Unprotected anal intercourse between potentially HIV-serodiscordant men who have sex with men, San Francisco

A Pilot Trial of a Sexual Health Counseling Intervention for HIV-Positive Gay and Bisexual Men Who Report Anal Sex without Condoms

Background

Even in the presence of promising biomedical treatment as prevention, HIV incidence among men who have sex with men has not always decreased. Counseling interventions, therefore, continue to play an important role in reducing HIV sexual transmission behaviors among gay and bisexual men and other men who have sex with men. The present study evaluated effects of a small-group counseling intervention on psychosocial outcomes and HIV sexual risk behavior.

Method

HIV-positive (HIV+) peer counselors administered seven 2-hour counseling sessions to groups of 5 to 8 HIV+ gay and bisexual men. The intervention employed information provision, motivational interviewing, and behavioral skills building to reduce sexual transmission risk behaviors.

Results

There was a significant reduction in condomless anal sex (CAS) with HIV-negative and unknown HIV-status partners, from 50.0% at baseline to 28.9% of the sample at 3-month follow-up. Findings were robust even when controlling for whether the participant had an undetectable viral load at baseline. Significant reductions were also found in the two secondary psychosocial outcomes, loneliness and sexual compulsivity.

Conclusions

The findings provide preliminary evidence that this intervention may offer an efficient way of concurrently reducing CAS and mental health problems, such as sexual compulsivity and loneliness, for HIV+ gay and bisexual men.

Trial Registration

ClinicalTrials.gov NCT02546271

"Hedge Your Bets": Technology's Role in Young Gay Men's Relationship Challenges

Technology is playing an increasingly pervasive role among young gay men in the process of meeting potential romantic or sexual partners. We investigated challenges posed by technology related to young gay men's relationships. Focus groups (n = 9) of young gay men aged 18-24 (n = 43) were transcribed verbatim, and thematic analysis was used to identify two major themes regarding challenges to relationship development and maintenance. Subthemes include unrealistic expectations of relationships, inauthentic self-presentation online, sexual primacy over romance, increased opportunities for infidelity, and jealousy. The implications of this study for sexual education and sexual health promotion are discussed.

Longitudinal Trends in Sexual Behaviors Without a Condom Among Sexual Minority Youth: The P18 Cohort Study

Given the heightened risk for HIV and other STIs among young men who have sex with men (YMSM) as well as the racial/ethnic disparities in HIV/STI risk, an understanding of longitudinal trends in sexual behaviors is warranted as YMSM emerge into adulthood. Drawing from an ongoing prospective cohort study, the present analysis employed latent growth curve modeling to examine trends in distinct types of sexual activity without condoms over time in sample of YMSM and examine differences by race/ethnicity and perceived familial socioeconomic status (SES). Overall, White and Mixed race YMSM reported more instances of oral sex without condoms as compared to other racial/ethnic groups with rates of decline over time noted in Black YMSM. White YMSM also reported more receptive and insertive anal sex acts without a condom than Black YMSM. Declines over time in both types of anal sex acts without condoms among Black men were noted when compared to White men, while increases over time were noted for mixed race YMSM for condomless insertive anal sex. The effects for race/ethnicity were attenuated with the inclusion of perceived familial SES in these models. These findings build on previous cross sectional studies showing less frequent sex without condoms among Black YMSM despite higher rates of HIV incidence in emerging adulthood, as well as the importance of considering economic conditions in such models. Efforts to understand racial/ethnic disparities in HIV/STIs among YMSM must move beyond examination of individual-level sexual behaviors and consider both race/ethnicity and socioeconomic conditions in order to evaluate how these factors shape the sexual behaviors of YMSM.

The difference between HIV and syphilis prevalence and incidence cases: results from a cohort study in Nanjing, China, 2008-2010

The available estimates of incidence and prevalence of syphilis among men who have sex with men (MSM) in Mainland China are high. We used respondent-driven sampling to recruit MSM in the study population. The participants were followed up to monitor the incidence and change of risk behaviours. A face-to-face interview was used to collect information about high-risk behaviours, demographics and recreational drug use. To test the difference between prevalent and incident cases, two nested matched case-control studies were carried out. The cases were the HIV or syphilis positives found at baseline and during follow-up. We used density sampling to sample six controls for each case. Our results indicate that compared to incident cases, prevalent cases had a higher proportion of reported unprotected anal intercourse for both HIV and syphilis. Regression analysis indicated that unprotected anal intercourse was the main risk factor among HIV-prevalent cases but not in HIV-incident cases. These differences could possibly be explained by the implementation of the risk reduction interventions. Syphilis was not a risk factor for HIV-prevalent cases but was highly associated with HIV-incident cases. Tailored interventions addressing unprotected anal intercourse and other risk factors can help to reduce the prevalence and incidence of HIV and syphilis.

Comparison of HIV behavioral indicators among men who have sex with men across two survey methodologies, San Francisco, 2004 and 2008

BACKGROUND

Our goal was to examine whether community-based behavioral surveys can augment data collected for the National HIV Behavioral Surveillance System (NHBS) among men who have sex with men (MSM) in San Francisco.

METHODS

We compared estimates of sexual risk behaviors among MSM using data from two cycles of NHBS (2004 and 2008) and outreach surveys conducted by STOP AIDS Project (SAP) during the same years. We compared estimates of unprotected anal intercourse (UAI) and other indicators to assess concordance of estimates across methodologies.

RESULTS

Of the 3248 interviews conducted, the NHBS sample included more nonwhite and older MSM, more self-reported HIV positive, and less sexually active men than the SAP sample. Estimates of UAI in the last 6 months were slightly higher in the NHBS survey than in the SAP surveys (2004: 40% vs. 36%, P = 0.03; 2008: 44% vs. 38%, P = 0.08). In 2008, where respondent-partner HIV-discordant status could be measured, estimates of UAI with a potentially discordant partner were similar (12% vs. 12%, P = 0.87). Also, the NHBS and SAP surveys observed similar estimates of UAI by high-risk positioning with potentially discordant partners (HIV-positive men reporting insertive UAI with a potentially HIV-negative partner: 13% vs. 11%, P = 0.45; HIV-negative men reporting receptive UAI with a potentially HIV-positive person: 5% vs. 4%, P = 0.85).

CONCLUSIONS

Behavioral estimates drawn from convenience sampling methods can provide informative surveillance estimates of key behavioral indictors that can augment data from more rigorous national HIV behavioral surveillance surveys.

Rectal microbicide development

The last few years have seen important progress in demonstrating the efficacy of oral pre-exposure prophylaxis, vaginal microbicides, and treatment as prevention as effective strategies for reducing the risk of acquiring or transmitting HIV infection. There has also been significant progress in the development of rectal microbicides. Preclinical non-human primate studies have demonstrated that antiretroviral microbicides can provide significant protection from rectal challenge with SIV or SHIV. Recent Phase 1 rectal microbicide studies have characterized the safety, acceptability, compartmental pharmacokinetics (PK), and pharmacodynamics (PD) of both UC781 and tenofovir gels. The tenofovir gel formulation used in vaginal studies was not well tolerated in the rectum and newer rectal-specific formulations have been developed and evaluated in Phase 1 studies. The PK/PD data generated in these Phase 1 studies may reduce the risk of advancing ineffective candidate rectal microbicides into late stage development. Tenofovir gel is currently poised to move into Phase 2 evaluation and it is possible that a Phase 2B/3 effectiveness study with this product could be initiated in the next 2-3 years.

