A case-control study of human immunodeficiency virus type 1 seroconversion and risk-related behaviors in the Chicago MACS/CCS Cohort, 1984-1992. Multicenter AIDS Cohort Study. Coping and Change Study

Poppers use and HIV infection-a literature review

INTRODUCTION

During the HIV surge in the 1980s, inhaled volatile nitrites (poppers) were hypothesized as a possible cause of the AIDS. Later it was found that poppers use was not the cause but rather a marker associated with HIV acquisition and sexual behaviors without the use of prevention tools.

OBJECTIVES

This article reviews the available literature regarding the association between poppers use and newly acquired HIV, aiming to support the hypothesis that there is no causal association between nitrites use and HIV transmission and to discuss other contributing factors.

METHODS

We searched all studies published until March 2022 that discussed poppers use and HIV. We extracted relevant information, such as authors and publication year, country where the study was conducted, study design, characteristics of the population, number of participants, objectives of the study, methods, results, and limitations.

RESULTS

The search identified 1956 abstracts, and 1915 were excluded after title review. Forty-one abstracts were assessed, and 17 studies met the inclusion criteria. The majority of the studies found an association between nitrites use and HIV transmission. Four studies associated HIV transmission with sexual behavior without the use of prevention tools, and 5 articles associated nitrites use with this kind of sexual behavior.

CONCLUSIONS

Our findings show a complex association among nitrites use, sexual behaviors without the use of prevention tools, and sexually transmitted infections; furthermore, it is impossible to make causal inferences between poppers use and HIV disease. The data suggest that it is vital to consider this substance use when planning health policies for specific populations, such as men who have sex with men, focusing on harm reduction strategies, psychoeducation, and orientations on sex with the use of prevention tools.

CLINICAL TRIAL REGISTRATION

PROSPERO CRD42020181437. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=181437.

Pilot study of extended-release lorcaserin for cocaine use disorder among men who have sex with men: A double-blind, placebo-controlled randomized trial

OBJECTIVE

To determine if men who have sex with men (MSM) with cocaine use disorder (CUD) and actively-using cocaine could be enrolled and retained in a pharmacologic intervention trial of lorcaserin-a novel 5-HT2cR agonist-and determine the degree to which participants would adhere to study procedures.

METHODS

This was a phase II randomized, double-blind, placebo-controlled pilot study with 2:1 random parallel group assignment to daily extended-release oral lorcaserin 20 mg versus placebo (clinicaltrials.gov identifier-NCT03192995). Twenty-two of a planned 45 cisgender MSM with CUD were enrolled and had weekly follow-up visits during a 12-week treatment period, with substance use counseling, urine specimen collection, and completion of audio-computer assisted self-interview (ACASI) behavioral risk assessments. Adherence was measured by medication event monitoring systems (MEMS) caps and self-report. This study was terminated early because of an FDA safety alert for lorcaserin's long-term use.

RESULTS

Eighty-six percent completed the trial, with 82% of weekly study follow-up visits completed. Adherence was 55.3% (lorcaserin 51.6% vs. placebo 66.2%) by MEMS cap and 56.9% (56.5% vs. placebo 57.9%) by self-report and did not differ significantly by treatment assignment. Intention-to-treat analyses (ITT) did not show differences in cocaine positivity by urine screen between the lorcaserin and placebo groups by 12 week follow-up (incidence risk ratio [IRR]: 0.96; 95%CI = 0.24-3.82, P = 0.95). However, self-reported cocaine use in timeline follow-back declined more significantly in the lorcaserin group compared to placebo (IRR: 0.66; 95%CI = 0.49-0.88; P = 0.004).

CONCLUSION

We found that it is feasible, acceptable, and tolerable to conduct a placebo-controlled pharmacologic trial for MSM with CUD who are actively using cocaine. Lorcaserin was not associated with significant reductions in cocaine use by urine testing, but was associated with significant reductions in self-reported cocaine use. Future research may be needed to continue to explore the potential utility of 5-HT2cR agonists.

Knowledge, attitude, and status of nitrite inhalant use among men who have sex with men in Tianjin, China

Background

Nitrite inhalants have become popular as recreational drugs among the homosexual population in some developed countries since the 1980s. These drugs, also called RUSH in China, have become attractive among Chinese men who have sex with men (MSM) in the past few years. The aim of this cross-sectional study was to understand the knowledge, attitude, and status of nitrite inhalant use among Chinese MSM.

Methods

The study participants were recruited from Tianjin, China between April and August 2012. Information, including demographics, sexual behavior, and RUSH use, was obtained through structured interviewer questionnaires. Blood samples were also collected to identify the status of HIV, HSV, and syphilis infections.

Results

A total of 500 participants were interviewed. Of the participants, 64.0% knew that RUSH could increase sexual pleasure and 38.6% of the participants had used RUSH at least once. The mean duration of RUSH use was 1.5 years. Among the participants who were familiar with RUSH, 60.0% had heard of RUSH for the first time after 2011, 55% received information about RUSH via the internet, and only 42.2% knew the side effects of RUSH. RUSH users were more likely to work in companies (Odds ratio [OR]: 2.61; 95% CI: 1.65–4.12), live with homosexual partners (OR: 1.88; 95% CI: 1.19–2.92), not live alone (OR: 2.26; 95% CI: 1.29–3.96), smoke cigarettes (OR: 1.49; 95% CI: 1.02–2.17), use alcohol (OR: 1.63; 95% CI: 1.12–2.39), and seek sexual partners on the internet (OR: 2.59; 95% CI: 1.50–4.50).

