Sexual health and life experiences: voices from behaviourally bisexual Latino men in the Midwestern USA

Revisiting the Prevalence of Unhealthy Alcohol Use Among Ethnic Minority Immigrant Gay, Bisexual Men, and Other Men Who Have Sex with Men in North America: A Systematic Review and Meta-analysis

Unhealthy alcohol use is a significant public health concern among ethnic minority immigrant gay, bisexual men, and other men who have sex with men (GBMSM) in North America. The definition of unhealthy alcohol use is any use that increases the risk of health consequences or has already led to negative health consequences. Despite its association with various health problems, this issue remains understudied in this population. Therefore, we aim to synthesize key findings to provide the prevalence of unhealthy alcohol use and related factors among this population in North America. We conducted a comprehensive literature search in multiple scientific databases to identify studies on alcohol use among ethnic minority immigrant GBMSM. Using random-effect modeling strategies, we aggregate and weigh the individual estimates, providing a pooled prevalence of unhealthy alcohol use within this population. Our review included 20 articles with 2971 participants (i.e., 53% were Latino, 45% were Asian/Pacific Islanders, and 2% were African). The meta-analysis revealed that 64% (95% CI 0.50, 0.78) of the participants reported recent alcohol use, while 44% (95% CI 0.30, 0.59) engaged in unhealthy alcohol use. Co-occurring health issues identified in the studies are other substance use (32%; 95% CI 0.21, 0.45), positive HIV status (39%; 95% CI 0.14, 0.67), and mental health issues (39%; 95% CI 0.21, 0.58). We also identified several factors associated with unhealthy alcohol use, including risky sexual behaviors, experiences of discrimination based on race and sexual orientation, and experiences of abuse. However, meta-regression results revealed no statistically significant associations between alcohol use and co-occurring health problems. This is the first study to systematically review unhealthy alcohol use among ethnic minority immigrant GBMSM. Despite the high burden of alcohol use, there is a dearth of research among Asian and African GBMSM. Our findings underscore the need for more research in these groups and provide insights to inform targeted clinical prevention and early intervention strategies to mitigate the adverse consequences of unhealthy alcohol use among ethnic minority immigrant GBMSM.

The Impact of Sibling Relationships on Behavioral and Sexual Health among Latino Sexual Minority Men

Pre-exposure prophylaxis (PrEP) is a highly effective method for preventing HIV acquisition and plays a crucial role in the Ending the HIV Epidemic in the US initiative. However, there are various barriers that hinder the access and uptake of PrEP among Latino sexual minority men (SMM) at individual, interpersonal, and cultural levels. While the significance of cultural factors in designing and implementing HIV prevention programs for Latino populations has been consistently emphasized in the literature and prioritized by the Centers for Disease Control and Prevention, few studies have directly integrated these cultural factors into their programs. Our study aimed to investigate the potential influence of siblings in promoting the utilization of PrEP for HIV prevention, an area that has received limited attention. We conducted interviews with 31 pairs of siblings between December 2020 and January 2021, which were held in either English or Spanish and lasted approximately 45-60 min. The data were analyzed using a deductive thematic content analysis approach. The interviews revealed several key themes and categories, including: (1) Sibling support for coming out; (2) Types of support that siblings provide to each other for behavior change; (3) Sibling support for PrEP; and (4) The impact of the study interview on the quality of the sibling relationships. Our findings indicated that siblings were willing to provide support for PrEP in various ways, ranging from emotional support for brothers who may be concerned about potential rejection to practical support such as transportation or financial assistance. These results have significant implications for the design of HIV prevention interventions for Latinos. Incorporating siblings or other extended family members into these interventions can facilitate communication between siblings and their brothers, ultimately encouraging the use of PrEP or similar prevention methods. By considering the unique dynamics and support systems within Latino communities, researchers can develop more effective strategies to promote HIV prevention and support the well-being of Latino SMM.

A Systematic Literature Review of Community-Based Participatory Health Research with Sexual and Gender Minority Communities

Purpose:

The objective was to review sexual and gender minority (SGM) health research studies to gain an understanding of how the community-based participatory research (CBPR) framework has been operationalized.

Methods:

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to conduct a review of all SGM health research studies published in the past 10 years that cited a CBPR approach (PROSPERO Registration No. CRD42016036608). CINAHL, PubMed, and PsycINFO databases were systematically searched in October 2020. Dimensions of community involvement (e.g., shared decision-making; flexibility to community needs and priorities) and the strength of evidence for each dimension were rated using guidance from the Agency of Healthcare Research and Quality.

Results:

The 48 eligible articles identified reported a range of 0–11 (out of 13) community elements. Seven studies reported zero elements. Qualitative studies (n=28; 58.3%) had an average quality score of 2.32 (range: 1.43–2.5). The 15 (31.3%) cross-sectional studies had an average quality score of 2.08 (range: 1.64–2.27).

Conclusion:

Adhering to the CBPR framework is challenging. The benefits of striving toward its principles, however, can move us toward transformative and sustainable social change within SGM communities.

Sexual Health, HIV Care and Pre-exposure Prophylaxis in the African Immigrant Population: A Needs Assessment

The objective was to gain insight, from the perspective of healthcare professionals, non-medical service providers and community-based organizations working with a large majority of African immigrant patients or clients, regarding sexual health and the potential for the use of HIV PrEP in this priority population. Thirty key informants participated in a needs assessment. A questionnaire was used to obtain information through focus groups, structured interviews and by self-administration. There are cultural and linguistic barriers to engaging Africans in discussing sexual health issues. Key challenges to uptake of PrEP are multi-dimensional: socioeconomic [immigration status, housing]; cultural [talking about sex 'taboo', HIV related stigma, no concept of preventive care]; provider-related (cultural competency, inadequate PrEP education, language barrier); and individual (lack of awareness, perception of HIV risk). Meeting basic needs like housing, assuring access to care (including PrEP), community-based education, relevant training of providers, and tailored messaging are strongly recommended. Effectively addressing HIV incidence in the African-born immigrant population redonequires a multi-pronged approach.