Gay and bisexual men's use of the Internet: research from the 1990s through 2013

We document the historical and cultural shifts in how gay and bisexual men have used the Internet for sexuality between the 1990s and 2013-including shifting technology as well as research methods to study gay and bisexual men online. Gay and bisexual men have rapidly taken to using the Internet for sexual purposes: for health information seeking, finding sex partners, dating, cybersex, and pornography. Men have adapted to the ever-evolving technological advances that have been made in connecting users to the Internet-from logging on via dial-up modem on a desktop computer to geo-social-sexual networking via handheld devices. In kind, researchers have adapted to the Internet to study gay and bisexual men. Studies have carefully considered the ethics, feasibility, and acceptability of using the Internet to conduct research and interventions. Much of this work has been grounded in models of disease prevention, largely as a result of the ongoing HIV/AIDS epidemic. The need to reduce HIV in this population has been a driving force to develop innovative research and Internet-based intervention methodologies. The Internet, and specifically mobile technology, is an environment gay and bisexual men are using for sexual purposes. These innovative technologies represent powerful resources for researchers to study and provide outreach.

A phase 1 randomized, double blind, placebo controlled rectal safety and acceptability study of tenofovir 1% gel (MTN-007)

Objective

Rectal microbicides are needed to reduce the risk of HIV acquisition associated with unprotected receptive anal intercourse. The MTN-007 study was designed to assess the safety (general and mucosal), adherence, and acceptability of a new reduced glycerin formulation of tenofovir 1% gel.

Methods

Participants were randomized 1∶1:1∶1 to receive the reduced glycerin formulation of tenofovir 1% gel, a hydroxyethyl cellulose placebo gel, a 2% nonoxynol-9 gel, or no treatment. Each gel was administered as a single dose followed by 7 daily doses. Mucosal safety evaluation included histology, fecal calprotectin, epithelial sloughing, cytokine expression (mRNA and protein), microarrays, flow cytometry of mucosal T cell phenotype, and rectal microflora. Acceptability and adherence were determined by computer-administered questionnaires and interactive telephone response, respectively.

Results

Sixty-five participants (45 men and 20 women) were recruited into the study. There were no significant differences between the numbers of ≥ Grade 2 adverse events across the arms of the study. Likelihood of future product use (acceptability) was 87% (reduced glycerin formulation of tenofovir 1% gel), 93% (hydroxyethyl cellulose placebo gel), and 63% (nonoxynol-9 gel). Fecal calprotectin, rectal microflora, and epithelial sloughing did not differ by treatment arms during the study. Suggestive evidence of differences was seen in histology, mucosal gene expression, protein expression, and T cell phenotype. These changes were mostly confined to comparisons between the nonoxynol-9 gel and other study arms.

Conclusions

The reduced glycerin formulation of tenofovir 1% gel was safe and well tolerated rectally and should be advanced to Phase 2 development.

Trial Registration

ClinicalTrials.gov NCT01232803.

Patterns of HIV disclosure and condom use among HIV-infected young racial/ethnic minority men who have sex with men

Recent findings highlight the continued rise in cases of HIV infection among racial/ethnic minority young men who have sex with men (YMSM). In adults, disclosure of HIV status has been associated with decreased sexual risk behaviors but this has not been explored among YMSM. In this study of 362 HIV-infected racial/ethnic minority YMSM, rates of disclosure were high, with almost all disclosing their status to at least one person at baseline. The majority had disclosed to a family member, with higher disclosure rates to female relatives compared with males. After adjustment for site, disclosure to sex partners and boyfriends was associated with an increase in condom use during both oral and anal sex. Future studies should consider skills training to assist youth in the disclosure process, facilitate how to determine who in their family and friend social network can be safely disclosed to and support family-based interventions.

What do we need to learn for policy decision-making on sexually transmitted infections prevention and treatment in Israel?

The rising trend of sexually transmitted infections (STIs) reported in several western countries has also affected Israel. To review epidemiological trends and to address additional issues needed for a wider overview on STIs in Israel, we analysed notified data on infectious syphilis, gonorrhoea, Chlamydia trachomatis and HIV/AIDS during 1998–2007, by age groups, and each available publication on STIs in Israel. The trend of each disease had a unique pattern, probably influenced by different screening procedures, case definition, mix of populations and better access to care for high-risk populations. Higher rates were found among patients aged 25–34 years. Rates found in different peak years for gonorrhoea, HIV, chlamydia and infectious syphilis reached 43.6, 18.9, 10.8 and 8.1 cases per 100,000 population, respectively. We compare trends to those of countries from World Health Organization (WHO) European Region and discuss interventions for subpopulations on which additional data are needed for evidence-based policy-making. Incidence rates of syphilis, gonorrhoea, chlamydia and HIV/AIDS are still low in Israel. We propose additional components needed for a more comprehensive evidence-based policy on STIs.

Correlates of unprotected anal sex among men who have sex with men in Tijuana, Mexico

Background

Although men who have sex with men (MSM) are disproportionately affected by HIV/AIDS in Mexico, data on current risk behaviors in this population are lacking. This study investigated the prevalence and correlates of unprotected anal intercourse (UAI) in a sample of 260 MSM in Tijuana, Mexico.

Methods

In June 2010, men attending a gay pride celebration were invited to complete a sexual risk survey. Men who reported UAI with a male partner in the past year were compared with men who reported only protected anal sex during the same period.

Results

Mean age of participants was 29.7; 54% had a high school diploma or less; and 43% were unemployed. In the past year, 55% had been tested for HIV, 21% reported using illicit drugs before or during sex, and 94% had sex only with men. Overall, 50% reported having UAI with another male in the past year. Factors independently associated with UAI in the past year were unemployment (AOR = 1.87), attending adult movie theaters (AOR = 2.21), using illicit drugs before or during sex (AOR = 2.43), and not having a recent HIV test (AOR = 1.85).

Conclusions

Interventions to promote HIV testing and condom use among men who have sex with men may want to consider venue-specific approaches, as well as focus on drug-use issues in the context of unsafe sex.

Sexual risk taking and club drug use across three age cohorts of HIV-positive gay and bisexual men in New York City

This study examined club drug use (i.e., cocaine, ecstasy, ketamine, gamma-hydroxybutyrate [GHB], and methamphetamine) and unprotected anal intercourse (UAI) in an ethnically and racially diverse sample of 166 New York City-based seropositive, club drug-using, gay and bisexual men, ages 19-61, and considered these behaviors in relation to age category (20s, 30s, and 40 +) and number of years living with HIV. Club drug use was common across all age categories, with differences arising only in the type of club drug used. Multivariate logistic regression modeling indicated older participants (30s and 40 +) were more likely to use cocaine and methamphetamine and less likely to use GHB and ketamine than those in their 20s. We examined UAI with casual partners in relation to age category, the number of years living with HIV, and club drug use. The likelihood of engaging in UAI with seronegative casual partners was greater among those in their 20s than those in their 30s or 40+. Further, participants were equally likely to engage in unprotected receptive anal intercourse and unprotected insertive anal intercourse with each casual partner serostatus type. With regard to number of years living with HIV, those living longer with the disease were more likely to report UAI with casual partners with a seropositive status than with a negative or unknown serostatus. Our findings suggest that UAI and club drug use is common among seropositive gay and bisexual men regardless of age category, but that differential patterns of risk emerge in relation to the number of years one has been living with HIV and age. These findings are of significance as both the aging population of seropositive gay and bisexual men and HIV infection rates continue to grow, and demonstrate a need for differentiated and tailored prevention strategies across the age continuum.

