Contexts for last occasions of unprotected anal intercourse among HIV-negative gay men in Sydney: The health in men cohort

The effects of intimate relationship characteristics on unprotected anal intercourse among same-sex male couples in China: a dyadic analysis using the actor-partner interdependence model

BACKGROUND

Unprotected anal intercourse (UAI) within the context of concurrent sexual relationship are prevalent among men who have sex with men (MSM) who have regular male sex partners and it aggravates the risk of HIV infection among this community. The aim of this study was to assess the effect of intimate relationship characteristics on UAI among MSM couples at the dyadic level.

METHODS

Two hundred four MSM couples were recruited from a HIV testing clinic from April 2017 to April 2018 in Guangzhou, China. The actor-partner interdependence model (APIM) was applied for dyadic analysis. Each MSM couple was divided into the insertive role and the receptive role according to their regular anal sex role. In this context, actor effect is the impact of an MSM's intimate relationship characteristics on his own UAI, and partner effect is the impact of his partner's intimate relationship characteristics on his UAI.

RESULTS

Of the 408 participants, 58.82% had UAI with regular male sex partner (UAI-RP) and 8.09% had concurrent UAI. Intimate relationship characteristics were associated with concurrent UAI, but not associated with UAI-RP. For the receptive role, his relationship investment exerted significant actor and partner effects on concurrent UAI (AOR actor = 1.31, P < 0.001; AOR partner = 1.17, P < 0.001). Meanwhile, receptive role's violence experience within relationship exerted significant actor effects on his own concurrent UAI (AOR actor = 6.43, P = 0.044).

CONCLUSIONS

Relationship investment and violence experience influenced concurrent UAI among MSM couples and it varied in different sex roles. Additional assistance on empowerment, relationship therapy and sexual agreement is urgently needed to reduce their high possibility on engagement of HIV-related risk behaviors.

The future of drugs: recreational drug use and sexual health among gay and other men who have sex with men

There are complex historical connections between sexual minoritisation and desires to chemically alter bodily experience. For gay men, drug and alcohol use can be a creative or experimental response to social marginalisation - and not necessarily a problematic one in every instance. Numerous studies have found that infection with HIV and other sexually transmissible infections (STIs) is more likely among gay and men who have sex with men (MSM) who use recreational drugs than those who do not, but the causal nature of these relations is uncertain. Sexualised drug use is associated with a range of other problems, including dependence, mental health issues, accident and overdose. A growing body of work in the Alcohol and Other Drugs (AOD) field demonstrates the action of drugs and their purported effects to be a product of their relations with various other actors, contexts and practices. Given these contingencies, it is impossible to predict the future of drugs or their effect on the sexual health of gay and MSM with any degree of certainty. This article outlines some of the conditions most likely to mediate such futures in the medium term. Public funding for lesbian, gay, bisexual, transgender and queer drug issues should not remain restricted to questions of HIV prevention and sexual health. It should be expanded to equip sexual health and AOD service providers with the cultural and sexual literacy to mitigate stigma and allow them to respond constructively to drug problems among sexual and gender minorities as a matter of priority.

Mental health, drug use and sexual risk behavior among gay and bisexual men

BACKGROUND

Compared to the general population, among gay and bisexual men (GBM) prevalence rates of anxiety and depression, and of drug use, are high.

OBJECTIVE

This paper explores the relationship between mental health, sexual risk behavior, and drug use among Australian GBM. We identify factors associated with indicators of poor mental health.

METHODS

Between September 2014 and July 2017, 3017 GBM responded to measures of anxiety and depression in an online cohort study of drug use.

RESULTS

Mean age was 35.3 years (SD 12.8). 17.9% screened positive for current moderate-severe anxiety and 28.3% for moderate-severe depression. The majority (52.2%) reported use of illicit drugs in the previous six months, including 11.2% who had used methamphetamine. One third had high (20.4%) or severe (10.6%) risk levels of alcohol consumption, and 18.3% who were current daily smokers. Most illicit drug use in general was not associated with either anxiety or depression, but men who used cannabis were more likely to show evidence of depression (p = 0.005). Among recent methamphetamine users, 28.0% were assessed as dependent: dependent users were more likely to show evidence of both depression and anxiety than were non-dependent users. High or severe risk drinking was associated with depression and daily tobacco use was associated with both anxiety and depression. Depression and anxiety was associated with: less personal support, viewing oneself as 'feminine', and being less socially engaged with gay men. Sexual risk behavior was not associated with either depression or anxiety.

CONCLUSION

Prevalence of anxiety and depression was high, as was prevalence of licit and illicit drug use. Substance use was associated with anxiety and depression only when the use was considered problematic or dependent. Social isolation and marginalization are strong drivers of poor mental health, even within this population for whom anxiety and depression are common.