The Health of Undocumented Latinx Immigrants: What We Know and Future Directions

Undocumented Latinx immigrants experience unique factors prior to migration, during migration, and after migration that shape their health. Our review summarizes the limited but growing literature highlighting how exposure to trauma, immigration enforcement, changes to social networks, and discrimination negatively affect the mental and physical health of undocumented Latinx immigrants. We also discuss how policies and social ties can promote their health. We focus on areas of particular concern, including health care, mental health, and HIV. Future research should use interdisciplinary approaches and intersectional frameworks to understand and address health inequities. Conducting research with undocumented Latinx immigrant communities requires community engagement, assurance of confidentiality, and creative recruitment and retention strategies. Recommendations for public health practice include investing in community health centers and organizations to ensure access to health and social services; presenting results with sufficient contextualization to interpret their generalizability; and advocating for federal-, state-, and local-level policy changes that reduce the negative health consequences associated with being undocumented.

Understanding HIV risk and vulnerability among cisgender men with transgender partners

In the HIV pandemic, cisgender (ie, non-transgender) men with transgender partners are an underserved population. Complexities of sexuality and gender affect HIV vulnerability for this group, including not identifying with conventional sexual orientation categories (eg, bisexual, heterosexual, or gay) and having attractions based on gender role or expression rather than genital anatomy. Only one HIV prevention interventional study in this population was identified, and one study that assessed the perceived acceptability of an intervention. We found no data for interventions using pre-exposure prophylaxis, interventions for cisgender men with transgender men partners, or cisgender men with casual or transactional sexual partnerships with transgender people. Cisgender men with transgender partners are not easily categorised using traditional HIV risk categories. Additional research is needed to understand stigma and other structural drivers of HIV vulnerability, sexual networks and practices, substance use patterns, and biomedical prevention interest and uptake for this group. Studies that use an intersectional lens and syndemic framework could offer key insights.

Meeting the Sexual Health Needs of Bisexual Men in the Age of Biomedical HIV Prevention: Gaps and Priorities

The field of HIV/STI prevention has primarily focused on gay men (or "men who have sex with men" [MSM] as a broad category) with limited attention to bisexual men in particular. Although bisexual men are also at increased risk for HIV and other STI, they are less likely to utilize HIV/STI prevention services than gay men, and very few interventions have been developed to address their unique needs. Further, while biomedical advances are changing the field of HIV prevention, bisexual men are also less likely to use biomedical HIV prevention strategies (e.g., pre-exposure prophylaxis [PrEP]) than gay men. In an effort to advance research on bisexual men and their sexual health needs, the goals of this commentary are: (1) to review the empirical literature on the prevalence of HIV/STI among bisexual men, the few existing HIV/STI prevention interventions developed for bisexual men, and the use of biomedical HIV prevention among bisexual men; (2) to describe the ways in which the field of HIV/STI prevention has largely overlooked bisexual men as a population in need of targeted services; and (3) to discuss how researchers can better address the sexual health needs of bisexual men in the age of biomedical HIV prevention.

Meeting the Sexual Health Needs of Bisexual Men in the Age of Biomedical HIV Prevention: Gaps and Priorities

The field of HIV/STI prevention has primarily focused on gay men (or "men who have sex with men" [MSM] as a broad category) with limited attention to bisexual men in particular. Although bisexual men are also at increased risk for HIV and other STI, they are less likely to utilize HIV/STI prevention services than gay men, and very few interventions have been developed to address their unique needs. Further, while biomedical advances are changing the field of HIV prevention, bisexual men are also less likely to use biomedical HIV prevention strategies (e.g., pre-exposure prophylaxis [PrEP]) than gay men. In an effort to advance research on bisexual men and their sexual health needs, the goals of this commentary are: (1) to review the empirical literature on the prevalence of HIV/STI among bisexual men, the few existing HIV/STI prevention interventions developed for bisexual men, and the use of biomedical HIV prevention among bisexual men; (2) to describe the ways in which the field of HIV/STI prevention has largely overlooked bisexual men as a population in need of targeted services; and (3) to discuss how researchers can better address the sexual health needs of bisexual men in the age of biomedical HIV prevention.

Humanizing an Invisible Population in India: Voices from Bisexual Men Concerning Identity, Life Experiences, and Sexual Health

Research examining the sexual identities, behaviors, and experiences of bisexual men outside of Western contexts (including in India) is limited. Individuals who self-identify as bisexual due to their orientation toward partners of more than one gender face distinct psychosocial challenges relative to exclusively heterosexual, gay/lesbian, or other individuals. We conducted four focus group discussions (n = 22) and in-depth interviews (n = 50) with self-identified bisexual men (age 18 years and older) who were recruited from the metropolitan area of Mumbai, India, between June and August 2013. We triangulated and analyzed focus group and interview data using standard qualitative research techniques. Findings from our study suggest that multiple factors influence the sexual experiences of self-identified bisexual men in Mumbai, including contexts of sexual interactions, sexual positioning, and the gender of sexual partners. Participants described cultural meaning systems and psychosocial dynamics that regulate bisexual identity development, disclosure, and sexual decision making with male, female, and other partners. Secrecy, discretion, and sexual pleasure also influenced sexual behaviors and relationships. Although Western sexual identity categories are not necessarily equivalent in the Indian context, it is interesting and important to note that a number of individuals in India continue to use the identity label of "bisexual." Before developing interventions to meet unique sexual health needs of bisexual men, it is crucial to understand how these men perceive themselves, reconcile the ordinary aspects of their lives with their sexuality, and structure their relationships with partners.