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

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

Behaviors of recently HIV-infected men who have sex with men in the year postdiagnosis: effects of drug use and partner types

OBJECTIVES

Assess behavior change of recently HIV-infected men who have sex with men (MSM).

METHODS

From 2002 to 2006, 193 recently HIV-infected MSM in the Southern California Acute Infection and Early Disease Research Program were interviewed every 3 months. Changes in HIV status of partners, recent unprotected anal intercourse (UAI), drug use, use of antiretroviral therapy (ART), detectable viral load, and partnership dynamics over 1 year were used to predict recent UAI in a random effect logistic regression.

RESULTS

Over a year significantly fewer partners in the past 3 months were reported (mean 8.81 to 5.84; P < 0.0001). Percentage of recent UAI with HIV-status unknown last partners decreased from enrollment to 9 months (49%-27%) and rebounded at 12 months to 71%. In multivariable models controlling for ART use, recent UAI was significantly associated with: baseline methamphetamine use [adjusted odds ratio (AOR): 7.65, 95% confidence interval (CI): 1.87 to 31.30], methamphetamine use at follow-up (AOR: 14.4, 95% CI: 2.02 to 103.0), HIV-uninfected partner at follow-up (AOR: 0.14, 95% CI: 0.06 to 0.33), and partners with unknown HIV status at follow-up (AOR: 0.33, 95% CI: 0.11 to 0.94). HIV viral load did not influence rate of UAI.

CONCLUSIONS

Transmission behaviors of these recently HIV-infected MSM decreased and serosorting increased after diagnosis; recent UAI with serostatus unknown or negative partners rebounded after 9 months, identifying critical timepoints for interventions targeting recently HIV-infected individuals. There was no evidence in this cohort that the viral load of these recently infected men guided their decisions about protected or unprotected anal intercourse.

Sexual risk behaviours and HIV-1 prevalence among urban men who have sex with men in Cape Town, South Africa

BACKGROUND

Distinct homosexual and heterosexual HIV epidemics have previously been recognised in South Africa. However, linked HIV prevalence and self-reported sexual risk behaviour data have not been reported for men who have sex with men (MSM) in Cape Town since 1986.

METHODS

We conducted a cross-sectional, anonymous, venue-based HIV risk behaviour and prevalence study of 542 self-identified MSM in greater Cape Town using a self-administered risk questionnaire and the OraSure testing device to asses HIV-1 prevalence.

RESULTS

This sample had an overall HIV prevalence of 10.4% (56/539). We found that self-identifying as gay, homosexual or queer (adjusted odds ratio (AOR) 4.5, 95% confidence interval (CI) 1.0-20.0) and reporting ever having had a sexually transmissible infection diagnosis (AOR 4.3, 95% CI: 2.3-8.3) were significantly predictive of testing HIV-1 positive, while reporting unprotected anal intercourse with a known HIV-negative partner (AOR 0.4, 95% CI: 0.2-0.9) was significantly protective.

CONCLUSION

These data suggest a mature epidemic with consistent high-risk taking among MSM in Cape Town, and significant associations of select self-reported risk behaviours and HIV-1 serostatus. There is a need for continued and robust HIV surveillance along with detailed risk behaviour trends over time to inform the development of targeted risk-reduction interventions for this population.

Sex with older partners is associated with primary HIV infection among men who have sex with men in North Carolina

BACKGROUND

Studies from the 1990s suggested sex with older partners was associated with HIV infection. We evaluated the hypothesized association between primary HIV infection (PHI) and having older sexual partners among men who have sex with men (MSM).

METHODS

MSM with PHI and HIV-uninfected MSM completed audio computer-assisted self-interviews exploring behaviors involving their 3 most recent sexual partners before enrollment (if uninfected) or diagnosis (if PHI).

RESULTS

Of 74 men reporting any lifetime sex with men, 20 had PHI (27%). Demographics (including age) were similar between groups; 39% were non-white and 74% identified as gay. The mean age of sex partners differed significantly: men with PHI had partners on average 6 years older than themselves, whereas uninfected men's partners were 4 months their junior (P < 0.001). After adjusting for race, sex while intoxicated, and having a serodiscordant/serostatus unknown partner, a participant had twice the odds of PHI if his sex partner was 5 years his senior (odds ratio 2.0, 95% confidence interval: 1.2 to 3.3).

CONCLUSIONS

Among a sample of young MSM, the odds of HIV infection increased significantly as the age of sexual partners increased. These findings can inform behavioral interventions in communities of at-risk MSM and secondary prevention efforts among those already living with HIV.

Prevalence of unprotected anal intercourse among HIV-diagnosed MSM in the United States: a meta-analysis

OBJECTIVE

To integrate the empirical findings on the prevalence of unprotected anal intercourse (UAI) among HIV-diagnosed men who have sex with men (MSM) in the United States.

METHODS

Comprehensively searching MEDLINE, EMBASE, PsycINFO (2000-2007), hand searching bibliographic lists, and contacting researchers. Thirty US studies (n = 18,121) met selection criteria. Analyses were conducted using random-effects models and meta-regression.

RESULTS

The prevalence of UAI was considerably higher with HIV-seropositive partners (30%; 95% confidence interval 25-36) than with serostatus unknown (16%; 95% confidence interval 13-21) or HIV-seronegative partners (13%; 95% confidence interval 10-16). The prevalence of UAI with either a serostatus unknown or HIV-seronegative partner was 26%. The UAI prevalence did not differ by the length of the behavioral recall window but did vary by the type of anal intercourse (insertive vs. receptive). Studies with the following features had a lower UAI prevalence: recruiting participants before 2000, MSM of color being the majority of study sample, recruiting participants from medical settings, using random or systematic sampling methods, and having interviewers administer the questionnaire. Being on antiretroviral therapy, having an undetectable viral load, and reporting more than 90% medication adherence were not associated with UAI.

CONCLUSION

Most HIV-diagnosed MSM protect partners during sexual activity, but a sizeable percentage continues to engage in sexual behaviors that place others at risk for HIV infection and place themselves at risk for other sexually transmitted infections. Prevention with positives programs continues to be urgently needed for MSM in the United States.

Increases in unprotected anal intercourse with serodiscordant casual partners among HIV-negative gay men in Sydney

Prevalence of unprotected anal intercourse between casual male partners (UAIC) has been increasing worldwide. We explored trends in serodiscordant UAIC and the associated factors among gay men in Sydney. Proportions of HIV-positive and negative men with serodiscordant casual partners increased during 2003-2006. Prevalence of serodiscordant UAIC increased among HIV-negative men. Age, number of partners, seeking partners online, drug use and esoteric practices were associated with serodiscordant UAIC. Increases in serodiscordant UAIC may be related to growing disclosure. These findings do not indicate a core group of high-risk men. More research is needed about the context in which serodiscordant UAIC happens.