Conclusions

The impact of RUSH abuse on the expanding HIV epidemic among MSM has been demonstrated in China. Our findings suggest that the communication and awareness of health hazard of recreational drugs should be reinforced in HIV prevention education, especially through new media. Future research is needed to further explore how integrative strategies should be used to reduce the substance abuse and risky sexual behaviors.

HIV Testing and Positivity Patterns of Partners of HIV-Diagnosed People in Partner Services Programs, United States, 2013-2014

OBJECTIVE

Human immunodeficiency virus (HIV) partner services are an integral part of comprehensive HIV prevention programs. We examined the patterns of HIV testing and positivity among partners of HIV-diagnosed people who participated in partner services programs in CDC-funded state and local health departments.

METHODS

We analyzed data on 21 484 partners submitted in 2013-2014 by 55 health departments. We conducted descriptive and multivariate analyses to examine patterns of HIV testing and positivity by demographic characteristics and geographic region.

RESULTS

Of 21 484 partners, 16 275 (75.8%) were tested for HIV; 4503 of 12 886 (34.9%) partners with test results were identified as newly HIV-positive. Compared with partners aged 13-24, partners aged 35-44 were less likely to be tested for HIV (adjusted odds ratio [aOR] = 0.86; 95% confidence interval [CI], 0.78-0.95) and more likely to be HIV-positive (aOR = 1.35; 95% CI, 1.20-1.52). Partners who were male (aOR = 0.89; 95% CI, 0.81-0.97) and non-Hispanic black (aOR = 0.68; 95% CI, 0.63-0.74) were less likely to be tested but more likely to be HIV-positive (male aOR = 1.81; 95% CI, 1.64-2.01; non-Hispanic black aOR = 1.52; 95% CI, 1.38-1.66) than partners who were female and non-Hispanic white, respectively. Partners in the South were more likely than partners in the Midwest to be tested for HIV (aOR = 1.56; 95% CI, 1.35-1.80) and to be HIV-positive (aOR = 2.18; 95% CI, 1.81-2.65).

CONCLUSIONS

Partner services programs implemented by CDC-funded health departments are successful in providing HIV testing services and identifying previously undiagnosed HIV infections among partners of HIV-diagnosed people. Demographic and regional differences suggest the need to tailor these programs to address unique needs of the target populations.

Viral Loads Among HIV-Infected Persons Diagnosed With Primary and Secondary Syphilis in 4 US Cities: New York City, Philadelphia, PA, Washington, DC, and Phoenix, AZ

BACKGROUND

Incident syphilis among HIV-infected persons indicates the ongoing behavioral risk for HIV transmission. Detectable viral loads (VLs) among coinfected cases may amplify this risk.

METHODS

Primary and secondary cases reported during 2009-2010 from 4 US sites were crossmatched with local HIV surveillance registries to identify syphilis case-persons infected with HIV before or shortly after the syphilis diagnosis. We examined HIV VL and CD4 results collected within 6 months before or after syphilis diagnosis for the coinfected cases identified. Independent correlates of detectable VLs (≥200 copies/mL) were determined.

RESULTS

We identified 1675 cases of incident primary or secondary syphilis among persons with HIV. Median age was 37 years; 99.5% were men, 41.1% were African American, 24.5% were Hispanics, and 79.9% of the HIV diagnoses were made at least 1 year before syphilis diagnosis. Among those coinfected, there were no VL results reported for 188 (11.2%); of the 1487 (88.8%) with reported VL results, 809 (54.4%) had a detectable VL (median, 25,101 copies/mL; range, 206-3,590,000 copies/mL). Detectable VLs independently correlated with syphilis diagnosed at younger age, at an sexually transmitted disease clinic, and closer in time to HIV diagnosis.

CONCLUSIONS

More than half of syphilis case-persons identified with HIV had a detectable VL collected within 6 months of the syphilis diagnosis. This suggests virologic and active behavioral risk for transmitting HIV.

A systematic review of evidence to inform HIV prevention interventions among men who have sex with men in Europe

An estimated 42% of all newly diagnosed HIV cases in Europe in 2013 were transmitted during sex between men. This review was performed to identify and describe studies evaluating the efficacy and effectiveness of HIV prevention interventions among men who have sex with men (MSM), in relation to implementation data from European settings. A systematic search was performed individually for 24 interventions.Data were extracted from studies including efficacy or implementation data from European settings,appraised for efficacy, implementation and plausibility, and assigned a grade (1-4) according to the Highest Attainable Standard of Evidence (HASTE)framework. Four interventions (condom use, peer outreach,peer-led groups, and using universal coverage of antiretroviral treatment and treatment as prevention)were assigned the highest HASTE grade, 1. Another four interventions were assigned 2a for probable recommendation, including voluntary counseling and testing for HIV, using condom-compatible lubricant,using post-exposure prophylaxis, and individual counselling for MSM living with HIV. In addition, seven interventions were assigned a grade of 2b, for possible recommendation. Encouragingly, 15 interventions were graded to be strongly, probably or possibly recommended.In the relatively resource-rich European setting, there is an opportunity to provide global leadership with regard to the regional scale-up of comprehensive HIV prevention interventions for MSM.

