Sexual contexts and the process of risk reduction

Combination HIV Prevention Strategies Among Montreal Gay, Bisexual, and Other Men Who Have Sex with Men in the PrEP Era: A Latent Class Analysis

Pre-exposure prophylaxis (PrEP) became publicly available in Quebec for gay, bisexual and other men who have sex with men (GBM) in 2013. We used baseline data from Engage, a cohort of GBM recruited by respondent-driven sampling, to examine patterns of combination HIV prevention use among Montreal GBM since PrEP became available. Latent class analysis, stratified by HIV status, was used to categorize GBM by self-reported use of biomedical and behavioural prevention strategies. Correlates of resulting classes were identified using multinomial logistic regression. Among HIV-negative/unknown GBM (n = 968), we identified four classes: low use of prevention (32%), condoms (40%), seroadaptive behaviour (21%), and biomedical (including PrEP; 7%). Those using prevention (condoms, seroadaptive behaviour, and biomedical) had a higher number of anal sex partners and were more likely to report a recent sexually transmitted infection diagnosis. GBM using biomedical prevention also had a higher level of formal education. Among GBM living with HIV (n = 200), we identified three classes: mainly antiretroviral treatment (ART) with viral suppression (53%), ART with viral suppression and condoms (19%), and ART with viral suppression and seroadaptive behaviour (18%). Again, the number of anal sex partners was higher among those using condoms and seroadaptive behaviours. Our findings show antiretroviral-based prevention, either alone or in combination with other strategies, is clearly a component of the HIV prevention landscape for GBM in Montreal. Nevertheless, PrEP uptake remains low, and there is a need to promote its availability more widely.

"Losing the Phobia:" Understanding How HIV Pre-exposure Prophylaxis Facilitates Bridging the Serodivide Among Men Who Have Sex With Men

The use of HIV serostatus information has played a pivotal role in partner selection norms. A phenomenon known as serosorting is the practice of selecting a partner based on a perception that they are of the same HIV status in order to avoid transmission from one partner to the other. An understudied aspect of serosorting is that it has a divisive effect-one accepts or rejects a potential partner based on a singular characteristic, the partner's HIV status, and thus excludes all others. This division has been formally referred to as the HIV serodivide. In this study, we explored partner selection strategies among a group of HIV-negative, young men who have sex with men (n = 29) enrolled in a PrEP demonstration project in Northern California. We found that trends in serosorting were in fact shifting, and that a new and opposite phenomenon was emerging, something we labeled "seromixing" and that PrEP use played a part in why norms were changing. We present three orientations in this regard: (1) maintaining the phobia: in which men justified the continued vigilance and exclusion of people living with HIV as viable sex or romantic partners, (2) loosening/relaxation of phobia: among men who were reflecting on their stance on serosorting and its implications for future sexual and/or romantic partnerships, and (3) losing the phobia: among men letting go of serosorting practices and reducing sentiments of HIV-related stigma. The majority of participants spoke of changing or changed attitudes about intentionally accepting rather than rejecting a person living with HIV as a sex partner. For those who maintained strict serosorting practices, their understandings of HIV risk were not erased as a result of PrEP use. These overarching themes help explain how PrEP use is contributing to a closing of the HIV serodivide.

A Latent Class Analysis of Seroadaptation Among Gay and Bisexual Men

Initial research into seroadaptive strategies suggests that, individually, they are potentially effective behavioral methods to reduce risk of HIV transmission. Combining strategies, therefore, has the potential to increase risk reduction. The aim of this study was to determine how gay and bisexual men (GBM) combine strategies. To this end, a total of 774 sexually active GBM, aged ≥16 years, in Metro Vancouver, Canada, were recruited. Grouped by self-reported HIV status, latent class analysis of self-reported condom use, strategic positioning, anal sex avoidance, serosorting, viral-load sorting, and withdrawal were conducted. Multinomial logistical regression identified explanatory variables of class membership (i.e., sensation seeking, treatment optimism, sexual altruism, relationship status, number of partners, anal sex preference). Four latent classes were identified: Condom Users, Multiple Prevention Users, Viral-Load Sorters, and Serosorters. The majority of HIV-negative/unknown men (72 %) and a large proportion of HIV-positive men (42 %) belonged to the Condom Users class. Class membership was associated with age, relationship status, treatment optimism, sexual altruism, sensation seeking, number of recent male anal sex partners, and recent condomless anal sex with a serodiscordant or unknown-status partner. Understanding these distinct patterns allows for tailored interventions addressing GBM's sexual health needs.