Effects of a short individually tailored counselling session for HIV prevention in gay and bisexual men receiving Hepatitis B vaccination

Background

There is currently a trend towards unsafe unprotected anal intercourse (UAI) among men who have sex with men. We evaluated a short individual counselling session on reducing UAI among gay and bisexual men.

Methods

A quasi-experimental design was used to evaluate the counselling session. This session was conducted during consulting hours at four municipal health clinics during a Hepatitis B vaccination campaign. These clinics offered free vaccination to high-risk groups, such as gay and bisexual men.

All gay and bisexual men attending health clinics in four cities in the Netherlands were asked to participate. Each participant in the intervention group received a fifteen-minute individual counselling based on the Theory of Planned Behaviour and Motivational Interviewing. Changes in UAI were measured over a 5-months period, using self-administered questionnaires. UAI was measured separately for receptive and insertive intercourse in steady and casual partners. These measures were combined in an index-score (range 0–8).

Results

While UAI in the counselling group remained stable, it increased in the controls by 66% from 0.41 to 0.68. The results show that the intervention had a protective effect on sexual behaviour with steady partners. Intervention effects were strongest within steady relationships, especially for men whose steady-relationship status changed during the study. The intervention was well accepted among the target group.

Conclusion

The fifteen-minute individually tailored counselling session was not only well accepted but also had a protective effect on risk behaviour after a follow-up of six months.

A behavioral intervention reduces HIV transmission risk by promoting sustained serosorting practices among HIV-infected men who have sex with men

OBJECTIVE

To examine factors that explain the effect of a cognitive-behavioral intervention on reductions in HIV transmission risk among HIV-infected men who have sex with men (MSM).

METHOD

Of the 1910 HIV-infected MSM screened, 616 participants considered to be at risk of transmitting HIV were randomized to a 15-session, individually delivered cognitive-behavioral intervention (n=301) or a wait-list control (n=315).

RESULTS

Consistent with previous intent-to-treat findings, there was an overall reduction in transmission risk acts among MSM in both intervention and control arms, with significant intervention effects observed at the 5-, 10-, 15-, and 20-month assessments (risk ratios=0.78, 0.62, 0.48, and 0.38, respectively). These intervention-related decreases in HIV transmission risk acts seemed to be partially due to sustained serosorting practices. MSM in the intervention condition reported a significantly greater proportion of sexual partners who were HIV infected at the 5- and 10-month assessments (risk ratios=1.14 and 1.18).

CONCLUSIONS

The Healthy Living Project, a cognitive-behavioral intervention, is efficacious in reducing transmission risk acts among MSM. This seems to have been due in large part to the fact that MSM in the intervention condition reported sustained serosorting practices.

Frequency of discussing HIV prevention and care topics with patients with HIV: influence of physician gender, race/ethnicity, and practice characteristics

BACKGROUND

Because people living with HIV now have greater life expectancy and reduced morbidity, there is a greater need for physicians to discuss HIV transmission risk reduction with these patients. Very limited data are available examining how frequently this discussion is held.

OBJECTIVE

We examined the frequency of discussing HIV prevention and HIV care topics, as well as the associations of gender, race/ethnicity, and practice characteristics of physicians caring for persons with HIV.

METHODS

In a 4-city (Miami, Atlanta, Baltimore, Los Angeles) survey, 417 licensed physicians who primarily cared for patients with HIV were mailed a 58-item questionnaire about how frequently they discussed HIV transmission risk reduction, adherence to HIV antiretroviral treatment (ART), adherence to opportunistic infection (OI) prophylaxis, and how to take medicines. Multivariate logistic regression analyses were used to examine the association between physician gender, race/ethnicity, and practice characteristics, and the frequency of discussing these topics.

RESULTS

A total of 317 physicians responded to the mailed questionnaire. Less than 40% of the physicians reported always discussing HIV transmission risk reduction with patients. In contrast, 83.9% and 65.0% reported always discussing adherence to ART and to OI prophylaxis, respectively. Of these physicians, 65.1% strongly agreed or somewhat agreed that they had sufficient time to provide the care and information needed to their patients. In multivariate analysis, the frequency of discussing HIV transmission risk reduction was higher for physicians who were Hispanic (P = 0.03) or Asian/Pacific Islander (P = 0.001), for physicians who reported they had enough time to provide care and information to patients (P = 0.003), and for physicians who cared for fewer patients (P = 0.05). The frequency of discussing HIV transmission risk reduction was suggestive of a higher rate for female physicians, but did not quite reach statistical significance.

CONCLUSIONS

We observed a lower frequency of discussing the topic of HIV prevention compared with that of HIV care among the physicians surveyed. This infrequent discussion with patients with HIV represents a missed opportunity, and physicians should be encouraged to include discussion of prevention as a standard of care.

Gay men who engage in substance use and sexual risk behaviour: a dual-risk group with unique characteristics

'Recreational' substances used among men having sex with men, and their association with risky unprotected anal intercourse (RUAI) were examined--for the first time in Israel--in an internet-based questionnaire assessing knowledge, practices and motivation. Between March and May 2005, 2873 participants completed the entire questionnaire. Of the total, 669 (23%) reported RUAI during the last six months, and 1319 (46%) used substances during sex. Use of substance was significantly higher among those performing RUAI than those who did not (31.5% versus 26.4%, P=0.03). Involvement in both substance use and RUAI was reported by 366 participants (13%). HIV rates were higher in this dual-risk group (P<0.01), and individuals reported more partners in the last six months than those not part of this dual risk (11.6 versus 8.2, P=0.02). In multivariate analyses, Tel-Aviv residency, lower education, performing receptive RUAI, misperception of HIV transmission and limited negotiation skills were positively associated with this dual-risk behaviour.

Circuits, networks, and HIV risk management

Drawing on a survey of men who have sex with men conducted at Toronto's largest gay and lesbian event (N = 947), this study examines the characteristics of men who report that they like to participate in the "bareback scene" and cruise "bareback Web sites" by comparing them with men who (a) report having had at least one incident of unprotected anal intercourse but no bareback connections, or (b) report consistently protected anal intercourse (UAI). Overall, 62.0% of the surveyed men reported having had a casual male partner in the last 6 months, 14.2% of whom reported having had UAI. Including these men, with men who report UAI with or without ejaculation, with casual or regular partners, accounts for 40.6% of the sample. MSM in bareback scenes or Web sites form a circuit insofar as they are significantly overrepresented in a set of bars, baths, parks, and Web sites, that aligns closely with one of the circuits identified in a factor analysis of venues attended by men in the sample. They also show a distinctive pattern of beliefs and perceptions of appropriate norms for sexual conduct, and are more likely to have had five or more partners in the last 6 months.

HIV prevention altruism and sexual risk behavior in HIV-positive men who have sex with men

An understanding of men's motivations to avoid risk behavior is needed to create efficacious HIV prevention programs for HIV-positive men who have sex with men (MSM). This study investigates the relationship between sexual risk behavior and HIV prevention altruism, which is defined as the values, motivations, and practices of caretaking towards one's sexual partners to prevent the transmission of HIV. In a sample of 637 HIV-positive MSM, HIV prevention altruism significantly protects against serodiscordant unprotected anal intercourse (SDUAI) in crude analysis, but not after adjustment for drug use and compulsive sexual behavior. HIV prevention altruism is also related to not engaging in anal intercourse, but is not related to serodisclosure to secondary partners. Lack of altruism appears related to sexual risk behavior in HIV-positive MSM, although other psychological and contextual factors play significant roles. The promotion of HIV prevention altruism may provide a formidable new direction for HIV prevention programs.