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

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

Individual-Level, Partnership-Level, and Sexual Event-Level Predictors of Condom Use During Receptive Anal Intercourse Among HIV-Negative Men Who Have Sex with Men in Los Angeles

We examined individual-level, partnership-level, and sexual event-level factors associated with condom use during receptive anal intercourse (RAI) among 163 low-income, racially/ethnically diverse, HIV-negative men who have sex with men (MSM) in Los Angeles (2007-2010). At baseline, 3-month, and 12-month visits, computer-assisted self-interviews collected information on ≤3 recent male partners and the last sexual event with those partners. Factors associated with condom use during RAI at the last sexual event were identified using logistic generalized linear mixed models. Condom use during RAI was negatively associated with reporting ≥ high school education (adjusted odds ratio [AOR] = 0.32, 95 % confidence interval [CI] 0.11-0.96) and methamphetamine use, specifically during RAI events with non-main partners (AOR = 0.20, 95 % CI 0.07-0.53) and those that included lubricant use (AOR = 0.20, 95 % CI 0.08-0.53). Condom use during RAI varies according to individual-level, partnership-level, and sexual event-level factors that should be considered in the development of risk reduction strategies for this population.

Is Location of Sex Associated with Sexual Risk Behaviour in Men Who Have Sex with Men? Systematic Review of Within-Subjects Studies

To understand associations between location of sex and sexual risk, it is most helpful to compare sexual encounters within persons. We systematically reviewed within-subjects comparisons of sexual encounters reported by men who have sex with men (MSM) with respect to location of sex. Within-subjects comparisons of sexual risk and location of sex were eligible if they collected data post-1996 from samples of MSM. We independently screened results and full-text records in duplicate. Of 6,336 deduplicated records, we assessed 138 full-text studies and included six, most of which compared unprotected anal intercourse against other anal intercourse. This small, but high quality, body of evidence suggests that associations between attendance at sex-on-premises venues and person-level sexual risk may be due to overall propensity towards unprotected sex. However, there may be some location factors that promote or are associated with serononconcordant unprotected anal intercourse. Health promoters may wish to focus on person-level characteristics.

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

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

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.

Drug use moderates associations between location of sex and unprotected anal intercourse in men who have sex with men: nested cross-sectional study of dyadic encounters with new partners

OBJECTIVES

This nested cross-sectional study of dyadic sexual encounters with new male partners reported by men living in England who have sex with men tested moderation between drug use and location of sex in associations with unprotected anal intercourse (UAI).

METHODS

Data were drawn from two waves of a longitudinal monthly internet survey of men living in England who have sex with men conducted in 2011. Using generalised estimating equations and logit link, we tested the relationship with UAI of any respondent drug use before sex, specific respondent drug use before sex, location of sex (distinguishing private, sex-on-premises venue and cruising locations) and location-drug use interactions.

RESULTS

Any respondent drug use (OR 1.57, 95% CI 1.31 to 1.88) was associated with increased odds of UAI. Relative to encounters in private locations, encounters in sex-on-premises venues (0.69, 95% CI 0.52 to 0.91), but not cruising locations, were associated with decreased odds of UAI. Any respondent drug use, respondent use of poppers and respondent use of alcohol were each associated with increased UAI in sex-on-premises venues.

DISCUSSION

This analysis presents evidence of moderation between drug use and location of sex in associations with UAI. Though this analysis used a large sample, it relied on community-recruited respondents. Our findings may reflect either 'totalising' effects of drug use across venues or site-specific use of drugs as a mechanism for cognitive escape. Additional qualitative research is necessary to understand these findings in context.

Daily associations between alcohol use and unprotected anal sex among heavy drinking HIV-positive men who have sex with men

Men who have sex with men (MSM) account for the largest proportion of new HIV infections in the United States. Alcohol may facilitate HIV transmission by increasing unprotected anal sex, but few studies have focused on transmission behaviors in HIV-positive MSM. This study explored daily associations between alcohol use and sexual behavior among heavy drinking HIV-positive MSM using a 30-day Timeline Followback interview. Results of generalized estimating equations indicated that greater alcohol consumption on a given day was associated with a linear increase in the odds of having unprotected anal sex with partners of any HIV status. However, the odds of reporting unprotected anal sex with HIV-negative or HIV-status unknown partners increased in a curvilinear fashion, occurring primarily at very heavy levels of use (12+ drinks). Results suggest that very heavy drinking increases the risk of engaging in sexual behavior that has the potential for transmitting HIV to other men.

Sexual practices and sex-seeking behaviours among East and Southeast Asian men who have sex with men in Toronto: Implications for HIV prevention

This study explored sexual practices and sex-seeking behaviours in a sample of 222 East and Southeast Asian men recruited through two gay venues. Over half of the respondents reported having a current regular partner; the rate of unprotected anal sex with their regular partner was high (45.1%). Among all respondents, 74.8% (166) reported having casual sex with an average of 16 partners in the previous six months; 26.5% of these 166 respondents reported unprotected anal sex with their casual partners. Respondents used multiple venues to seek sex, but bathhouses and the internet were most commonly cited. Bivariate analysis demonstrated that respondents who sought men for sex via both bathhouses and the internet in the past six months were most likely to have had a casual partner, to have had unprotected anal sex with a casual partner, and to have had prior HIV and STI testing. In comparison to respondents who used only bathhouses to seek sex, respondents who used only the internet had fewer casual partners but were more likely to have unprotected anal sex with a casual partner. Given these findings, additional research is needed to further explore the individual and structural factors that shape the condom use behaviour of these sub-populations. HIV prevention efforts must include culturally relevant information about HIV and STI transmission to promote condom use. It is also critical to develop culturally and linguistically appropriate online prevention education for Asian MSM who seek sex primarily through the internet.

