Causal Effects of Alcohol Intoxication on Sexual Risk Intentions and Condom Negotiation Skills Among High-Risk Men Who Have Sex with Men (MSM)

Patterns and Factors Associated With Alcohol Misuse Among Young Black Men Who Have Sex With Men in New York City

Alcohol misuse is a significant health concern among gay, bisexual, same-gender-loving, and other men who have sex with men (MSM). Yet, little is known about the severity and predictors of alcohol misuse among self-reported young Black MSM. This study aimed to identify patterns of and factors associated with alcohol misuse in a sample of young Black MSM living in New York City. Baseline data from a randomized controlled trial aimed at improving the uptake of HIV testing among 250 MSM aged 18 to 29 were analyzed. Log-binominal regression analyses were conducted to assess the association of demographic and psychosocial factors with alcohol misuse in the past year and past 3 months among young Black MSM. Overall, 33.2% and 28.0% of young Black MSM in the study experienced alcohol misuse in the past year and past 3 months, respectively. In the adjusted model, factors positively associated with past-year alcohol misuse included marijuana use, a history of drug use, and having one-two or more than two male sex partners. Likewise, participants who used marijuana and those with one-two or more than two male partners were more likely to report past 3-month alcohol misuse. No significant association was found between positive screening for depressive symptoms, chemsex, internalized homophobia, and the likelihood of having alcohol misuse. The high prevalence of alcohol misuse underscores the importance of raising awareness of alcohol misuse and designing alcohol risk reduction programs that jointly address HIV risk among young Black MSM.

Alcohol, Sexual Arousal, and Partner Familiarity as Predictors of Condom Negotiation: An Experience Sampling Study

Numerous contextual factors contribute to risky sexual decision-making among men who have sex with men (MSM), with experimental laboratory-based studies suggesting that alcohol consumption, sexual arousal, and partner familiarity have the potential to impact condom negotiations during sexual encounters. The purpose of the current study was to extend this line of inquiry outside of the laboratory and into the everyday lives of MSM. We collected six weeks of daily data on alcohol consumption and sexual behaviors from 257 moderate- and heavy-drinking MSM to examine the within- and between-subjects effects of alcohol consumption, average daily sexual arousal, and partner familiarity on condom negotiation processes during sexual encounters. We hypothesized that alcohol consumption, higher levels of average daily sexual arousal, and greater partner familiarity would all contribute to a reduced likelihood of condom negotiation prior to sexual activity, and that they would also affect the difficulty of negotiations. Contrary to hypotheses, none of these three predictors had significant within-subjects effects on condom negotiation outcomes. However, partner familiarity and average daily sexual arousal did exert significant between-subjects effects on the incidence of negotiation and negotiation difficulty. These findings have important implications for risk-reduction strategies in this population. They also highlight the challenges of reconciling results from experimental laboratory research and experience sampling conducted outside of the laboratory on sexual risk behavior.

Patterns of Polysubstance Use in Young Black and Latinx Sexual Minority Men and Transgender Women and Its Association with Sexual Partnership Factors: The PUSH Study

Background: Adult studies have demonstrated that polysubstance use increases HIV acquisition risk through increased sexual behaviors, however, few studies have examined polysubstance in young Black and Latinx sexual minority men (SMM) and transgender women (TW). Methods: We used cross-sectional data from 466 young Black and Latinx SMM and TW living in four high HIV-burden US cities enrolled in the PUSH Study, a status-neutral randomized control trial to increase HIV prevention and treatment adherence. We examined data for patterns of polysubstance use comparing age differences of use and explored associations between substance use and sexual partnership factors - inconsistent condom use, pressure to have condomless anal sex, and older partner, using bivariate and multivariate analyses. Results: Most participants described prior substance use with alcohol and cannabis being most common (76% each) and 23% described other illicit drug use, including stimulants, cocaine, hallucinogens, sedatives, opioids, and inhalants. Polysubstance use was common with nearly half (47%) of participants reporting alcohol and cannabis use, 20% reporting alcohol, cannabis, and one other illicit drug use, and 19% reporting alcohol or cannabis use plus one other illicit drug use. Polysubstance use was associated with greater adjusted odds of pressure to have condomless anal sex, older partner (>5 years older), and inconsistent condom use. Conclusions: Associations of polysubstance use with sexual practices and sexual partnerships that are known predictors of HIV acquisition or transmission among Black and Latinx SMM and TW underscore the need for combination interventions that include substance use treatment alongside antiretroviral-based and partner-based HIV prevention and treatment interventions.Trial Registration: ClinicalTrials.gov Identifier: NCT03194477.