Paths to Parenthood Among Self-Identified Bisexual Individuals in the United States

Bisexual parents have been notably absent from prior research on parenting, despite comprising the largest proportion of parents among "lesbian, gay, and bisexual" (LGB) individuals. Indeed, recent national probability data indicate that young bisexual women are more likely than their heterosexual counterparts to report having at least one child. Intentions to have children, patterns of family planning and contraception use, and related issues have important implications for health and healthcare-related decisions and priorities among bisexual parents. We conducted in-depth interviews with a sample of 33 bisexual parents from across the U.S. who reported having at least one child (genetic, adopted, step or foster child, guardian, and/or warden of the state). In cases of intentional pregnancies, participants considered relationship and financial stability, job security and their ideal family size. Unintentional pregnancies, as well as pregnancy terminations, were often reframed as positive experiences. After deciding not to have more children, participants reported using contraceptive methods, including sterilization or long-acting reversible contraceptive methods (e.g., intrauterine devices). Instances of deception, in which partners deceived participants with false beliefs regarding their contraceptive use, were recalled negatively for the relatively small number of participants who reported such experiences. Overall, our findings point to a diversity in the intentions and ways bisexual individuals become parents, similar to parents of other sexual identities. Acknowledgements of the diverse experiences and concerns faced by bisexual parents may be beneficial in improving efforts related to providing appropriate and relevant health- and healthcare-related services.

Exploring the Roles of Race, Ethnicity, Nationality, and Skin Color in the Sexual Partner Choices of Bisexual Latino Men

Racial and ethnic differences are well-documented social factors shaping sexual interactions. However, these racial/ethnic dynamics have been mostly overlooked in the context of sexual fluidity, specifically for bisexual individuals. Furthermore, there is limited literature on how sexual objectification based on skin color and ethnicity, factors well documented to influence individual's sexual partnering decision, might be different for male, female, and/or transgender partners of bisexual individuals. From 2009 to 2014, we conducted a mixed methods study examining how bisexual Latino men construct and participate in their sex markets. In the qualitative component of the study, we asked behaviorally bisexual Latino men (n = 148) how race/ethnicity, prejudice, stereotyping, and objectification intersected with their sexuality, specifically perceptions of their sexual experiences, decision making regarding sexual partners, and their reflection of their own race/ethnicity in their sexuality. We conducted a content analysis and identified three recurrent themes that are fully described in this article: (1) Bisexual Latino men objectify other men based on skin color, ethnicity, and race; (2) the race and ethnicity of women and transgender partners were not a dominant factor in sexual partnering decision making; and (3) sexual objectification based on skin color and ethnicity was a frequent, dominant experience throughout the sexual histories of our study participants. In summary, our findings suggest that bisexual Latino men participate in sex markets where race, ethnic, and nationality differences play a role in shaping men's desires for other men as sexual partners and they themselves are objects of desire.

Reasons for Non-Disclosure of Sexual Orientation Among Behaviorally Bisexual Men: Non-Disclosure as Stigma Management

Although bisexual men are known to be less likely to disclose their sexual orientation to others than gay men, the reasons why bisexual men choose or feel unable to disclose have received minimal research attention. To examine the reasons behaviorally bisexual men offer for not disclosing to their friends, family, and female partners, in-depth interviews were conducted with an ethnically diverse sample of 203 men who had not disclosed their same-sex behavior to their female sexual partners in New York City. Men were recruited from multiple venues and online sources using a targeted sampling approach. Transcripts were thematically analyzed using Atlas.ti software. Contrary to the theory that non-disclosure is due to uncertainty about one's sexual identity, the reasons offered for non-disclosure revealed that it was largely a method to avoid stigmatizing reactions from others. Men reported a number of specific reasons for non-disclosure, including (1) anticipation of negative emotional reactions; (2) anticipation of negative changes in relationships; (3) belief that others held stigmatizing attitudes toward homosexuality; (4) prior experience with negative reactions to disclosure; (5) wanting to maintain others' perceptions of him; (6) fear that those told would disclose to additional people; and (7) fear of rejection due to culture or religion. These findings provide insights into the reasons why many behaviorally bisexual men choose not to disclose, potential reasons why bisexual and gay men differ in the extent to which they disclose, and potential reasons why some bisexual men report greater emotional distress than gay men. Further, they suggest that greater attention needs to be placed on addressing the stigmatizing contexts that confront bisexual men and providing them with strategies to manage stigma.

Promoting Pre-exposure Prophylaxis to Prevent HIV Infections Among Sexual and Gender Minority Hispanics/Latinxs

Sexual and gender minority Hispanics/Latinxs (henceforth: Latinxs) continue to be disproportionately impacted by HIV/AIDS in the U.S. Pre-exposure prophylaxis (PrEP) is a biomedical prevention approach which holds significant promise for at risk and vulnerable populations. We discuss barriers and facilitators to uptake of PrEP among sexual and gender minority Latinxs living in the U.S. through an ecosocial lens that takes into account structural, community, and individual contexts. The impact of immigration status on PrEP uptake emerges as a major and recurrent theme that must be understood and addressed by HIV prevention programs aiming to promote an inclusive strategy for sexual and gender minority Latinxs living in the U.S.

Promoting the wellbeing of lesbian, gay, bisexual and transgender forced migrants in Canada: providers' perspectives

Researchers are beginning to document the experiences of lesbian, gay, bisexual and transgender (LGBT) forced migrants in settlement. However, studies exploring the perceptions of service providers working with this vulnerable population are limited. These may shed light on the challenges of meeting the needs of LGBT forced migrants, especially mental health issues and problems. This qualitative study elicited the views of 22 Canadian service providers, including advocates, lawyers and mental health practitioners, who serve LGBT forced migrants. Grounded theory analysis revealed the following four themes: facilitating safety, buffering rejection; tracking avoidance patterns; interpreting mental health; and negotiating identity paradigms. Participants' accounts suggest that LGBT forced migrants may be best served by providers who understand the exigencies of establishing trust and safety for their clients; recognise their clients' nuanced social support needs; facilitate the refugee claims process; grasp the complexity of their clients' mental health challenges; and interrogate their own cultural biases regarding sexual orientations and gender identities.

Evaluating the impact of immigration policies on health status among undocumented immigrants: a systematic review

Over the past two decades, new anti-immigration policies and laws have emerged to address the migration of undocumented immigrants. A systematic review of the literature was conducted to assess and understand how these immigration policies and laws may affect both access to health services and health outcomes among undocumented immigrants. Eight databases were used to conduct this review, which returned 325 papers that were assessed for validity based on specified inclusion criteria. Forty critically appraised articles were selected for analysis; thirty articles related to access to health services, and ten related to health outcomes. The articles showed a direct relationship between anti-immigration policies and their effects on access to health services. In addition, as a result of these policies, undocumented immigrants were impacted by mental health outcomes, including depression, anxiety, and post-traumatic stress disorder. Action items were presented, including the promotion of cultural diversity training and the development of innovative strategies to support safety-net health care facilities serving vulnerable populations.