The oral mucosa immune environment and oral transmission of HIV/SIV

The global spread of human immunodeficiency virus (HIV) is dependent on the ability of this virus to efficiently cross from one host to the next by traversing a mucosal membrane. Unraveling how mucosal exposure of HIV results in systemic infection is critical for the development of effective therapeutic strategies. This review focuses on understanding the immune events associated with the oral route of transmission (via breastfeeding or sexual oral intercourse), which occurs across the oral and/or gastrointestinal mucosa. Studies in both humans and simian immunodeficiency virus (SIV) monkey models have identified viral changes and immune events associated with oral HIV/SIV exposure. This review covers our current knowledge of HIV oral transmission in both infants and adults, the use of SIV models in understanding early immune events, oral immune factors that modulate HIV/SIV susceptibility (including mucosal inflammation), and interventions that may impact oral HIV transmission rates. Understanding the factors that influence oral HIV transmission will provide the foundation for developing immune therapeutic and vaccine strategies that can protect both infants and adults from oral HIV transmission.

HIV incidence and associated risk factors among female sex workers in a high HIV-prevalence area of China

BACKGROUND

Heterosexual sex is replacing injection drug use as the main mode of HIV transmission in China. The objective of this study is to determine HIV incidence and associated risk factors among female sex workers (FSWs) in China.

METHODS

From March 2006 to November 2009, FSWs in Kaiyuan City, Yunnan were recruited into an open cohort study. Participants were interviewed and tested for HIV and sexually transmitted infections every 6 months. A multivariate Cox proportional hazards regression model with time-dependent variables was used to measure associations between independent variables and HIV seroconversion.

RESULTS

During 3.5 years of follow-up, 19 incident cases of HIV infection were diagnosed, yielding an overall incidence of 1.44 per 100 person-years (95% confidence interval [CI]: 0.87-2.24). In the multivariate Cox proportional hazards regression model, noninjection drug use (adjusted hazard ratio [AHR]: 6.7, 95% CI: 2.25-19.93), inconsistent condom use with clients in the previous week (AHR: 2.9, 95% CI: 1.03-8.34), and number of clients in the previous week ≥7 (AHR: 4.9, 95% CI: 1.81-13.13) were all independent risk factors for HIV seroconversion.

CONCLUSION

These results underscore the urgency for preventive interventions on sexual and drug use behaviors among FSWs, including condom promotion as well as sexually transmitted infection screening and treatment.

Associations between substance use, erectile dysfunction medication and recent HIV infection among men who have sex with men

We conducted a case-control study to compare illicit substance and erectile dysfunction medication (EDM) use between recently HIV-infected and uninfected men who have sex with men (MSM). Eighty-six recently (previous 12 months) HIV-infected MSM (cases) and 59 MSM who recently tested HIV-negative (controls) completed computer-assisted self-interviews. There were no statistical differences in demographics or number of sexual partners by HIV status. Cases were more likely than controls to report methamphetamine or nitrite use, but not EDM, gamma hydroxybutyrate, 3,4 methylenedioxymethamphetamine, cocaine, or marijuana use, in the previous 12 months and with their last three sexual partners in multivariate logistic regression models. Use of nitrites and amphetamine may increase HIV risk among MSM.

The relationship between methamphetamine and popper use and risk of HIV seroconversion in the multicenter AIDS cohort study

BACKGROUND

The association between methamphetamine use and HIV seroconversion for men who have sex with men (MSM) was examined using longitudinal data from the Multicenter AIDS Cohort Study.

METHODS

Seronegative (n = 4003) men enrolled in 1984 to 1985, 1987 to 1991, and 2001 to 2003 were identified. Recent methamphetamine and popper use was determined at the current or previous visit. Time to HIV seroconversion was the outcome of interest. Covariates included race/ethnicity, cohort, study site, educational level, number of sexual partners, number of unprotected insertive anal sexual partners, number of unprotected receptive anal sexual partners, insertive rimming, cocaine use at the current or last visit, ecstasy use at the current or last visit, any needle use since the last visit, Center for Epidemiologic Study of Depression symptom checklist score >16 since the last visit, and alcohol consumption.

RESULTS

After adjusting for covariates, there was a 1.46 (95% confidence interval [CI]: 1.12 to 1.92) increased relative hazard of HIV seroconversion associated with methamphetamine use. The relative hazard associated with popper use was 2.10 (95% CI: 1.63 to 2.70). The relative hazard of HIV seroconversion increased with the number of unprotected receptive anal sexual partners, ranging from 1.87 (95% CI: 1.40 to 2.51) for 1 partner to 9.32 (95% CI: 6.21 to 13.98) for 5+ partners. The joint relative hazard for methamphetamine and popper use was 3.05 (95% CI: 2.12 to 4.37). There was a significant joint relative hazard for methamphetamine use and number of unprotected receptive anal sexual partners of 2.71 (95% CI: 1.81 to 4.04) for men with 1 unprotected receptive anal sexual partner, which increased in a dose-dependent manner for >1 partners.

CONCLUSIONS

Further examination of the mechanisms underlying the synergism of drug use and sexual risk behaviors on rates of HIV seroconversion is necessary for the development of new targeted HIV prevention strategies for non-monogamous drug-using MSM.

Nitrite inhalant use among young gay and bisexual men in Vancouver during a period of increasing HIV incidence

BACKGROUND

Nitrite inhalants ("poppers") are peripheral vasodilators which, since the beginning of the epidemic, have been known to increase risk for acquiring HIV infection among men who have sex with men (MSM). However, few studies in recent years have characterized use. From 1999 to 2004, new HIV diagnoses among MSM in British Columbia increased 78%, prompting us to examine the prevalence and correlates of this modifiable HIV risk factor.