External validity of analogue sexual risk laboratory data

This article presents data on the external validity of an alcohol administration study of sexual decision-making in men who have sex with men (MSM) ages 21-50. Men (N = 135) randomized to alcohol (blood alcohol concentration [BAC] = .075%) or water control conditions reported intentions to engage in condomless anal intercourse (CAI) in response to video vignettes. Following the experiment participants provided 6 weeks of experience sampling method (ESM) data assessing intoxication, sexual arousal, partner relationship, and sexual behavior. Laboratory CAI intentions were hypothesized to predict future CAI behavior, and associations were hypothesized to be conditional upon sexual arousal and intoxication contextual factors as well as laboratory beverage condition. The hypotheses were partially supported. CAI intentions were correlated with subject proportions of days engaging in CAI (r = .29). A multilevel analysis indicated, on average, CAI intention predicted increased probability of CAI versus anal intercourse with a condom (relative risk ratio [RRR] = 1.43). There was mixed evidence of CAI intentions effects being conditional upon laboratory condition as well as arousal and intoxication contextual factors. Graphs of conditional marginal effects identified regions of significance. Effects of CAI intention for men in the alcohol condition on the CAI versus No Sex contrast were significant when sexual arousal was elevated. CAI intentions for men in the water control condition predicted a higher probability of CAI versus anal intercourse with a condom when intoxication was moderately elevated and/or arousal moderately low. The results support the external validity of alcohol administration experiments of sexual decision-making among MSM and, reciprocally, provide support for the validity of ESM assessment of sexual behavior. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Latent Class Analysis of Polysubstance Use and Sexual Risk Behaviors among Men Who Have Sex with Men Attending Sexual Health Clinics in Mexico City

Men who have sex with men (MSM) are more likely to use drugs and other substances compared to their heterosexual peers. No studies have evaluated patterns of substance use among MSM adults in Mexico. We used latent class analysis (LCA) to identify MSM subgroups with specific substance use patterns and their associations with sexual behaviors. Methods: Data from 1850 adult MSM were collected at HIV clinics in Mexico City between September 2018 and December 2019. The structural equation modeling approach was used to estimate a LC model to identify patterns of substance use by self-report of substance use (i.e., cigarette smoking, alcohol, and drugs). To evaluate LC membership, we included HIV status, condomless anal sex (CAS), and serosorting, while controlling for demographic variables. Results: 30.3% were under the age of 22. Alcohol use in last 30 days (76.2%), binge drinking (29.2%), marijuana (29.4%), sex-drugs (23.9%), stimulants (13.7%), and depressants (6.3%). MSM reported engaging in CAS (55.9%) and serosorting (13.5%) behaviors, and 40% reported being HIV positive. LCA indicated three general categories of MSM substance users: Class 1 (49.0%), Class 2 (29.8%), and Class 3 (20.4%). Members of Class 3 were younger: 23–28 age years (aOR = 1.86) and 29–33 age years (aOR = 1.86), more educated: completed graduate studies (aOR = 1.60), had a high probability of polysubstance use and were more likely to engage in CAS and serosorting. Conclusions: Attempts to detect alcohol and problematic use of substances are needed for MSM followed by culturally competent approaches that address alcohol and drug use disorders.

