Barebacking: a review of the literature

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.

Sexually Explicit Internet Media Consumption and Sexual Risk Behaviors Among Chinese Male Sexual Minorities: The Moderating Role of Perceived Realism

Western research has suggested that viewing sexually explicit internet media (SEIM) may result in sexual risk behaviors (SRBs) among gay, bisexual, and other men who have sex with men. This study explored the relationship between SEIM consumption and SRBs and whether perceived realism could moderate this relationship among Chinese male sexual minorities. We assessed SEIM consumption from two aspects: consumption frequency and preference for specific content (condomless and group sex). This study recruited 360 participants from various online channels. Consistent with the sexual script acquisition, activation, application model (₃AM), we found that both SEIM consumption frequency and content preference were related to SRBs, and that perceived realism moderated the relationship between SEIM consumption and SRBs. Preference for group sex SEIM was significantly associated with an increased likelihood of casual sex when perceived realism was higher. SEIM use frequency was significantly associated with an increased likelihood of unprotected anal intercourse when perceived realism was higher. These findings may be used to promote HIV prevention, which necessitates joint effort from multiple stakeholders.

HIV Prevention Research on Men Who Have Sex With Men: A Scoping Review of Systematic Reviews, 1988-2017

In the United States, men who have sex with men (MSM) are disproportionately affected by HIV. To identify research gaps and inform HIV prevention for MSM, we conducted a scoping review of systematic reviews using CDC's Prevention Research Synthesis database. Eligibility criteria comprised English-language systematic reviews focused on HIV prevention for MSM, published during 1988-2017, and included at least one U.S. primary study. We coded data type, subpopulations, topics, and key findings. To assess study quality, we used the Assessment of Multiple Systematic Reviews (AMSTAR). Among 129 relevant systematic reviews, study quality was high or moderate for 63%. Most common topics were sexual behavior and disease vulnerability. The most frequently mentioned MSM subgroups were HIV-positive, Black or African American, and young. Research gaps include Hispanic/Latino MSM, pre-exposure prophylaxis (PrEP), treatment as prevention, social determinants of health, health disparities, syndemics, and protective factors for sexual health.

Discordant Reporting of Partner Labels, HIV Testing and Sexual Behavior Among a Sample of Partnered Men Who have Sex with Men in the US

There is growing evidence that sexual behaviors among male couples are strongly shaped by emotional and quality characteristics of the relationship, and that the labels that men attach to their relationships may indicate how men perceive and engage in risk taking. There has been a lack of attention to how male couples label their relationships, and how discordant understandings of relationship labels may shape HIV risk behavior. Using data from a sample of 804 partnered men who have sex with men, this analysis examines associations between discordant relationship labeling and participation in HIV testing and sexual behavior. Men who labeled their relationship differently from their partners were less likely to have been recently tested for HIV and more likely to engage in sexual risk. The results underscore the need to develop interventions that provide spaces and skills for men to learn how to effectively navigate HIV risks in their relationships.

Mediation Analysis of Peer Norms, Self-Efficacy, and Condom Use Among Chinese Men Who Have Sex with Men: A Parallel Process Latent Growth Curve Model

The objective of this study was to examine direct and indirect relationships among peer norms, self-efficacy, and condom use among Chinese men who have sex with men (MSM). A longitudinal study determined the effectiveness of a condom use video promotion among Chinese MSM in 2015. In this analysis, 804 Chinese MSM were recruited at baseline and then followed at 3 weeks and 3 months after the intervention. Parallel process latent growth curve modeling (LGM) with multiple indicators and bootstrapping was conducted using Mplus 7.4. The LGM model fit indexes were good with RMSEA = 0.046, 90% CI (0.044, 0.048), CFI = 0.956, TLI = 0.955. Our results showed that the initial measure of peer norms affected the initial measure of condom use indirectly through the initial measure of self-efficacy (αβ = 0.414, 95% CI 0.260-0.759). The rate of change in peer norms over time also significantly affected the rate of change in condom use through the rate of change in self-efficacy (αβ = 0.101, 95% CI 0.014-0.262). Self-efficacy mediated the association between peer norms and condom use, indicating a strong potential of causal relationship between peer norms and self-efficacy among Chinese MSM.

Generational differences in sexual behaviour and partnering among gay, bisexual, and other men who have sex with men

INTRODUCTION

Given that different generations of gay, bisexual, and other men who have sex with men (gbMSM) have been influenced by substantially different life course events and cultural contexts, we explored differences in sexual behaviour between millennials, Gen-Xers, and baby boomers.

METHODS

Sexually active gbMSM from Metro Vancouver, ≥16 years, were recruited using respondent-driven sampling between 2012-2015 and completed computer-assisted self-interviews every 6 months, up to 2017. To explore differences between generations (millennials born ≥1987, Gen-Xers born 1962-1986, baby boomers born <1962) we used multivariable logistic regression models using baseline, RDS-weighted data. We also examined 6-month trends, stratified by generation, in partner number, prevalence of high-risk sex, and relationship status using hierarchical mixed-effects models.

RESULTS

Among 774 gbMSM (190 millennials, 469 Gen-Xers, 115 baby boomers), median age of first anal sex with a male partner decreased from 20 (aQ1,aQ3:17,25) among baby boomers to 18 (aQ1,aQ3: 16,20) among millennials (x ² (DF=2, N=764)=12.920, p=0.002). After controlling for relevant demographics, differences were observed for some sexual behaviours (i.e., anal sex positioning, giving oral sex, sex toys, masturbation, sexual app/website use, transactional sex) but not others (i.e., receiving oral sex, rimming, fisting, watersports, group sex). At baseline, millennials reported less high-risk sex than other generations but all trended toward less high-risk sex, fewer partners, and regular partnering over the course of the study.

CONCLUSIONS

While there was notable similarity across generations, millennial gbMSM reported earlier age at first anal intercourse and less high-risk sex. However, all generations trended towards less high-risk sex, fewer partners, and regular partnering over time.

Risk behaviors for HIV infection. A review of emerging trends

HIV infection, acquired with the conscious participation of the recipient, is a complex problem of international concern, especially among men who have sex with men. Behaviors emerge such as bareback (intentionally unprotected anal sex between men) and bugchasing (bareback sex when one participant is HIV+ and the other is not). A group of emerging risk behaviors for HIV infection was characterized. A review of the literature in the MEDLINE, Web of Science and regional SciELO databases was performed. HIV-related search terms such as unprotected sex, barebacking/bareback and bug chasing, were used. Bareback and bug chaser behaviors occur, among other factors, through social homonegativity, ART positive coverage, insufficient prevention campaigns, search for new sensations and attempts to strengthen the relationship with the HIV+ member. Unprotected sex is primarily associated with having HIV/AIDS diagnoses, physical violence due to sexual orientation, viewing homosexual sex sites, and having bought or sold sex. It is necessary to work with individual behaviors that draw individuals close to infection.

