August 2020 via videoconferencing technology compliant with the Health Insurance Portability and Accountability Act. Potential participants from an established research participant registry at State University of New York Downstate Health Sciences University were invited and screened for study participation on the basis of inclusion criteria. A semistructured interview guide was followed. A general inductive approach was used to analyze the data. Findings in two general areas of interest, the impact of the COVID-19 pandemic on stimulant use and ART adherence, emerged directly from the raw data.

RESULTS

A total of 12 ethnically diverse participants over the age of 25 years took part in the study. Results were heterogeneous in terms of the effects of the pandemic on both stimulant use and ART adherence among MSM living with HIV. Some men indicated increased or sustained stimulant use and ART adherence, and others reported decreased stimulant use and ART adherence. Reasons for these behavioral changes ranged from concerns about their own health and that of their loved ones to challenges brought about by the lack of daily structure during the lockdown phase of the pandemic and emotion regulation difficulties.

CONCLUSIONS

The COVID-19 pandemic has had a differential impact on stimulant use and ART medication adherence among MSM living with HIV. The reasons for behavioral change identified in this study may be salient intervention targets to support ART medication adherence and lower stimulant use among MSM in the aftermath of the of the COVID-19 pandemic, as well as beyond.

Patterns of sexual and HIV-related stigma among men who have sex with men and women living with HIV in Haiti

Vulnerability to contracting HIV among Men who have Sex with Men and Women (MSMW) was recognized early in the epidemic. However, while global HIV efforts have made tremendous progress for the heterosexually-identified population, the specific needs of MSMW were not directly addressed with tailored and context-adapted interventions. The purpose of this study was to inform this area of research by exploring patterns of stigma through sexual identity developmental history as well as coping mechanisms among MSMW living with HIV in Haiti. A qualitative descriptive study comprised of in-depth interviews with 32 MSMW living with HIV was carried out. Participants were recruited using snowball techniques. An inductive thematic analysis was conducted in NVivo, contextualized by the socio-ecological context of Haiti. MSMW reported struggling with their sexuality since their adolescence, often because of enacted stigma from family members, the community, and cultural conflicts. Most participants described experiencing anxiety, psychological distress, depression, social isolation, suicidal ideation and suicide attempts. Mechanisms for coping with stigma included self-acceptance, social support, hiding their sexual orientation, and tolerance of the voodoo religion. To combat stigma, and improve HIV treatment adherence and retention among MSMW, culturally-tailored multilevel initiatives should be implemented.

Sexual behaviors, cannabis, alcohol and monkeypox infection

The emergence of the monkeypox virus (MPXV) outbreak in 2022 is a worldwide health issue. The rapid increase of monkeypox cases caused the WHO to designate the escalating global monkeypox outbreak a Public Health Emergency of International Concern on July 23, 2022. The WHO has called on the group currently most affected by the virus, men who have sex with men (MSM), to limit their sexual partners. The diminution in number of sexual partners not only decreases the proportion of infected MSM but could also increases the number of days needed to reach a given infection level among the general population. Several behavioral factors could be associated with high levels of different sexual partners, such as cannabis use and alcohol consumption. Firstly, this review focuses on the association between cannabis and alcohol consumption and the number of sexual partners, and their possible impact on the current MPXV outbreak by impairing the immune responses. Secondly, this review investigated in the UK Biobank cohort the relationship between alcohol and cannabis use and the number of sexual partners. Among the 115,604 participants, 1.8% declared to be MSM, 1.9% to be WSW (women having sex with women), 43.3% men heterosexuals and 53.0% women heterosexuals. MSM and WSW showed higher lifetime sexual partners (N = 17.4 (SD:17.52) and N = 13.65 (SD: 13.21), respectively) compared to heterosexual men (N = 6.89 (SD: 9.47) and women (N = 5.19 (SD:6.56), p < 0.001. After adjustment for age, body mass index, lifetime sexual activity, educational and income levels, tobacco and cardiovascular diseases, cannabis use and alcohol consumption remained significantly associated with increase in the number of different sexual partners in all four subgroups. Thus, cannabis use and alcohol consumption may have two detrimental effects on the MPXV outbreak: by participating in the increase of the number of sexual partners which are mainly responsible for the augmentation of the number of new MPXV infected cases and by impairing the immune response to a viral infection. Health and safety policies should address the factors and practices, including chemsex, leading to an increase in risk of sexual behaviors responsible for MPXV dissemination in the worldwide population.

Cannabis and Alcohol Co-Use and Condomless Anal Sex Among Men Who have Sex with Men Living with HIV: An Event-Level Analysis

Men who have sex with men (MSM) account for more than two thirds of new HIV diagnoses annually. Sexual behavior that increases risk for onward transmission of HIV is associated with both alcohol and cannabis use. However, little is known about the influence of cannabis and alcohol co-use on engagement in condomless anal sex (CAS). The current study explored daily associations between substance use and CAS among HIV-positive MSM using a 42-day timeline followback interview (N = 101). Generalized estimating equation (GEE) logistic regression models were used to examine the association between cannabis and alcohol co-use and CAS at the sexual event while controlling for study site, condition, adherence to antiretroviral therapy, sex-related alcohol expectancies, and partner type. Participants provided data for 1052 sexual activity days, 60.7% of which involved CAS. Of 638 CAS days, 9.1% involved no substances, 72.0% involved either cannabis or alcohol use, and 18.9% involved cannabis and alcohol co-use. Results indicated that the odds of engaging in CAS were higher for sexual events in which cannabis and alcohol co-use occurred (aOR 2.98; 95% CI 1.27, 6.97) compared to events in which no substance use occurred (p = 0.012), but this relationship was no longer significant when cannabis and alcohol co-use was compared to single substance use (aOR 1.57; 95% CI 0.85, 2.90; p = 0.15). Future research should identify specific substance use (e.g., quantity) and partner characteristics (e.g., level of intoxication) that may uniquely influence the relationship between cannabis and alcohol co-use and condomless sex.

Marijuana and illicit drugs: Correlates of condomless anal sex among adolescent and emerging adult sexual minority men

The association between "illicit drugs" (e.g., cocaine/crack, methamphetamine, gamma-hydroxybutyrate-GHB, ketamine, and ecstasy) and condomless anal sex (CAS) with casual partners is well established for sexual minority men (SMM). Recent evidence from adult SMM has indicated that marijuana is associated with the occurrence of CAS with casual partners above and beyond illicit drug use. The purpose of the current study was to evaluate associations between CAS and the use of marijuana and illicit drugs in a sample of young SMM (aged 15-24). Participants (n = 578) completed an online survey assessing demographics, current PrEP prescription, age, marijuana use, as well as drug use and sexual behavior in the past 90 days. A hurdle model simultaneously predicted the occurrence of CAS as well as the frequency of CAS among those reporting it. Illicit drug use was associated with both the occurrence (OR = 2.26; p = .01) and frequency of CAS (RR = 1.63; p = .02). In contrast, marijuana use was associated with the occurrence (OR = 1.69; p = .01), but not the frequency of CAS (RR = 1.07; p = .74). Findings mirror recent observations in large samples of adult SMM. While the effect size of marijuana is more modest than illicit drug use, marijuana does have significant and unique associations with the occurrence of CAS. HIV prevention services for young SMM may therefore benefit from assessing and addressing marijuana use in the context of HIV sexual behavior.