Game Plan-a Brief Web-Based Intervention to Improve Uptake and Use of HIV Pre-exposure Prophylaxis (PrEP) and Reduce Alcohol Use Among Gay and Bisexual Men: Content Analysis

Background

HIV pre-exposure prophylaxis (PrEP) has considerable potential for reducing incidence among high-risk groups, such as gay, bisexual, and other men who have sex with men (GBM). However, PrEP’s effectiveness is closely linked with consistent use, and a variety of individual-level barriers, including alcohol use, could impede optimal uptake and use. Web-based interventions can encourage medication adherence, HIV prevention behaviors, and responsible drinking and may help support PrEP care, particularly in resource-limited settings.

Objective

We previously developed a web application called Game Plan that was designed to encourage heavy drinking GBM to use HIV prevention methods and reduce their alcohol use and was inspired by brief motivational interventions. This paper aims to describe the web-based content we designed for integration into Game Plan to help encourage PrEP uptake and consistent use among GBM. In this paper, we also aim to describe this content and its rationale.

Methods

Similar to the original site, these components were developed iteratively, guided by a thorough user-centered design process involving consultation with subject-matter experts, usability interviews and surveys, and user experience surveys.

Results

In addition to Game Plan’s pre-existing content, the additional PrEP components provide specific, personal, and digestible feedback to users about their level of risk for HIV without PrEP and illustrate how much consistent PrEP use could reduce it; personal feedback about their risk for common sexually transmitted infections to address low-risk perceptions; content challenging common beliefs and misconceptions about PrEP to reduce stigma; content confronting familiar PrEP and alcohol beliefs; and a change planning module that allows users to select specific goals for starting and strategies for consistent PrEP use. Users can opt into a weekly 2-way SMS text messaging program that provides similar feedback over a 12-week period after using Game Plan and follows up on the goals they set.

Conclusions

Research preliminarily testing the efficacy of these components in improving PrEP outcomes, including uptake, adherence, sexually transmitted infection rates, and alcohol use, is currently ongoing. If supported, these components could provide a scalable tool that can be used in resource-limited settings in which face-to-face intervention is difficult.

How Alcohol Influences Mechanisms of Sexual Risk Behavior Change: Contributions of Alcohol Challenge Research to the Development of HIV Prevention Interventions

This paper examines the contributions of laboratory-based alcohol challenge research (ACR) to the development of HIV prevention interventions. Following a brief overview of HIV prevention interventions and related health behavior change models, we discuss how alcohol may influence mechanisms of behavior change. The paper highlights the value of ACR for: (1) elucidating mechanisms of action through which alcohol affects sexual risk behavior, (2) testing how alcohol may influence mechanisms thought to underlie HIV prevention interventions, (3) clarifying moderators of the causal influences of alcohol, (4) identifying novel intervention targets, and (5) developing strategies to reduce sexual risk among those who consume alcohol. We conclude with a discussion of the importance of using experimental research to identify mechanisms of behavior change that are specific to populations at high risk for HIV and outline some key implications for developing HIV prevention interventions that integrate the role of alcohol.

Game Plan, a Web-Based Intervention to Improve Adherence and Persistence to HIV Pre-exposure Prophylaxis and Reduce Heavy Drinking in Gay, Bisexual, and Other Men Who Have Sex With Men: Usability and User Experience Testing

Background

Encouraging consistent use of pre-exposure prophylaxis (PrEP) is essential for reducing HIV incidence, particularly among gay, bisexual, and other men who have sex with men (GBM), and especially those who engage in heavy drinking. Although practice guidelines recommend providing adherence counseling to PrEP patients, clinics and providers may not have the resources or expertise to provide it. Internet-facilitated interventions have been shown to improve HIV prevention outcomes, including medication and care adherence. Game Plan is a website we created to help users make a tangible plan for reducing their HIV risk. We designed additional components of Game Plan to address key individual level barriers to PrEP use.

Objective

The aim of this mixed methods research is to test the usability and user experience of these components with intended users: GBM who drink heavily and are on PrEP.

Methods

In study 1 (usability), we completed a detailed individual interview in which participants (n=10) walked through a prototype of the website, thinking aloud as they did, and completed a follow-up interview and web-based survey afterward. Study 2 (user experience) involved providing participants (n=40) with a link to the prototype website to explore on their own and asking them to complete the same follow-up survey afterward. Qualitative data were analyzed using thematic analysis, and descriptive statistics were used to analyze quantitative data.