"Cum play" among gay men

The exchange of semen, often referred to as "cum play," has featured in gay literature and may be a unique aspect of many gay men's sexual behavior. We investigated the prevalence of "cum play" and its context among 1153 HIV-negative and 147 HIV-positive Australian gay men in an online survey. Receptive cum play (partner ejaculating or rubbing his semen over participant's anus, or participant using partner's semen as lubricant) was reported by one in six HIV-negative and one quarter of HIV-positive men on the same occasion of protected anal intercourse with a casual partner (PAIC). HIV-negative men who engaged in receptive cum play during PAIC often believed that their partner was HIV seroconcordant and tended to trust that partner. They were also generally more optimistic about the likelihood of HIV transmission, and they often only used condoms at their partners' instigation. Cum play was not uncommon and highlights the narrowness (or danger) of focusing on condom use without considering the implications of broader sexual practices and their meaning for sexual health promotion. "Safe sex" for some gay and bisexual men does not necessarily mean consistent commitment to condom use or to avoiding semen exchange. Many feel confident in their knowledge of their partner's HIV serostatus and only use condoms with these partners at their partner's request. Their commitment to safe sex may not necessarily be compromised by their practice of cum play, but the extent to which this could represent a risk for HIV transmission depends on the reliability of their assessment of their partners' HIV serostatus.

Changes in metabolic, inflammatory and coagulation biomarkers after HIV seroconversion--the Health in Men (HIM) Biomarker Substudy

BACKGROUND

Biomarkers of inflammation, coagulation, lipids and vitamin D have been associated with cardiovascular and mortality risk in HIV-infected individuals. Scarce data exist on changes in these markers from pre- to post-HIV seroconversion.

METHODS

The study participants were drawn from the Health in Men Study, which recruited HIV-negative homosexual men. Participants with incident HIV infection (n=26) were compared with HIV-negative controls (n=52) matched on age at enrolment, date of visit and reported intravenous drug use. Levels of metabolic (lipids and vitamin D), inflammatory (C-reactive protein and interleukin-6) and coagulation (D-dimer and fibrinogen) biomarkers were measured at pre- and post-HIV seroconversion visits and corresponding visits for controls. Random-effect models were used to compare changes in markers between cases and controls.

RESULTS

The median gap between pre- and post-seroconversion or matched first and second visits in controls was 12 months. HIV seroconversion was associated with decline in high density lipoprotein (HDL-C; difference in mean change between cases and controls -0.14 mmol/l; 95% CI -0.22, -0.01; P=0.035). There were no significant differences in changes in other lipids, markers of inflammation, coagulation or vitamin D.

CONCLUSIONS

Decline in HDL-C seems to be the main proatherogenic change within 1-1.5 years after HIV seroconversion. HIV seroconversion was not associated with profound changes in other lipids, or markers of inflammation, coagulation and vitamin D. Longitudinal assessment of these markers in comparable population needs further assessment.

A review of the literature on event-level substance use and sexual risk behavior among men who have sex with men

In the United States, there continues to be high incidence of HIV infection among men who have sex with men (MSM), who represent 57% of new infections in 2009. While many studies report associations between non-injection substance use and sexual risk behavior among MSM, overall results are mixed. Summarizing these studies is difficult because researchers have used a variety of assessment periods for substance use and sexual behavior. We review the scientific literature on event-level measures, which assess substance use and sexual risk behavior immediately before or during a sexual encounter and provide the most precise link between these two behaviors. From January 2009 through March 2010, we searched four databases: Ovid (MEDLINE and PsycINFO), Web of Knowledge, and Sociofile. Across studies, results varied by substance with little within substance consistency or a lack of research except for two notable exceptions: methamphetamine and binge alcohol use. The findings underscore the importance of providing HIV risk-reduction interventions for substance-using MSM.

Gay men are less likely to use condoms with casual sex partners they know 'well'

Health in Men (HIM) was an open cohort study of 1,427 HIV-negative homosexual men in Sydney. The majority of respondents' unprotected anal intercourse (UAIC) events were with partners whose HIV status they did not know. Nonetheless, with casual partners with whom they engaged in UAIC, respondents indicated that they knew 'well' 28.9% of the HIV-negative partners and 26.2% of HIV-positive partners, but only 7.6% of the HIV status unknown partners. Respondents were more likely to have engaged in UAIC with partners they knew well (McNemar P < 0.001). The challenge for HIV prevention is that many gay men's decisions about condom use may be driven as much by their relationship with individual partners as their commitment to 'safe sex'.

Correlates of unprotected anal sex at last sexual episode: analysis from a surveillance study of men who have sex with men in Montreal

Recent increases in rates of unprotected anal sex (UAS) among men who have sex with men (MSM) signal the need to continually refine our understanding of factors associated with risky sexual behavior. Data were collected using a questionnaire eliciting information about the last sexual episode (LSE) with another man in the past 6 months. Logistic regression was used to identify both event-level and background correlates of UAS at LSE. 965 participants who reported having sex with a partner with whom they were not in a couple relationship at LSE were studied. Several event-level variables were significantly associated with UAS after adjusting for background factors, including finding the partner at LSE sexually attractive and using alcohol or cocaine at LSE. Our findings parallel the results of other HIV prevention studies which have highlighted the importance of interpersonal factors that influence risk-taking at the moment of a sexual act among MSM.