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

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

Condom Use Rather Than Serosorting Explains Differences in HIV Incidence Among Men Who Have Sex With Men

BACKGROUND

HIV incidence is high and increasing among men who have sex with men (MSM) attending the Sexually Transmitted Infection (STI) Outpatient Clinic in Amsterdam but remains low among MSM in the Amsterdam Cohort Studies (ACS). We studied whether sexual behaviors in these 2 groups are consistent with serosorting and if serosorting explains the difference in HIV incidence.

METHODS

In 2004 to 2006, a survey of sexual behaviors and HIV status regarding up to 4 traceable partners in the prior 6 months was performed in MSM attending the STI Outpatient Clinic (high-risk) and in MSM in the ACS (lower risk). Moreover, pooled information was collected on anonymous partners. We used logistic regression to test whether sexual behaviors are consistent with serosorting and to test whether risk group is associated with having concordant traceable partners among men reporting unprotected anal intercourse (UAI).

RESULTS

We included 513 MSM (54% lower risk and 75% HIV-negative). Lower risk and high-risk MSM with concordant traceable partners were more likely to have UAI than MSM with discordant partners or partners of unknown HIV status (P < 0.001). Risk group was not associated with having concordant UAI. Compared with lower risk MSM, however, high-risk MSM frequently had UAI with nonconcordant traceable partners and with anonymous partners.

CONCLUSIONS

Sexual risk behaviors with traceable partners are consistent with serosorting. Nonetheless, the higher level of UAI with anonymous or nonconcordant traceable partners more likely explains the increasing HIV incidence seen among STI Outpatient Clinic attendees than a difference in serosorting behavior.

Preliminary findings of an intervention integrating modified directly observed therapy and risk reduction counseling

Various interventions have been proposed to address these ongoing needs of HIV-positive patients as they encounter challenges with medication adherence and risk reduction. This report presents the findings of a study that pilots 'DAART+', an intervention that integrates modified directly observed therapy (MDOT), and risk reduction counseling for a population of marginally housed, substance-using persons. The pilot study intended to assess the feasibility of the intervention and to obtain data to assess the intervention's potential effectiveness. The preliminary data reveal that 83% of participants who completed the intervention (n=18) had undetectable viral load (VL) (VL< or =400 copies/mL) which represents a 2.15 log(10) decrease from baseline. Risk behaviors also changed modestly with self-reported increases in condom usage.

Prevalence of HIV infection and predictors of high-transmission sexual risk behaviors among men who have sex with men

OBJECTIVES

We sought to determine the prevalence of HIV and novel cofactors of high-transmission-risk behavior in a probability sample of men who have sex with men (MSM).

METHODS

We performed a cross-sectional telephone survey of 1976 adult MSM in San Francisco.

RESULTS

We found an HIV prevalence of 25.2%. Predictors of unprotected insertive anal intercourse with a serodiscordant (not having the same HIV/AIDS serostatus) partner among HIV-infected men included use of Viagra and a greater number of partners in the past 12 months. Unprotected receptive anal intercourse with a serodiscordant partner among men not known to be HIV infected was independently associated with having lived in San Francisco for less than 1 year, use of crystal methamphetamine and amyl nitrites, a greater number of partners, and agreement with the statement, "You are less careful about being safe with sex or drugs than you were several years ago because there are better treatments for HIV now."

CONCLUSIONS

Strategies to prevent HIV for urban MSM should focus on new predictors of HIV transmission.

HIV incidence and HIV testing behavior in men who have sex with men: using three incidence sources, The Netherlands, 1984-2005

BACKGROUND

In The Netherlands, the western part, including Rotterdam and Amsterdam harbors the majority of the known HIV-infected population, of whom men who have sex with men (MSM) comprise the largest transmission category. Given a general rise in sexually transmitted infections (STI) and risky sexual behavior, we examine the HIV incidence among MSM in the Netherlands with data from three different sources.

METHODS

To describe the HIV epidemic among MSM we use: a prospective cohort study in Rotterdam (ROHOCO: 1998-2003, n = 265) and another in Amsterdam (ACS: 1984-2005, n = 1498]) plus an anonymous HIV surveillance study (Amsterdam STI clinic: 1991-2004, n = 3733) in which HIV-positive MSM were tested with a less-sensitive HIV assay. We evaluated calendar trends in HIV incidence, also focusing on age effects.

RESULTS

Since the start of the HIV epidemic in the early 1980s, incidence has declined strongly in the ACS. In recent years, an increase was noted among older MSM attending the Amsterdam STI clinic (P = 0.0334). In both cohort studies, HIV incidence was lower and recent time-trends were not statistically significant. Among recently infected men at the STI clinic, only 40% accepted named HIV testing at their STI consultation.

CONCLUSIONS

Data suggest that among MSM in the Netherlands, the HIV incidence is between one and four infections per 100 person-years. The epidemic expands among older STI clinic attendees. Prevention should be developed specifically for older men, along with a more efficient HIV testing approach such as routine HIV testing of MSM when they are screened for STI.

Increases in sexually transmitted infections and sexual risk behaviour without a concurrent increase in HIV incidence among men who have sex with men in San Francisco: a suggestion of HIV serosorting?

BACKGROUND

Sexually transmitted infections (STI) and unprotected anal intercourse (UAI) have been increasing among men who have sex with men (MSM) in San Francisco. However, HIV incidence has stabilised.

OBJECTIVES

To describe recent trends in sexual risk behaviour, STI, and HIV incidence among MSM in San Francisco and to assess whether increases in HIV serosorting (that is, selective unprotected sex with partners of the same HIV status) may contribute to preventing further expansion of the epidemic.

METHODS

The study applies an ecological approach and follows the principles of second generation HIV surveillance. Temporal trends in biological and behavioural measures among MSM were assessed using multiple pre-existing

DATA SOURCES

STI case reporting, prevention outreach programmatic data, and voluntary HIV counselling and testing data.

RESULTS

Reported STI cases among MSM rose from 1998 through 2004, although the rate of increase slowed between 2002 and 2004. Rectal gonorrhoea cases increased from 157 to 389 while early syphilis increased from nine to 492. UAI increased overall from 1998 to 2004 (p<0.001) in community based surveys; however, UAI with partners of unknown HIV serostatus decreased overall (p<0.001) among HIV negative MSM, and among HIV positive MSM it declined from 30.7% in 2001 to a low of 21.0% in 2004 (p<0.001). Any UAI, receptive UAI, and insertive UAI with a known HIV positive partner decreased overall from 1998 to 2004 (p<0.001) among MSM seeking anonymous HIV testing and at the STI clinic testing programme. HIV incidence using the serological testing algorithm for recent HIV seroconversion (STARHS) peaked in 1999 at 4.1% at the anonymous testing sites and 4.8% at the STI clinic voluntary testing programme, with rates levelling off through 2004.

CONCLUSIONS

HIV incidence among MSM appears to have stabilised at a plateau following several years of resurgence. Increases in the selection of sexual partners of concordant HIV serostatus may be contributing to the stabilisation of the epidemic. However, current incidence rates of STI and HIV remain high. Moreover, a strategy of risk reduction by HIV serosorting can be severely limited by imperfect knowledge of one's own and one's partners' serostatus.