Results

Users in both studies gave the website excellent ratings for usability, overall satisfaction, and quality, and most often described the site as informative, helpful, and supportive. Users also rated the site’s content and feel as respectful of them and their autonomy, empathetic, and they stated that it conveyed confidence in their ability to change. The study 1 interviews highlighted the importance of the website’s esthetics to the participants’ engagement with it and its credibility in prompting genuine reflection.

Conclusions

GBM who reported heavy drinking and used PrEP generally found a website focused on helping them to create a plan to use PrEP consistently to be helpful. Adopting user-centered design methods and attending to the esthetics of mobile health interventions are important steps toward encouraging engagement and reducing at-risk behaviors.

Cognitive-emotional mechanisms of alcohol intoxication-involved HIV-risk behavior among men who have sex with men (MSM)

Alcohol use is a key risk factor for HIV infection among men who have sex with men (MSM), primarily because it interferes with condom use. However, little is known about the cognitive-emotional mechanisms through which alcohol influences decisions to use condoms with high-risk partners among MSM. In this study, we tested whether alcohol-related deficits in inhibitory control and attention bias toward sexual cues (vs. condoms and neutral cues) accounted for increases in condomless anal sex (CAS) intentions after drinking among MSM. Heavy-drinking, high-risk MSM (N = 83) were randomly assigned to receive (a) alcohol, (b) placebo, or (c) control beverages before behavioral tasks assessing inhibitory control and attention bias, and a video-based sexual risk scenario that assessed several aspects of sexual decision making. Results showed that inhibitory control and attention bias to sexual cues did not mediate associations between intoxication and CAS intentions. Inhibitory control deficits also did not moderate the indirect effects of intoxication on CAS intentions through attention bias. Three-way interactions between alcohol/placebo condition, inhibitory control, and attention bias were also not significant. Together, these findings provide little evidence that these two processes play a significant role in alcohol-involved HIV risk, at least as assessed by the specific tasks used in this study. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Using ecological momentary assessment (EMA) to explore mechanisms of alcohol-involved HIV risk behavior among men who have sex with men (MSM)

BACKGROUND AND AIMS

Heavy drinking is associated with increased risk of incident HIV infection among men who have sex with men (MSM). Past studies suggest that this association may be due to the tendency for intoxication to interfere with condom use. However, research on potential causal mechanisms explaining this relationship has been limited primarily to laboratory studies. In this study, we tested several potential mediators of the relationship between alcohol use level and HIV risk behavior.

DESIGN

Ecological momentary assessment (EMA) methods conducted over a 30-day period.

SETTING AND PARTICIPANTS/CASES

MSM (n = 100) in the northeastern United States.

MEASUREMENTS

Participants completed daily diary surveys and up to six experience sampling surveys randomly prompted throughout the day.

FINDINGS

Very heavy levels of drinking (12+ drinks) increased the odds of engaging in any sex [odds ratio (OR) = 1.87, P < 0.001]. Coefficient products and 95% confidence intervals indicated that both subjective sexual arousal (OR = 1.52, P < 0.001) and sex intentions (OR = 1.74, P < 0.001) significantly mediated the association between very heavy drinking and the odds of sex. When participants reported sex, the odds of engaging in high-risk condomless anal sex (CAS) increased incrementally after drinking heavily (five to 11 drinks; OR = 3.27, P = 0.006) and very heavily (12+ drinks; OR = 4.42, P < 0.001). Only subjective sexual arousal significantly mediated the association between alcohol use level and high-risk CAS (OR = 1.16, P = 0.040).

CONCLUSIONS

Increases in subjective sexual arousal after drinking heavily appear to partly account for alcohol-related HIV risk behaviors in the daily lives of men who have sex with men. Alcohol's role in strengthening motivationally consistent emotional states may therefore play a more important role in facilitating alcohol-involved HIV risk than explicit sexual motivation.