Changes in sexual behaviours: from secular trends to public health policies

OBJECTIVE

To explore the relative contribution of secular trends and public health policies to changes in sexual behaviour.

DESIGN

Three random probability surveys of the sexual behaviour of people aged 18-69 years were conducted in 1970, 1992 and 2006 in France.

METHODS

Data of the 2006 survey (n = 12,364) were compared with those from two surveys carried out in 1970 (n = 2625) and 1992 (n = 20,055).

RESULTS

Over the last decades, median age at first intercourse has decreased by 4 years for women (22.0 in the 1930s vs. 17.6 in the 2000s) and 1 year for men (18.1 vs. 17.2). Lifetime number of sexual partners increased for women (1.8 in 1970 vs. 4.4 in 2006), but not for men (11.8 vs. 11.6). At the same time, the proportion of respondents, especially women, who reported nonpenetrative sexual practices and considered sexual intercourse essential to well being was on the increase. These changes are mainly attributed to an increase in women's social status. A marked increase in condom use was observed following the first AIDS/HIV prevention campaigns in the 1980s.

CONCLUSION

Public health interventions that are synergistic with trends in social norms are likely to be more effective than those that run counter to them. In France, sexual health and HIV prevention policies aimed at harm limitation appear to have chimed with secular trends. The evidence of greater diversification of sexual practices offers potential to increase the range of safer sex messages used in public health interventions.

Environmental factors in relation to unprotected sexual behavior among gay, bisexual, and other MSM

This descriptive article illustrates the casual sexual behaviors of a diverse sample (N = 311) of gay, bisexual, and other men who have sex with men (MSM) regularly attending gyms in New York City. Approximately 88% of the sample noted sex with a casual partner in the previous 6 months. Participants reported the frequency of unprotected sexual acts, the perceived HIV status of their partners, and the contexts where they met their casual sex partners. The study findings suggest that the context in which MSM choose to meet casual sex partners has an effect on both the number of casual sex partners they meet and the number of casual sex partners with whom they engage in unprotected receptive anal intercourse and unprotected insertive anal intercourse. We found that the highest risk sexual behaviors took place at bareback sex parties, which are often held at private venues. Men who meet their sexual partners at bareback sex parties are also likely to frequent bathhouses/sex clubs and nonbareback sex parties, suggesting a varied exploration of sexual contexts, partners, and behaviors. We attempt to enhance individual-level models of understanding sexual behavior and risk by proposing that the individual is influenced by the physical context where he makes his decisions.

Gay men who engage in group sex are at increased risk of HIV infection and onward transmission

Among 746 participants in the Three or More Study (TOMS) of gay men who engaged in group sex in the previous 6 months, 22.4% reported unprotected anal intercourse (UAI) with any partners they did not know to be the same HIV serostatus as themselves. Not knowing oneself to be HIV-negative, not having a clear intention to use condoms, and more frequent group sex were independently associated with UAI. This study shows that gay men who engage in group sex represent an important priority for targeted HIV prevention activities and research.

Intensive sex partying amongst gay men in Sydney

Intensive sex partying is a framework developed to analyse specific frequent behaviours amongst a small minority of gay men in Sydney, Australia. The behaviours included a higher frequency of dance party attendance, more frequent sex, more anal sex, multiple sex partners, more unprotected anal intercourse with casual partners and more frequent drug taking. These occur at a contextual intersection between a sub-group of sexually adventurous gay men and 'party boys'. The men appear to be involved in both high-risk, adventurous sex practices and a specific form of partying distinguishable from dance partying and 'clubbing'. Sex partying occurs on multiple sites (domestic spaces; within dance parties; sex parties; sex-on-premises venues) and appears to be geared to the maximisation of sexual pleasure. Intensive sex partying describes this coincidence of factors and locates them in relation to the multiple pleasures offered by sex partying. It emphasises the importance of 'intensity' in order to understand better the relations between sex, drug use, pleasure, care and risk in some gay men's lives.

Use of illicit drugs and erectile dysfunction medications and subsequent HIV infection among gay men in Sydney, Australia

INTRODUCTION

Use of illicit drugs and oral erectile dysfunction medications (OEM) have been associated with risk behavior among gay men.

AIM

To determine the effects of illicit drugs and OEM as risk factors for HIV seroconversion in a community-based cohort of HIV-negative homosexually active men in Sydney, Australia.

MAIN OUTCOME MEASURES

Drug use in the previous 6 months and at the most recent sexual encounter; Most recent occasions of unprotected and protected anal intercourse; HIV-positive diagnosis.

METHODS

From June 2001 to June 2007, participants were followed up with 6-monthly detailed behavioral interviews and annual testing for HIV. Detailed information about sexual, drug-using and other behavior was collected.