Sexual risk behavior among HIV-positive men who have sex with men: a literature review

OBJECTIVE

To review research on sexual risk behavior among HIV-positive men who have sex with men (MSM) after the year 2000.

METHOD

The review included 53 published studies that reported on unprotected anal intercourse (UAI) in cross-sectional and longitudinal surveys of HIV-positive MSM and MSM of mixed HIV status.

RESULTS

The findings indicate high levels of UAI among HIV-positive MSM, particularly with HIV-negative or HIV status unknown partners. In studies of MSM of mixed HIV status, we found that the rate of UAI among HIV-positive MSM was much higher than that of HIV-negative MSM. Furthermore, the prevalence of UAI among HIV-positive MSM has increased in recent years.

CONCLUSION

Although studies indicate that HIV-positive MSM have adopted risk reduction strategies, roughly two in five HIV-positive MSM continue to engage in UAI, which represents a risk for continued HIV and STI (sexually transmitted infection) transmission.

PRACTICE IMPLICATIONS

Prevention efforts targeting HIV-positive MSM to assist them in adopting and maintaining safer sexual behaviors need to be intensified.

Nonnegligible increasing temporal trends in unprotected anal intercourse among men who have sexual relations with other men in montreal

OBJECTIVE

To determine temporal trends in unprotected anal intercourse (UAI) among men who have sex with men (MSM) participating in the Omega Cohort Study, 1997 through 2003.

METHODS

The Omega Cohort Study was a longitudinal study of HIV-negative MSM aged 16 years or older and living in Montreal. Participants completed self-administered questionnaires and interviews every 6 months. Trend analysis using the generalized estimating equation was done for length of cohort membership (visits) and by calendar time for all visits per type of sexual partner. Odds ratios (ORs) were calculated to measure the odds of increasing UAI per 6-month period.

RESULTS

Among subjects who were followed for at least 4 years, UAI increased with regular seroconcordant partners (OR = 1.06, 95% confidence interval [CI]: 1.04 to 1.09) and any type of partner (OR = 1.05, 95% CI: 1.03 to 1.07). There was a nonnegligible increase in UAI with casual partners (OR = 1.05, 95% CI: 1.01 to 1.09). For the analysis by calendar time, there were increases in UAI between regular seroconcordant partners (OR = 1.04, 95% CI: 1.02 to 1.05) and any type of partner (OR = 1.03, 95% CI: 1.02 to 1.04). There were nonnegligible increases in UAI with casual partners (OR = 1.03, 95% CI: 1.00 to 1.05) and with any type of partner except a regular seroconcordant partner from 15.7% to 18.8% (OR = 1.02, 95% CI: 1.00 to 1.04).

CONCLUSIONS

There was a nonnegligible and consistent increase in UAI among Omega Cohort Study participants between 1997 and 2003. Continuous trend analysis is important because it allows us to follow UAI closely and to implement intervention strategies that may help to stop or reduce the present trend.

Potential bridges for HIV infection to men who have sex with men in Guangzhou, China

To assess the potential for HIV acquisition among men who have sex with men (MSM) in Guangzhou, China, we conducted a cross-sectional, anonymous, face-to-face survey of MSM in the metropolitan area of Guangzhou, China. As a pilot recruitment for a cohort study, participants were recruited by convenience sampling through newspaper and television advertising, website information, and respondent referral. Blood samples were tested for HIV, hepatitis B (HBV), hepatitis C (HCV), and syphilis. Client-centered HIV and STD counseling was provided.A total of 201 MSM were interviewed and 200 blood samples were tested. The prevalence of HIV antibody was 0% (97.5% CI 0-1.8%); 17.5% of MSM were HBV surface antigen positive; 1.0% had HCV antibodies; 10.5% had antibodies to syphilis. Syphilis seropositivity was associated with sex with a foreign MSM in the last six months and 10.4% reported sex with a foreign MSM overall. The majority (54.7%) reported unprotected anal sex with other men. Nearly one-third (31.8%) had regular female partners; 25.9% were currently married to a woman; 6% had casual female partners; 4.5% had sex with a female sex worker; 4.5% had sex with a male sex worker; and 12.9% had unprotected vaginal sex and unprotected anal sex with a man in the past six months. Only one MSM reported injection drug use (0.5%). The currently low prevalence of HIV but high level of unprotected anal sex, high prevalence of syphilis infection, and sexual networks that include foreign MSM point to a transient window for HIV prevention among MSM in Guangzhou. We recognize challenges to recruiting a representative sample of MSM and retaining them in longitudinal cohort studies.

Unsafe sexual behavior and correlates of risk in a probability sample of men who have sex with men in the era of highly active antiretroviral therapy

OBJECTIVE

To assess the levels and correlates of potential exposure to and transmission of HIV in a contemporary, community-based probability sample of men who have sex with men (MSM).

METHODS

In 2003, 311 sexually active MSM participated in a random-digit dial telephone survey in Seattle neighborhoods with a high prevalence of MSM. The primary outcomes were potential exposure to and transmission of HIV, defined as unprotected anal intercourse with a man of opposite or unknown HIV status in the preceding 12 months.

RESULTS

Fourteen percent of respondents reported being HIV-positive, 77% reported being HIV-negative, and 8% had not been tested. Of 241 HIV-negative MSM, 25 (10%; 95% confidence interval [CI], 7-15%) were potentially exposed to HIV; among 45 HIV-positive MSM, 14 (31%; 95% CI, 20-46%) were potential HIV-transmitters. Among HIV-negative men, the strongest bivariate correlates of potential exposure to HIV were recent bacterial sexually transmitted disease (odds ratio [OR], 5.8), number of recent male sexual partners (OR, 1.01 per partner), recent sex at a bathhouse (OR, 9.1), and recent use of sildenafil (OR, 4.4), amyl nitrite (OR, 6.2), and methamphetamine (OR, 8.0). Among HIV-infected men, the strongest correlates of potential HIV transmission were recent use of amyl nitrite (OR, 3.1), number of recent male sex partners (OR, 1.07 per partner), and having a male spouse or domestic partner (OR, 0.3).

CONCLUSIONS

Most MSM knew their HIV status and adopted safer sexual behaviors to reduce their risk of HIV acquisition or transmission. However, 10% of HIV-negative MSM and 31% of HIV-positive MSM recently engaged in behaviors that placed them at high risk for acquiring or transmitting HIV.

Transmission Behaviors of Recently HIV-Infected Men Who Have Sex With Men

OBJECTIVES

Analyze postdiagnosis behaviors of recently HIV-infected men who have sex with men (MSM).

METHODS

Recently HIV-infected MSM were interviewed at 6 weeks (n = 153) and 3 months (n = 113) after diagnosis. Behaviors from baseline to follow-up were compared; multivariate logistic regression identified associations between baseline characteristics and behavior at follow-up.