Sex-seeking mobile application use and risk behavior among men who have sex with men in Brazil

This is a cross-sectional study based on an open web survey with the primary objective to assess associations between the use of apps for seeking sex partners and vulnerabilities related to human immunodeficiency virus (HIV) acquisition among men who have sex with men (MSM) in Brazil. Participants were recruited to the study through ads posted in social media such as Twitter, Facebook, and WhatsApp. Consenting respondents completed a questionnaire on demographics, history of sexually transmitted infections (STIs), and risk behaviors and perceptions, including calculation of the Risk Behavior Score for HIV infection proposed by Rocha et al. Among the 859 participants, 714 (83.1%) reported they used apps for seeking sex partners. Use of apps for seeking sex partners was associated with high-risk behavior for HIV infection, self-reported syphilis, self-perception of HIV risk, and use of marijuana. The use of apps for seeking sex partners has rapidly become the norm for MSM in Brazil. The associations with STIs and risk behaviors should be seen as an opening to improve public health, presenting opportunities to promote knowledge, safer sex practices, and referral to HIV/STI screening and prevention interventions.

Using Smartphone Survey Data and Machine Learning to Identify Situational and Contextual Risk Factors for HIV Risk Behavior Among Men Who Have Sex with Men Who Are Not on PrEP

"Just-in-time" interventions (JITs) delivered via smartphones have considerable potential for reducing HIV risk behavior by providing pivotal support at key times prior to sex. However, these programs depend on a thorough understanding of when risk behavior is likely to occur to inform the timing of JITs. It is also critical to understand the most important momentary risk factors that may precede HIV risk behavior, so that interventions can be designed to address them. Applying machine learning (ML) methods to ecological momentary assessment data on HIV risk behaviors can help answer both questions. Eighty HIV-negative men who have sex with men (MSM) who were not on PrEP completed a daily diary survey each morning and an experience sampling survey up to six times per day via a smartphone application for 30 days. Random forest models achieved the highest area under the curve (AUC) values for classifying high-risk condomless anal sex (CAS). These models achieved 80% specificity at a sensitivity value of 74%. Unsurprisingly, the most important contextual risk factors that aided in classification were participants' plans and intentions for sex, sexual arousal, and positive affective states. Findings suggest that survey data collected throughout the day can be used to correctly classify about three of every four high-risk CAS events, while incorrectly classifying one of every five non-CAS days as involving high-risk CAS. A unique set of risk factors also often emerge prior to high-risk CAS events that may be useful targets for JITs.

Characteristics of Sex Events, Partners, and Motivations and Their Associations with HIV-Risk Behavior in a Daily Diary Study of High-Risk Men Who Have Sex with Men (MSM)

In the United States, men who have sex with men (MSM) continue to be at high-risk for HIV and other STIs, and condoms represent the most popular, affordable, and accessible method of prevention. Although a vast body of research has explored various factors associated with condom use in MSM, fewer studies have explored situation-level characteristics that affect their decisions about sex partners and condom use. Daily diary studies are well-suited to help improve our understanding of these event-level factors in detail, including the sex events themselves, partner characteristics, and motivations. As part of a larger study using ecological momentary assessment methods, high-risk MSM completed daily diary surveys about their sexual behavior on their smartphones each day for 30 days. This study explored detailed descriptive characteristics of sex events, partner characteristics, and motivations for sex and condom use, and examined whether specific aspects of these characteristics were associated with having condomless anal sex (CAS) with high-risk partners. High-risk CAS was common among MSM, with the majority of participants having met their partners online and many reporting sex the same day they met. Results showed that the odds of CAS were not higher with partners met online versus those met in other ways, but MSM were more likely to have asked online partners about their HIV status and testing history before sex. The odds of engaging in high-risk CAS was higher when MSM reported intimacy or self-assurance motives. Not having condoms readily available was a CAS motivation reported more commonly when MSM had sex with high-risk partners. Findings suggest that interventions should incorporate strategies that help MSM be safer specifically when meeting partners online and when having sex for intimacy or re-assurance. Interventions that remind MSM to carry condoms at opportune moments may also help reduce some HIV risk.