RESULTS

Among 1,427 participants enrolled, 53 HIV seroconverters were identified by June 2007. At baseline, 62.7% reported using illicit drugs in the previous 6 months, including 10.7% who reported at least weekly use. Illicit drug use was associated with unprotected anal intercourse with casual partners (P < 0.001). Use of illicit drugs was associated with increased risk of HIV infection at a univariate level, and this risk increased with greater frequency of use. This was also true of the use of OEM. Use of each type of illicit drug was included in multivariate analysis, and after controlling for sexual risk behaviors, only use of OEM remained significantly predictive of HIV infection (Hazard ratios [HR] = 1.75, CI = 1.31-2.33, P < 0.001), although amyl nitrite was of borderline significance (HR = 1.26, CI = 0.98-1.62, P = 0.074).

CONCLUSION

The association between drug use and increased risk of HIV infection was strongest for drugs used specifically to enhance sexual pleasure, particularly OEM. The risk of infection was substantially increased when both OEM and methamphetamine were used. Within more "adventurous" gay community subcultures, the interconnectedness of sexual behavior and drug use may be key to understanding HIV risk and is an appropriate priority in HIV-prevention efforts in this population.

The role of drugs during group sex among gay men in Australia

Background: Drug use has been associated with risk behaviour among gay men. We examined the use of drugs and sexual risk behaviour among homosexually-active men who engaged in group sex in Australia. Methods: We used an anonymous, self-complete survey about participants’ most recent occasion of group sex with other men and in-depth interviews with a small number of these survey participants. The 746 men who reported having engaged in group sex within the previous 6 months were included in these analyses. Results: Among 746 men who engaged in group sex within the previous 6 months, 63.0% reported using illicit drugs at the group sex encounter. Men commonly reported using drugs specifically to enhance their sexual experience and to intensify the pleasure of that experience. After controlling for each drug type and other risk factors, only use of methamphetamine (odds ratio = 1.74, confidence interval = 1.06–2.88, P = 0.030) and having more than five drinks (odds ratio = 2.41, confidence interval = 1.34–4.33, P = 0.003) were independently associated with unprotected anal intercourse with non-HIV seroconcordant partners in multivariate analysis. Conclusion: Methamphetamine and heavy alcohol use are associated with increased sexual risk behaviour among men who engage in group sex. Within more ‘adventurous’ gay community subcultures, drug use is often for the explicit purpose of enhancing the sexual experience and this complex relationship may be key to understanding HIV risk among these men.

Sexual practices of gay, bisexual, and other nonidentified MSM attending New York City gyms: patterns of serosorting, strategic positioning, and context selection

This descriptive paper characterizes the sexual behaviors of a diverse sample (N=311) of gay, bisexual, and other nonidentified men who have sex with men (MSM) who regularly attended gyms in New York City. Approximately 50% of the sample indicated sex with primary male partners, while 88% of the men had sexual relations with male casual partners in the 6 months prior to assessment. The participants met their casual partners in a variety of different venues, including the Internet. Differences were noted along key demographic factors with regard to the contexts in which men met their partners. The data indicate that the men use serosorting, strategic positioning, and contexts in which they meet other men, to influence choices concerning sexual partners and practices as a form of health protection. It is proposed that these patterns of sexual behavior are representative of the totality of the lives of gay, bisexual, and other MSM, because despite engaging in gym behaviors, which might be considered health promoting, these men are simultaneously taking risks. Such findings point to varying motivations as to why gay, bisexual, and other MSM actually attend the gym.

Sex work and risk behaviour among HIV-negative gay men

Gay men who engage in sex work may be at increased risk through risk behaviour outside the context of sex work. Among participants in the Health in Men (HIM) cohort of HIV-seronegative gay men in Sydney, 19.7% had ever engaged in sex work. Five percent reported being paid for sex in a six-month period during the study (2001-2006); a minority (18.3%) of these current sex workers reported unprotected anal intercourse (UAI) with clients and 62.0% reported UAI with any casual partners. The practice of sex work itself may not represent increased risk for HIV transmission but sex workers in this study were, nonetheless, at markedly increased risk in other aspects of their lives.

Homosexual men in Australia: population, distributionand HIV prevalence

Objectives: To assess the size, distribution and changes in the population of homosexual and bisexual men in Australia, and the capacity of available measures to make this estimation. Methods: We used data from five sources: the Australian Study of Health and Relationships, the Gay Community Periodic Surveys, HIV Futures, the Health in Men cohort study, the Australian National HIV and AIDS Registries and the Australian Household Census. Results: We estimated that in 2001 there were ~74 000 homosexual and bisexual men in New South Wales (NSW), ~42 000 in Victoria and ~37 000 in Queensland. There was, however, some discrepancy between datasets in the estimates of the overall proportions and distribution of homosexual and bisexual men across states. We also estimated HIV prevalence rates among homosexual and bisexual men in 2001 at ~8% in NSW, 5% in Victoria and 4% in Queensland. There were insufficient data to estimate whether the state-specific populations of homosexual men were changing with time. Conclusion: There are ~75% more homosexual and bisexual men in NSW than in Victoria and about twice as many as in Queensland. There are about two-thirds as many HIV-positive men in NSW as in Victoria and Queensland combined. Improved collection of population-based data on homosexuality are required.