Trust, Sexual Trust, and Sexual Health: An Interrogative Review

Trust is experienced almost constantly in all forms of social and interpersonal relationships, including sexual relationships, and may contribute both directly and indirectly to sexual health. The purpose of this review is to link three aspects of trust to sexual health: (1) the role of trust in sexual relationships; (2) the role of trust in sexually transmitted infection (STI) prevention, particularly condom use; and (3) the relevance of trust in sexual relationships outside of the traditional model of monogamy. The review ends with consideration of perspectives that could guide new research toward understanding the enigmas of trust in partnered sexual relations in the context of sexual and public health.

Does HIV Pre-Exposure Prophylaxis Modify the Effect of Partnership Characteristics on Condom Use? A Cross-Sectional Study of Sexual Partnerships Among Men Who Have Sex with Men in San Francisco, California

Increasing rates of sexually transmitted infections (STIs) in the United States among men who have sex with men (MSM) have raised concerns that pre-exposure prophylaxis (PrEP) has been associated with higher engagement in condomless anal intercourse (CAI). While partnership characteristics have previously been found to influence condom use, the extent to which PrEP use may modify their effect on CAI remains unknown. A secondary analysis of 535 sexual partnerships from a cross-sectional study in San Francisco was conducted to evaluate interactions between PrEP use and partnership characteristics on CAI. Bivariate and multivariate generalized estimating equation (GEE) logistic regression models were used to estimate relative measures of association, adjusted for confounding by seroconcordance and partnership type, as well as account for repeated partnerships per respondent. Partnerships where both partners used biomedical prevention had significantly greater odds of CAI [odds ratio (OR) = 5.19, 95% confidence interval (CI): 2.27-11.9] compared to those where only one partner used biomedical prevention, while those where neither partner used biomedical prevention had significantly lower odds of CAI (OR = 0.61, 95% CI: 0.40-0.93). There was no significant association between meeting place (online vs. offline) and sexual risk taking (OR = 1.03, p = 0.894). Having one partner disclose their HIV status (compared to neither partner having disclosed) was associated with significantly higher odds of CAI among partnerships of PrEP-using MSM [adjusted OR (aOR) = 5.28, 95% CI: 1.91-14.61], while the association was not significant among the partnerships of non-PrEP-using MSM (aOR = 1.29, 95% CI: 0.75-2.21). Differences in condom use among MSM using PrEP may not be well explained by differences in the effect of partnership characteristics. MSM using PrEP appear to commonly practice biomedical matching and high engagement in CAI with other biomedical prevention users, which could indicate relatively concentrated sexual networks and partly explain their disproportionate risk for STIs. Future studies should further investigate biomedical matching to develop interventions that further promote the sexual health of those using PrEP.

Population size and self-reported characteristics and sexual preferences of men-who-have-sex-with-men (MSM) in Germany based on social network data

Background

In the absence of detailed information about the population size and behaviour data of men-who-have-sex-with-men (MSM), the estimation of prevalence rates of sexually transmitted infections (STIs) and the design of public health interventions become difficult. The aim of the present study is to estimate the lower boundary of age-specific population sizes and retrieve self-reported information from this population.

Methods

We used publicly accessible data from a large online dating and social network website for MSM in Germany to retrieve data on the age and regional distribution of profiles. The profiles were also stratified by their information on the preferred position during anal intercourse, safer sex, and sexual identity.

Results

A total of 464,873 user profiles correspond to an average 15.2 profiles per 1,000 male inhabitants in Germany, varying between 7.6 and 45.6 across federal states. Although the information on the absolute numbers for different age groups is limited by the search engine, age-specific relative frequencies were found to increase from 12.9 in the age group of 18 to 20 year olds to 24.6 profiles per 1,000 male inhabitants in the 28 to 30 year olds. The data shows age-specific trends for safer sex with an increasing easiness of reporting “never” engaging in safer sex or stating that safer sex “needs discussion” with increasing age. Around one third of profile owners stated to be versatile with respect to the preferred position in anal intercourse. All other options (“only bottom”, “more bottom”, “only top”, “more top”) were preferred equally likely by roughly 10% of profile owners, respectively.

Conclusions

Online social network or dating sites can provide some information about specific populations in the absence of other data sources. The presented results are the first to report age-specific rates of MSM per 1,000 male inhabitants in Germany and may be useful to estimate age-specific prevalence or incidence rates as well as to inform health promotion activities and modelling studies for MSM in Germany.

Thirty Years of Research on Gay Men and HIV Prevention in France: A Narrative Review of the Literature

Research on homosexuality and HIV/AIDS in the social sciences has evolved into a vast and multiform field of study since the beginning of the epidemic in the Global North. Studies from France in this domain have remained relatively unknown at the international level. This article offers a narrative review of publications that resulted from research on homosexuality and HIV/AIDS, from 1985 to 2016. It offers an analysis of how the constitution of a field of research conditions the ways scientific questions are asked (and answered). This epistemological concern is addressed through a sociohistorical contextualization of the main issues surrounding prevention and how they have been addressed by researchers in France. A review of French publications on HIV prevention among gay men reveals certain specificities. In terms of the social science disciplines, psychology and psychoanalysis are much less present in this domain, whereas epidemiology, sociology, and anthropology are the most represented. The works analyzed in this article also reveal the circulation and local adaptations of risk categories imported from the English-speaking world, such as "relapse" and "bareback." Regardless, research on HIV prevention in France largely evolved contemporaneously in the same way that it did elsewhere.

"It Was Supposed To Be a Onetime Thing": Experiences of Romantic and Sexual Relationship Typologies Among Young Gay, Bisexual, and Other Men Who Have Sex with Men

Young gay, bisexual, and other men who have sex with men (MSM) are at elevated risk for HIV infection, highlighting the need to understand the elements of prevention and risk associated with their relationships. We employed a phenomenological approach to explore how young MSM become involved in different romantic and sexual experiences. We analyzed 28 semi-structured interviews conducted with young MSM living in Michigan. Using a phenomenological approach, we analyzed the data using an inductive coding strategy and thematic analysis. Participants defined their romantic and sexual interactions with a limited set of partner classifications (e.g., dating, hooking up, friends-with-benefits), but recognized how these classifications were shifting, sometimes unexpectedly so (e.g., a date turning into a hook up and vice versa). Young MSM described relationships in transition that at times defied available typologies or hybridized elements of multiple partner types at once. Based on our analyses, we underscore the need to acknowledge the fluctuating and contextual nature of young MSM's romantic and sexual experiences. We discuss the relevance of our findings in terms of the developmental period of young adulthood and the implications our findings have HIV prevention efforts among young MSM.

The clinical effectiveness of individual behaviour change interventions to reduce risky sexual behaviour after a negative human immunodeficiency virus test in men who have sex with men: systematic and realist reviews and intervention development

BACKGROUND

Men who have sex with men (MSM) experience significant inequalities in health and well-being. They are the group in the UK at the highest risk of acquiring a human immunodeficiency virus (HIV) infection. Guidance relating to both HIV infection prevention, in general, and individual-level behaviour change interventions, in particular, is very limited.

OBJECTIVES

To conduct an evidence synthesis of the clinical effectiveness of behaviour change interventions to reduce risky sexual behaviour among MSM after a negative HIV infection test. To identify effective components within interventions in reducing HIV risk-related behaviours and develop a candidate intervention. To host expert events addressing the implementation and optimisation of a candidate intervention.