'He's still with these girls': exploring perceptions of HIV risk among men with behaviourally bisexual male partners

Recent studies have called for more nuanced research into the relationships between behaviourally bisexual men and their sexual partners. To address this, we conducted a longitudinal qualitative study with self-identifying gay men; participants took part in timeline-based interviews and relationship diaries. We conducted a thematic analysis of verbatim transcripts to understand how relationship motivations, emotions and relationship dynamics influenced perceptions of HIV risk with behaviourally bisexual male partners. Participants described how partnership types (main and casual) and relationship dimensions (exclusivity, commitment, emotional attachment and relationship designation) strongly influenced perceptions of HIV risk and shaped their decisions to choose behaviourally bisexual male sex partners. Results reveal the crucial role relationship dynamics play in the shaping of HIV risk perceptions, sexual decision-making and HIV risk between partners, and provide potential insight on how to message HIV risk to gay men and their behaviourally bisexual male partners. It is imperative that HIV prevention is able to message key concepts of risk, decision-making and partner negotiation in a way that does not act to stereotype or create stigma against behaviourally bisexual men and their male partners.

Saliendo Adelante: Stressors and Coping Strategies Among Immigrant Latino Men Who Have Sex With Men in a Nontraditional Settlement State

Immigrant Latino men who have sex with men (MSM) are marginalized along multiple dimensions (e.g., ethnicity, sexual orientation, language use), which can negatively affect their health and well-being. As little is known about how this subgroup experiences the stress of marginalization and how, in turn, they cope with such stress, this study investigated stressors and coping strategies to better understand the factors shaping Latino MSM health. Assisted by a community advisory committee, we conducted in-depth interviews with 15 foreign-born Latino MSM in a nontraditional settlement state. Drawing on grounded theory methods, we analyzed transcripts iteratively to identify processes and characterize themes. Results were confirmed in member check interviews (n = 4) and findings were further contextualized through key informant interviews (n = 3). Participants reported ubiquitous, concurrent stressors due to being an immigrant, being a sexual minority, and being working poor. In particular, homophobia within families and local Latino communities was seen as pervasive. Some participants faced additional stressors due to being undocumented and not being Mexican. Participants drew on four types of coping strategies, with no dominant coping response: passive coping (i.e., not reacting to stressors); attempting to change stressors; seeking social support; and seeking distractions. Family ties, especially with mothers, provided key emotional support but could also generate stress related to participants' sexuality. This study lays a foundation for future work and is particularly relevant for Latino MSM in nontraditional settlement states. Findings may inform future interventions to reduce stressors and increase resiliency, which can positively affect multiple health outcomes.

Adaptation of a Couple-Based HIV/STI Prevention Intervention for Latino Men Who Have Sex With Men in New York City

Predominantly Spanish-speaking Latino men who have sex with men (MSM) and their same-sex partners continue to be at high risk for HIV and STIs. Behavioral research has identified how relationship dynamics for male couples are associated with sexual risk behavior. Connect 'n Unite (CNU), an evidence-based HIV/STI prevention intervention originally created for Black MSM and their same-sex partners, was adapted for predominantly Spanish-speaking Latino MSM and their same-sex partners on the assumption that its key elements would be translatable while its efficacy would be retained. A systematic adaptation process utilizing qualitative methods was used, including intervention adaptation sessions with 20 predominantly Spanish-speaking Latino gay couples and 10 health service providers. The process included five steps: (1) engaging community stakeholders, (2) capturing the lived experiences of Latino gay couples, (3) identifying intervention priorities, (4) integrating the original intervention's social cognitive theory into a relationship-oriented, ecological framework for Latino gay couples, and (5) adapting intervention activities and materials. The adapted intervention, which we called Latinos en Pareja or Latinos in a Relationship, incorporates elements that effective HIV prevention interventions share, including: a solid theoretical foundation; emphasis on increasing risk reduction norms, sexual communication skills and social support for protection; and guidance on how to utilize available, culturally and linguistically appropriate services. The systematic adaptation approach used for a couples-based HIV prevention intervention also can be employed by other researchers and community stakeholders to adapt evidence-based interventions that promote wellness, linkage to care, and disease prevention for populations not originally targeted.

Syndemic factors associated with drinking patterns among Latino men and Latina transgender women who have sex with men in New York City

Alcohol consumption is a significant public health concern among Latino men and Latina transgender women who have sex with men. However, characteristics and behaviors associated with alcohol consumption in this population, particularly in regard to the complex influence of syndemic factors, remain understudied. The purpose of this study was to examine predictors of high-risk alcohol consumption (i.e. binge or heavy drinking). Between January and March of 2014, 176 Latino men and Latina transgender women in New York City completed an interviewer-administered questionnaire. We developed a syndemics scale to reflect the total number of syndemic factors - clinically significant depression, childhood sexual abuse, intimate partner violence, and discrimination - reported by each participant. We also carried out a multinomial logistic regression model predicting binge and heavy drinking. Forty-seven percent of participants reported high-risk alcohol consumption in the past 30 days (21% binge and 26% heavy). Approximately 16% of participants reported no syndemic factors, 27% reported one factor, 39% reported two factors, and 18% reported three or four. In the multinomial logistic regression model, our syndemic factors scale was not significantly associated with binge drinking. However, participants who reported three or four factors were significantly more likely to report heavy drinking. In addition, having multiple sexual partners was associated with an increased risk of binge and heavy drinking; involvement in a same-sex relationship was associated with binge drinking. Further work is needed to develop effective prevention intervention approaches for high-risk alcohol consumption within this population.

