An opportunity for prevention: prevalence, incidence, and sexual risk for HIV among young Asian and Pacific Islander men who have sex with men, San Francisco

Modelling HIV/AIDS epidemiological complexity: A scoping review of Agent-Based Models and their application

OBJECTIVE

To end the AIDS epidemic by 2030, despite the increasing poverty and inequalities, policies should be designed to deal with population heterogeneity and environmental changes. Bottom-up designs, such as the Agent-Based Model (ABM), can model these features, dealing with such complexity. HIV/AIDS has a complex dynamic of structural factors, risk behaviors, biomedical characteristics and interventions. All embedded in unequal, stigmatized and heterogeneous social structure. To understand how ABMs can model this complexity, we performed a scoping review of HIV applications, highlighting their potentialities.

METHODS

We searched on PubMed, Web of Science, and Scopus repositories following the PRISMA extension for scoping reviews. Our inclusion criteria were HIV/AIDS studies with an ABM application. We identified the main articles using a local co-citation analysis and categorized the overall literature aims, (sub)populations, regions, and if the papers declared the use of ODD protocol and limitations.

RESULTS

We found 154 articles. We identified eleven main papers, and discussed them using the overall category results. Most studies model Transmission Dynamics (37/154), about Men who have sex with Men (MSM) (41/154), or individuals living in the US or South Africa (84/154). Recent studies applied ABM to model PrEP interventions (17/154) and Racial Disparities (12/154). Only six papers declared the use of ODD Protocol (6/154), and 34/154 didn't mention the study limitations.

CONCLUSIONS

While ABM is among the most sophisticated techniques available to model HIV/AIDS complexity. Their applications are still restricted to some realities. However, researchers are challenged to think about social structure due model characteristics, the inclusion of these features is still restricted to case-specific. Data and computational power availability can enhance this feature providing insightful results.

Chlamydial and gonorrheal neglected sexually transmitted diseases among Pacific Islanders of the Western Pacific Region-A narrative review and call to action

The Pacific Island countries of the Western Pacific Region have some of the highest rates of sexually transmitted Chlamydia trachomatis and Neisseria gonorrhoeae infections in the world. Despite this, there are few research studies that include Pacific Islanders. We conducted a narrative review of original research and surveys, including World Health Organization and Pacific Community reports, to determine the prevalence, management, and treatment of C. trachomatis and N. gonorrhoeae compared to HIV and syphilis from 1980 to 2022. Available epidemiologic data on C. trachomatis and N. gonorrhoeae indicated an extremely high prevalence-approximately 30% and 13%, respectively-among Pacific Islanders during this timeframe. These neglected sexually transmitted infections represent a significant burden and health disparity. Robust epidemiologic research is needed to identify modifiable risk factors for designing interventions and control strategies. Appropriate policies along with regional and international advocacy and aid are required to improve reproductive health among these vulnerable, understudied populations to avert preventable infections and sequelae.

HIV Risk Behaviors in Relation to Psychosocial Factors and Internet Usage Among Asian and Pacific Islander (API) Men Who Had Sex With Men (MSM) in California

Very few studies have been conducted to investigate HIV risk and protective behaviors in relation to psychosocial factors among Asian and Pacific Islander (API) MSM whose HIV/AIDS prevalence is lower than those of other racial/ethnic groups. This study, based on an online survey targeting API MSM in California revealed that API MSM often met sex partners online and that psychosocial factors (e.g., homophobia and identity with API gay community) were correlated with condomless receptive anal sex (RAS) with casual partners. In particular, an Asian cultural construct, interdependency, was correlated with condom use for RAS; that is, those who consider sex partners' health and value harmony tend to engage in safe sex. This finding sheds light on re-thinking the current over-emphasis on assertiveness and self-responsibility to keep free from HIV/STIs during negotiation with partners. Future STI prevention programs for API MSM should incorporate Asian cultural constructs and target specific risk groups.