Predictors of frequent use of amphetamine type stimulants among HIV-negative gay men in Sydney, Australia

BACKGROUND

Rates of use of amphetamine type stimulants among gay men have raised questions about the role of these drugs in increases in HIV infections and risk behaviour, but the role risk behaviours play with regard to illicit drug use within this population has not been investigated.

METHOD

Health in men (HIM) is a cohort of 1427 HIV-negative men in Sydney, Australia. All participants undergo annual face-to-face interviews. We examined onset of use of methamphetamine and of ecstasy (MDMA) after their baseline interview.

RESULTS

Among baseline non-frequent users who completed an annual follow-up interview, 67 commenced at least weekly use of ecstasy, while 71 commenced at least weekly use of methamphetamine. Factors independently associated with commencing more frequent use of these drugs included being younger, greater involvement in gay social life, and having engaged in unprotected anal intercourse with casual partners.

CONCLUSIONS

The transition from non- or less-frequent drug use to more frequent drug use may be associated with changes in sexual behaviour. While it may be true that illicit drug use leads to unsafe sexual behaviour, it is equally true that illicit drugs are used to enhance sexual performance and pleasure. The relationship is bidirectional and complex and must be understood within the contexts of particular sexual sub-cultural practices: engaging in sexual risk behaviour may be an indicator of future drug use as much as the reverse.

Differences between men who report frequent, occasional or no unprotected anal intercourse with casual partners among a cohort of HIV-seronegative gay men in Sydney, Australia

Past research on unprotected anal intercourse with casual partners (UAIC) contrasts those who report no UAIC with any UAIC. This paper examines differences among three groups of men who had any UAIC on the basis of the number of UAIC acts reported in a six-month period, namely no UAIC (n = 507), occasional UAIC (1-5 acts, n = 251) and frequent UAIC (more than 5 acts, n = 148). The occasional UAIC group had values lying between those of the no- and the frequent-UAIC group. As compared with the frequent-UAIC group, men in the occasional-UAIC group were less likely to have a steady partner, held less favorable attitudes toward condoms and higher levels of HIV treatments optimism and were more likely to report some disclosure of serostatus to or by casual partners and a range of esoteric sexual practice. On the other hand, men in the no-UAIC group had lower levels of 'feeling bad' (distress) and were less likely to use drugs to enhance sexual pleasure in casual encounters. Disclosure of serostatus had a strong association with frequent UAIC and this finding calls for both more research and more community exploration of issues surrounding sexual decision-making.

HIV risk and communication between regular partners in a cohort of HIV-negative gay men

This paper reports on the breaking of agreements between regular partners among HIV-negative gay men in Sydney. Data were from the 1333 men completing face-to-face interviews through December 2003 for the Health in Men (HIM) open cohort of HIV-negative gay men in Sydney.822 men had a primary regular partner during the six month period before their 2003 interview. Most of these men had entered into agreements with their partners about sex either with each other or with other partners (87.2%). They most commonly agreed not to use condoms with each other (50.6%). Regarding casual sex, they most commonly agreed to always use condoms (34.2%) or to have no sex with men outside their relationships (28.6%). 48.8% reported some discomfort discussing with their partner their sex outside the relationship. Among those with agreements with their partners, 27.7% reported ever breaking those agreements. Those who found it more difficult to discuss issues of HIV serostatus and sexuality were more likely to report having broken their agreements (p<.001; p=.021 at one-year follow-up) and were more likely to have engaged in unprotected anal intercourse with casual partners (p<.001). A third of those men who broke their agreements did not inform their partner. A substantial proportion of gay men with agreements with their regular partners report some discomfort discussing sexuality and HIV serostatus with their partners. Difficulty discussing these issues may place these men at increased risk of breaking their agreements and may place both themselves and their partners at increased risk of infection.

Use of illicit drugs among gay men living with HIV in Sydney

BACKGROUND

Illicit drug use among gay men is common and is associated with behaviours that are at high risk for HIV transmission.

METHODS

We explored illicit drug use within an ongoing cohort study of gay men living with HIV in Sydney, Australia. Most (84.3%) of the 274 New South Wales participants interviewed in 2004 for the Positive Health Cohort of HIV-seropositive gay men had used illicit drugs in the 6 months before their baseline interview.

RESULTS

One in six men (17.8%) used 'party drugs' at least monthly. At 12 months' follow-up, in 2005, these patterns of illicit drug use were similar. Being younger, participating in gay 'party scenes' and engaging in 'esoteric sex practices' at baseline were associated with any and more frequent use of party drugs, both in 2004 and 2005. Illicit drug use was, however, not associated with condom use at the most recent sexual encounters.

DISCUSSION

Illicit drug use appears to be highly contextual among these gay men living with HIV, and the association with risk behaviour may reflect participation in sexually adventurous subcultures as much as a direct causal effect.

Prevention with HIV-infected men: recommendations for practice and research

In the United States in 2004, 74% of the new AIDS cases and 70% of the new HIV cases were in men; in addition, 75% of the cases of HIV in women were classified as heterosexually acquired. These numbers make it clear that expanded prevention efforts for men who are infected with HIV would make a large contribution to containing the epidemic. This report explores epidemiologic and psychosocial issues related to prevention in men with HIV and compares how those variables relate to prevention efforts. The report ends with a discussion of a method to approach HIV risk reduction in clinical care settings.