Community-Based Participatory Research Studies on HIV/AIDS Prevention, 2005-2014

The recent literature on community-based participatory research (CBPR) approaches to preventing HIV infection in diverse communities was systematically reviewed as part of the planning process for a new study. Published HIV prevention studies that employed CBPR methods were identified for the period January 1, 2005 to April 30, 2014 using PubMed databases and MeSH term and keyword searches. A total of 44 studies on CBPR and HIV or AIDS prevention were identified, of which 3 focused on adolescents, 33 on adults, and 8 on both adolescents and adults. A variety of at-risk populations were the focus of the studies including men who have sex with men, African American or Hispanic men, and African American or Hispanic women. Few studies focused on Asian/Pacific Islander or American Indian populations in the U.S. Six studies employed CBPR methods to address HIV prevention in church settings. Many of the studies were limited to formative research (ethnographic research, in-depth interviews of key informants, or focus groups). Other studies had a pre-/post-test design, quasi-experimental, or randomized design. Additional CBPR studies and faith-based interventions are needed with adequate sample sizes and rigorous study designs to address lack of knowledge of HIV and inadequate screening in diverse communities to address health disparities.

Integration of Social, Cultural, and Biomedical Strategies into an Existing Couple-Based Behavioral HIV/STI Prevention Intervention: Voices of Latino Male Couples

INTRODUCTION

Successful HIV prevention and treatment requires evidence-based approaches that combine biomedical strategies with behavioral interventions that are socially and culturally appropriate for the population or community being prioritized. Although there has been a push for a combination approach, how best to integrate different strategies into existing behavioral HIV prevention interventions remains unclear. The need to develop effective combination approaches is of particular importance for men who have sex with men (MSM), who face a disproportionately high risk of HIV acquisition.

MATERIALS AND METHODS

We collaborated with Latino male couples and providers to adapt Connect 'n Unite, an evidence-based intervention for Black male couples, for Latino male couples. We conducted a series of three focus groups, each with two cohorts of couples, and one focus group with providers. A purposive stratified sample of 20 couples (N = 40, divided into two cohorts) and 10 providers provided insights into how to adapt and integrate social, cultural, and biomedical approaches in a couples-based HIV/AIDS behavioral intervention.

RESULTS

The majority (N = 37) of the couple participants had no prior knowledge of the following new biomedical strategies: non-occupational post-exposure prophylaxis (nPEP); pre-exposure prophylaxis (PrEP); and HIV self-testing kits. After they were introduced to these biomedical interventions, all participants expressed a need for information and empowerment through knowledge and awareness of these interventions. In particular, participants suggested that we provide PrEP and HIV self-testing kits by the middle or end of the intervention. Providers suggested a need to address behavioral, social and structural issues, such as language barriers; and the promotion of client-centered approaches to increase access to, adaptation of, and adherence to biomedical strategies. Corroborating what couple participants suggested, providers agreed that biomedical strategies should be offered after providing information about these tools. Regarding culturally sensitive and responsive approaches, participants identified stigma and discrimination associated with HIV and sexual identity as barriers to care, language barriers and documentation status as further barriers to care, the couple-based approach as ideal to health promotion, and the need to include family topics in the intervention.

DISCUSSION

We successfully adapted an evidence-based behavioral HIV prevention intervention for Latino male couples. The adapted intervention, called Conectando Latinos en Pareja, integrates social, cultural, behavioral and biomedical strategies to address the HIV epidemic among Latino MSM. The study highlights the promise regarding the feasibility of implementing a combination approach to HIV prevention in this population.

Assessing Collectivism in Latino, Asian/Pacific Islander, and African American Men Who Have Sex With Men: A Psychometric Evaluation

The study of collectivism has implications for HIV prevention research, especially in studies that use a social networking or community mobilization approach. However, research on collectivism in race/ethnicity and sexual minority groups is limited. We psychometrically evaluated a brief version of the Individualism-Collectivism Interpersonal Assessment Inventory (ICIAI) in a chain-referral sample of 400 Latino, 393 Asian/Pacific Islander, and 403 African American men who have sex with men (MSM). Data were collected via a one-time survey on demographics, the ICIAI, acculturation, and ethnicity identity. We conducted a multiple groups confirmatory factor analysis to assess for measurement invariance across the three groups of MSM, as well as tested its reliability and validity. The ICIAI evidenced good psychometric properties and was invariant across all groups. We highlight implications for how this measure of collectivism can be applied toward the study of HIV prevention and in lesbian, gay, bisexual and transgender communities.

Sexual Relationships, Behaviors, and Experiences among Bisexual Men in Mumbai, India

This exploratory study aimed to assess a range of sexual behaviors, relationships and related factors among a sample of bisexual men in Mumbai, India. Data collection occurred in two separate phases: 1. focus group discussions were facilitated with local community members in order to finalize an interviewer-administered questionnaire, and 2. structured interviews were conducted with a sample of 50 bisexual men using this questionnaire. Participants self-reported a wide range of sexual behaviors and relationships. Findings have implications for future research and practice focusing on bisexual men in India, as well as their partners of all genders.

HIV practitioners in Madrid and New York improving inclusion of underrepresented populations in research

Practitioners have frequent contact with populations underrepresented in scientific research--ethnic/racial groups, sexual minorities and others at risk for poor health and whose low participation in research does not reflect their representation in the general population. Practitioners aspire to partner with researchers to conduct research that benefits underrepresented groups. However, practitioners are often overlooked as a work force that can help erase inclusion disparities. We recruited (n = 282) practitioners (e.g. physicians, social workers, health educators) to examine associations between their attitudes toward research purposes, risks, benefits and confidentiality and their involvement in recruitment, interviewing and intervention facilitation. Participants worked in community-based agencies in Madrid and New York City (NYC), two large and densely populated cities. We used cross-sectional data and two-sample tests to compare attitudes toward research and practitioner involvement in recruiting, interviewing and facilitating interventions. We fit logistic regression models to assess associations between practitioner attitudes toward ethical practices and recruitment, interviewing and facilitating interventions. The likelihood of recruiting, interviewing and facilitating was more pronounced among practitioners agreeing more strongly with ethical research practices. Though Madrid practitioners reported stronger agreement with ethical research practices, NYC practitioners were more involved in recruiting, interviewing and facilitating interventions. Practitioners can be trained to improve attitudes toward ethical practices and increase inclusion of underrepresented populations in research. Funders and researchers are encouraged to offer opportunities for practitioner involvement by supporting research infrastructure development in local agencies. Practices that promise to facilitate inclusion herein may be used in other countries.