Global Challenges to Human Immunodeficiency Virus Prevention

Because of the high prevalence of human immunodeficiency virus (HIV), men who have sex with men (MSM) is socially branded in many countries, and epidemiological approaches have become difficult for this group. This study reviewed the clinical development and political challenges associated with HIV infection. Organizing and disseminating clinical medical advances can help us eliminate social stigmas and the dishonor linked to MSM. In addition, dealing with the worldwide infection problem of MSM can help to reestablish international joint confrontation and political agendas to promote disease eradication efforts. In many countries, socioeconomic problems are not related to increased numbers of HIV infections. Improving social issues such as human rights and economic problems depending on the circumstances of each country should help reduce the risk of HIV infection. The stigmas affecting HIV-infected persons vary greatly depending on the country. It is a serious problem in many countries, including Korea. It is also an important obstacle to those who work to prevent HIV infection. This stigma is a factor that prevents HIV patients from being diagnosed and treated at an early stage. Delayed diagnosis of and delayed treatment for HIV-infected people not only worsen an individual's prognosis but also can spread HIV socially. Efforts to reduce the stigma are necessary not only for individuals with HIV but also for public health.

HIV risk behaviours among immigrant and ethnic minority gay and bisexual men in North America and Europe: A systematic review

HIV surveillance systems show that gay, bisexual, and other men who have sex with men (MSM) bear a disproportionate burden of HIV in North American and European countries. Within the MSM category, HIV prevalence is often elevated among ethnic minority (i.e., Latino, Asian, and Black) MSM, many of whom are also foreign-born immigrants. Little research has focused specifically on foreign-born populations, though studies that provide data on the nativity of their samples offer an opportunity to investigate the potential role of transnational migration in informing HIV risk among ethnic minority MSM. This systematic review of ethnic minority MSM studies where the nativity of the sample is known provides a robust alternative to single studies measuring individual-level predictors of HIV risk behaviour. In this review, HIV prevalence, unprotected sex, drug use, and HIV testing are analysed in relation to the ethnicity, nativity, and location of the samples included. The results, which include high rates of HIV, unprotected sex, and stimulant use in foreign-born Latino samples and high rates of alcohol and club drug use in majority foreign-born Asian Pacific Islander (API) samples, provide baseline evidence for the theory of migration and HIV risk as syndemics within ethnic minority populations in North American and European countries. The findings also suggest that further research on the contextual factors influencing HIV risk among ethnic minority MSM groups and especially immigrants within these groups is needed. These factors include ethnic networks, individual post-migration transitions, and the gay communities and substance use cultures in specific destination cities. Further comparative work may also reveal how risk pathways differ across ethnic groups.

Transactional sex among men who have sex with men in the French Antilles and French Guiana: frequency and associated factors

The French Antilles (Martinique, Saint Martin and Guadeloupe) and French Guiana are the French territories most affected by the HIV epidemic. Some population groups such as men who have sex with men (MSM), especially those involved in transactional sex, are thought to be particularly vulnerable to HIV but few data exist to help characterize their health-related needs and thus implement relevant prevention interventions. To fill this knowledge gap, we used data collected from an HIV/AIDS Knowledge, Attitudes, Behaviours and Practices survey conducted in 2012 among MSM living in the French Antilles and French Guiana and recruited through snowball sampling. Our objectives were to compare social and demographic characteristics and sexual behaviours between MSM engaging in transactional sex and MSM not engaging in transactional sex and to identify factors associated with transactional sex involvement using a logistic regression model. A total of 733 MSM were interviewed, 21% of whom reported to undergo transactional sex. Their behaviour and social and demographic characteristics were different from other MSMs' and they were more exposed to factors that are recognized to potentiate HIV vulnerability, at the individual, community, network and structural levels. The variables positively associated with sex trade involvement were having ever consumed drug (OR = 2.84 [1.23-6.52]; p = .002), having a greater number of sex partners than the median (OR = 8.31 [4.84-14.30]; p < .001), having experienced intimate partner violence (OR = 1.72 [0.99-3.00]; p = .053) and having undergone physical aggression because of sexual orientation (OR = 2.84 [1.23-6.52]; p = .014). Variables negatively associated with sex trade involvement were being older (OR = 0.93 [0.90-0.97] per year; p = .001), having a stable administrative situation (OR = 0.10 [0.06-0.19]; p < .001), having a stable housing (OR = 0.29 [0.15-0.55]; p < .001) and being employed full-time (OR = 0.29 [1.23-6.52]; p = .002).