Substance use and sexual behaviours of Japanese men who have sex with men: a nationwide internet survey conducted in Japan

Background

Japanese men who have sex with men (MSM), especially those living in large metropolitan areas such as Tokyo and Osaka, are facing a growing HIV/AIDS epidemic. Although the Internet is used as a new venue for meeting sex partners, it can also serve as a useful research tool for investigating the risk behaviours of Japanese MSM. This Internet survey explored the extent of substance use and its association with sexual risk behaviours among Japanese MSM.

Methods

Between 28 February 2003 and 16 May 2003 MSM were recruited through 57 Japanese gay-oriented Web sites, gay magazines, and Internet mailing lists. Participants completed a structured questionnaire anonymously through the Internet.

Results

In total, 2,062 Japanese MSM completed the questionnaire. The average age of participants was 29.0 years and 70.5% identified as gay, 20.8% as bisexual, and 8.7% as other. Overall, 34.5% reported never using a substance, 45% reported ever using one type of substance (lifetime reported single substance users), and 19.6% had used more than 1 type of substance (lifetime reported multiple substance users) in their lifetimes. The substances most commonly used were amyl nitrite (63.2%), 5-methoxy-N, N-diisopropyltryptamine (5MEO-DIPT) (9.3%), and marijuana (5.7%). In the multivariate analysis, unprotected anal intercourse, having had 6 or more sexual partners, visiting a sex club/gay venue in the previous 6 months, a lower education level, and being 30 to 39 years of age were associated with both lifetime single and lifetime multiple substance use. Lifetime reported multiple substance use was also correlated with having a casual sex partner, having symptoms of depression, being diagnosed as HIV-positive, and greater HIV/AIDS-related knowledge.

Conclusion

This is the first Internet-based research focused on the sexual and substance use behaviours of MSM in Asia. Our findings suggest a compelling need for prevention interventions to reduce HIV risk-related substance use behaviours among Japanese MSM. The results also suggest that the Internet is potentially a useful tool for collecting behavioural data and promoting prevention interventions among this population.

Unintentional HIV exposures from young men who have sex with men who disclose being HIV-negative

OBJECTIVE

To evaluate the proportion of new sexual partners potentially exposed to HIV from young MSM who disclosed being HIV-negative.

DESIGN

Cross-sectional, observational study of men aged 23-29 years recruited from randomly sampled MSM-identified venues in six US cities.

METHODS

Participants were interviewed and tested for HIV. Analyses were restricted to MSM who reported last testing HIV-negative and having one or more new partners in the prior 6 months.

RESULTS

Of 1701 MSM who reported a total of 11 793 new partners, 1075 (63%) disclosed being HIV-negative to 4253 (36%) new partners before having sex with them for the first time. Of disclosers, 352 (33%) reported last testing HIV-negative > 1 year before their interview and 80 (7%) tested HIV-positive (HIV-infected unaware). By race, 24% of black, 5% of Hispanic, and 3% of white disclosers tested HIV-positive. Of the 4253 new partners, 296 (7%) were partners of the 80 HIV-infected unaware MSM. By race, 22% of new partners of black, 3% of new partners of Hispanic, and 4% of new partners of white MSM, were partners of HIV-infected unaware MSM who disclosed being HIV-negative.

CONCLUSIONS

Many new sex partners may be unintentionally exposed to HIV from young MSM, particularly those who are black and who disclose being HIV-negative based on an earlier test. Young MSM should test for HIV more frequently and consistently use condoms with all partners unless they are in a mutually monogamous relationship in which both partners have tested HIV-negative at least 3 months since their last potential HIV exposure.

Risk factors for HIV seroconversion in homosexual men in Australia

BACKGROUND

Rates of newly acquired HIV infection are increasing in Australia, and sexual contact between men accounts for 85% of cases.

OBJECTIVE

To investigate behavioural risk factors for HIV seroconversion among gay and bisexual men from Sydney and Melbourne, Australia.

METHODS

103 men with newly acquired HIV infection were recruited from clinics in Sydney and Melbourne and behavioural risk factor questionnaires were administered between January 2003 and October 2004. Results were compared with a cross sectional and a cohort study performed by our group that enrolled similar populations of men.

RESULTS

The majority of seroconverters (73%) reported more than five sexual partners in the last six months. Ninety-five men (92%) were able to identify a high-risk event (HRE) that they thought had led to their HIV seroconversion. Most (70%) reported receptive unprotected anal intercourse (UAI), insertive UAI, or both at their HRE. Sixteen men (16%) reported no UAI in the preceding six months including the HRE. Men were more likely to report receptive UAI at their HRE when they perceived a partner to be HIV-negative as compared with when they perceived a partner to be HIV-positive (P = 0.05). Injection drug use was reported by 22% of the men in the previous six months, and 62% reported intoxication with alcohol (> or =5 drinks) or mood altering recreational drug use at the HRE.

CONCLUSIONS

Gay and bisexual men who have recently seroconverted are highly sexually active and report high rates of unprotected anal intercourse and recreational drug use at the HRE.