METHODS

Self-administered questionnaires were completed between October 2002 and May 2004 as part of an open cohort study of HIV-seronegative young MSM. We measured nitrite inhalant use during the previous year and use during sexual encounters with casual partners specifically. Correlates of use were identified using odds ratios.

RESULTS

Among 354 MSM surveyed, 31.6% reported any use during the previous year. Nitrite inhalant use during sexual encounters was reported by 22.9% of men and was strongly associated with having casual partners, with greater numbers of casual partners (including those with positive or unknown serostatus) and with anal intercourse with casual partners. Nitrite inhalant use was not associated with non-use of condoms with casual sexual partners per se.

CONCLUSION

Contemporary use of nitrite inhalants amongst young MSM is common and a strong indicator of anal intercourse with casual sexual partners. Since use appears to increase the probability of infection following exposure to HIV, efforts to reduce the use of nitrite inhalants among MSM should be a very high priority among HIV prevention strategies.

Unprotected anal intercourse and substance use among men who have sex with men with recent HIV infection

OBJECTIVES

To examine within-subjects and combined between- and within-subjects associations between substance use and unprotected anal intercourse (UAI) among men who have sex with men (MSM) with recent HIV infection.

METHODS

One hundred ninety-four MSM who were recently infected with HIV completed a computer-assisted questionnaire regarding sexual behaviors and substance use with their last 3 partners. Associations between UAI and substance use were assessed using conditional logistic regression (CLR) to assess associations among the 116 MSM reporting UAI with some but not all partners and generalized linear mixed effects models (GLMMs) to examine a combination of within- and between-subjects associations in the entire sample (N = 194).

RESULTS

In multivariate CLR models and GLMMs, UAI was associated with the use of methamphetamine (odds ratio [OR] = 4.9 and OR = 3.5, respectively), marijuana (OR = 4.0 and OR = 2.2, respectively) and erectile dysfunction medications (EDMs) when used with a main partner (OR = 13.8 and OR = 10.1, respectively).

CONCLUSIONS

Results indicate that a direct association may exist between specific substances and UAI and provide evidence that the use of methamphetamine and EDMs may contribute to HIV transmission.

Reconciling Different Infectivity Estimates for HIV-1

In our article, "HIV-1 Epidemics Driven by Late Stage Disease," we conclude that the probability of transmission of HIV through promiscuous or casual sexual contacts is significantly higher in the third or symptomatic stage of the disease. Our results differ greatly from those of the current literature. The primary stage or first stage has been reported to be the most infectious based on an article by Jacquez et al. More recently, the Wawer et al study of monogamous heterosexual couples in Rakai, Uganda found that the transmission of HIV was most likely to occur in the first 5 months after infection. We describe how the findings of the Wawer et al study might be compatible with our results. We also respond to a response by Koopman and Simon, who seem to criticize their own paper severely and choose not to defend it against our remarks.

Oral transmission of HIV, reality or fiction? An update

Human immunodeficiency virus (HIV) and many other viruses can be isolated in blood and body fluids, including saliva, and can be transmitted by genital-genital and especially anal-genital sexual activity. The risk of transmission of HIV via oral sexual practices is very low. Unlike other mucosal areas of the body, the oral cavity appears to be an extremely uncommon transmission route for HIV. We present a review of available evidence on the oral-genital transmission of HIV and analyse the factors that act to protect oral tissues from infection, thereby reducing the risk of HIV transmission by oral sex. Among these factors we highlight the levels of HIV RNA in saliva, presence of fewer CD4+ target cells, presence of IgA antibodies in saliva, presence of other infections in the oral cavity and the endogenous salivary antiviral factors lysozyme, defensins, thrombospondin and secretory leucocyte protease inhibitor (SLPI).

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.

Risk factors for HIV infection among men who have sex with men

OBJECTIVES

Risk factors for HIV acquisition were examined in a recent cohort of men who have sex with men (MSM).

DESIGN

A longitudinal analysis of 4295 HIV-negative MSM enrolled in a randomized behavioral intervention trial conducted in six US cities.

METHODS

MSM were enrolled and assessed for HIV infection and risk behaviors semi-annually, up to 48 months.

RESULTS

In multivariate analysis, men reporting four or more male sex partners, unprotected receptive anal intercourse with any HIV serostatus partners and unprotected insertive anal intercourse with HIV-positive partners were at increased risk of HIV infection, as were those reporting amphetamine or heavy alcohol use and alcohol or drug use before sex. Some depression symptoms and occurrence of gonorrhea also were independently associated with HIV infection. The attributable fractions of high number of male partners, use of alcohol or drugs before sex, and unprotected receptive anal intercourse with unknown status partners and the same with presumed negative partners accounted for 32.3, 29.0, 28.4 and 21.6% of infections, respectively.

CONCLUSIONS

The challenge is to develop strategies to identify men in need. Interventions are needed to help men reduce their number of sexual partners, occurrences of unprotected anal intercourse, alcohol or drug use before sex and address other mental health issues.

Club drugs as causal risk factors for HIV acquisition among men who have sex with men: a review

We reviewed medical and psychology databases for articles published between January 1980 and August 2005 demonstrating associations between HIV/Sexually Transmitted Infection risk and club drug use. Seventy-four articles were reviewed, of which 30 provided adjusted risk ratios for associations between HIV/sexually transmitted infection risk and club drug use among men who have sex with men. Definitions and lists of club drugs were broad and inconsistent. We constructed a conceptual framework of biologically plausible pathways for causation. Using Hill's criteria to examine club drugs as causal risk factors for HIV, we found the most evidence for methamphetamine and volatile nitrites; however, more studies are needed.