"You just can't trust everybody": the impact of sexual risk, partner type and perceived partner trustworthiness on HIV-status disclosure decisions among HIV-positive black gay and bisexual men

HIV remains an intractable public health concern in the USA, with infection rates notably concentrated among Black gay and bisexual men. Status disclosure by HIV-positive individuals can be an important aspect of risk reduction but doing so poses dilemmas concerning privacy, stigma and self-protection, especially among populations subjected to multiple types of stigmatisation. Understanding the factors related to the disclosure process can help to inform prevention efforts. Using exploratory in-depth interviews, this qualitative study examines the disclosure process among a sample of twenty HIV-positive Black gay and bisexual men (mean age = 40) recruited through a non-profit health centre in a mid-western city in the USA. Data were analysed using a thematic analysis approach with HIV-disclosure as an a priori sensitising concept. Fears of stigma and secondary disclosure within social networks were critical barriers to talking about HIV with sexual partners and disclosure decisions involved a complex process centred on three primary themes: degree of sexual risk, partner type and perceived partner trustworthiness. The unique combinations of these contextual factors resulted in increased or decreased likelihood of disclosure. A conceptual model explicating a potential process by which these contextual factors influence disclosure decisions is presented.

Network dynamics of HIV risk and prevention in a population-based cohort of young Black men who have sex with men

Critical to the development of improved HIV elimination efforts is a greater understanding of how social networks and their dynamics are related to HIV risk and prevention. In this paper, we examine network stability of confidant and sexual networks among young black men who have sex with men (YBMSM). We use data from uConnect (2013–2016), a population-based, longitudinal cohort study. We use an innovative approach to measure both sexual and confidant network stability at three time points, and examine the relationship between each type of stability and HIV risk and prevention behaviors. This approach is consistent with a co-evolutionary perspective in which behavior is not only affected by static properties of an individual's network, but may also be associated with changes in the topology of his or her egocentric network. Our results indicate that although confidant and sexual network stability are moderately correlated, their dynamics are distinct with different predictors and differing associations with behavior. Both types of stability are associated with lower rates of risk behaviors, and both are reduced among those who have spent time in jail. Public health awareness and engagement with both types of networks may provide new opportunities for HIV prevention interventions.

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.

Barriers to Sexual Expression and Safe Sex Among Mexican Gay Men: A Qualitative Approach

Same-sex sexual practices among men in Mexico City are stigmatized. This article analyzes sexual practices and experiences of gay men in Mexico City and its implications on emotional and sexual health. The concept of sexual practices is used from a public health perspective, and the concept of sexual experiences from a psychological one, intending to understand both physical and emotional discomfort and pleasure in sexual contexts. The aim of this article is to analyze sexual practices and experiences of gay men in Mexico City and its implications on health, particularly emotions that can lead to depression, anxiety, substance abuse, and unsafe sex. Fifteen in-depth interviews were carried out with gay men of three generations who live in Mexico City. The data were analyzed using techniques from grounded theory to identify categories, and critical discourse analysis as an analytical approach to understand how social discourses affect subjectivity, emotions, and practices. Sexual practices and experiences are the result of homoerotic desire, which gender and heteronormative culture encourage to be kept hidden and clandestine. This leads men into risk contexts where practices are hardly negotiated, thus exposing themselves to sexually transmitted infections and abuse. These practices also produce a series of emotions such as guilt, shame, fear, and sadness that may develop into mental health issues such as depression and anxiety. Interventions at all levels must consider homophobic discrimination as part of gay men's daily lives and should be oriented toward decreasing it, to diminish discomforting emotions and reduce the probability of unsafe sex practices.