DATA SOURCES

All major electronic databases (British Education Index, BioMed Central, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Educational Resource Index and Abstracts, Health and Medical Complete, MEDLINE, PsycARTICLES, PsycINFO, PubMed and Social Science Citation Index) were searched between January 2000 and December 2014.

REVIEW METHODS

A systematic review of the clinical effectiveness of individual behaviour change interventions was conducted. Interventions were examined using the behaviour change technique (BCT) taxonomy, theory coding assessment, mode of delivery and proximity to HIV infection testing. Data were summarised in narrative review and, when appropriate, meta-analysis was carried out. Supplemental analyses for the development of the candidate intervention focused on post hoc realist review method, the assessment of the sequential delivery and content of intervention components, and the social and historical context of primary studies. Expert panels reviewed the candidate intervention for issues of implementation and optimisation.

RESULTS

Overall, trials included in this review (n = 10) demonstrated that individual-level behaviour change interventions are effective in reducing key HIV infection risk-related behaviours. However, there was considerable clinical and methodological heterogeneity among the trials. Exploratory meta-analysis showed a statistically significant reduction in behaviours associated with high risk of HIV transmission (risk ratio 0.75, 95% confidence interval 0.62 to 0.91). Additional stratified analyses suggested that effectiveness may be enhanced through face-to-face contact immediately after testing, and that theory-based content and BCTs drawn from 'goals and planning' and 'identity' groups are important. All evidence collated in the review was synthesised to develop a candidate intervention. Experts highlighted overall acceptability of the intervention and outlined key ways that the candidate intervention could be optimised to enhance UK implementation.

LIMITATIONS

There was a limited number of primary studies. All were from outside the UK and were subject to considerable clinical, methodological and statistical heterogeneity. The findings of the meta-analysis must therefore be treated with caution. The lack of detailed intervention manuals limited the assessment of intervention content, delivery and fidelity.

CONCLUSIONS

Evidence regarding the effectiveness of behaviour change interventions suggests that they are effective in changing behaviour associated with HIV transmission. Exploratory stratified meta-analyses suggested that interventions should be delivered face to face and immediately after testing. There are uncertainties around the generalisability of these findings to the UK setting. However, UK experts found the intervention acceptable and provided ways of optimising the candidate intervention.

FUTURE WORK

There is a need for well-designed, UK-based trials of individual behaviour change interventions that clearly articulate intervention content and demonstrate intervention fidelity.

STUDY REGISTRATION

The study is registered as PROSPERO CRD42014009500.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Scenes as Micro-Cultures: Examining Heterogeneity of HIV Risk Behavior Among Gay, Bisexual, and Other Men Who Have Sex with Men in Toronto, Canada

Using latent class analysis (LCA), we examined patterns of participation in multiple scenes, how sexual risk practices vary by scene, and psychosocial factors associated with these patterns among 470 gay, bisexual, and other men who have sex with men (GBM) recruited from Toronto. We calculated posterior probability of being in a class from participation in nine separate scenes. We used Entropy, the Bayesian information criterion and the Lo-Mendel-Rubin likelihood ratio test to identify the best fit model. Fit indices suggested a four-class solution. Half (50%) of the GBM reported no or minimal participation in any scene, 28% reported participating in the dance club scene, 16% reported participating in the BDSM, bear, and leather scenes, and 6% reported participating in circuit, party and play, and sex party scenes. Compared to GBM who did not participate in scenes, GBM participating in the BDSM-Bear-Leather scene were more likely to be older, white, to report higher sexual self-esteem, and to engage in condomless anal sex; Party and Play scene members were more likely to be of Asian origin, and to use drugs before and during sex, whereas Dance Club scene members were more likely to be younger and to report lower self-esteem but higher hope. LCA allowed us to identify distinct social niches or micro-cultures and factors characterizing these micro-cultures. GBM differ in their risk for HIV and STIs according to characteristics associated with participation in distinct micro-cultures associated with scenes. Tailored interventions may be needed that focus on reducing HIV risk and promoting sexual health in specific contexts such as the BDSM-Bear-Leather and Party and Play.

Reflections on the history of bareback sex through ethnography: the works of subjectivity and PrEP

Throughout the history of bareback sex (condomless sex between men), 'subjects' have been created, particularly through scientific literature, to characterise the men who engage in the sexual practice. For example, a gay man who does not use a condom may be framed as a pathologised subject. This paper first presents this history. Afterwards, by relying upon ethnographic data such as interviews collected from fieldwork research done in Toronto in 2014 with young gay men who have bareback sex, it shows exactly how these young gay men related themselves to those subjects. Then, it focuses on the pre-exposure prophylaxis (PrEP) Truvada as a new HIV prevention technology. Although PrEP can allow condomless sex to occur while diminishing the risk of HIV transmission, at the time of the research, none of the young gay men were interested in using this tool despite being the subjects for whom the drug is tailored. This paper argues that PrEP and subjectivity are coproduced and can have conflicting meanings. This contradiction of meanings is a result of the various representations and symbols of bareback sex and the men who engage in the practice that have been produced throughout the history of bareback sex.

Assessing gender stereotypes and sexual risk practices in men who have sex with men

OBJECTIVE

To analyze the construct validity and the internal consistency of the 12-item Bem Sex Role Inventory (BSRI-12) questionnaire and to study the association between gender stereotypes and sexual risk practices in men who have sex with men (MSM).

METHODS

Cross-sectional study of 601 MSM who voluntarily and anonymously responded to an online survey on risk practices and gender stereotypes. The BSRI-12 was used to obtain gender stereotypes (masculine, feminine, undifferentiated and androgynous). For data analysis, exploratory factor analysis (EFA) of the BSRI-12 and logistic regression were performed.

RESULTS

Two main factors (Cronbach alpha 0.95 and 0.81) were obtained from the EFA. Using the androgynous roles as the reference category, we found lower odds of engaging in unprotected anal intercourse (UAI) among those who endorse feminine roles (OR: 0.53; 95%CI: 0.29-0.95). Endorsing masculine roles with alcohol consumption (OR: 1.92; 95%CI: 1.15-3.20) or the undifferentiated when not knowing the partner's serological status (OR: 1.55; 95%CI: 1.02-2.35) were associated with higher odds of UAI compared to those endorsing the androgynous roles. Undifferentiated participants also perform receptive UAI using poppers (OR: 2.19; 95%CI: 1.24-3.87), and insertive UAI not knowing the serological status of the sexual partner (OR: 1.69; 95%CI: 1.04-2.76) compared to androgynous participants.

CONCLUSION

The BSRI is a valid and consistent instrument for identifying gender stereotypes in MSM. A greater proportion of participants within the undifferentiated and the masculine category engage in risk practices with the influence of substance consumption and unawareness of their sexual partner's serological status. The information obtained may be useful to define intervention and prevention programs.