"Serosorting" in casual anal sex of HIV-negative gay men is noteworthy and is increasing in Sydney, Australia

This paper addresses the question of whether HIV-negative gay men engage in "serosorting" in casual encounters. Serosorting, defined as engaging in unprotected anal intercourse with casual partners who they report to be HIV negative, has been increasing among HIV-negative gay men in Sydney. Prevention and intervention programmes are urgently needed to alert HIV-negative gay men to the risks associated with "serosorting", and remind them of the need for consistent condom use.

Prevalence and risk factors of hepatitis C in HIV-negative homosexual men in Sydney, Australia

OBJECTIVE

To determine the prevalence and risk factors for hepatitis C (HCV) in HIV-negative homosexual men in Sydney.

METHODS

A cohort study was conducted in a sample of community-based, HIV-negative, homosexual men in Sydney. Participants underwent a face-to-face interview regarding sexual behaviour, sexually transmissible infections, and injecting drug use (IDU).

RESULTS

Eight hundred and twenty-four men consented to HCV testing, and the prevalence was 0.85% (95% CI 0.34-1.74). HCV seropositivity was strongly associated with a history of IDU (OR = 60.43, 95% CI 6.70-544.79). All HCV seropositive individuals reported a history of either IDU or other means by which they may have had parenteral exposure to HCV. There was no evidence of an independent association between sexual behaviour and HCV infection.

CONCLUSION

The prevalence of HCV in this cohort was about the same as in the general population in Australia, and there was no evidence for sexual transmission in this population.

How has the sexual behaviour of gay men changed since the onset of AIDS: 1986-2003

OBJECTIVE

To report changes in sexual behaviour among gay men in Sydney from 1986 to 2003.

METHODS

Baseline data from four studies of gay men in Sydney were used: the Social Aspects of the Prevention of AIDS study (1986/87: 91 HIV-positive and 444 HIV-negative men); the Sydney Men and Sexual Health cohort (1993-95: 237 HIV-positive and 910 HIV-negative men); the Health in Men cohort of HIV-negative gay men (2001-03: 1,148 men); the Positive Health cohort of HIV-positive gay men (2001/02: 237 men). Each sample was recruited and interviewed using similar methods.

RESULTS

Fewer HIV-positive men had sex with casual partners over time (76.9% in 1986/87 to 63.7% in 2001/02; p = 0.001), but more HIV-negative men had sex with 10 or more casual partners in the previous six months (27.7% in 1986/87 to 37.7% in 2001-03; p = 0.012). The proportions engaging in particular sex practices with casual partners changed over time: anal intercourse without condoms that included ejaculation in the rectum fell from 29.4% among HIV-positive men and 32.4% among other men in 1986/87 to 17.8% and 10.0% respectively in 1993-95 (p = 0.034 and p < 0.001 respectively), but increased to 37.7% and 18.4% respectively in 2001-03 (p-values < 0.001); rimming one's partner increased from 36.8% among HIV-positive men and 17.6% among other men in 1986/87 to 63.6% and 52.3% respectively in 2001-03 (p = 0.001 and p < 0.001 respectively).

CONCLUSION

Gay men's sexual behaviour with casual partners has changed over time, perhaps partly in response to HIV and partly as a general expansion of sexual repertoires. These changes have implications for gay men's health.

Epidemic syphilis among homosexually active men in Sydney

OBJECTIVES

To describe trends in the notification of infectious syphilis in New South Wales, the characteristics of homosexually active men recently notified with early syphilis, and the seroprevalence and incidence of syphilis, as well as associated risk factors, in a Sydney cohort of HIV-negative homosexually active men.

DESIGN, SETTING AND PARTICIPANTS

Secondary analysis of New South Wales infectious syphilis surveillance data from 1998 to 2003; a case series of 57 homosexually active men diagnosed with early syphilis in inner Sydney from December 2002 to January 2004; and a prospective cohort study of syphilis among 1333 HIV-negative homosexually active men in Sydney recruited from June 2001 to December 2003.

MAIN OUTCOME MEASURES

Rates of notification of infectious syphilis in New South Wales and in areas of inner Sydney; behavioural and clinical features of men with syphilis in the case series; and incidence of syphilis and hazard ratios (HRs) associated with sexual behaviours in the cohort study.

RESULTS

Infectious syphilis notifications in inner Sydney rose more than 10-fold (from 6 in 1999 to 162 in 2003), and the increase was confined to men. Of 57 men with early syphilis in the case series, 54% were HIV-positive and 32% reported no symptoms of syphilis. These 57 men were highly sexually active and likely to report recreational drug use. In the cohort study, 1292 men (97% of participants) consented to syphilis testing; the incidence of syphilis was 0.78 per 100 person-years, and risk factors included reporting unprotected anal intercourse with HIV-positive partners (HR, 5.31; 95% CI, 2.00-184.93) and insertive oral sex (HR, 4.55; 95% CI, 1.14-18.18).

CONCLUSION

Syphilis has been re-established among homosexually active men in Sydney, and HIV-positive men are over-represented. Frequent screening is needed in this population to curb the transmission of both syphilis and HIV.