HIV-negative gay men's accounts of using context-dependent sero-adaptive strategies

We enrolled 166 gay and bisexual men who tested HIV-negative at a community sexual health clinic in Vancouver, British Columbia, into a year-long mixed-methods study. A subsample of participants who reported recent condomless anal sex (n = 33) were purposively recruited into an embedded qualitative study and completed two in-depth qualitative interviews. Analysis of baseline interviews elicited three narratives relevant to men's use of context- or relationally-dependent HIV-risk management strategies: (1) seroadaptive behaviours such as partner testing and negotiated safety agreements used with primary sexual partners, (2) serosorting and seroguessing when having sex with new partners and first-time hookups and (3) seroadaptive behaviours, including one or more of seropositioning/strategic positioning, condom serosorting and viral load sorting, used by participants who knowingly had sex with a serodiscordant partner. Within men's talk about sex, we found complex and frequently biomedically-informed rationale for seroadaptation in men's decisions to have what they understood to be various forms of safe or protected condomless anal sex. Our findings support the need for gay men's research and health promotion to meaningfully account for the multiple rationalities and seroadaptive strategies used for having condomless sex in order to be relevant to gay men's everyday sexual decision-making.

The eroticism of Internet cruising as a self-contained behaviour: a multivariate analysis of men seeking men demographics and getting off online

Most studies on men seeking men and who use the Internet for sexual purposes have focused on the epidemiological outcomes of Internet cruising. Other research has only focused on online sexual behaviours such as cybersex. The present study examines men who find the acts of Internet cruising and emailing to be erotic as self-contained behaviours. We surveyed 499 men who used craigslist.org for sexually-oriented purposes, and ran an ordinary least squares multiple regression model to determine the demographic characteristics of men seeking men who found Internet cruising erotic. Our results showed that younger compared to older men seeking men found the acts erotic. Likewise, men seeking men from mid-sized cities and large cities compared to men from smaller cities found Internet cruising and emailing to be erotic. Most notably, bisexual- and heterosexual-identifying men seeking men compared to gay-identifying men found these acts to be more erotic. Our results suggested that self-contained Internet cruising might provide dual functions. For some men (e.g., heterosexual-identifying men), the behaviour provides a sexual outlet in which fantasy and experimentation may be explored without risking stigmatization. For other men (e.g., those from large cities), the behaviour may be an alternative to offset sexual risk while still being able to 'get off'.

Sexual event-level characteristics of condom use during anal intercourse among HIV-negative men who have sex with men

BACKGROUND

Condom use remains central to sexually transmitted infections/HIV prevention among gay men and other men who have sex with men (MSM). To support the development of accurate and appropriate interventions, a better understanding is needed as to how the characteristics of a given sexual event differentially influence condom use during anal intercourse.

METHODS

Daily diary data were collected from (n = 3877) HIV-negative MSM who were members of several online Web sites facilitating social or sexual interactions with other men. Sexual event-specific factors related to condom use during anal intercourse were evaluated using logistic regression, with generalized estimating equation adjustment for multiple within-participant sexual events (STATA, 10.0; all P < 0.05).

RESULTS

Participants contributed 25,149 behavioral diaries. Of these, men reported 730 (2.9%) acts of anal intercourse as insertive partner and 662 (2.6%) as receptive partner. Condoms were used during 25.5% (n = 184) of insertive events, and 18.8% (n = 125) of receptive events. For both insertive and receptive anal roles, condom use was more likely with casual partners (OR = 4.24-6.59). Positive ratings of sexual pleasure were associated with condom use among men who were the insertive partner during anal intercourse, whereas condom nonuse was significantly related to higher ratings of pleasure among men who were the receptive partner.

CONCLUSIONS

Event-level relational and sexual-situational factors predict condom use differently, depending on whether men are the insertive or receptive partner in anal intercourse. Understanding these differences will help clinicians and health educators engage MSM in dialogue to increase condom use in situations where it is warranted.