Psychometric evaluation of the Condom Barriers and Motivations Scale (CBMS)

The Condom Barriers and Motivations Scale (CBMS) was developed to measure four distinct categories of barriers and motives to condom use, including: risk reduction motivations, pleasure reduction barriers, intimacy interference barriers, and partner pressure barriers. The CBMS is a 16-item scale with four items that correspond to each of these subscales. The CBMS was tested in two samples of gay and bisexual men. Results support the reliability and validity of the scale and its structure. Results also indicate that CBMS subscales are distinct from general measures of sexual wellbeing, personality factors, or relationship quality (i.e., discriminant validity) and are associated with self-reported condom use with different partner types (i.e., construct validity). The CBMS can be helpful in better understanding the dynamics of condom use in the context of pre-exposure prophylaxis decision-making, and can shed light on innovative approaches to enhance condom use as part of comprehensive HIV prevention and sexual health goals.

Preferences for Condomless Sex in Sexually Explicit Media Among Black/African American Men Who Have Sex with Men: Implications for HIV Prevention

Accumulating evidence suggests that viewing sexually explicit media (SEM; i.e., pornography) may be related to the sexual behaviors of men who have sex with men (MSM). Furthermore, stereotypical depictions of Black/African American MSM engaging in sexual risk behaviors in SEM may serve to normalize condomless sex, reinforce low peer norms around condom use, and facilitate HIV risk taking among Black/African American MSM. Despite this evidence, very little is known about the correlates of SEM consumption among Black/African American MSM, including HIV risk behaviors and their relation to preferences for viewing condomless sex in SEM. Participants were 653 HIV-seronegative Black-identified MSM ages 18-62 (M 33.58, SD 11.01) who completed a cross-sectional survey as a part of a HIV prevention trial in Atlanta, Georgia. Over three-quarters of the men (n = 514) reported a preference for condomless sex in SEM. In multivariate models, engaging in serodiscordant condomless sex was not significantly associated with preferences for condomless sex in SEM; however, men who self-identified as bisexual, engaged in transactional sex, and reported greater agreement with sexual risk cognitions (i.e., heat-of-the-moment thoughts about condom use) had significantly greater odds of reporting a preference for condomless sex in SEM. Study findings highlight the need for future research exploring the role of SEM in the sexual health of Black/African American MSM, including the extent to which SEM exposure alters norms and expectations about sexual behaviors among Black/African American MSM and how this might be addressed in HIV prevention programs.

Sexual Behaviors Linked to Drug and Alcohol Use Among Men Who Have Sex With Men in China

BACKGROUND

High-risk sexual behaviors drive the HIV epidemic among men who have sex with men (MSM). Alcohol consumption and use of club drugs may increase sexual risk behaviors. We evaluated effects of drug and alcohol use on sexual behaviors with both their male and female partners as well as on HIV and syphilis infections among MSM in China.

METHODS

As the part of a community randomized clinical trial that conducted among MSM in Beijing from 2013 to 2015, we recruited a total of 3,680 participants cross-sectionally. A self-administered questionnaire was employed to collect information regarding demographics, sexual behaviors, and a history of alcohol and drug use. Blood sample was collected for HIV and syphilis testing.

RESULTS

A total of 3,588 MSM completed the survey and were included in the data analysis. The mean age was 29.9 with 97.3% of Han-ethnicity and 85.0% unmarried. The HIV and syphilis prevalence was 12.7% and 7.4%, respectively. Drug use was significantly associated with higher odds of HIV infection (aOR = 1.3, 95% Confidence Interval [CI] = 1.0,1.6), but not associated with syphilis. A higher level of alcohol consumption was similarly associated with higher odds of HIV risks with both male (e.g., condomless sex acts) and female partners (e.g., numbers of sexual partners).

CONCLUSION

The association between drug and alcohol use and high-risk behaviors is notable among MSM in China. Integrated HIV interventions that target substance use among MSM may be more effective than programs that only target HIV alone.

Beyond Condoms: Risk Reduction Strategies Among Gay, Bisexual, and Other Men Who Have Sex With Men Receiving Rapid HIV Testing in Montreal, Canada

Gay, bisexual, and other men who have sex with men (MSM) have adapted their sexual practices over the course of the HIV/AIDS epidemic based on available data and knowledge about HIV. This study sought to identify and compare patterns in condom use among gay, bisexual, and other MSM who were tested for HIV at a community-based testing site in Montreal, Canada. Results showed that while study participants use condoms to a certain extent with HIV-positive partners and partners of unknown HIV status, they also make use of various other strategies such as adjusting to a partner's presumed or known HIV status and viral load, avoiding certain types of partners, taking PEP, and getting tested for HIV. These findings suggest that MSM who use condoms less systematically are not necessarily taking fewer precautions but may instead be combining or replacing condom use with other approaches to risk reduction.

Correlates and Racial/Ethnic Differences in Bareback Sex Among Men Who Have Sex with Men with Unknown or Negative HIV Serostatus

Men who have sex with men (MSM), particularly racial/ethnic minority MSM, are disproportionately affected by HIV in the United States and Texas. Bareback sex or condomless anal intercourse (CAI) can be a high HIV risk behavior. Despite this, a majority of MSM continues to engage in barebacking. Research suggests racial/ethnic differences in barebacking exist; however, these conclusions remain unclear due to insufficient sample sizes to compare racial/ethnic groups. Our cross-sectional correlational design explores barebacking correlates (substance use during sex, safe sex fatigue, and optimistic HIV treatment beliefs) within and between racial/ethnic groups among 366 MSM. Regression models are significant for Latino and African-American MSM alone and for all MSM combined, though not significant for European-American and Other Race/Ethnicity MSM alone. Our findings suggest motivations and behaviors underlying barebacking among MSM vary by racial/ethnic membership with clinical implications for informing culturally sensitive HIV interventions and prevention programs for target racial/ethnic groups.

What Parents and Their Gay and Bisexual Sons Say About HIV Prevention

Despite ongoing prevention efforts, young gay and bisexual men (YGBM) accounted for more than three fourths of all recent HIV infections. Furthermore, they continue to engage in high-risk sexual behaviors at alarming rates. Nowadays, families are beginning to emerge as important resources for these youth. However, the viewpoints of YGBM and their families are largely missing from HIV prevention research and intervention development. To address this gap, we solicited the opinions of YGBM and their parents as to why YGBM engage in unsafe sex and what might be done to help them avoid HIV. Participants discussed youth's sense of invulnerability, sexual arousal, parental disapproval, and lack of societal acceptance as contributors to unsafe sex. Participants called for gay-sensitive sex education and community programming as well as increased societal acceptance. Overall, respondents recommended interpersonal and structural-level interventions that emphasized the importance of reducing stigma as a key component of HIV prevention.