Syndemic Profiles and Sexual Minority Men's HIV-Risk Behavior: A Latent Class Analysis

Syndemic theory posits that "syndemic conditions" (e.g., alcohol misuse, polydrug use, suicidality) co-occur among sexual minority men and influence HIV-risk behavior, namely HIV acquisition and transmission risk. To examine how four syndemic conditions cluster among sexual minority men and contribute to HIV-risk behavior, we conducted latent class analysis (LCA) to: (1) classify sexual minority men (n = 937) into subgroups based on their probability of experiencing each syndemic condition; (2) examine the demographic (e.g., race/ethnicity) and social status (e.g., level of socioeconomic distress) characteristics of the most optimally fitting four syndemic classes; (3) examine between-group differences in HIV-risk behavior across classes; and (4) use syndemic class membership to predict HIV-risk behavior with sexual minority men reporting no syndemic conditions as the reference group. The four classes were: (1) no syndemic, (2) alcohol misuse and polydrug use syndemic, (3) polydrug use and HIV syndemic, and (4) alcohol misuse. HIV-risk behavior differed across these latent classes. Demographic and social status characteristics predicted class membership, suggesting that syndemic conditions disproportionately co-occur in vulnerable subpopulations of sexual minority men, such as those experiencing high socioeconomic distress. When predicting HIV-risk behavior, men in the polydrug use and HIV syndemic class were more likely (Adjusted Risk Ratio [ARR] = 2.93, 95% CI: 1.05, 8.21) and men in the alcohol misuse class were less likely (ARR = 0.17, 95% CI: 0.07, 0.44) to report HIV-risk behavior than were men in the no syndemic class. LCA represents a promising methodology to inform the development and delivery of tailored interventions targeting distinct combinations of syndemic conditions to reduce sexual minority men's HIV-risk behavior.

Day-level associations between drug use and sexual behavior in male couples: Actor partner interdependence modeling of timeline follow-back data

BACKGROUND

Both marijuana and other illicit drugs (e.g., cocaine/crack, methamphetamines, ecstasy, gamma-hydroxybuterate, and ketamine) have been linked to the occurrence of condomless anal sex (CAS) with casual partners among sexual minority men (SMM) and these associations largely generalize to partnered SMM. Software advances now permit testing the day-level correspondence between participants' sexual behavior and their own drug use (actor effects) as well as their partners' (partner-effects).

METHODS

Participants comprised 50 couples (100 individuals) recruited in the New York City metro area. All were 18 or older and identified as cis male. In each couple, at least one partner was 18-29 years old, HIV-negative, reported recent (past 30 day) drug use and recent (past 30 day) CAS with a casual partner or CAS with a non-monogamous or sero-discordant main partner at screening.

RESULTS

Marijuana was associated with CAS between main partners on days both partners reported its use. A similar pattern was observed for other illicit drugs. Respondents were more likely to report CAS with casual partners on days CAS between main partners occurred. Both marijuana and other illicit drugs were associated with increased likelihood of CAS with casual partners on days a main partner did not use drugs. These associations were attenuated on days where partners reported the use of different drugs.

CONCLUSIONS

The co-occurrence of CAS with main and casual partners maximizes shared sexual risk. Results support the continued emphasis on dyadic HIV prevention interventions and the development of theoretically-based interventions that may address drug use by both partners in the relationship.

Using mobile health technologies to test the association of cocaine use with sexual desire and risky sexual behaviors among people with and without HIV who use illicit stimulants

BACKGROUND

Cocaine use is broadly associated with risky sexual behavior potentially through elevated sexual desire. Understanding the within-person effects of cocaine on sexual desire and risky sexual behavior and the modification of HIV infection may inform primary and secondary HIV interventions.

METHODS

We conducted a mobile health (mHealth) study in a community sample of males and females with (n = 28) and without (n = 32) HIV who use illicit stimulant drugs. Participants completed ecological momentary assessments (EMAs) and daily diaries over 28 days. Mixed effects models were employed to examine the within-person association of cocaine use with sexual desire and risky sexual behavior.

RESULTS

Participants completed 3505 EMA responses, with 36 % involving recent cocaine use, including powder and/or crack cocaine. They completed 1427 daily diary responses, with cocaine use reported on 49 % of these days and sexual behavior on 21 % of these days. Sexual desire was highest in the first hour since cocaine use and gradually decreased with time. Sexual desire was lowest when participants had not used any cocaine in the past 6 h, and it correlated positively with the amount of use. Participants were more likely to have risky sexual behavior on days they used cocaine. These associations were similar for participants with and without HIV.

CONCLUSION

This study demonstrates the dynamic and proximal effects of cocaine use on sexual desire and risky sexual behavior. Our findings support the development of HIV prevention interventions that utilize mHealth technology to reduce sexual risk behavior among persons who use stimulant drugs.

A Theory-Based mHealth Intervention (Getting Off) for Methamphetamine-Using Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial

Background

Methamphetamine (meth) use among men who have sex with men (MSM) is associated with increased HIV prevalence and transmission and substandard advancement along the HIV prevention and care continuum. Given the growth of mobile health (mHealth) technologies, it is no longer necessary to limit meth treatment options to physical, brick-and-mortar sites, and administration using generic, nontailored content.

Objective

In a 2-arm randomized controlled trial (RCT; N=300), we aim to evaluate the use of an mHealth intervention (Getting Off) to assess the impact and noninferiority of a cross-platform app (developed from a manualized meth treatment intervention) to help MSM reduce meth use and HIV sexual risk behaviors and improve their advancement along the HIV prevention and care continuum (HIV testing, pre-exposure prophylaxis uptake and persistence, and antiretroviral therapy uptake and adherence).

Methods

Participants will be randomized into 2 arms: arm A, with immediate access to the app (immediate delivery: n=150), or arm B, with delayed access to the app after a 30-day period (delayed delivery: n=150). Participants in both arms will use the same Getting Off app and will have 30 days to complete the 24 sessions. Participants will be assessed at the 1-, 2- (delayed delivery arm only), 3-, 6-, and 9-month timepoints to determine observed treatment effects and will be compared with a historical matched sample of participants (n=~600) who received the brick-and-mortar group-based Getting Off intervention.

Results

Recruitment began in January 2019 for phase 1, the formative phase. In January and February 2019, 4 focus groups (N=36) were formed to provide input on the adaptation of the group-based manual intervention to a mobile app. Data collection for phase 2, the RCT, is expected to be completed in January 2023. The final results are anticipated in April 2023.

Conclusions

By creating a culturally responsive mobile app, Getting Off aims to reduce meth use and improve sexual health outcomes among meth-using MSM. The Getting Off app could have significant public health impact by greatly expanding access to effective, affordable, private, culturally competent, and highly scalable meth treatment for MSM.

Trial Registration

Clinicaltrials.gov NCT03884946; https://clinicaltrials.gov/ct2/show/NCT03884946

International Registered Report Identifier (IRRID)

DERR1-10.2196/22572

Association of Sexualized Drug Use Patterns with HIV/STI Transmission Risk in an Internet Sample of Men Who Have Sex with Men from Seven European Countries

We estimated the prevalence of overall sexualized drug use (SDU) and of chemsex in particular, assessed patterns of drug use, and identified subpopulations of men who have sex with men (MSM) where SDU and chemsex are more frequent. Using data from an online survey of 9407 MSM recruited during 2016 in 7 European countries, we calculated the proportion of participants who reported SDU and chemsex (mephedrone, methamphetamine, and/or GHB/GBL) in the last 12 months. We grouped the different drug-use combinations in patterns and described sexual risk behaviors, sexually transmitted infections (STI), and HIV seropositivity for each one of them. Factors associated with SDU and chemsex were assessed with two logistic regression models. SDU was reported by 17.7% and chemsex by 5.2%. Risk indicators increased through the different SDU patterns but were higher within those including chemsex drugs. In the multivariate analysis, chemsex was independently associated with living in Slovenia. Both SDU and chemsex were independently associated with living in Spain; being < 50 years old; living in cities of > 500,000 inhabitants; being open about their sex life; reporting transactional sex; condomless anal intercourse; having received an STI diagnosis and with being HIV positive or having been tested ≤ 12 months ago. Magnitude of associations was higher in the chemsex model. One in five participants reported SDU, but prevalence of chemsex was notably lower. However, the risk profiles and higher prevalence of HIV/STIs among those involved in chemsex suggest the existence of a subpopulation of MSM that could be playing a relevant role in the HIV and STI epidemics, especially in very large cities of some countries.