Sexual Risk, Nitrite Inhalant Use, and Lack of Circumcision Associated With HIV Seroconversion in Men Who Have Sex With Men in the United States

Men who have sex with men (MSM) continue to account for the largest number of new HIV infections in the United States, but limited data exist on independent risk factors for infection beyond the early 1990s. The HIV Network for Prevention Trials Vaccine Preparedness Study enrolled 3257 MSM in 6 US cities from 1995 to 1997. HIV seroincidence was 1.55 per 100 person-years (95% confidence interval: 1.23-1.95) over 18 months of follow-up. On multi-variable analysis using time-dependent covariates, independent risk factors for HIV seroconversion were increased number of reported HIV-negative male sex partners (adjusted odds ratio (AOR) = 1.14 per partner, population attributable risk (PAR) = 28%), nitrite inhalant use (AOR = 2.2, PAR = 28%), unprotected receptive anal sex with an HIV unknown serostatus partner (AOR = 2.7, PAR = 15%) or HIV-positive partner (AOR = 3.4, PAR = 12%), protected receptive anal sex with an HIV-positive partner (AOR = 2.2, PAR = 11%), lack of circumcision (AOR = 2.0, PAR = 10%), and receptive oral sex to ejaculation with an HIV-positive partner (AOR = 3.8, PAR = 7%). Having a large number of male sex partners, nitrite inhalant use, and engaging in receptive anal sex explained the majority of infections in this cohort and should be targeted in prevention strategies for MSM.

Unprotected Anal Intercourse Associated With Recreational Drug Use Among Young Men Who Have Sex With Men Depends on Partner Type and Intercourse Role

OBJECTIVE

The objective of this study was to measure associations of unprotected anal intercourse (UAI) and substance use by sexual partner (regular vs. casual) and role [insertive (I) vs. receptive (R)].

GOAL

The goal of this study was to identify determinants of the association of specific drugs and UAI.

STUDY

We conducted a prospective study of young men who have sex with men (MSM), 1997-2002. Odds ratios (ORs) for association of substance use and UAI during the previous year were adjusted for age and calendar year.

RESULTS

UAI was significantly associated with sexual situation-specific use of marijuana (OR, 1.43), crystal methamphetamine (OR, 1.75), ecstasy (OR, 1.88), and ketamine (OR, 2.17); global use associations were similar. Situation-specific associations with alcohol (OR, 1.93) and gamma-hydroxybutyrate (GHB; OR, 1.98) were not seen with global measures. GHB and ketamine were specifically associated with IUAI with regular partners, and methamphetamine with RUAI with casual partners.

CONCLUSION

Type of drug use measure, partner, and role are important determinants of the association of specific substances and UAI.

Regional patterns and correlates of substance use among young men who have sex with men in 7 US urban areas

OBJECTIVES

We sought to characterize substance use patterns in young men who have sex with men (MSM) in 7 US urban areas and sociodemographic characteristics and history associated with such use.

METHODS

We examined data collected from 1994 through 1998 in a venue-based, cross-sectional survey.

RESULTS

Among the 3492 participants, 66% reported use of illicit drugs; 28%, use of 3 or more drugs; 29%, frequent drug use (once a week or more); and 4%, injection drug use. These practices were more common among participants who were White, self-identified as bisexual or heterosexual, had run away, or had experienced forced sex.

CONCLUSIONS

Effective drug prevention and treatment programs addressing local drug-use patterns and associated factors are urgently needed for young MSM, a population with a high rate of illicit drug use.

HIV transmission among gay men through oral sex and other uncommon routes: case series of HIV seroconverters, Sydney

Seventy-five homosexual men with recently acquired HIV were interviewed about their risk behaviour. Fifty-nine reported unprotected anal intercourse, and one shared injecting equipment, with a partner not known to be HIV negative. Of the remaining 15, 11 reported protected anal intercourse. In five of the 15 we judged oral sex to be the most likely source of infection, including three men who had a genital piercing. The possible transmission risk from genital piercing should be investigated.

Determinants of human immunodeficiency virus (HIV) prevalence in homosexual and bisexual men screened for admission to a cohort study of HIV negatives in Belo Horizonte, Brazil: Project Horizonte

Project Horizonte, an open cohort of homosexual and bisexual human immunodeficiency virus (HIV-1) negative men, is a component of the AIDS Vaccine Program, in Belo Horizonte, Minas Gerais, Brazil. The objective of this study was to compare volunteers testing HIV positive at cohort entry with a sample of those who tested HIV negative in order to identify risk factors for prevalent HIV infection, in a population being screened for enrollment at Project Horizonte. A nested case-control study was conducted. HIV positive volunteers at entry (cases) were matched by age and admission date to three HIV negative controls each. Selected variables used for the current analysis included demographic factors, sexual behavior and other risk factors for HIV infection. During the study period (1994-2001), among the 621 volunteers screened, 61 tested positive for HIV. Cases were matched to 183 HIV negative control subjects. After adjustments, the main risk factors associated with HIV infection were unprotected sex with an occasional partners, OR = 3.7 (CI 95% 1.3-10.6), receptive anal intercourse with an occasional partner, OR = 2.8 (95% CI 0.9-8.9) and belonging to the negro racial group, OR = 3.4 (CI 95% 1.1-11.9). These variables were associated with an increase in the risk of HIV infection among men who have sex with men at the screening for admission to an open HIV negative cohort.