Using participant-empowered visual relationship timelines in a qualitative study of sexual behaviour

This study examines how the use of participant-empowered visual relationship timelines adds to the quality of an ongoing qualitative data collection in a case study examining the influence of emotions on sexual risk-taking and perceptions of HIV risk among men who have sex with men. Gay and bisexual men (n = 25) participated in a 10-week, three-phase study. During a baseline in-depth interview, participants created a visual timeline using labelled stickers to retrospectively examine their dating/sexual histories. Participants then completed three web-based quantitative personal relationship diaries, tracking sexual experiences during follow-up. These data were extracted and discussed in a timeline-based debrief interview. The visual cues assisted with data collection by prompting discussion through the immediate identification of patterns, opportunities for self-reflection, and rapport-building. The use of flexible data collection tools also allowed for a participant-empowered approach in which the participant controlled the interview process. Through this process, we learned strategies for improving a participant-empowered approach to qualitative research, including: allowing visual activities to drive the interview, using flexible guidelines to prompt activities, and using discrete imagery to increase participant comfort. It is important that qualitative data collection utilise more participatory approaches for gains in data quality and participant comfort.

Assessing the role of masculinity in the transmission of HIV: a systematic review to inform HIV risk reduction counseling interventions for men who have sex with men

HIV affects over 1.2 million people in the United States; a substantial number are men who have sex with men (MSM). Despite an abundance of literature evaluating numerous social/structural and individual risk factors associated with HIV for this population, relatively little is known regarding the individual-level role of masculinity in community-level HIV transmission risk. To address this gap, the current analysis systematically reviewed the masculinity and HIV literature for MSM. The findings of 31 sources were included. Seven themes were identified: (1) number of partners, (2) attitudes toward condoms, (3) drug use, (4) sexual positioning, (5) condom decision-making, (6) attitudes toward testing, and (7) treatment compliance. These factors, representing the enactment of masculine norms, potentiate the spread of HIV. The current article aligns these factors into a masculinity model of community HIV transmission. Opportunities for counseling interventions include identifying how masculinity informs a client's cognitions, emotions, and behaviors as well as adapting gender-transformative interventions to help create new conceptualizations of masculinity for MSM clients. This approach could reduce community-level HIV incidence.

HIV Serosorting, Status Disclosure, and Strategic Positioning Among Highly Sexually Active Gay and Bisexual Men

Researchers have identified harm reduction strategies that gay, bisexual, and other men who have sex with men (GBMSM) use to reduce HIV transmission--including serosorting, status disclosure, and strategic positioning. We report on patterns of these behaviors among 376 highly sexually active (i.e., 9+partners, <90 days) GBMSM: mean age of 37, 49.5% men of color, 87.8% gay identified, 57.5% college educated. We found evidence that many men engaged in serosorting, status disclosure, and strategic positioning; however, rates varied based on the participant's HIV status. HIV-positive and HIV-negative men both engaged in sex with men of similar status more often than they engaged in sex with men known to be a different HIV status (i.e., serosorting). However, HIV-negative men disclosed their HIV-status with about half of their partners, whereas HIV-positive participants disclosed with only about one-third. With regard to strategic positioning, HIV-positive participants were the receptive partner about half the time with their HIV-negative partners and with their HIV-positive partners. In contrast, strategic positioning was very common among HIV-negative participants-they rarely bottomed with HIV-positive partners, bottomed about one-third of the time with status-unknown partners, and 42% of the time (on average) with HIV-negative partners. Highly sexually active GBMSM are a critical population in which to both investigate HIV prevention strategies as well as develop effective intervention programs. Providers and clinicians might be well served to include a wide range of behavioral harm reduction strategies in addition to condom use and biomedical approaches to reduce onward HIV transmission.

HIV risk and sense of community: French gay male discourses on barebacking

This paper analyses the use of the concept of 'barebacking' as a risk category in the discourses of French gay men. It discusses how the rise and spread of the term barebacking contributes to reframing gay men's personal experiences of HIV prevention and their sense of belonging (or a lack thereof) to a gay community. The study is based on 30 qualitative interviews with French gay men conducted between 2005 and 2008. An import from the USA, the term barebacking emerged publicly in France in the late-1990s and was first used to describe intentionally unprotected sexual practices. Debates surrounding this risk category were marked by violent controversy over its use and its definition among HIV prevention actors. There remains a general lack of consensus on the definition of the term, despite its use by activists, in porn culture and in the daily discourses of gay men. By focusing on the relational roots of risk perception, I consider how uses of the term barebacking invoke a moral framework around risk taking.

[Type of partner, socio-economic factors and risk practices in men who have sex with men]

OBJECTIVE

Men who have sex with men (MSM) perform risk practices that pose a challenge to prevention strategies. The aim of this study was to analyse the association between receptive and insertive unprotected anal intercourse (RUAI and IUAI) according to the type of partner and the practice of barebacking with socioeconomic factors.

METHODS

A descriptive study was conducted through a self-administered questionnaire distributed by a software tool in social networks and non-governmental organizations from June-2014 to January-2015. Participants consisted of 601 people living in Spain. Pearson's χ(2) test and logistic regression models were applied with odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

In stable couples, the risk of RUAI increased in individuals with a medium income (OR: 1.79; 95%CI: 1.14-2.80) and in those who lived together (OR: 2.94; 95%CI: 1.74-4.98) and IUAI increased in individuals living with a partner (OR: 5.58; 95%IC: 3.24-9.59). When the partner was a friend, the risk of RUAI was higher among individuals with secondary education (OR: 2.20; 95%CI: 1.44-3.36) and those who were retired (OR: 3.6; 95%CI: 1.25-10.37), while living with a partner was a protective factor (OR: 0.56; 95%CI: 0.32-0.98). The risk of barebacking was greater in younger men (OR: 2.59; 95%CI: 1.27-5.28), in those with secondary education (OR: 1.51; 95%CI: 0.99-2.29) and in those living with a partner (OR: 3.64; 95%CI: 2.12-6.24).

DISCUSSION

There is a need to reduce vulnerability due to socioeconomic factors that influence engagement in risk practices and to highlight the importance of barebacking, mainly in young MSM. Partner-based interventions and harm reduction strategies should be incorporated into preventive strategies.

Comparing Psychosocial Correlates of Condomless Anal Sex in HIV-Diagnosed and HIV-Nondiagnosed Men Who Have Sex with Men: A Series of Meta-Analyses of Studies from 1993-2013

PURPOSE

Men who have sex with men (MSM) continue to be overrepresented in rates of incidence and prevalence of human immunodeficiency virus (HIV). Both HIV-diagnosed (HIV-D) and HIV-nondiagnosed (HIV-N) MSM report a variety of reasons for intentional and unintentional nonuse of condoms. Elucidating and comparing reasons for continued engagement in condomless anal sex specific to both HIV-D and HIV-N MSM likely is important to identifying effective prevention.

METHODS

This study employed meta-analytic methods to evaluate and compare correlates to condomless anal sex in both HIV-D and HIV-N MSM from primary studies from 1993 to February 2013.

RESULTS

Of the 19 individual correlates assessed within the subgroup of HIV-D MSM, variables that achieved significant effect were alcohol, mind-altering substance use, sexual-enhancement medication, intentional condom nonuse, self-efficacy, attitudes toward condom use, social support, gay identity, compulsivity, trading sex, and number of sex partners. Those that were statistically non-significant were intention to use a condom, perceived risk, perceived norms, perceived responsibility, HIV medical management, treatment optimism, mental health, and setting. Of the 12 correlates assessed within the subgroup of HIV-N MSM, variables that achieved significant effect were alcohol, mind-altering substance use, intentional condom nonuse, attitudes toward condom use, perceived risk, and setting. Those observed as statistically non-significant were perceived norms, social support, gay identity, mental health, trading sex, and number of sex partners.