Cross-sectional analysis of chemsex drug use and gonorrhoea diagnosis among men who have sex with men in the UK

Background Illicit drug use among men who have sex with men (MSM) has been associated with sexual risk and HIV. Less is documented about associations with other sexually transmissible infections (STIs). The aim of the present study was to determine whether the use of drugs commonly associated with chemsex is associated with increased risk of gonorrhoea among MSM.

METHODS

Using data from 16065 UK-based respondents to the European MSM Internet Survey (2010), we examined associations between a recent diagnosis of gonorrhoea and three chemsex drugs (crystal methamphetamine, γ-hydroxybutyric acid (GHB)/γ-butyrolactone (GBL) and mephedrone). Univariate logistic regression identified determinants of gonorrhoea diagnosis and multivariate logistic regression models calculated adjusted odds ratios (aORs) for independent associations between chemsex drugs and gonorrhoea.

RESULTS

MSM who reported using crystal methamphetamine and GHB/GBL in the previous year had 1.92- and 2.23-fold higher odds of gonorrhoea respectively over the same period (P=0.0001 and P<0.0001; n=15137) after adjusting for age, recruitment website, HIV status, residence and use of other chemsex drugs. MSM reporting the use of all three chemsex drugs had the highest increased odds (aOR 3.58; P<0.0001; n=15174). Mephedrone alone was not associated with gonorrhoea in multivariate models.

CONCLUSIONS

Use of chemsex drugs is associated with a higher risk of gonorrhoea. The results of this study complement existing research about crystal methamphetamine and indicate a role for GHB/GBL in adverse sexual health outcomes. The use of mephedrone alongside other chemsex drugs may account for its lack of association with gonorrhoea in multivariate models. Future research should use encounter-level data, examine other STIs and attribute pathways through which chemsex leads to infection.

Factors Associated with Drug Use Among HIV-Infected Men Who Have Sex with Men in China

Drug use is globally more prevalent in HIV-positive men who have sex with men (HIVMSM) than their heterosexual counterparts. Yet, few studies have investigated the factors associated with drug use among this population beyond Western societies. A cross-sectional survey was conducted to examine factors associated with drug use among 415 HIVMSM in Chengdu, China. The results show that 10.8% of the participants had used drugs in the past 30 days. Among participants who had anal intercourse in the past 30 days, 11.5% had used drugs during anal intercourse. After adjusting for background variables, logistic regression models show that life satisfaction was associated with past 30-day drug use [Adjusted Odds Ratio (ORa) = 0.90, p < 0.001], and with drug use during anal intercourse in the past 30 days (ORa = 0.89, p < 0.01). Participants with more nonregular partners were more likely to use drugs with or without sex in the past 30 days, whereas those with one regular partner were less likely to use drugs during anal intercourse compared to their counterparts with no regular partners. The findings of this study are informative for designing effective substance-use intervention programs targeting HIVMSM.

Relationship Stigma and HIV Risk Behavior Among Cisgender Men Partnered with Transgender Women: The Moderating Role of Sexual Identity

Cisgender men partnered with transgender women are an understudied and hard to engage population in HIV prevention efforts. Relationship stigma-the anticipation of negative treatment based on having a relationship with a member of a stigmatized group-has been linked to adverse health behaviors, but it remains unclear whether different sources of relationship stigma (i.e., family, friends, and the general public) are associated with HIV risk behaviors and whether these associations may vary by men's sexual identities (e.g., gay, bisexual, and heterosexual). The current study examined associations between relationship stigma and HIV risk behaviors and whether these associations were moderated by sexual identity. We recruited a convenience sample of 185 cisgender men in primary partnerships with transgender women to participate in a one-time survey. Gay identified men reported greater levels of relationship stigma from the general public compared with heterosexually identified men. In multivariable models, higher levels of relationship stigma from the public were associated with increased odds of engaging in drug use prior to having condomless sex and receiving an STI diagnosis in the last 30 days. There were significant interaction effects such that higher levels of relationship stigma from the public were associated with both indicators of HIV risk for gay identified men but not for heterosexually identified men. Findings support the importance of HIV prevention approaches accounting for relationship stigma from the general public and the diverse sexual identities of men partnered with transgender women when seeking to increase linkage to and engagement in HIV prevention services, including biomedical prevention strategies.

Chemsex among men who have sex with men in Germany: motives, consequences and the response of the support system

Background In Germany, drug use in sexual settings (i.e. chemsex) among men who have sex with men (MSM) has increasingly been the subject of discussion for considerable time. At the same time, however, little is known about this practice. It is against this background that what is currently known about chemsex among MSM in Germany is discussed.

METHODS

The present study observations are essentially based on the results of two research projects of a qualitative-explorative nature. In-depth interviews with drug-using MSM (n=14), as well as qualitative, problem-centred interviews with drug-using MSM (n=75) and expert interviews (n=27) were conducted within these research projects.

RESULTS

Chemsex is a minority behaviour among MSM in Germany. The reasons for using drugs in sexual settings are manifold. For the most part, the effects of the drugs are used to intensify sexual feelings and to achieve greater intimacy. Men who consider their consumption to be problematic, in particular, report a range of negative consequences, such as sexually transmissible infections. Even though chemsex is a minority behaviour, suitable offers of support are, hence, necessary, especially for these men. However, such offers are not yet available in most German cities.

CONCLUSIONS

In order to close this gap in provision of support services, tangible practical steps, such as further training of people who work at drug and gay advisory services, are necessary, along with further research into the backgrounds and contexts of chemsex.

Recreational drug and excessive alcohol use among HIV-infected men who have sex with men in Central Israel

Background

HIV-infected men who have sex with men (MSM) who use recreational drugs (RD) or excessive alcohol (EA) may be involved in risky sexual behaviours, including unprotected anal intercourse (UAI). This study describes the prevalence RD/EA-use among HIV-infected MSM, and compares those who used RD/EA with those who did not.

Methods

This cross-sectional study included HIV-infected MSM who were recruited in a convenient sample from two AIDS-treatment centres and events for HIV-infected MSM in Israel in 2016. Participants completed anonymous questionnaires including RD/EA-use and their sexual behaviours. RD/EA-use was defined as consumption of any psychoactive stimulants or dissociative anaesthetics, or an uptake of alcohol until drunkenness before or during sex.

Results

Of all 276 HIV-infected MSM, 202 (73.2%) used RD/EA. Those who used RD/EA were younger, reported earlier sexual debut, had more sexual partners, were more likely to perform UAI with casual partners, more commonly involved in paid sex, used psychiatric medications and more likely to be unsatisfied with their health-status compared to those who did not use RD/EA. HIV-infected MSM who used RD/EA reported a lower CD4-count and higher viral-load than those who did not. In a multivariate analysis, being younger, reported earlier sexual debut and been prescribed psychiatric drugs were associated with RD/EA-use among HIV-infected MSM.

Conclusions

A large proportion of HIV-infected MSM used RD/EA and also engaged in risky sexual behaviours. A subset of HIV-infected MSM can benefit from mental support during their routine treatment at the AIDS treatment centres and should also receive harm reduction intervention by their providers in order to minimize potential risks pertaining to RD/EA-use.

Differential Patterns of Risk and Vulnerability Suggest the Need for Novel Prevention Strategies for Black Bisexual Men in the HPTN 061 Study

BACKGROUND

Black men who have sex with men (BMSM) and some who also have sex with women (BMSMW) account for over 70% of new HIV infections in the United States representing an elevated HIV risk in this group, also informing risks of HIV transmission to other BMSM and female sexual partners.

SETTINGS

We examined trajectories of self-reported substance use, HIV-related sexual risk behaviors, and psychosocial vulnerabilities among BMSMW versus BMSM over a 1-year study period.