RESULTS

At follow-up, MSM reported a significantly lower mean of partners (7.9 vs. 5.2) and lower means of 1-time (1.9 vs. 0.8), unknown (3.7 vs. 2.6), and acquaintance (1.1 vs. 0.5) partners than at baseline. In multivariate analyses, unprotected anal intercourse (UAI) with the last partner at follow-up was more likely if the last partner at baseline was a main partner (odds ratio [OR] = 2.94, 95% confidence interval [CI]: 1.04 to 8.33) or HIV-positive partner (OR = 3.36, 95% CI: 1.27 to 8.88) but less likely if, at follow-up, the last partner was HIV-negative (OR = 0.28, 95% CI: 0.08 to 1.00) or of unknown HIV status (OR = 0.23, 95% CI: 0.08 to 0.71), the participant had a history of nonconsensual sex (OR = 0.25, 95% CI: 0.09 to 0.72), or the participant had more than 1 partner (OR = 0.28, 95% CI: 0.09 to 0.86). More than 1 partner at follow-up was associated with no main partner at baseline or follow-up (OR = 2.76, 95% CI: 1.12 to 6.78), more partners in the last 12 months (OR = 1.02, 95% CI: 1.01 to 1.04), and UAI with the last partner (OR = 0.36, 95% CI: 0.14 to 0.90).

CONCLUSIONS

After diagnosis, some but not all recently HIV-infected MSM reduced risky sexual behavior permitting potential HIV transmission.

HIV prevalence and sexual risk behaviors among men who have sex with men: results from a statewide population-based survey in California

OBJECTIVES

To investigate HIV prevalence, sexual risk behaviors, and HIV testing among men who have sex with men (MSM) between 18 and 64 years old living in California.

DESIGN

Cross-sectional study of a statewide population-based sample of MSM.

METHODS

Using data from the 2001 California Health Interview Survey (CHIS 2001), 398 men who self-identified as gay or bisexual were recontacted and interviewed by telephone for a follow-up study in 2002. Study participants were interviewed regarding their demographic characteristics and sexual behavior, HIV testing history, and HIV infection status. Those who self-reported as HIV-negative or of unknown status were offered an HIV test using a home urine specimen collection kit.

RESULTS

HIV prevalence among MSM in California was 19.1% (95% confidence interval [CI]: 12.8% to 25.3%) with higher rates seen among the following subgroups: high school or less education (40.4%), annual income less than dollar 20,000 (35.0%), or history of ever injecting recreational drugs (40.3%). Young age and Hispanic or African-American race/ethnicity were associated with higher proportions of risky sexual behavior and lower HIV testing rates.

CONCLUSIONS

HIV prevalence among MSM living in California continues to be high across the whole state, and population-based studies are needed periodically to complement findings from surveys using other sampling designs.

Changing patterns of sexual behaviour in the era of highly active antiretroviral therapy

PURPOSE OF REVIEW

To describe changing patterns of sexual behaviour in the era of highly active antiretroviral therapy among gay/bisexual men in Europe, Canada, USA and Australia.

RECENT FINDINGS

While there has been a substantial increase in high-risk sexual behaviour among gay men since 1996, this now appears to be levelling off in some cities. Overall the empirical evidence does not support the suggestion that taking highly active antiretroviral therapy or having an undetectable viral load leads to risky sexual behaviour among people with HIV. Nor can HIV treatment optimism alone explain the recent increase in high-risk sexual behaviour. Since 1996, an increasing number of gay men have begun to use the Internet to look for sexual partners. By serosorting on the Internet, HIV-positive men are more likely to meet online, rather than off-line, other HIV-positive men for unprotected sex. While serosorting does not present a risk of HIV transmission to an uninfected person, it does present a risk of other sexually transmitted infections and co-infection with resistant virus for HIV-positive men themselves. This review also explores emerging behaviours such as barebacking and strategic positioning as well as the role of crystal meth and Viagra.

SUMMARY

The review reminds us of the complexity of human and sexual behaviour. Among gay men, sexual behaviour in the era of highly active antiretroviral therapy has been characterized by risk reduction and stabilization as well as increasing risk. These changing patterns provide a new challenge as well as new opportunities for HIV prevention.

Nonnegligible Increasing Temporal Trends in Unprotected Anal Intercourse Among Men Who Have Sexual Relations With Other Men in Montreal

OBJECTIVE

The objective of this study is to determine temporal trends in unprotected anal intercourse (UAI) among men who have sex with other men (MSM) participating in the Omega Cohort Study, 1997-2003.

METHODS

The Omega Cohort Study was a longitudinal study of HIV-negative MSM aged 16 years or older and living in Montreal. Participants completed self-administered questionnaires and interviews every 6 months. Trend analysis using the generalized estimating equation was done for length of cohort membership (visits) and by calendar time for all visits, per type of sexual partner. Odds ratios (ORs) were calculated to measure the odds of increasing UAI per 6-month period.

RESULTS

Among subjects who were followed for at least 4 years, UAI increased with regular seroconcordant partners (OR, 1.06, 95% CI 1.04-1.09), and any type of partner (OR, 1.05, 95% CI 1.03- 1.07). There was a nonnegligible increase in UAI with casual partners (OR, 1.05; 95% CI, 1.01-1.09). For the analysis by calendar time, there were increases in UAI between with regular seroconcordant partners (OR, 1.04; 95% CI, 1.02-1.05) and any type of partner (OR, 1.03; 95% CI, 1.02-1.04). There were nonnegligible increases in UAI with casual partners (OR, 1.03; 95% CI, 1.00-1.05) and with any type of partner except regular seroconcordant partner from 15.7% to 18.8% (OR, 1.02; 95% CI, 1.00-1.04).

CONCLUSIONS

There was a nonnegligible and consistent increase in UAI among Omega participants, between 1997 and 2003. Continuous trend analysis is important because it allows us to closely follow UAI and to implement intervention strategies that may help to stop or reduce the present trend.

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.

Effect of Relationship Factors on Safer Sex Decisions in Older Inner-City Women

OBJECTIVES

Heterosexual transmission of the human immunodeficiency virus (HIV) in older women is on the rise, yet little is known about safer sex practices in these women. We sought to determine the prevalence of and effect of relationship factors on safer sex practices among older women living in a high HIV incidence region.

METHODS

In a cross-sectional study at an ambulatory medicine clinic of a large inner-city hospital, participants were women over age 50 seeking medical services at the study site. Measurements included (1) partner trust, (2) dependence on partner, (3) personally obtaining condoms, (4) safer sex (frequent condom use or abstinence), (5) knowledge of condom efficacy, and (6) perceived HIV risk.

RESULTS

Of 155 participants in a current relationship, 81% were sexually active; however, only 13% of these women used condoms frequently. No significant differences were found between participants who did and did not practice safer sex with respect to their age, race, employment, marital status, knowledge of condom efficacy, or perceived HIV risk. Trust in partner was independently associated with lower odds of safer sex (OR 0.3, 95% CI 0.08-1.06). Personally obtaining condoms (OR 9.2, 95% CI 1.9-44.2) and dependence on partner for condoms (OR 12.3, 95% CI 3.0-50.3) were independently associated with higher odds of safer sex. CONCLUSIONS. Few older women in high HIV incidence areas practice safer sex. Relationship factors impact the risk of acquiring HIV through safer sex decisions. HIV prevention messages geared to older women should incorporate references to the role these factors can play in reducing their HIV risk.