CONCLUSION

Study results have clinical implications that may guide future prevention research and practice by highlighting risk variables shared between HIV-N and HIV-D MSM, as well as variables observed to be unique to each group that may warrant more tailored intervention. Further investigation is recommended to elucidate the relationships among these variables such that optimal intervention can be determined.

Preferred aspects of sexually explicit media among men who have sex with men: where do condoms fit in?

Sexually explicit media (SEM) is viewed by many men who have sex with men (MSM) and is widely available via the Internet. Though research has investigated the link between SEM and sexual risk behaviour, little has been published about preferences for characteristics of SEM. In an Internet-based cross-sectional study, 1390 adult MSM completed an online survey about their preferences for nine characteristics of SEM and ranked them in order of importance. Respondents preferred free, Internet-based, anonymous SEM portraying behaviours they would do. Cost and looks were the most important characteristics of SEM to participants, while condom use and sexual behaviours themselves were least important. Results suggest that while participants may have preferences for specific behaviours and condom use, these are not the most salient characteristics of SEM to consumers when choosing.

Developing a conceptual framework of seroadaptive behaviors in HIV-diagnosed men who have sex with men

BACKGROUND

Seroadaptive behaviors are strategies employed by men who have sex with men (MSM) to reduce the transmission risk for human immunodeficiency virus (HIV). It has been suggested that they contribute to the increasing diagnoses of sexually transmitted infections in HIV-diagnosed MSM. To understand the context in which the reemerging sexually transmitted infections appear, we developed a social epidemiological model incorporating the multiple factors influencing seroadaptive behaviors.

METHODS

A literature review of seroadaptive behaviors in HIV-diagnosed MSM was conducted. The literature was synthesized using a social epidemiological perspective.

RESULTS

Seroadaptive behaviors are adopted by MSM in high-income countries and are a way for HIV-diagnosed men to manage and enjoy their sexual lives. Influences are apparent at structural, community, interpersonal, and intrapersonal levels. There is little evidence of whether and when the behavior forms part of a premeditated strategy; it seems dependent on the social context and on time since HIV diagnosis. Social rules of HIV disclosure and perception of risk depend on the setting where partners are encountered.

CONCLUSIONS

Seroadaptive behaviors are strongly context dependent and can reduce or increase transmission risk for different infectious diseases. Further data collection and mathematical modeling can help us explore the specific conditions in more detail.

'Sometimes people let love conquer them': how love, intimacy, and trust in relationships between men who have sex with men influence perceptions of sexual risk and sexual decision-making

Men who have sex with men account for a disproportionate burden of HIV incidence in the USA. Although much research has examined the drivers of sexual risk-taking, the emotional contexts in which men make sexual decisions has received little attention. In this three-phase, 10-week longitudinal qualitative study involving 25 gay and bisexual men, we used timeline-based interviews and quantitative web-based diaries about sexual and/or dating partners to examine how emotions influence HIV risk perceptions and sexual decision-making. Participants described love, intimacy, and trust as reducing HIV risk perceptions and facilitating engagement in condomless anal intercourse. Lust was not as linked with risk perceptions, but facilitated non condom-use through an increased willingness to engage in condomless anal intercourse, despite perceptions of risk. Results indicate that gay and bisexual men do not make sexual decisions in an emotional vacuum. Emotions influence perceptions of risk so that they do not necessarily align with biological risk factors. Emotional influences, especially the type and context of emotions, are important to consider to improve HIV prevention efforts among gay and bisexual men.

Repro-sexual intersections: sperm donation, HIV prevention and the public interest in semen

In the scientific literature on fertility and assisted reproduction, and in the corresponding area of clinical practice, increasing attention has been paid to two groups: people living with the human immunodeficiency virus (HIV) and gay men. However, research on fertility in the context of HIV focuses almost exclusively on heterosexual couples, whereas studies on non-heterosexual reproduction rarely mention HIV, despite the fact that, in many western countries, HIV prevalence among men who have sex with men is higher than ever before and men who have sex with men are the only group in which new HIV infections are on the rise. This review identifies links between reproduction, HIV and homosexuality, showing that, historically, they are closely intertwined, which has important implications for current issues facing HIV care and fertility services. Considering sex and parenthood as two different but related kinds of intimacy and kinship, the dual role semen plays in sexually transmitted infection and in assisted reproduction is discussed. The review reflects on the future of sperm donation and HIV prevention, asking whether two challenges that potentially face healthcare and medicine today - the shortage of 'high-quality' sperm and the 'surplus' of infected semen - could be addressed by a greater exchange of knowledge.

The GAy MEn Sex StudieS: Anodyspareunia Among Belgian Gay Men

Introduction

Anal intercourse is commonly associated with male homosexuality, but not all gay males engage in anal sex. Receptive anal intercourse can cause pain. Little is known about this sexual dysfunction.

Aim

This study aims to determine the 4-week incidence of anodyspareunia (AD) in a sample of Belgian men who have sex with men (MSM) population and to assess the relevance of possible predictors such as age, relationship, and sexual behavior.

Methods

An internet-based survey on sexual behavior and sexual dysfunctions, called GAy MEn Sex StudieS, was administered to the MSM aged 18 years or older, between April and December 2008. A part of the questionnaire was focusing on anal eroticism. The participants, who self-reported being human immunodeficiency virus-positive or not having anal intercourse, were excluded.

Main Outcome Measure

Female Sexual Function Index questions on pain domain adapted for anal intercourse.

Results

A total of 1,752 Belgian MSM completed the questionnaire. Of the 1,190 (68%) participants who reported engaging in receptive anal sex in the last 4 weeks, 59% indicated having some degree of anal pain during and after sexual intercourse. For 44%, the level of pain was acceptable. Mild AD was reported by 32%, 17% had mild to moderate AD, 4% had moderate AD, and 2% had severe AD. Independent predictors for the presence of AD were age, having a steady relationship, frequency of sex with their partner, number of sex partners, number of sex partners at the same time, and massaging the anal sphincter before anal sex. The prevalence and severity of AD among the MSM were lower among older participants, the MSM who more frequently had sex with their partner, and participants with a higher number of sex partners. Inadequate lubrication and lack of oral or digitoproctic stimulation prior to penetration were the most important factors predicting pain. Unsafe anal sex was performed by 28%.

Conclusion

One-third of the participants reported not engaging in receptive nor penetrative anal sex. The 59% of participating Belgian MSM, who had anal receptive intercourse, reported some degree of AD. These findings highlight the need for more education about anal eroticism for MSM, and more research into AD is needed. Vansintejan J, Vandevoorde J, and Devroey D. The GAy MEn Sex StudieS: Anodyspareunia among Belgian gay men. Sex Med 2013;1:87–94.