METHODS

We analyzed baseline, 6-, and 12-month follow-up data from the HIV Prevention Trials Network "BROTHERS" Study (HPTN 061; n = 1126). Categorizing participants by sexual partner type across 3 time points: (1) BMSMO: having male and no female partners across assessments and (2) BMSMW: having sex with male and one or more female partners at least at 1 time point. Using generalized estimating equations, we estimated associations between being BMSMW (versus BMSMO) and changes in psychosocial vulnerability, substance use, and HIV-related sexual risk behaviors.

RESULTS

Generalized estimating equation models controlling for sociodemographics, time-varying effects, and intervention status showed that BMSMW versus BMSMO had 50% increased odds of crack use, 71% increased odds of alcohol use during condomless anal intercourse (CAI), 51% greater odds of using drugs at last CAI, and twice the odds of receiving goods at last CAI.

CONCLUSIONS

Findings show stable and comparatively elevated illicit drugs, alcohol, and exchange sex during last CAI among BMSMW. Future intervention research should focus on ways to address changes in substance-related HIV-transmission behaviors over time in this population of men.

Association Between Marijuana Use and Condom Use: A Meta-Analysis of Between-Subject Event-Based Studies

OBJECTIVE

With the current public health burden of sexually transmitted infections, it is important to identify factors affecting condom use. The association between marijuana use and condom use is especially important because of the increasing number of U.S. states legalizing marijuana; however, relevant research findings are mixed. The goal of this study was to perform a meta-analysis assessing the relationship between marijuana and condom use at instances of sexual intercourse.

METHOD

A systematic search of four databases was performed. Data were extracted and pooled estimates were calculated using random-effects models with inverse variance weighting. Heterogeneity was evaluated using the Cochran Q chi-square test.

RESULTS

Eleven studies were included. There was a statistically significant relationship between marijuana and condom use in the overall pooled analysis (odds ratio [OR] = 0.71, 95% CI [0.56, 0.89]), and studies were homogeneous, I² = 12%, χ²(10) = 11.37, p = .33. Stratified analyses showed that although the pooled OR was not significant for adults (OR = 0.92, 95% CI [0.64, 1.33]), there was a significant relationship between condom use and marijuana use for adolescents (OR = 0.62, 95% CI [0.47, 0.82]).

CONCLUSIONS

This meta-analysis found that the odds of condom use were lower for those who used marijuana around the time of intercourse than for those who did not, with this effect only significant for adolescents in a subgroup analysis. As the adolescent populations in this analysis were not representative of a general population of adolescents, future research should focus not only on those considered high risk.

Determining the Roles that Club Drugs, Marijuana, and Heavy Drinking Play in PrEP Medication Adherence Among Gay and Bisexual Men: Implications for Treatment and Research

Researchers have established that substance use interferes with anti-retroviral medication adherence among gay and bisexual men (GBM) living with HIV. There is limited parallel examination of pre-exposure prophylaxis (PrEP) adherence among HIV-negative GBM. We conducted retrospective 30-day timeline follow-back interviews and prospective semi-weekly diary data for 10 weeks with 104 PrEP-using GBM, half of whom engaged in club drug use (ketamine, ecstasy, GHB, cocaine, or methamphetamine)-generating 9532 days of data. Participants reported their day-by-day PrEP, club drug, marijuana, and heavy alcohol use (5 + drinks in one sitting). On average, club drug users were no more likely to miss a dose of PrEP than non-club drug users (M = 1.6 doses, SD = 3.0, past 30 days). However, we found that club drug use (at the event level) increased the odds of missing a dose on the same day by 55% and the next day (e.g., a "carryover effect") by 60%. Further, missing a dose on one day increased the odds of missing a dose the following day by eightfold. We did not identify an event-level effect of marijuana use or heavy drinking on PrEP adherence. Our data suggest club drug users could have greater protective effects from daily oral or long-acting injectable PrEP compared to a time-driven PrEP regimen because of the concurrence of club drug use and PrEP non-adherence.

Cost effectiveness of text messages to reduce methamphetamine use and HIV sexual risk behaviors among men who have sex with men

Methamphetamine use is highly prevalent among gay, bisexual, and other men who have sex with men (MSM) in the United States and has been associated with condomless anal intercourse (CAI), a common route of HIV infection. Text messaging is a very low-cost method of delivery for intervention content. This paper presents a cost-effectiveness analysis of a randomized controlled trial testing three nested methods of text message delivery designed to reduce methamphetamine use and HIV sexual risk behaviors among MSM (Project Tech Support2). From March 2014 to January 2016, 286 non-treatment seeking methamphetamine-using MSM were randomized into one of three study arms: 1) Interactive text message conversations with Peer Health Educators, plus five daily automated, unidirectional theory-based messages, plus a weekly self-monitoring text message assessment (TXT-PHE; n = 94); or, 2) Five daily automated, unidirectional theory-based messages plus a weekly self-monitoring text message assessment (TXT-Auto; n = 99); or, 3) The weekly self-monitoring text message assessment only (AO; n = 93). Methamphetamine use at nine months post-enrollment was lower than at baseline in all three arms. The addition of Peer Health Educators and/or theory-based text messages did not produce cost-effective reductions in methamphetamine use over the weekly AO text messages. However, both intervention arms outperformed the AO arm in reducing HIV risk behaviors, but the TXT-Auto arm dominated the TXT-PHE arm in achieving greater reductions in days of methamphetamine use and CAI at lower cost. The TXT-Auto arm achieved greater reductions in CAI than the attentional control at a cost in the base case of ~$37.50 per episode of CAI reduced per month. Sensitivity analyses showed that results were robust to a number of changes in assumptions. Interventions seeking to reduce methamphetamine use among non-treatment-seeking MSM may seek to add minimal attentional control-style text messages to their routines querying about recent methamphetamine use and/or high-risk sex. Interventions seeking to additionally reduce HIV sexual risk behaviors among non-treatment-seeking MSM, specifically engagement in CAI, may seek to additionally apply theory-based text messages.

Knowledge about HIV/AIDS and implications of establishing partnerships among Hornet® users

OBJECTIVE

To evaluate the knowledge of men, who have sex with men who use geolocation-based dating software, about HIV/AIDS, and the implications of establishing partnerships.

METHOD

Descriptive study with 30 Hornet® users. The statements generated had statistical treatment in the IRaMuTeQ software, analyzed through the Descending Hierarchical Classification.

RESULTS

The sexual frequency in the last 30 days was 2.9 partners, of which 2.1 were found by the application, of which 63.3% reported having sex without condoms. There were four classes: Knowledge about HIV/AIDS prevention measures; PrEP/truvada as a measure of HIV/AIDS prevention; Risky behaviors in relation to HIV infection; Establishment of sexual partnerships through applications.

CONCLUSION

Hornet users have insufficient knowledge about HIV prevention measures, especially when discarding the male condom. The relationships established through the application are permeated by high individual vulnerability and behaviors that have potential exposure to the risk of HIV infection.

Associations between sociodemographic characteristics and substance use disorder severity among methamphetamine-using men who have sex with men

Background: Men who have sex with men (MSM) have elevated rates of substance use disorders (SUDs) and differences across sociodemographic sub-groups of MSM are associated with a greater risk of deleterious outcomes. Although studies have shown that MSM report greater rates of polysubstance use relative to other adult populations, the associations between sociodemographic characteristics and both acute substance use and substance use severity among methamphetamine-using MSM are unknown. Objectives: The present study examines associations between sociodemographic characteristics and (a) recent substance use and (b) SUD severity. Method: From March 2014 to January 2016, 286 methamphetamine-using MSM were recruited to complete a baseline Audio Computer-Assisted Self-Interview (ACASI) assessment and the SCID MINI. Multivariable analyses employed generalized structural equation modeling given the non-continuous nature of the endogenous variables. Results: All measured sociodemographic characteristics except gay self-identification were significantly associated with recent substance use (all ps ≤ .05), and all characteristics except current homelessness were significantly associated with diagnostic SUD severity (all ps ≤ .05). However, nuanced risks were observed in participants' use of specific substances regarding recent substance use and substance use severity. Conclusion: These results suggest that multiple factors contribute to the risks of SUD severity among methamphetamine-using MSM. As such, these results are useful in the tailoring of clinical and psychosocial intervention strategies that serve this and other high-risk populations.