The Association Between Alcohol Consumption and Condom Use: Considering Correlates of HIV Risk Among Black Men Who Have Sex with Men

Epidemiological data indicate Black men who have sex with men (MSM) are the most at-risk group for HIV infection. However, the factors driving this disparity are not fully understood. Condom use remains a significant point of intervention in mitigating sexually transmitted infections. Alcohol consumption is highly prevalent among Black MSM, has a significant role in the culture of sex, and may significantly interfere with condom use. This review will examine the relationship between alcohol consumption and condom use among Black MSM. In this review we, (a) discuss the prevalence of alcohol use among MSM and its association with condom use; (b) consider the role of alcohol in the culture of MSM; (c) review the literature on the relationship between alcohol and condom use; and (d) discuss the role of several empirically-supported moderating variables in strengthening the relationship between alcohol use and noncondom use. This review places the finding and implications for HIV risk among Black MSM in the context of the broader literature on MSM.

Heteronormativity and sexual partnering among bisexual Latino men

Our analyses address the question of how bisexual Latino men organize their sexual partnerships. Heteronormativity can be understood as the set of social norms and normative structures that guide sexual partnering among men and women. We provide descriptive statistics to describe bisexual Latino men's sexual partnerships. Logistic and linear regression modeling were used to explore bivariate and multivariate relationships. Of our total sample (N = 142), 41.6 % had unprotected vaginal intercourse 2 months prior to the interview; 21.8 % had unprotected anal intercourse with female partners; 37.5 % had unprotected insertive anal intercourse with male partners; and 22.5 % had unprotected receptive anal intercourse with male partners. In our multivariate model, machismo was directly associated with meeting female partners through formal spaces (workplace, school, and/or church), but inversely associated with meeting male partners in formal spaces. Machismo was positively associated with meeting male sex partners through social networks (i.e., friendship and kinship networks). The more comfortable men were with homosexuality the less likely they were to meet men online and the more likely they were to meet men through social networks of friends and kinship. Interventions to reduce sexually transmitted diseases that target bisexual behavior as an epidemiological "bridge" of transmission from homosexual to heterosexual networks might very well benefit from a more complex understanding of how Latino bisexuality is patterned. Thus, this exploratory analysis might lead to a rethinking of how to address risk and vulnerability among Latino bisexual men and their sexual networks.

Beyond the bisexual bridge: sexual health among U.S. men who have sex with men and women

CONTEXT

Men who have sex with both men and women (MSMW) experience health problems in ways that distinguish them from men who only have sex with men (MSM) and men who only have sex with women (MSW). Historically, an undue focus on MSMW's potential role in transmitting HIV to women has resulted in limited understanding of these men's unique sexual health needs. This article discusses the sexual health of MSMW in the U.S.

EVIDENCE ACQUISITION

The author searched PubMed, Sociological Abstracts, PsycINFO, and GoogleScholar to acquire peer-reviewed studies pertaining to MSMW that were published during January 2008 and December 2013. Reference lists for these studies provided additional studies not acquired through this search.

EVIDENCE SYNTHESIS

MSMW are more likely than MSW to be infected with HIV. MSMW may be at increased risk for some other sexually transmitted infections (STIs) compared with both MSW and MSM. Some factors that affect their sexual health include unprotected sex, early sexual debut, forced sexual encounters, increased numbers of sexual partners, substance use, exchange sex, risk behaviors of their male and female partners, and pregnancy-related considerations. These factors uniquely shape MSMW's vulnerability to HIV/STIs and other sexual health problems. Anti-bisexual sentiment, socioeconomic marginalization, culturally specific masculine ideologies, and sexual identity can negatively influence their sexual partnerships and likelihood of disease acquisition.

CONCLUSIONS

Risk-reduction interventions alone are likely insufficient to improve MSMW's sexual health. Efforts should also address the social contexts affecting MSMW in order to decrease HIV/STI vulnerability and mitigate other barriers to MSMW's sexual health.

Types of female partners reported by black men who have sex with men and women (MSMW) and associations with intercourse frequency, unprotected sex and HIV and STI prevalence

We used baseline data from a study of Black MSM/MSMW in 6 US cities to examine the association of female partnership types with disease prevalence and sexual behaviors among the 555 MSMW participants. MSMW reported more than three times as many total and unprotected sex acts with each primary as they did with each non-primary female partner. We compared MSMW whose recent female partners were: (1) all primary ("PF only", n = 156), (2) both primary and non-primary ("PF & NPF", n = 186), and (3) all non-primary ("NPF only", n = 213). HIV/STI prevalence did not differ significantly across groups but sexual behaviors did. The PF only group had the fewest male partners and was the most likely to have only primary male partners; the PF & NPF group was the most likely to have transgender partners. PF & NPF men reported the most sex acts (total and unprotected) with females; NPF only men reported the fewest. Implications for HIV risk and prevention are discussed.

Are bisexually active men a 'bridge' for HIV transmission to the 'general population' in Germany? Data from the European Men-Who-Have-Sex-With-Men Internet Survey (EMIS)

To assess the situation of bisexually active men in the German HIV epidemic, data from a 2010 internet survey about sexual health among men who have sex with men were used to assess HIV testing rates, condom use and risk contact among the following groups of respondents: bisexually active single men, bisexually active men with a regular female partner, bisexually active men with a regular male partner and exclusively homosexually active men. Of the 54,387 respondents from Germany, 12% reported having sex contacts with both men and women in the previous year. Descriptive statistics were used to explore the sample's socio-demographic characteristics and to identify relevant inter-group differences in sexual attraction, identity, awareness among contacts of attraction to men, number of sex partners, history of anal intercourse, recruitment of partners online, history of HIV testing and drug use. Multivariable regression analyses were used to assess potential associations between these variables and risk contacts, defined as having reported unprotected anal intercourse with male partners of unknown or discordant serostatus in the previous year. Bisexually active groups reported relatively few risk contacts, strengthening the argument that there is little support for the existence of a substantial 'bisexual bridge' in Germany.