Technology, normalisation and male sex work

Technological change, particularly the growth of the Internet and smart phones, has increased the visibility of male escorts, expanded their client base and diversified the range of venues in which male sex work can take place. Specifically, the Internet has relocated some forms of male sex work away from the street and thereby increased market reach, visibility and access and the scope of sex work advertising. Using the online profiles of 257 male sex workers drawn from six of the largest websites advertising male sexual services in Australia, the role of the Internet in facilitating the normalisation of male sex work is discussed. Specifically we examine how engagement with the sex industry has been reconstituted in term of better informed consumer-seller decisions for both clients and sex workers. Rather than being seen as a 'deviant' activity, understood in terms of pathology or criminal activity, male sex work is increasingly presented as an everyday commodity in the market place. In this context, the management of risks associated with sex work has shifted from formalised social control to more informal practices conducted among online communities of clients and sex workers. We discuss the implications for health, legal and welfare responses within an empowerment paradigm.

Beyond prevention: containment rhetoric in the case of bug chasing

Bug chasing, the practice of pursuing HIV positive sexual partners in order to acquire HIV, presents multiple dilemmas for health affiliates in terms of how to address discourses and practices that challenge widely held beliefs about health and medicine. In order to examine how researchers respond to controversial counterpublic rhetorics, this essay chronicles the construction of "bug chasing" in published social science literature. Guided by a theory of containment rhetoric, I analyze how bug chasers are configured in the language of social science used to describe and explain them. I find that social scientific coverage of bug chasing often addresses the behavior using a recipe of rhetorical containment: first, authors gaze upon bug chasers via distanced descriptions of the community; second, authors characterize the behavior as exhibiting an idealistic naiveté; and, third, authors stress the inconceivable, and therefore reproachable, sacrifice that bug chasing ultimately demands of its onlookers and participants. In closing, I evaluate the consequences of this containment rhetoric and offer three rhetorical maneuvers to aid future scholarship that examines the discourses and communities that counter dominant health ideologies.

Masculinity and Barebacker Identification in Men who have Sex with Men

Purpose:

Barebacking is a term that is used to refer to intentional involvement in unprotected anal sex. This paper examines the relationship between masculinity and self-identification as a barebacker, and how these factors related to HIV risk practices in a sample of men who have sex with other men (MSM).

Method:

As part of the Men4Men Study, a brief Internet-based survey was completed in 2007 with English-speaking MSM aged 18+ who were not involved in a marital/romantic relationship at the time of interview. 886 participants were recruited by placing electronic postings and banner advertisements on Weblogs, social and sexual networking sites, and listservs frequented by MSM.

Results:

A number of factors differentiated men who self-identified as barebackers from those who did not, and barebacking identity was linked with greater involvement in HIV risk practices. Multivariate analysis revealed that having a high level of masculinity was associated with a greater likelihood of self-identifying as a barebacker.

Conclusions:

HIV prevention and intervention efforts targeting MSM ought to address issues of self-identification as a barebacker as well as the extent to which men adhere to a masculine ideology.

O uso da argumentação científica na opção por estilos de vida arriscados no cenário da aids

Investigam-se os usos de argumentos científicos que circulam no cotidiano de homens que fazem sexo com homens (HSH), em parceria casual, como estratégia para gerir riscos associados às práticas sexuais. O aporte teórico da pesquisa refere-se às práticas discursivas sobre estilos de vida arriscados no cenário da aids. Por meio da técnica snowball foram selecionados sete participantes, que responderam a uma entrevista semiestruturada. Os resultados indicam a assimilação de informações científicas que circulam no cotidiano dos interlocutores deste estudo interpretadas como potencial fonte na gestão de riscos. Esses homens desenvolvem estratégias de gestão de risco de infecção por DST, HIV e/ou a reinfecção pelo HIV sem basear-se, necessariamente, nas políticas oficiais de prevenção do governo brasileiro.

Sex, HIV, and the Internet: Exploring Variations in the Online Profiles of MSM in the United States

With the increasing pervasiveness of social media, the Internet has become an important venue for dating and sex. Not only does the Internet introduce a unique array of opportunities and risks for men who have sex with men (MSM), it also presents a valuable means through which to study sexual behavior. In this study, data on what men report in their online profiles were collected from two dating/hookup websites to explore possible geographical differences in men's sexual preferences and expectations (N = 5,588). Across the 15 selected cities, significant differences emerged in reported HIV status and stated preference for safer sex (condom use). These patterns suggest important contextual and demographic variations and point to a need for targeted, population-specific interventions and further research to identify the underlying social and psychological constructs. With a better understanding of the local factors driving risky sexual behavior, health communication messages and tailored online interventions could be developed to address the needs and concerns of specific groups.

The dynamic relationship between social norms and behaviors: the results of an HIV prevention network intervention for injection drug users

AIMS

Social norms are a key source of influence on health behaviors. This study examined changes in social norms and relationships between HIV injection risk behaviors and social norms among injection drug users (IDUs) involved in an experimental intervention.

DESIGN

Randomized clinical trial.

SETTING

An HIV Prevention Trials Network study, Philadelphia, USA.

PARTICIPANTS

IDUs, called indexes, and their social network members, who were drug or sex partners, were recruited for an HIV prevention intervention and followed for up to 30 months (n = 652). Indexes were randomized into a peer education intervention or control condition.

MEASUREMENTS

Outcomes of injection-related HIV risk behaviors (sharing needles, sharing cookers, sharing cotton, front-/back-loading) were measured every 6 months and the social norms of these four risk behaviors were assessed every 12 months.

FINDINGS

There was a statistically significant intervention effect on all four social norms of injection behaviors, with participants in the intervention reporting less risky social norms compared with controls (changes in mean score: needles, -0.24, P = 0.007; cookers, -0.33, P = .004; cottons, -0.28, P = .0165; front-/back-loading, -0.23, P = .002). There was also a statistically significant bidirectional association with social norms predicting injection risk behaviors at the next assessment and risk behaviors predicting social norms at the subsequent visit.

CONCLUSIONS

Through social network interventions it is feasible to change both injection risk behaviors and associated social norms. However, it is critical that social network interventions focus on publically highlighting behavior changes, as changing social norms without awareness of behaviors change may lead to relapse of risk behaviors.

Are HIV-negative men who have sex with men and who bareback concerned about HIV infection? Implications for HIV risk reduction interventions

The emergence of barebacking (intentional unprotected anal intercourse in situations where there is risk of HIV infection) among men who have sex with men (MSM) has been partially attributed to a decrease in HIV-related concerns due to improved anti-retroviral treatment. It is important to understand the level of concern these men have regarding HIV infection because it can affect their interest in risk reduction behaviors as well as their possible engagement in risk reduction interventions. As part of a study on MSM who use the Internet to seek sexual partners, 89 ethnic and racially diverse men who reported never having an HIV-positive test result completed an in-depth qualitative interview and a computer-based quantitative assessment. Of the 82 men who were asked about concerns of HIV infection during the qualitative interviews, 30 expressed "significant concern" about acquiring HIV, 42 expressed "moderate concern," and 10 expressed "minimal concern." Themes that emerged across the different levels of concern were their perceptions of the severity of HIV infection, having friends who were HIV positive, and their own vulnerability to HIV infection. However, these themes differed depending on the level of concern. Among the most frequently mentioned approaches to decrease risk of HIV infection, participants mentioned avoiding HIV-positive sex partners, limiting the number of partners with whom they barebacked, and not allowing partners to ejaculate inside their rectum. Findings suggest that many MSM who bareback would be amenable to HIV prevention efforts that do not depend solely on condom use.