Attitudes towards highly active antiretroviral therapy are associated with sexual risk taking among HIV-infected and uninfected homosexual men

OBJECTIVE

To determine whether attitudes towards highly active antiretroviral therapy (HAART) are associated with unprotected anal sex among sexually active homosexual men.

DESIGN

Cross-sectional study nested within an ongoing prospective cohort study.

SETTING

Multicenter AIDS Cohort Study, from April through September 1999.

PARTICIPANTS

Five-hundred and forty-seven homosexual men reporting anal sex (218 HIV-negative and 329 HIV-positive) during study interviews in 1999, including a 20-item validated scale on attitudes toward HAART and HIV risk behaviors (e.g., 'Because of HAART, I am less concerned about becoming HIV-infected or infecting someone'), and safer sex fatigue (e.g., 'I am tired of always having safer sex').

MAIN OUTCOME MEASURES

Self-reported unprotected receptive anal sex (RAS) and insertive anal sex (IAS) in the prior 6 months.

RESULTS

More than 50% of HIV-negative and HIV-positive men who reported having anal sex also reported recent unprotected RAS and/or IAS. HIV-negative men who most agreed that HAART reduced concern about becoming infected were more likely to report unprotected RAS compared to other HIV-negative men [adjusted odds ratio (AOR), 3.31; 95% confidence interval (CI), 1.27-8.62]. Moreover, HIV-positive men with greatest reduced concern due to HAART or safer sex fatigue were more likely to report unprotected IAS (AOR, 6.05; 95% CI, 2.24-16.63 and AOR, 4.57; 95% CI, 1.70-12.24, respectively) compared to other HIV-positive men.

CONCLUSIONS

Among sexually active homosexual men, lessened concern about HIV transmission due to HAART was strongly associated with sexual risk taking, as was safer sex fatigue among HIV-positive men. Prevention programs should take into account underlying attitudes for unprotected sex in the era of HAART among both HIV-infected and uninfected men.

Expectancies of sexual "escape" and sexual risk among drug and alcohol-involved gay and bisexual men

PURPOSE

We tested the hypotheses that sexual risk would relate to gay/bisexual men's patterns of combining alcohol or drugs with sex, their motivation to use drugs to cognitively "escape" awareness of HIV risk, and their use of bars as social and sexual settings.

METHODS

We conducted extensive interviews among African-American (n = 139) and White (n = 112) gay and bisexual men who were attending a behavioral intervention for safer sex results. Those who frequently combined drugs with sex reported higher rates of sexual risk and Hepatitis B infection than did men who infrequently combined substances with sex, or who combined only alcohol with sex. Sexual risk was pronounced among more frequent drug users who also reported strong expectancies that alcohol or drugs facilitate sex and cognitively escape from awareness of HIV risk. Frequenting bars per se was not an important factor in sexual risk.

IMPLICATIONS

Men who use alcohol or drugs to enhance sexuality and escape self-awareness of HIV risk have a significantly diminished capacity to avoid sexual risk.

Circuit party attendance, club drug use, and unsafe sex in gay men

PURPOSE

We examined the population demographics and club drugs used in gay circuit parties and estimated the reported unsafe sexual behavior associated with each drug, the reasons for attending circuit parties, and the unsafe sex associated with different reasons.

METHODS

A brief questionnaire was provided to a nonrandom sample of party attendees covering demographics, drugs used, sexual activity, and reasons for attending gay circuit parties at three major North American parties in 1998-1999. A total of 1169 usable questionnaires were obtained. Odds ratios for unsafe sex for the drugs surveyed [alcohol, marijuana, methylenedioxymethamphetamine (Ecstasy), ketamine (Special K), crystal methamphetamine (crystal meth), cocaine, volatile nitrites (poppers), and gamma-hydroxybutyrate (GHB)] were calculated, as was significance of unsafe sex for the 10 major reasons for attending parties.

RESULTS

12-month party drug use was high: > 50% reported using alcohol, Ecstasy, and Special K. Frequent (rather than occasional) use of Ecstasy, Special K, and poppers had an association with unsafe sex at parties. Poppers also showed a statistically significant association with unsafe sex in 12 months (not necessarily at parties) while crystal meth and GHB showed a trend. Attending circuit parties "to look and feel good," "to have sex," and "to be uninhibited and wild" were associated with higher levels of unsafe sex in 12 months.

IMPLICATIONS

In this sample, circuit party attendees are well educated and financially secure. Party drug use is high. It appears that use of poppers, Ecstasy, Special K, crystal meth, and GHB are associated with various measures of unsafe sex. More comprehensive research on club drug use in gay men is required.

When risk is low: primary care physicians' counseling about HIV prevention

To explore the conceptualization of risk by primary care physicians about behaviors associated with a relatively low risk of HIV transmission, we performed open-ended telephone interviews with 59 primary care physicians throughout the United States. During the interviews, physicians were asked to respond to a series of clinical vignettes presenting situations where the risk of HIV transmission is relatively low or unknown. We performed a qualitative content analysis of physicians' responses to these clinical vignettes. We found that relatively few information-gathering statements were made in an effort to elicit the patient's perspective regarding risk, and that risk counseling by physicians often followed an 'all or nothing' heuristic that manifested itself as the advice to take maximum precautions under situations of any perceived risk, no matter how small. In addition, HIV testing was often incompletely explained. When combined with the all or nothing heuristic, this created advice that was potentially harmful by using testing as a means to achieve zero risk and forgo protective strategies in settings where patients may potentially be in the HIV negative 'window' phase of infection.