Gender matters: condom use and nonuse among behaviorally bisexual men

Although frequently cited as being at high risk for HIV/STI transmission, little is known about behaviorally bisexual men's patterns and experiences of condom use and nonuse with male and female sexual partners. Using a variety of recruitment techniques informed by a Community Advisory Committee, a total of 77 behaviorally bisexual men were recruited from Indianapolis, Indiana to participate in semi-structured interviews focused on sexual health. Qualitative data were collected containing detailed information on their patterns and experiences of condom use and nonuse with both male and female partners. Participants described numerous commonly reported barriers for consistent condom use, as well as distinct bisexual-specific barriers. The majority reported consistent condom use with male and female casual partners, but many who did not use condoms described doing so in the context of ongoing relationships. In addition, participants provided reasons for condom use and nonuse that varied based on the gender of the partner and the type of relationship with the partner. Future interventions focused on increasing condom use among behaviorally bisexual men should take into account the unique complexities of gender and relationship configurations in this distinct population.

Sex markets and sexual opportunity structures of behaviorally bisexual latino men in the urban metropolis of new york city

Sex markets (the spatially and culturally bounded arenas) that shape bisexual behavior among Latino men have been utilized as a deterministic concept without a sufficient focus on the ability of individuals to make autonomous decisions within such arenas. We nuance the theory of sex markets using the concept of sexual opportunity structures to investigate the ways in which behaviorally bisexual Latino men in the urban metropolis of New York City navigate sexual geographies, cultural meaning systems, sexual scripts, and social institutions to configure their bisexual behaviors. Drawing on 60 in-depth interviews with bisexual Latino men in New York City, we first describe and analyze venues that constitute sexual geographies that facilitate and impede sexual interaction. These also allow for a degree of autonomy in decision-making, as men travel throughout the urban sexual landscape and sometimes even manage to reject norms, such as those imposed by Christian religion. We explore some of the cultural meaning systems and social institutions that regulate sex markets and influence individual decision-making. Secrecy and discretion-regulated by the family, masculinity, migration, and religion-only partially shaped sexual behavior and relationships. These factors create a flux in "equilibrium" in bisexual sex markets in which sociocultural-economic structures constantly interplay with human agency. This article contributes to the literature in identifying dynamic spaces for sexual health interventions that draw on individual agency and empowerment.

Adaptation and implementation of HoMBReS: a community-level, evidence-based HIV behavioral intervention for heterosexual Latino men in the midwestern United States

Over the past decade, the midwestern United States has witnessed a dramatic increase in its Latino population. The lack of culturally and linguistically congruent resources coupled with high incidence and prevalence rates of HIV among Latinos living in the Midwest merits attention. HoMBReS: Hombres Manteniendo Bienestar y Relaciones Saludables (Men Maintaining Wellbeing and Healthy Relationships) is a community-level social network intervention designed for Latino men. We describe the adaptation and implementation of HoMBReS for Latino men living in Indianapolis, Indiana, the second largest city in the Midwest. Five Navegantes (lay health educators) were trained; they provided a total of 34 educational charlas (small group didactic sessions). A total of 270 Latino men attended the charlas and were offered no-cost screening for HIV and sexually transmitted infections (STI). Three participants tested HIV positive and 15 screened positive for STI. The charlas coupled with the testing initiative, served as a successful method to increase sexual health knowledge among Latino men and to link newly-diagnosed HIV/STI-positive individuals to treatment and care. The adaptation and implementation of HoMBReS respond to the CDC and NIH call to increase HIV testing and service provision among vulnerable populations.

[A couple-based approach: An innovative effort to tackle HIV infection among Latino gay men.]

The HIV epidemic is a serious and pervasive health issue in the Latino community. While prevention efforts have helped maintain stability in the overall number of infections among Latinos for more than a decade, this population continues to be affected by HIV at high levels. In particular, Predominantly Spanish-speaking Latino men who have sex with men (MSM) are disproportionately impacted by HIV. Several factors contribute to the HIV epidemic among Predominantly Spanish-speaking Latino MSM including substance use; intimate partner violence; the presence of certain STIs; same-sex relationship dynamics; avoidance of seeking testing counseling and treatment out of fear of discrimination and immigration status; and poverty, migration patterns, and language barriers. In particular, epidemiological behavioral research has identified how relationship dynamics in male couples are associated with sexual risk behavior. Consequently, further research is needed to identify and deliver interventions geared toward couple-based risk reduction among men in same-sex relationships. This paper describes the potential significance that innovative couple-based approaches can have on reducing HIV and AIDS cases among Predominantly Spanish-speaking Latino MSM and their same-sex partners.

Generational changes in the meanings of sex, sexual identity and stigma among Latino young and adult men

In this paper we examine the sexual identities of Latino men who have sex with men and women, in which an analysis was made of 150 sexual histories of Latino men aged 18-60. This study asks how the bisexual identity and experience of stigma is different for Latino men along the generational spectrum and how do these differences relate to kinship support and gender ideology? In the process of analysis, two main clusters of characteristics were identified to reflect this population: young men aged 18-25, whose open bisexual identity correlated positively with kinship/peer support and flexible gender and sexual roles, and men aged 26-60, who refused or were reluctant to identify as bisexual despite the fact that they were sexually active with both men and women. This group as a whole had less kinship and peer support, were more likely to identify with traditional gender roles and were less sexually versatile. Finally, a third group reflected Latino men across the generational divide who were less concerned with same-sex stigma, but who nevertheless felt the bisexual label to be confining, illegitimate or otherwise negative.