Correlates of Serodiscordant Condomless Anal Intercourse Among Virologically Detectable HIV-Positive Young Men Who Have Sex with Men

Sexual transmission risk occurs in the context of serodiscordant condomless anal intercourse (CAI) where the seropositive partner is virologically detectable (VL+) and/or seronegative partner is not on PrEP. We analyzed correlates of serodiscordant CAI among 688 VL+ young men who have sex with men (YMSM). In multivariable analyses, serodiscordant CAI was associated with a receiving a HIV diagnosis in the past 6 months, greater depressive symptoms, and cocaine use during the past 90 days. Although HIV+ YMSM currently experience disparities across the continuum of care, those new to care may need support adopting risk reduction strategies with their sexual partners.

Associations between Sociodemographic Characteristics and Sexual Risk Behaviors among Methamphetamine-using Men who Have Sex with Men

BACKGROUND

Methamphetamine-using men who have sex with men (MSM) exhibit elevated rates of HIV and STI prevalence, indicating increased engagement in sexual risk behaviors.

OBJECTIVES

This analysis elucidates associations between participant sociodemographics (i.e., age, racial/ethnic identity, sexual identity, educational attainment, and HIV status) and sexual risk behaviors, particularly substance use before/during sex, and engagement in condomless anal intercourse (CAI) with casual, anonymous, and/or exchange male partners.

METHODS

From March 2014 through January 2016, 286 methamphetamine-using MSM enrolled in a technology-based study to reduce methamphetamine use and HIV sexual risk behaviors. A robustly estimated generalized structural equation model employing the negative binomial family and log link function (n = 282) tested the simultaneous associations between participant sociodemographics and engagement in HIV sexual risk behaviors.

RESULTS

Participants' racial/ethnic identity (χ²₍₆₎ = 43.5; p < 0.0001), HIV status (χ²₍₆₎ = 22.0; p = 0.0012), educational attainment level (χ²₍₆₎ = 13.8; p = 0.0322), and years of age (χ²₍₆₎ = 32.4; p < 0.0001) all influenced participants' engagement in substance use before/during sex and engagement in CAI. Methamphetamine (χ²₍₂₎ = 7.0; p = 0.0309) and marijuana (χ²₍₂₎ = 9.7; p = 0.0079) use before/during sex influenced participants' engagement in CAI with casual, anonymous, and exchange male partners.

CONCLUSION

Results indicate the importance of intervention efforts focused on younger racial/ethnic minority MSM with fewer years of educational attainment, and provides evidence of the specific subpopulations of MSM at greatest risk of detrimental effects of illicit substance use.

Association Between Psychiatric Disorders, Substance Use, and Sexual Risk Behaviors in Perinatally HIV-Exposed Youth

As youth with perinatally acquired HIV infection age, there is a need for studies that identify predictors and correlates of sexual risk behaviors. We examined the association between psychiatric disorders and substance use disorders (SUD) with sexual risk behaviors in youth with perinatally acquired HIV infection and perinatally HIV-exposed but uninfected youth. Participants were recruited from four medical centers in New York City. The Diagnostic Interview Schedule for Children and the Adolescent Sexual Behavior Assessment were administered to assess psychiatric disorders and sexual behaviors, respectively. SUD and behavior disorders were correlated with either ever having had penetrative sex or recent condomless sex for participants with perinatally acquired HIV infection only. Results suggest that clinicians should screen and treat patients for SUD and behavioral disorders to reduce sexual risk behaviors in youth with perinatally acquired HIV infection.

Age and racial disparities in substance use and self-reported viral suppression among men who have sex with men with HIV

HIV disproportionately affects men who have sex with men (MSM). Substance use is common among people living with HIV and may affect antiretroviral therapy adherence. Nevertheless, research examining the association between substance use and viral suppression is lacking. The aims of this study were to determine the association between substance use and self-reported viral suppression, and by age and race among MSM living with HIV. Data were obtained from 309 HIV-positive MSM. Logistic regression was used to determine the association between substance use and self-reported viral suppression at baseline, and by age and race. Approximately 67% of participants reported they were virally suppressed. After adjusting for sociodemographics, every increase in substance use score was associated with a 7% decrease in the odds of reporting viral suppression (odds ratio [OR]: 0.93; 95% confidence interval [CI]: 0.89-0.98; p = 0.003). The negative association between substance use and self-reported viral suppression remained statistically significant among MSM aged 25-34 years (OR = 0.89; 95% CI: 0.79-1.00; p = 0.041) and statistically significant for Black MSM (OR = 0.92; 95% CI: 0.86-0.98; p = 0.009). Intervention programs for MSM living with HIV aimed at improving viral suppression should address substance use and consider the differences by age and race.

Typology of drug use in United Kingdom men who have sex with men and associations with socio-sexual characteristics

BACKGROUND

Analysis of specific drug use patterns in men who have sex with men (MSM) is important in targeting HIV prevention and harm reduction interventions and in developing a fuller picture of drug use in context beyond consideration of use of specific drugs in isolation.

OBJECTIVES

We sought to develop a typology of recent drug use in MSM, and to explore how distribution of MSM across the classes in this typology differs by socio-sexual characteristics.

METHODS

We examined last-year drug use reported by 16,814 MSM as part of a cross-sectional, internet-based survey of MSM living in the UK for which data were collected in late summer 2014. We tested models with between two and six classes for types of specific drug use, and related socio-sexual covariates to the classes in the best model using multinomial regression.

RESULTS

Our five-class model described a range of drug use patterns, including minimal users, low-threshold users, old-skool users, chemsex-plus users and diverse users. MSM identifying as gay were more likely to not be minimal users. HIV-positive MSM were more likely to be chemsex-plus users than HIV-negative MSM. Number and type of non-steady partners, ethnicity and education were each related to class membership, though trends were complex.

CONCLUSIONS

Findings from associations between correlates and latent classes suggest avenues for service development beyond current attention to opiates or chemsex drugs. Our findings draw attention to heterogeneity in drug use patterns in MSM beyond what current discourse on chemsex drugs would suggest.

Using a "Positive Deviance" Framework to Discover Adaptive Risk Reduction Behaviors Among High-Risk HIV Negative Black Men Who Have Sex with Men

Despite the high incidence of HIV among young Black MSM in the United States and engagement in high risk behaviors, many men in this group avoid infection. This suggests that some men may engage in systematic risk reduction behaviors when not always using condoms or abstaining from substances. Using a "positive deviance" framework, we conducted qualitative interviews with HIV-negative, Black MSM between 25 and 35 who reported unprotected anal sex and drug use in the past six months or current heavy drinking (N = 29) to discover behaviors that could facilitate remaining HIV-uninfected. Findings showed that MSM who remain HIV negative despite continuing to engage in high-risk behaviors may be engaging in adaptive risk reduction behaviors that, through successive decisions and advance planning along the timeline to a sexual event, could lead to increased condom use, avoidance or delay of a risky sexual event, or reduction of HIV positive partners.