Sex, drugs, and sexually transmitted infections: A latent class analysis among men who have sex with men in Amsterdam and surrounding urban regions, the Netherlands

BACKGROUND

Men who have sex with men (MSM) are at high risk for sexually transmitted infections (STI) and often have sex while under the influence of drugs (sexualized drug use). We aimed to identify classes of MSM in Amsterdam and in surrounding urban regions with distinctive patterns of sexualized drug use and their association with STI.

METHODS

In this cross-sectional study, data on MSM were collected at STI clinics in the Netherlands between September-December 2017. Information on drug use, sociodemographics and sexual risk behavior, including lab-confirmed STI (chlamydia, gonorrhea, syphilis and HIV) was collected and compared between Amsterdam and surrounding urban regions. Latent class analysis was used to identify classes with similar drug use patterns, which were then linked to sexual behavior and STI.

RESULTS

We included 4461 MSM who were a median 35 years old (IQR = 27-47) and mostly Dutch (56.9 %). Use of all drugs was more often reported in Amsterdam compared to surrounding regions (p<0.001). We identified four different classes based on sexualized drug use among Amsterdam participants and three classes in surrounding regions. In both regions, polydrug use classes (compared to classes of no drug use; alcohol use; or few, various drugs) were defined by higher numbers of sexual partners (median range 8-15 vs 4-6, respectively) and higher STI prevalence (range 30.5%-31.8% vs 18.6%-22.8%, respectively).

CONCLUSION

Given the high prevalence of risk behavior and STIs, MSM in urban settings partaking in sexualized polydrug use might benefit from tailored outreach, screening, and safe sex and drug use interventions.

Inconsistent condom use between serodifferent sexual partnerships to the human immunodeficiency virus

Objective:

to analyze predictors of inconsistent condom use among HIV-positive people with sexual immunodeficiency virus serodifferent sexual partnership.

Method:

cross-sectional, analytical study with a consecutive non-probabilistic sample consisting of people living with the human immunodeficiency virus with serodifferent sexual partnership and who were in outpatient clinical follow-up. Data were collected through individual interviews guided by a semi-structured questionnaire and subsequently analyzed with bivariate analysis and logistic regression.

Results:

Seven variables were independently associated with inconsistent condom use. Schooling less than 11 years of schooling (4.9 [2.4-10.1]), having multiple partnerships (5.0 [1.3-19.6]), using alcohol (2.1 [1.1 -4.4]) or other drugs (2.8 [1.2-6.3]), do not receive advice from a healthcare professional (2.0 [1.1-3.9]), have no knowledge of treatment as prevention (3.0 [1,2-6,9]) and not knowing that undetectable viral load reduces the risk of human immunodeficiency virus transmission (3.8 [1,1-13,7]) were predictors for inconsistent condom use.

Conclusion:

The study showed that psychosocial factors interfere with consistent condom use between serodifferent partnerships. Thus, it is highlighted that there is a need for comprehensive interventions that include the integration of clinical and psychosocial care.

Working memory moderates the association between condom use intentions and behavior among moderate-to-heavy drinking men who have sex with men

Men who have sex with men (MSM) are a high-risk population for HIV infection and this risk is increased for those who consume alcohol. Condomless anal intercourse (CAI) is the central transmission risk factor for this population. This study examined whether individual differences in working memory moderated the association between intentions to use condoms and the frequency of CAI among MSM who engaged in anal intercourse over a subsequent 6-week period. Moderate- and heavy-drinking MSM (n = 207) completed questionnaires regarding alcohol use and condom use intentions and an operation span task to assess working memory at baseline. Participants then completed 6 weeks of morning surveys via a mobile phone app to assess anal intercourse frequency with and without condoms. Negative binomial regression analyses showed that the association between intentions to use condoms and episodes of CAI during the monitoring period was moderated by working memory such that intentions predicted CAI for those high in working memory but not those low in working memory. These results support the view that self-reported intentions may be less-likely to translate into health behaviors among those with poorer executive functioning skills.