Sexual behaviors and experiences among behaviorally bisexual men in the midwestern United States

Research examining the sexual behaviors and experiences of behaviorally bisexual men is limited. Most studies focus primarily on highlighting sexual risk behaviors among groups of "men who have sex with men (MSM)" or "gay and bisexual men," which may not be appropriate in terms of behaviorally bisexual men's sexual repertoires with both men and women. This study aimed to assess a broad range of sexual behaviors and associated experiences among bisexual men living in the midwestern United States. An interviewer-administered questionnaire containing items from the National Survey of Sexual Health and Behavior assessed lifetime and recent (i.e., past 6 months and last event) sexual behaviors and experiences with both male and female partners among a diverse sample of 75 behaviorally bisexual men. Responses were quantified and analyzed using descriptive and multivariate statistics. A wide range of sexual behaviors with partners of both genders was found. Vaginal intercourse and oral sex with both men and women were the most commonly reported behaviors. Subjective reports of pleasure, arousal, and sexual function during sexual activity were similar with both male and female sexual partners. Many participants reported using condoms during insertive sexual behaviors with male and female partners, but less during oral sex. Unprotected receptive anal sex was less commonly reported. Overall, participants reported a variety of sexual behaviors and experiences; however, unlike other populations, they shared these with partners of both genders. Results have implications for interventions targeting the sexual behaviors and associated issues among behaviorally bisexual men.

Community involvement among behaviourally bisexual men in the Midwestern USA: experiences and perceptions across communities

Limited research exists regarding community involvement and social support among behaviourally bisexual men. Previous studies suggest that bisexual men experience high levels of social stigma in both heterosexual and homosexual community settings. Research focusing on social support has demonstrated that individuals with limited access to similar individuals experience greater risk for negative health outcomes. Using a community-based research design, participants were recruited using multiple methods. Researchers conducted in-depth, semi-structured interviews with 75 men who reported having engaged in bisexual behaviour within the past six months. Interviews elucidated the experiences of behaviourally bisexual men in heterosexual and homosexual settings, as well as their perceptions of the existence of a bisexual community or bisexual spaces. All participants perceived a lack of a visible bisexual community and expressed difficulty with being comfortable, or a feeling of belonging, within a variety of heterosexual and homosexual community spaces. Findings suggest the need for interventions focused on community building among, as well as creating spaces specifically designed for, bisexual men in order to increase perceived social support and decrease isolation and possible negative health outcomes.

The significance of privacy and trust in providing health-related services to behaviorally bisexual men in the United States

Previous research suggests that bisexual men face unique health concerns in comparison to their exclusively homosexual and heterosexual counterparts. However, little is known about behaviorally bisexual men's experiences with health services, including ways of providing services that would be most appropriate to meet the health needs of this population. This study sought to understand preferences for health-related services among behaviorally bisexual men in the Midwestern United States. Using a community-based research approach, a diverse sample of 75 behaviorally bisexual men was recruited for in-depth interviews. Qualitative data were analyzed utilizing inductive coding through established team-based protocols to ensure reliability. Themes emerged involving the importance of privacy and trust when reaching, recruiting, and engaging behaviorally bisexual men in health services. Findings suggest that multifaceted approaches are needed, including those that provide relevant and confidential services while allowing for the development and ongoing maintenance of trust.

Subjective Sexual Experiences of Behaviorally Bisexual Men in the Midwestern United States: Sexual Attraction, Sexual Behaviors, & Condom Use

Studies concerning behaviorally bisexual men continue to focus on understanding sexual risk in according to a narrow range of sexual behaviors. Few studies have explored the subjective meanings and experiences related to bisexual men's sexual behaviors with both male and female partners. In-depth, semi-structured interviews were conducted with 75 men who engaged in bisexual behavior within the past six months. Participants were asked about their subjective sexual experiences with male and female partners. Findings suggest adherence to normative gender roles, with attraction to men and women conforming to these stereotypes, as well as a segregation of sexual behaviors along gendered lines. Overall, condom use was influenced by perceptions of potential negative consequences. Based on these findings, it remains critical that public health and other social and behavioral sciences continue to study bisexual men's sexual health issues as separate and distinct from their exclusively homosexual and heterosexual counterparts.

Sexual Behaviors and Experiences among Behaviorally Bisexual Latino Men in the Midwestern United States: Implications for Sexual Health Interventions

The Midwestern United States (U.S.) has a high number of recent Latino migrants, but little information is available regarding their sexual behaviors. A total of 75 behaviorally bisexual men (25 Latino, 25 Black, and 25 White) participated in an exploratory study on sexual health. The data presented in this paper are restricted to the 25 self-identified Latino men. Qualitative in-depth interviews were conducted and optional self-administered sexual transmitted infection (STI) screening was provided. The measures used were taken from the National Survey of Sexual Health and Behavior (NSSHB), a probability study of the sexual behaviors of nearly 6000 individuals aged 14-94 in the U.S. In our sample of bisexual men, the most commonly reported sexual behaviors were masturbation, vaginal intercourse, and receiving oral sex from male and female partners. The majority of the participants were the insertive partner during anal sex with male partners. Many of the participants reported alcohol use during their most recent sexual activity. A fair number reported not using condoms during their last sexual event. Pleasure, arousal, orgasm, and erectile functioning were markedly similar despite partner gender. A small number of participants also engaged in sexual activities with transgender individuals. All of the Latino participants took part in the optional self-collection for STI specimens. The results of the study provide rich insights into the sexual behavior and related factors, as well as potential risk behaviors of bisexual Latino men that may be targeted for future sexual health promotion efforts.

Individual and Social Factors Related to Mental Health Concerns among Bisexual Men in the Midwestern United States

Research has not yet explored the potential impact of social stress, biphobia, and other factors on the mental health of bisexual men. In-depth interviews were conducted with a diverse sample of 75 men who engaged in bisexual behavior within the past six months. Interviewers explored potential mental health stressors and supports. Many participants reported personal and social challenges associated with bisexuality, which in turn influenced their mental health. Reported instances of stigma toward bisexuality, from both homosexual and heterosexual individuals, impacted participants' feelings regarding their own sexualities. Isolation was also commonly reported. Programs are greatly needed that focus on the specific mental health and other concerns voiced by these men. Based on our study findings, such programs should emphasize self-acceptance, social network and community building, and ways to maximize available social support, similar to community-level empowerment interventions that have shown success among gay-identified men.