The relation between mental health, homosexual stigma, childhood abuse, community engagement, and unprotected anal intercourse among MSM in China

The aim of the study was to explore the relation of various factors with unprotected anal intercourse (UAI) and provide some insight for HIV intervention on Chinese men who have sex with men (MSM). The current cross-sectional study recruited 365 MSM in Dalian, China. More than half of the respondents (117 respondents, 51.8% of the sample) had engaged in UAI. The multivariable logistic regression model suggested that poorer mental health (AOR: 7.16; 95% CI: 3.14–16.31), self-stigma (AOR: 1.53; 95% CI: 1.00–2.34), and experience(s) of physical abuse in childhood (AOR: 5.85; 95% CI: 1.77–19.30) were significantly and positively related to UAI. Community engagement was negatively associated with UAI (p < 0.05). It appears it is necessary to incorporate mental health services, eliminate the stigma against homosexuality, and facilitate MSM-related community engagement into intervention strategies to prevent UAI among Chinese MSM. Targeted UAI interventions in the subgroup with a history of childhood physical abuse should also be of great concern.

Awareness and willingness towards pre-exposure prophylaxis against HIV infection among individuals seeking voluntary counselling and testing for HIV in Taiwan: a cross-sectional questionnaire survey

OBJECTIVES

We aimed to investigate the awareness and willingness towards pre-exposure prophylaxis (PrEP) among individuals seeking voluntary counselling and testing (VCT) for HIV in Taiwan, where PrEP is currently not reimbursed by the insurance.

METHODS

Between April and October 2016, a questionnaire interview was conducted among VCT clients to inquire about the attitudes towards PrEP against HIV infection. Multivariate logistic regression analysis was performed to identify the associated factors with willingness to initiate PrEP.

RESULTS

During the 6-month period, 1173 VCT clients (99.8%) completed the interviews, with 67.4% being homosexual or bisexual male. While 67.2% of the clients knew of postexposure prophylaxis, 40.2% heard of PrEP. Overall, 546 clients (46.5%) were willing to initiate PrEP and 89.5% of them would choose event-driven PrEP. In multivariate analysis, male gender (OR 1.796; 95% CI 1.165 to 2.768), full-time job (OR 1.354; 95% CI 1.052 to 1.742), one-night stand (OR 1.374; 95% CI 1.043 to 1.810), having casual sex partners within 3 months (OR 1.329; 95% CI 1.031 to 1.714), condomless anal sex (OR 1.405; 95% CI 1.122 to 1.878) and ever having chemsex or attending a drug party in the past 1 year (OR 2.571; 95% CI 1.541 to 4.287), regular screening for HIV infection (OR 1.321; 95% CI 1.021 to 1.711) and knowledge of PrEP (OR 1.504; 95% CI, 1.159 to 1.953) were associated with willingness to initiate PrEP.

CONCLUSIONS

Understanding the willingness to initiate PrEP against HIV among the VCT clients in Taiwan, which was associated with male gender, risky sexual behaviours and awareness of PrEP, will help inform the implementation of PrEP programme.

Sexual Risk Behaviors Among Black Men Who Have Sex With Men Who Also Report Having Sex With Transgender Partners: Analysis of HIV Prevention Trials Network (HPTN) 061 Study

HIV Prevention Trials Network (HPTN 061) study data of Black MSM were analyzed to determine characteristics associated with having transgender sexual partners (TGP) and the association of having TGP with sexual risk. Of 1,449 cisgender MSM, 343(24%) reported also having TGP. MSM with TGP were more likely to be older, have a sexual orientation other than homosexual, have a history of incarceration, or have insufficient funds for necessities, but less likely to be HIV positive or report sex with men to health care providers. MSM with TGP were 3.67 times more likely to recently have 5+ new partners and 2.02 times more likely to report 6+ condomless sexual acts. Since MSM with TGP reported not disclosing sex with men to health care providers, these men may need tailored HIV prevention and care. Future studies should examine differing sexual risks MSM take with sexual partners with different gender identities.

Factors Associated with Sexual Risk of HIV Transmission Among HIV-Positive Latino Men Who have Sex with Men on the U.S.-México Border

We present results from a cross-sectional, clinic-based survey of border-region Latino men who have sex with men (MSM) and who also are living with HIV in the El Paso-Ciudad Juárez area. Among the 66 participants who reported serodiscordant anal or vaginal intercourse, we examined levels of psychological distress and substance use and the association of these variables with condomless sex. Bivariate analyses indicated that MSM who reported condomless sex with a serodiscordant partner were more likely to report higher scores on measures of anxiety, depression, and trauma. These men were also more likely to report more days of alcohol use to the point of intoxication. In multivariate logistic regression, no variables were independently associated with sexual risk behavior, but symptoms of anxiety trended toward statistical significance. Our study is one of few reports aimed at understanding the HIV epidemic among Latino MSM living with HIV in the El Paso-Ciudad Juárez border region. Although we found no evidence of a relation between our measures of psychological distress and substance use and sexual risk behavior in multivariate analyses, psychological distress and problematic alcohol use were common in the sample and are important targets for intervention in their own right.

Mental health in 2020 for men who have sex with men in the United States

Despite continued advances in HIV prevention and treatment, gay and bisexual men and other men who have sex with men (MSM) remain the population most impacted by HIV/AIDS in the US and many other Western countries. Additionally, MSM are disproportionately affected by various psychological problems, including depression, distress, trauma and substance use. These challenges frequently co-occur, and are associated with higher rates of behaviours related to HIV acquisition and transmission, HIV infection, and, for those living with HIV/AIDS, lower levels of treatment engagement. Moreover, racial disparities exist among MSM in the US; for example, young African American MSM bear a disproportionate burden of the continuing HIV epidemic, likely related to disparate HIV prevalence in partner pools as well as long-standing structural inequities. In this review, the mental health challenges facing MSM primarily in the US, related to HIV and STI prevention and across the HIV care cascade, including HIV diagnosis, engagement and retention in care, and antiretroviral adherence, are illustrated. Disparities among MSM including racial and ethnic, age-related and structural barriers associated with HIV prevention and treatment, as well as current interventions, are also described. Moving forward towards 2020, resources will be needed to assess and implement scalable intervention strategies to address psychological and social barriers to HIV and STI risk reduction and treatment for MSM, with a particular focus on the most vulnerable subpopulations. As access to prevention and treatment strategies expand, and new breakthroughs continue to emerge, behavioural strategies will continue to be needed to reduce risk and increase uptake and engagement among MSM most at risk through 2020 and beyond.

Contingent Vs. Non-Contingent Rewards: Time-Based Intervention Response Patterns Among Stimulant-Using Men Who Have Sex With Men

Stimulant use rates are higher among men who have sex with men (MSM) than the general population. Contingency management (CM) may be an effective intervention for reducing stimulant use in this population. To specify both the mechanism and temporal effects of contingent reward on behavior change, logistic growth trajectory modeling (LGTM) was used to contrast a non-contingent matched rewards condition (i.e., non-contingent yoked controls; NCYC) to a voucher-based CM intervention (maximum=$430) to reduce stimulant use among MSM. Stimulant-using MSM were randomized to either a CM intervention (n=70) or a NCYC condition (n=70). Results from a LGTM (analytical sample n=119; nCM=61; nNCYC=58) indicated four distinct intervention response patterns: responders (i.e., predicted >90% stimulant metabolite-free urinalyses; 64.7% of sample); worsening intervention response (14.3%); non-responders (12.6%); and, single-positive (8.4%); all estimated trajectory coefficients were significant at p<0.03 (2-tailed). Participants receiving CM were significantly overrepresented in the responder (64%) and single-positive (80%) categories (χ2(3)=29.04; p<0.001); all non-responders and 76.5% of the worsening intervention response category were in the NCYC condition. Results demonstrate the utility of trajectory modeling and further support the contingent application of reward as the operative mechanism associated with patterns of stimulant abstinence with CM applied to a sample of stimulant-using MSM outside the context of formal drug treatment.

Illicit drug use and its association with sexual risk behaviour among MSM: more questions than answers?

PURPOSE OF REVIEW

Illicit drug use before or during sex - known as sexualized drug use (colloquially 'chemsex' or 'party and play') - has evolved as novel psychoactive substances have entered the market in many parts of the world. Here, we review key conceptual issues in associations between illicit drug use and sexual risk-behaviour in MSM.