New pleasures and old dangers: reinventing male sex work

Understandings of male sex workers (MSWs) shift with technological, conceptual, and social changes. Research has historically constructed MSWs as psychologically unstable, desperate, or destitute victims and their clients as socially deviant perverts. These perceptions, however, are no longer supported by contemporary research and changing societal perceptions of the sex industry, challenging how we understand and describe "escorts." The changing understandings of sexuality and the increasing power of the Internet are both important forces behind recent changes in the structure and organization of MSWs. The growth in the visibility and reach of escorts has created opportunities to form an occupational account of MSWs that better accounts for the dynamic and diverse nature of the MSW experience in the early 21st century. Recent changes in the structure and organization of male sex work have provided visibility to the increasingly diverse geographical distribution of MSW, the commodification of race and racialized desire, new populations of heterosexual men and women as clients, and the successful dissemination of safer sexual messages to MSWs through online channels. This article provides a broad overview of the literature on MSWs, concentrating its focus on studies that have emerged over the past 20 years and identifying areas for future research.

Condom Use, Disclosure, and Risk for Unprotected Sex in HIV-Negative Midlife and Older Men Who Have Sex With Men

Sexual risk behaviors account for most HIV infections in men who have sex with men (MSM), and the risk of exposure from each sexual encounter increases with age. The focus of this study was to investigate which behaviors in midlife and older MSM influence their sexual risk/protection. Cross-sectional data were collected from a community-based sample of 802 MSM aged 40 years and older from community venues (e.g., bars) who completed an anonymous questionnaire. Data from a subset of 420 MSM who were HIV-negative (aged 40-81 years) were used to investigate which behaviors were associated with greater risk for unprotected anal sex. Regression analyses indicated that erection difficulties (odds ratio [OR] = 4.7; 95% confidence interval [CI] = 1.8-12.2), practicing safe sex with outside partners but not with one’s primary partner (OR = 0.54; 95% CI = 0.3-0.94), and recreational drug use (OR = 2.6; 95% CI = 1.3-5.1) were associated with higher risk for unprotected receptive anal intercourse. Younger age (OR = 0.96; 95% CI = 0.9- 0.9), not telling partners about HIV status (OR = 3.2; 95% CI = 1.5-6.5), finding partners in backrooms/sex clubs (OR = 2.8; 95% CI = 1.1- 6.8), and erection difficulties (OR = 10.3; 95% CI = 2.8-37.8) were associated with higher risk for unprotected insertive anal intercourse. These data indicate there may be certain factors specific to older MSM that influence their sexual risk taking behaviors. Programs may be more effective if they are tailored for older cohorts of MSM and address interpersonal communication, erection problems, and substance use to reduce health risks and promote healthier lifestyles.

A pilot study of HIV/STI risk among men having sex with men using erectile dysfunction medications: challenges and opportunities for sexual medicine physicians

INTRODUCTION

A growing literature suggests relationships between erectile dysfunction medications (EDM) and riskier sexual behavior among men who have sex with men (MSM). Questions remain concerning EDM use and related HIV/sexually transmitted infections (STI) risk among older MSM, particularly those 40 years and over, for whom EDM may be medically warranted.

AIM

This exploratory pilot study explores the relationship between EDM and risky sexual behavior in a convenience sample of MSM using EDM and attending historic sex-on-premises venues.

METHODS

We examined anonymous surveys from 139 MSM. Bivariate relationships were examined. We then fit a multiple logistic regression model to determine predictors of engaging in unprotected anal intercourse (UAI) at last EDM, using variables identified as being significantly related to UAI in the bivariate analyses. Potential predictors entered the model in a stepwise fashion.

MAIN OUTCOME MEASURES

The primary outcome measure was engaging in UAI at last EDM use.

RESULTS

MSM participating in the study ranged from 27 to 77 years and averaged 52.0 years (standard deviation = 10.73 years). These participants were primarily older MSM; fewer were younger MSM (12.12%), under age 40. Participants reporting UAI at last EDM use (N = 41) were significantly younger (P < 0.01). Men visiting bars within the last 6 months reported less UAI (P < 0.01). Both variables were independent predictors of UAI in the logistic regression model (P < 0.01).

CONCLUSIONS

Similar to reports from younger MSM, our findings suggest older MSM using EDM and reporting UAI are also recreational drug users. We include recommendations for urologists and other sexual medicine physicians treating MSM who may be at elevated risk for HIV/STI infection because of joint EDM and club drug use.

Use of a rapid HIV home test prevents HIV exposure in a high risk sample of men who have sex with men

The study assessed whether at-risk HIV-uninfected men who have sex with men (MSM) who never or rarely use condoms and have multiple partners would use a rapid, oral fluid, HIV home test (HT) to screen potential sexual partners. Participants received 16 HT kits, were monitored weekly for 3 months, and then interviewed in depth. Twenty-seven ethnically diverse MSM used HT kits before intercourse with approximately 100 partners in private and public spaces. Testing had high acceptability among ethnic minority participants. Ten tested individuals received HIV-antibody positive results. Seven were potential sexual partners, and three were acquaintances of the participants; six of the ten were unaware of their status. No sexual intercourse took place after positive tests. Very few problems occurred. Most participants strongly desired to continue using HT and to buy it freely. HT use results in detection of previously unknown infections. Making HT available within networks where high-risk sexual practices are common may be a cost-efficient and effective prevention method.

The relationship between pornography use and sexual behaviours among at-risk HIV-negative men who have sex with men

OBJECTIVES

Although pornography is widely available and frequently used among many adults in the USA, little is known about the relationship between pornography and risk factors for HIV transmission among men who have sex with men.

METHODS

Baseline assessments from a behavioural intervention trial for at-risk men who have sex with men were conducted in Atlanta, GA in 2009. Univariate and multivariate generalised linear models were used to assess the relationships between known risk factors for HIV infection, time spent viewing pornography, and sex behaviours.

RESULTS

One hundred forty-nine men reporting HIV-negative status and two or more unprotected anal sex partners in the past 6 months were enrolled in an intervention trial and completed survey assessments. Time spent viewing pornography was significantly associated with having more male sexual partners (B=0.45, SE=0.04, P<0.001) and unprotected insertive anal sex acts (B=0.28, SE=0.04, P<0.001). Moreover, increased substance use (drug use, B=0.61, SE=0.14, P<0.001; alcohol use, B=0.03, SE=0.01, P<0.01) and decreased perception of risk for HIV infection (B=-0.09, SE=0.04, P<0.05) were found to be significantly associated with greater time spent viewing pornography.

CONCLUSIONS

This exploratory study is novel in that it sheds light on the associations between viewing pornography and sexual risk taking for HIV infection. Future studies in this area should focus on understanding how the content of pornography; in particular, the viewing of unprotected and protected sex acts, may affect sexual risk taking behaviour.