Risk factors associated with HIV infection among young gay and bisexual men in Canada

OBJECTIVE

To assess risk factors associated with HIV prevalence and incidence among gay and bisexual men in two prospective Canadian cohorts.

METHODS

The Vanguard Project and the Omega Cohort are prospective cohort studies of gay and bisexual men ongoing in Vancouver and Montreal, respectively. For this analysis, baseline sociodemographic characteristics, sexual behavior, and substance use data from these two cohorts were combined. Assessment of risk factors for HIV seroprevalence and seroconversion were carried out using univariate and multivariate analysis.

RESULTS

This analysis was based on 1373 gay and bisexual men aged 16 to 30 years. Men who were HIV-seropositive at baseline (n = 48) were more likely to report living in unstable housing, to have had less than a high school education, and to have been unemployed than those who were HIV-negative (n = 1325). HIV-positive men were also more likely to report having engaged in sexual risk behavior, including having had consensual sex at a younger age, having had at least 6 partners during the previous year, ever having been involved in the sex trade, and having engaged in unprotected receptive anal intercourse. With respect to substance use, HIV-positive men were more likely to report the use of crack, cocaine, heroin, and marijuana and to use injection drugs. Similarly, men who seroconverted during the course of the studies (n = 26) were more likely to report having less than a high school education and having lived in unstable housing at baseline. Compared with HIV-negative men, men who seroconverted were more likely to report ever having been involved in the sex trade and engaging in unprotected receptive anal intercourse. Reports of cocaine use and injection drug use were also significantly higher for men who seroconverted compared with HIV-negative men.

CONCLUSIONS

Our data indicate that HIV-positive gay and bisexual men are more likely to be living in unstable conditions and to report more risky sexual and substance use behaviors than HIV-negative men.

The relation of alcohol use to HIV-risk sexual behavior among adults with a severe and persistent mental illness

The authors examined the relationship between alcohol use and HIV-risk sexual behavior and tested whether alcohol use immediately prior to sex is related to decreased condom use. The participants were 159 adults living with a severe and persistent mental illness. Each participated in a structured interview to assess all sexual and drug-use behavior over a 3-month period. Analysis of 3,026 sexual behaviors reported by 123 sexually active participants indicated that at the global level, participants who drank more heavily were more likely to have engaged in sexual risk behavior. At the event level, however, alcohol use was not related to condom use during vaginal or anal intercourse; that is, participants who used condoms when sober tended to use them to the same extent when drinking.

The relation of alcohol use to HIV-risk sexual behavior among adults with a severe and persistent mental illness

The authors examined the relationship between alcohol use and HIV-risk sexual behavior and tested whether alcohol use immediately prior to sex is related to decreased condom use. The participants were 159 adults living with a severe and persistent mental illness. Each participated in a structured interview to assess all sexual and drug-use behavior over a 3-month period. Analysis of 3,026 sexual behaviors reported by 123 sexually active participants indicated that at the global level, participants who drank more heavily were more likely to have engaged in sexual risk behavior. At the event level, however, alcohol use was not related to condom use during vaginal or anal intercourse; that is, participants who used condoms when sober tended to use them to the same extent when drinking.

HIV topic update: oro-genital transmission of HIV

Several viruses, including the human immunodeficiency virus (HIV), can be found in blood and many body fluids including saliva, and are transmissible sexually across genital and particularly anal mucosae. A persisting concern has been the question of transmission of HIV by oral sexual practices. This review discusses the evidence for oro-genital transmission of HIV, detailing the presence and infectivity of HIV in genital fluids and saliva, the case reports and epidemiology of oro-genital HIV transmission, and the evidence from animal studies. Oral intercourse is not risk-free. The evidence suggests that the risk of HIV transmission from oro-genital sexual practices is substantially lower than that from penile-vaginal or penile-anal intercourse, that exposure to saliva presents a considerably lower risk than exposure to semen, and that oral trauma and ulcerative conditions might increase the risk of HIV transmission.

Perceptions of health care professionals and patients about the risk of HIV transmission through oral sex: a qualitative study

We explored health care professionals' beliefs and methods for counseling patients about risks for transmitting human immunodeficiency virus (HIV) through oral sex and HIV-seropositive patients' beliefs and practices regarding oral sex behavior. Health care professionals used divergent counseling strategies, avoided specific recommendations, and expressed ambivalence about recommending barrier protection for oral sex. Patients expressed differing beliefs about oral sex risk; the majority have engaged in unprotected oral sex since diagnosis. Few professionals or patients mentioned oral sex risk for other sexually transmitted diseases (STDs), which can be cofactors for HIV. Although scientific evidence indicates a potential risk for transmitting HIV via oral sex, and patients in our sample want more information about this risk, the health care professionals we interviewed have adopted a largely noncommittal approach to communicating potential risk to patients. Health care professionals should consider discussing more specifically with patients the oral sex risk for transmission of HIV and other sexually transmitted diseases.

HIV incidence among repeat HIV testers with sexually transmitted diseases in Italy. STD Surveillance Working Group

OBJECTIVES

To provide data on the incidence of HIV infection among repeat testers with sexually transmitted diseases (STD) in Italy.

DESIGN

Retrospective longitudinal study.

METHODS

Study participants, enrolled by 47 STD centres throughout Italy, included individuals with a newly diagnosed STD who were tested for HIV at the time of the STD diagnosis and who had a previous documented HIV-negative test. 'Seroconverters' were defined as those individuals who tested HIV-positive at the time of the STD diagnosis. The cumulative and the annual incidence of HIV in this population were estimated.