RECENT FINDINGS

Although many studies have confirmed that MSM use drugs with greater prevalence than the general population, evidence is of variable quality and a sampling frame is difficult to establish. Moreover, psychosocial hypotheses linking drug use and sexual risk, including cognitive escape and sensation seeking, are unsatisfactory and generally ignore strategic use of drugs for sexual aims. Person-level associations between drug use history and both sexual risk behaviour and HIV infection tend to be consistent around the world, but evidence comparing encounters within subjects is generally unclear and out of date.

SUMMARY

There is a need for interventions for harm reduction targeted at MSM that account specifically for the social and cultural contexts of sexualized drug use. Expanded attention to surveillance of emerging drug use trends can help clinicians in sexual health and infectious diseases best anticipate the needs of their service users.

Examining the Efficacy of HIV Risk-Reduction Counseling on the Sexual Risk Behaviors of a National Sample of Drug Abuse Treatment Clients: Analysis of Subgroups

HIV counseling with testing has been part of HIV prevention in the U.S. since the 1980s. Despite the long-standing history of HIV testing with prevention counseling, the CDC released HIV testing recommendations for health care settings contesting benefits of prevention counseling with testing in reducing sexual risk behaviors among HIV-negatives in 2006. Efficacy of brief HIV risk-reduction counseling (RRC) in decreasing sexual risk among subgroups of substance use treatment clients was examined using multi-site RCT data. Interaction tests between RRC and subgroups were performed; multivariable regression evaluated the relationship between RRC (with rapid testing) and sex risk. Subgroups were defined by demographics, risk type and level, attitudes/perceptions, and behavioral history. There was an effect (p < .0028) of counseling on number of sex partners among some subgroups. Certain subgroups may benefit from HIV RRC; this should be examined in studies with larger sample sizes, designed to assess the specific subgroup(s).

The Use of Technology to Advance HIV Prevention for Couples

The majority of HIV prevention studies and programs have targeted individuals or operated at the community level. This has also been the standard approach when incorporating technology (e.g., web-based, smartphones) to help improve HIV prevention efforts. The tides have turned for both approaches: greater attention is now focusing on couple-based HIV prevention and using technology to help improve these efforts for maximizing reach and potential impact. To assess the extent that technology has been used to help advance HIV prevention with couples, a literature review was conducted using four databases and included studies that collected data from 2000 to early 2015. Results from this review suggest that technology has primarily been used to help advance HIV prevention with couples as a tool for (1) recruitment and data collection and (2) intervention development. Challenges and limitations of conducting research (e.g., validity of dyadic data) along with future directions for how technology (e.g., mHealth, wearable sensors) can be used to advance HIV prevention with couples are then discussed. Given the growing and near ubiquitous use of the Internet and smartphones, further efforts in the realm of mHealth (e.g., applications or "apps") and eHealth are needed to develop novel couple-focused HIV-preventive interventions.

Findings from within-subjects comparisons of drug use and sexual risk behaviour in men who have sex with men in England

Epidemiological evidence for the encounter-level association between sexualised drug use and unprotected anal intercourse in men who have sex with men is unclear and has not examined men who have sex with men in England. To estimate this association, we compared dyadic sexual encounters within respondents. We used encounter-level data from a longitudinal online survey of men who have sex with men living in England and multilevel models to test univariate and multivariate associations between any respondent or partner drug use, specific respondent drug use, additional situational characteristics and unprotected anal intercourse. Based on 6742 encounters from 2142 men who have sex with men, respondent drug use and respondent use of certain specific drugs were associated with increased unprotected anal intercourse odds. In univariate models, partner drug use was associated with increased unprotected anal intercourse odds, but in multivariate models, only non-specific knowledge of partner drug use was associated with the same. Encounters with non-regular-and-steady partners or that were not HIV-seroconcordant were associated with decreased unprotected anal intercourse odds. This is the first within-subjects comparison of drug use and unprotected anal intercourse conducted on a sample from England, and the largest of its kind. Findings are consistent with other studies, though associations between drug use and unprotected anal intercourse are shaped by social contexts that may change over time.

High levels of self-reported prescription opioid use by HIV-positive individuals

Prescription medication use (other than antiretroviral therapy (ART)) is highly prevalent among people living with HIV. Prescription medications may be used medically or non-medically: non-medical use includes using more medication than prescribed, using medication prescribed to someone else, or using medication for a purpose other than its prescribed use. During 12 weeks in 2014-2015, we characterized medical and non-medical prescription medication use among HIV-positive patients attending an academic medical center (n = 149) and a community clinic (n = 105). Separately for the past year and the past month, these 254 participants self-reported their use of prescription opioids, sedatives, stimulants, anti-anxiety medications, antipsychotic medications, and erectile dysfunction medications. Respondents were largely male (91%), aged 40 or older (61%), identified as gay or bisexual (79%), and were men who have sex with men (85%). ART use was nearly universal (95%). Nearly half (43%) of participants reported medical use of prescription opioids; 11% of the opioid use was reported as non-medical use. Anti-anxiety medication use was also frequent, and differed by site: 41% of community-clinic responders reported medical use of anti-anxiety medications compared to 23% of hospital clinic respondents who reported medical use. Prescription sedative use was also approximately twice as high among community-clinic participants, with medical use reported by 43% of respondents and non-medical use by 12%; in comparison, at the hospital clinic, sedative use was reported by 18% (medical) and 7% (non-medical) of participants. Stimulant use was rare in both sites. No demographic characteristic was significantly associated with medical or non-medical use of any prescription medication. The current focus of many studies on only non-medical prescription medication use not only underestimates the widespread exposure of HIV-positive individuals to these drugs, but may also underestimate potential adverse effects of prescription medications in this population.

Nested Event-Level Case-Control Study of Drug Use and Sexual Outcomes in Multipartner Encounters Reported by Men Who Have Sex with Men

Previous event-level analyses have often, but not always, found significant associations between drug use and sexual risk behaviour in men who have sex with men (MSM), but these analyses have rarely considered either multipartner encounters specifically, or other sexual outcomes such as pleasure and control. Using data from an internet-based longitudinal survey of MSM, we tested the association between drug use by respondent and by partners and unprotected anal intercourse (UAI), pleasure and control over sexual activity. Overall respondent substance use was significantly associated with increased odds of UAI, though not with pleasure or control. Respondent use of crystal methamphetamine was significantly associated with both increased odds of UAI and decreased odds of control over sexual activity. This analysis agrees with previous studies of dyadic encounters, and specifically suggests that the association between crystal methamphetamine and sexual risk behaviour may be mediated by loss of control.

Associations Between Drug and Alcohol Use Patterns and Sexual Risk in a Sample of African American Men Who Have Sex with Men

Men who have sex with men (MSM) are the largest risk group in the US HIV epidemic and African American MSM (AA MSM) are disproportionately affected. Substance-abusing sexual minorities warrant attention as they are at elevated risk for HIV, yet are not a homogeneous risk group. The purpose of this study was to use latent class analysis to identify patterns of drug and alcohol use in a sample of 359 AA MSM and examine associations with sexual risk. Three classes were identified: Individuals who used multiple substances (poly-users) (18 %), alcohol/marijuana users (33 %) and individuals who had low probability of reporting drug or problematic alcohol use (50 %). Results from multivariate analysis indicate that poly-users were older and more likely to report sex exchange and recent sexually transmitted infection compared to the other classes. Alcohol and poly-users were more likely to report sex under the influence. Identifying and defining substance use patterns can improve specification of risk groups and allocation of prevention resources.

The Relationship of Religiosity, Spirituality, Substance Abuse, and Depression Among Black Men Who Have Sex with Men (MSM)

HIV infection rates continue to disproportionately affect Black men who have sex with men (Black MSM) compared to other groups. Research has shown that higher rates of substance use and higher levels of depression are positively correlated with higher sexual risk behavior, and little research has examined relationships between high levels of religiosity and spirituality prevalent in Black culture and issues of substance use and depression among Black MSM. This study did just that and found a relationship between religiosity, spirituality, and risk behavior. These relationships suggest that future HIV prevention models might incorporate religiosity and spirituality to increase the efficacy of risk reduction interventions for Black MSM.