Provider fatalism reduces the likelihood of HIV-prevention counseling in primary care settings

We examined the relationship between provider fatalism, a belief that behavior change among HIV-infected patients is unlikely, and HIV-prevention counseling in 16 publicly funded clinics. HIV-seropositive patients (N = 618) completed surveys assessing prevention counseling in the past 6 months. Additionally, 144 interviews were conducted with providers, administrators, and patients to examine beliefs about prevention counseling. We summed the number of fatalistic comments made by providers and administrators in each clinic, and assigned these counts as clinic-level fatalism scores to survey participants. Patients in high fatalism clinics were less likely to report prevention counseling than patients in low fatalism clinics. This difference remained significant even after controlling for clinic characteristics or patients' sexual risk and health status. However, clients in high fatalism clinics were more likely to be White, gay, educated, and older. Provider fatalism is a barrier that must be addressed when implementing HIV-prevention counseling in primary care settings.

Increasing rates of sexually transmitted diseases in homosexual men in Western europe and the United States: why?

The recent increases in acute STDs among MSM must be viewed in the context of a post-AIDS era that is characterized by demographic shifts,changing sexual attitudes, and rapidly changing social contexts. A key driver seems to be the growing prevalent pool of HIV-positive MSM for whom the crucial motivator for safer sex (primary HIV prevention) no longer exists and where, given the prevalence of seroconcordant sexual mixing, consider-able uncertainty and conflicting advice regarding the rationale and benefits for continued safer-sex practice are unclear [105,106]. Although it is tempting to ascribe these changes to increases in risk behavior, it is essential that the contexts in which the changes are occurring are also considered. It may also be appropriate to contemplate whether further changes to the social environment (eg, structural interventions) are a suitable adjunct to our traditional prevention activities that operate largely in isolation from each other. It seems natural to advocate that interventions that adopt holistic approaches to the sexual health of MSM and that address upstream factors such as mental health, drug use, discrimination, and internalized homophobia should be included in the efforts to create more healthy environments for MSM. However, there is still some way to go in identifying which of these upstream interventions are effective, how they may be implemented within or alongside existing health care systems, and what impact, if any, they are likely to have on STD transmission. Such interventions are also likely to belong on implementation time, require consider political will, and be extremely hard to evaluate, and the benefits may not be seen within the same generation in which they are implemented. Therefore, there must be confidence that this is the appropriate route of travel. The consistency of findings from across industrialized countries confirms an increasing connectivity within the global MSM community;a community that is decreasingly defined by geographic boundaries and, in the era of the Internet and easier foreign travel, increasingly linked by shared interests and social and sexual networks. This is powerfully demonstrated in the near-simultaneous syphilis and LGV outbreaks among MSM in Europe and the United States [29]. In this regard, greater collaboration between researchers and providers working with MSM indifferent countries is now required. More specifically, consideration should be given to creating closer partnerships between sentinel cities, such as London, New York, San Francisco, Berlin, Paris, and Amsterdam, that have large MSM populations and are likely to be emerging, or rapid diffusion sites for new social and sexual trends that may impact on disease transmission. There are many benefits to such cross-national working,including earlier recognition and improved response to emerging threats,sharing innovative practice, avoiding duplication of effort, and creating a united front for dealing with what must be considered a cause for concern domestically and globally.

Sexual harm reduction practices of HIV-seropositive gay and bisexual men: serosorting, strategic positioning, and withdrawal before ejaculation

OBJECTIVE

This study assessed unprotected anal and oral sex behaviors of HIV-positive gay and bisexual men in New York City and San Francisco with their main and non-main sexual partners. Here we focus on the use of three harm reduction strategies (serosorting, strategic positioning, and withdrawal before ejaculation) in order to decrease transmission risk.

METHOD

The data from a baseline assessment of 1168 HIV-positive gay and bisexual men in the two cities were utilized. Men were recruited from a variety of community-based venues, through advertising and other techniques.

RESULTS

City differences were identified, with more men in San Francisco reporting sexual risk behaviors across all partner types compared with men in New York City. Serosorting was identified, with men reporting significantly more oral and anal sex acts with other HIV-positive partners than with HIV-negative partners. However, men also reported more unprotected sex with partners of unknown status compared with their other partners. Some evidence of strategic positioning was identified, although differences were noted across cities and across different types of partners. Men in both cities reported more acts of oral sex without ejaculation than with ejaculation, but the use of withdrawal as a harm reduction strategy for anal sex was more common among men from San Francisco.

CONCLUSION

Overall, evidence for harm reduction was identified; however, significant differences across the two cities were found. The complicated nature of the sexual practices of gay and bisexual men are discussed, and the findings have important implications for prevention efforts and future research studies.

Seroconcordant sexual partnerings of HIV-seropositive men who have sex with men

OBJECTIVES

To describe the sexual behaviors of HIV-positive men with their seroconcordant partners and to determine the factors associated with unprotected anal intercourse (UAI) in these sexual partnerings.

METHODS

The data were drawn from the baseline assessment of a randomized controlled intervention study of 1168 HIV-positive men who have sex with men recruited from mainstream gay venues, AIDS service organizations, and public/commercial sex environments.

RESULTS

Of the 1168 men, 596 engaged in sexual experiences with other HIV-positive men, and 371 of the 596 (62%) practised UAI with their seroconcordant partners. Those who engaged in UAI expressed less self-evaluation with regard to their unsafe sexual practices, had higher levels of hedonism associated with unsafe sex, and were more likely both to inject recreation drugs and use methamphetamine in particular. Furthermore, these participants expressed less concern with regard to HIV re-infection, infection with other sexually transmitted infections, and the transmission of pathogens causing opportunistic infections.

CONCLUSION

Our findings suggest that at least three sets of factors predispose HIV-positive men to engage in unsafe anal sexual behaviors with their concordant partners: a decreased belief that infection with other pathogens or re-infection with HIV present health problems; less evaluation of sexual activities and behaviors; more hedonistic expectations of sex and higher levels of sexual compulsivity, as well as recreational drug use with and without sex.

Predictors of the use of viagra, testosterone, and antidepressants among HIV-seropositive gay and bisexual men

OBJECTIVE

To examine the use and correlates of the use of prescription drugs that may affect sexual behavior among HIV-positive gay and bisexual men.

METHODS

In a cross-sectional assessment of baseline data from a behavioral intervention, we recruited 1168 HIV-positive gay and bisexual men in 2000-2001 from community venues in New York City and San Francisco, and determined the point prevalence of the use of viagra, testosterone, and antidepressants. We examined bivariate and multivariate associations between the use of each drug and demographics, health status, substance use, psychological symptoms, and sexual risk.

RESULTS

The current use of antidepressants was 21%, testosterone 19%, and viagra 12%. Some viagra users reported using drugs that could interact dangerously with viagra. The use of viagra, testosterone, or antidepressants was related to unprotected receptive anal intercourse and unprotected insertive oral intercourse (UIOI) with both HIV-positive and HIV-negative/unknown-status casual partners. The use of viagra was also associated with unprotected insertive anal intercourse. In multivariate models, viagra use was associated with being older, more educated, using ketamine, and engaging in UIOI with HIV-negative/unknown-status casual partners. Testosterone use was associated with being more educated and using nitrites (poppers). Antidepressant use was associated with race, using poppers, and being more depressed.

CONCLUSION

Prescription medications used by HIV-positive men can have unintended negative effects such as drug interactions or associations with risky sexual behavior, particularly a drug such as viagra that is fast acting, short lasting, and provides a desirable effect. Physicians should discuss these issues with patients when prescribing, and interventions should address these challenges.