RESULTS

Of 1950 patients, 47 were seroconverters, with an incidence rate of 1.7 per 100 person-years (PY) (95% confidence interval, 1.2-2.2). HIV incidence was higher among males than among females (2.5 versus 0.6 per 100 PY). The highest incidence rate was found among homosexual injecting drug users (IDU) (13.8 per 100 PY), whereas the lowest rate was observed among heterosexual non-IDU (0.4 per 100 PY). The annual incidence decreased from 1.8 per 100 PY in 1989 to 0.9 per 100 PY in 1996.

CONCLUSIONS

Our results show that new HIV infections have occurred among STD patients in Italy since 1988, although a clear decrease in incidence has occurred since 1989. However, the rate of seroconversion appears to be alarmingly high in some high-risk groups. These findings suggest that there is a need for continued monitoring of new HIV infections among STD patients, and these individuals may represent a useful sentinel population for a better understanding of the HIV epidemic.

Risk factors for human immunodeficiency virus infection and unprotected anal intercourse among young men who have sex with men

BACKGROUND AND OBJECTIVES

Few studies concerning human immunodeficiency virus (HIV) and its risk behaviors have been conducted among young men who have sex with men (YMSM). These are important because YMSM will have profound influence on the HIV/acquired immunodeficiency syndrome epidemic.

GOALS

To estimate the prevalence of and risk factors associated with HIV infection and recent unprotected anal intercourse (UAI) among YMSM in California.

METHODS

Between March and October, 1994, 836 men, 17 to 25 years of age, were surveyed at four California sites. The survey consisted of an interview from a standardized questionnaire and a blood draw for HIV antibody testing.

RESULTS

Almost 9.0% tested positive for HIV antibodies, whereas about 36.0% reported recent UAI. Several factors were associated both univariately and multivariately with HIV infection, as well as for recent UAI.

CONCLUSIONS

Young men who have sex with men in California continue to engage in behaviors risky for HIV infection. Efforts helping YMSM reduce them should target subgroups having a high HIV seroprevalence or recent UAI prevalence.

Histories of substance use and risk behavior: precursors to HIV seroconversion in homosexual men

OBJECTIVES

This study compared history of substance use and episodic use in terms of HIV seroconversion.

METHODS

A sample of 337 baseline HIV-negative gay men was followed for 6 years. Bivariate and survival analyses were used to compare 39 converters with nonconverters on substance use behaviors.

RESULTS

Seroconverters were consistently more likely to report use of marijuana, nitrite inhalants, amphetamines, and cocaine than nonconverters. Consistent use of nitrite inhalants and amphetamines increases the relative risk of seroconversion, while episodic use does not. Both patterns of cocaine use increase seroconversion risk.

CONCLUSIONS

There are three potential mechanisms for an increased risk of conversion due to consistent substance use.

Marijuana use and mortality

OBJECTIVES

The purpose of this study was to examine the relationship of marijuana use to mortality.

METHODS

The study population comprised 65171 Kaiser Permanente Medical Care Program enrollees, aged 15 through 49 years, who completed questionnaires about smoking habits, including marijuana use, between 1979 and 1985. Mortality follow-up was conducted through 1991.

RESULTS

Compared with nonuse or experimentation (lifetime use six or fewer times), current marijuana use was not associated with a significantly increased risk of non-acquired immunodeficiency syndrome (AIDS) mortality in men (relative risk [RR] = 1.12, 95% confidence interval [CI] = 0.89, 1.39) or of total mortality in women (RR = 1.09, 95% CI = 0.80, 1.48). Current marijuana use was associated with increased risk of AIDS mortality in men (RR = 1.90, 95% CI = 1.33, 2.73), an association that probably was not causal but most likely represented uncontrolled confounding by male homosexual behavior. This interpretation was supported by the lack of association of marijuana use with AIDS mortality in men from a Kaiser Permanente AIDS database. Relative risks for ever use of marijuana were similar.

CONCLUSIONS

Marijuana use in a prepaid health care-based study cohort had little effect on non-AIDS mortality in men and on total mortality in women.

Sexual adventurism, high-risk behavior, and human immunodeficiency virus-1 seroconversion among the Chicago MACS-CCS cohort, 1984 to 1992. A case-control study

BACKGROUND AND OBJECTIVES

To predict incident human immunodeficiency virus (HIV)-1 seroconversions among a cohort of gay and bisexual men based on recalled sexual behavior, drug use, partnership status, and an index of sexual adventurism/risk-seeking attitudes.

STUDY DESIGN

A nested case-control design was used in a retrospective study spanning a 9-year period.

RESULTS

Sexual adventurism was an important predictor of HIV-1 infection. The partial risk ratio for our 100-point adventurism scale indicated a marginal rate of increase in seroconversion risk of 4% (odds ratio = 1.04; 95% confidence interval = 1.02 to 1.06), with almost 79% of seroconverters scoring above the median on the index. As expected, partner status, drug use, and unprotected receptive anal (RA) intercourse were associated with seroconversion. However, multivariate results indicated that men using condoms consistently in RA sex were also at higher risk for infection (odds ratio = 2.68; 95% confidence interval = 1.04 to 6.95) than men who abstained from RA intercourse.

CONCLUSIONS

Results are discussed with respect to their implications for HIV prevention intervention and research. Recommendations include the development of new approaches and the adaptation of existing intervention techniques that recognize and treat persons with strong risk-taking predispositions.