Sexual Risk Behavior Among Virologically Detectable Human Immunodeficiency Virus-Infected Young Men Who Have Sex With Men

IMPORTANCE

Human immunodeficiency virus (HIV) diagnoses continue to increase among young men who have sex with men (YMSM). Many YMSM living with HIV engage in sexual risk behaviors, and those who have a detectable viral load can transmit HIV to sex partners. Understanding factors that are related to sexual risk taking among virologically detectable (VL+) YMSM can inform prevention and treatment efforts.

OBJECTIVES

To describe differences between virologically suppressed (VL-) and VL+ YMSM living with HIV and to identify correlates of condomless anal intercourse (CAI) and serodiscordant CAI among VL+ YMSM.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional survey conducted from December 1, 2009, through June 30, 2012, we studied 991 HIV-infected YMSM 15 to 26 years of age at 20 adolescent HIV clinics in the United States. Data analysis was conducted December 1, 2013, through July 31, 2015.

MAIN OUTCOMES AND MEASURES

Demographic, behavioral, and psychosocial assessments obtained using audio computer-assisted self-interviews. Viral load information was obtained via blood draw or medical record abstraction.

RESULTS

Of the 991 participants, 688 (69.4%) were VL+ and 458 (46.2%) reported CAI, with 310 (31.3%) reporting serodiscordant CAI in the past 3 months. The VL+ YMSM were more likely than the VL- YMSM to report CAI (detectable, 266 [54.7%]; suppressed, 91 [44.4%]; P = .01) and serodiscordant CAI (detectable, 187 [34.9%]; suppressed, 57 [25.0%]; P < .01). Multivariable analyses indicated that among VL+ YMSM, those reporting problematic substance use were more likely to report CAI (adjusted odds ratio [AOR], 1.46; 95% CI, 1.02-2.10) and serodiscordant CAI (AOR, 1.45; 95% CI, 1.06-1.99). Black VL+ YMSM were less likely to report CAI (AOR, 0.63; 95% CI, 0.44-0.90) or serodiscordant CAI (AOR, 0.66; 95% CI, 0.46-0.94) compared with other VL+ YMSM. In addition, VL+ YMSM who disclosed their HIV status to sex partners were more likely to report CAI compared with nondisclosing YMSM (AOR, 1.35; 95% CI, 1.01-1.81). Transgender participants were less likely to report CAI than cisgender participants (AOR, 0.35; 95% CI, 0.14-0.85). Last, VL+ YMSM who reported currently being employed were less likely to report serodiscordant CAI than those who were unemployed (AOR, 0.74; 95% CI, 0.55-0.99).

CONCLUSIONS AND RELEVANCE

Targeted multilevel interventions are needed to reduce HIV transmission risk behaviors among YMSM living with HIV, particularly among those who are VL+.

Exploring Unprotected Anal Intercourse among Newly Diagnosed HIV Positive Men Who Have Sex with Men in China: An Ethnographic Study

BACKGROUND

Unprotected anal intercourse (UAI) is a major pathway towards secondary HIV transmission among men who have sex with men (MSM). We explored the socio-cultural environment and individual beliefs and experiences conducive to UAI in the context of Southern China.

METHODS

We employed an ethnographic approach utilizing a socio-ecological framework to conduct repeated in-depth interviews with thirty one newly diagnosed HIV positive MSM as well as participant observations in Shenzhen based healthcare settings, MSM venues and NGO offices.

RESULTS

Some men (6/31) reported continuing to practice UAI after an initial diagnosis of being HIV positive. For MSM who had existing lovers or stable partners, the fear of losing partners in a context of non-serostatus disclosure was testified to be a major concern. MSM with casual partners reported that anonymous sexual encounters and moral judgments played a significant role in their sexual risk behaviors. Simultaneously, self-reported negative emotional and psychological status, perception and idiosyncratic risk interpretation, as well as substance abuse informed the intrapersonal context for UAI.

CONCLUSION

UAI among these HIV positive MSM was embedded in an intrapersonal context, related to partner type, shaped by anonymous sexual encounters, psychological status, and moral judgments. It is important that prevention and intervention for secondary HIV transmission among newly diagnosed HIV positive MSM in China take into account these contextual factors.

Anal intercourse without condoms among HIV-positive men who have sex with men recruited from a sexual networking web site, United States

BACKGROUND

The changing landscape of HIV prevention in the United States underscores the need to improve our ability to efficiently reach HIV-positive men who have sex with men (MSM) who engage in behaviors that could transmit HIV.

METHODS

We examined the prevalence of anal intercourse (AI) without condoms with HIV-negative or unknown serostatus partners ("at-risk partners") among 1319 HIV-positive adult male members of a sexual networking Web site for MSM. Sexual behaviors and substance use were measured over a 60-day recall period. Logistic regression was used to identify correlates of insertive and receptive AI without condoms with at-risk partners.

RESULTS

Approximately 25% of the men had been diagnosed as having HIV 12 months or less before study enrollment. Overall, 32% of men engaged in AI without condoms with at-risk partners. Multiple logistic regression identified behavioral predictors of insertive AI without condoms with at-risk partners, including HIV diagnosis within the last 12 months, sex with multiple male partners, substance use in conjunction with sex, and use of phosphodiesterase type 5 inhibitors. Receptive AI without condoms with at-risk partners was associated with younger age (19-24 years), residing outside metropolitan cities, substance use in conjunction with sex, and having multiple male partners.

CONCLUSIONS

High levels of sexual risk were found among these MSM. Increased Internet-based HIV prevention marketing efforts and prevention strategies should be considered to efficiently reach HIV-positive MSM who engage in serodiscordant AI without condoms.

Examining Delay Discounting of Condom-Protected Sex Among Men Who Have Sex with Men Using Crowdsourcing Technology

Some men who have sex with men (MSM) have unprotected anal intercourse (UAI) in situations that put them at risk for HIV infection despite having the knowledge and skills to avoid these risks. The present study examined the potential role of delay discounting in sexual HIV risk behavior among MSM. Participants (n = 108) completed the Sexual Discounting Task and a questionnaire regarding UAI and other variables associated with HIV risk (e.g., age, socioeconomic status, substance use, psychiatric problems). MSM discounted the value of condom-protected anal intercourse in a manner that was orderly, hyperbolic, and sensitive to partner characteristics that likely influence realworld decisions about using condoms. Steeper discounting was associated with UAI, and other factors related to sexual HIV risk among MSM, including young age, socioeconomic disadvantage, substance use, sex under the influence of substances, and depression). Delay discounting is likely a critical, but underappreciated facet of HIV risk among MSM.

Stimulant use patterns and HIV transmission risk among HIV-serodiscordant male couples

BACKGROUND

Substance use is strongly linked to HIV risk, and members of couples can have a powerful influence on each other's health behaviors. We examined whether couple-level patterns of stimulant use were differentially associated with engaging in condomless anal intercourse with primary partners and outside partners.

METHODS

Members of HIV serodiscordant male couples (N = 117 couples, 232 men) completed surveys, and HIV-positive men had blood drawn for viral load.

RESULTS

Results revealed that stimulant use by only one partner in the couple was associated with a decrease in the odds of engaging in condomless anal sex with one's primary partner (AOR = 0.09, 95% CI: 0.01, 0.89). When both partners reported stimulant use, the HIV-negative partner had an increase in the odds of condomless sex with outside partners (AOR = 6.68, 95% CI: 1.09, 8.01).

CONCLUSIONS

Understanding the role of couples' stimulant use patterns in HIV transmission risk is an important area for future research and intervention.