High Prevalence of HIV Infection and Bisexual Networks among a Sample of Men Who Have Sex with Men in Eastern China

OBJECTIVE

To examine homosexual and heterosexual behaviors, behavioral networks and HIV infection among men who have sex with men (MSM) in Eastern China.

METHODS

A cross-sectional survey was conducted among MSM in 2013 in a rural prefecture of Zhejiang province. Participants were interviewed for their sexual behaviors and sexual networks and were tested for HIV infection.

RESULTS

A total of 620 MSM from gay bath houses and bars participated in the survey. Of them, 58.2% aged 18 to 39 years and 49.5% were currently married with a female. The age of first homosexual contact was 26.7 years on average, ranging from 12 to 66 years. 91.0% had multiple male sex partners and 86.1% also had female sex partners in lifetime. 70 (11.3%) of the participants were tested HIV-positive. A total of 620 independent egocentric sexual networks involving 620 study participants and 1,971 reported sexual partners in the past 12 months were constructed, including 70 networks for the 70 HIV-positive participants with their 221 sexual partners and 550 networks for the 550 HIV-negative participants with their 1,750 sexual partners. The median network degree was 3 (IQR 2-4) overall and was not different between HIV-positive participants (Median: 3; IQR: 2-4) and HIV-negative participants (Median: 3; IQR: 2-4) (Mann-Whitney test, Z=-0.015, P=0.998). The proportion of networks with a multiple male sexual partnership was 63.7% overall, 62.8% for HIV-positive participants and 63.8% for HIV-negative participants (χ2=0.025, P=0.875). The proportion of networks with both male and female sexual partners was 44.8% overall, 47.1% for HIV-positive participants and 44.5% for HIV-negative participants (χ2=0.169, P=0.681). Consistent condom use and knowledge of HIV infection status were rare within the network partners.

CONCLUSIONS

The currently high HIV prevalence and complicated bisexual networks among MSM in the study area provides enhanced evidence for developing tailored prevention strategies for HIV transmission among and beyond the MSM population.

Venue-based network analysis to inform HIV prevention efforts among young gay, bisexual, and other men who have sex with men

In the USA, human immunodeficiency virus (HIV) incidence rates continue to increase among young gay, bisexual, and other men have sexual intercourse with men. Young men who have sex with men (YMSM) indicate interest in HIV prevention programming that is implemented in the social venues that they frequent when they want to socialize with other men. We sought to understand YMSM venues as a networked space to provide insights into venue-based HIV prevention intervention delivery. The present study used survey data reported by 526 YMSM (ages 18-24) in 2005 to conduct a venue-based social network analysis. The latter sought to determine if the structure and composition of the networks in Los Angeles could be used to facilitate the delivery of HIV prevention messages to YMSM. Degree of person sharing between venues was used to demonstrate interconnectivity between venues classified as low risk (e.g., coffee shops) and high risk (e.g., bars and clubs) by a Community Advisory Board. Sixty-five percent of the 110 venues nominated were bars and clubs. Nearly all YMSM were connected by a single venue and over 87 % were connected by the six most central venues. A handful of highly connected low-risk venues was central to the venue network and connected to popular high-risk venues. Venue-based network analysis can inform tailored HIV prevention messaging for YMSM. Targeted delivery of prevention messaging at low-risk centralized venues may lead to widespread diffusion among venue-attending YMSM.

A Synthesis of 20 Years of Research on Sexual Risk Taking Among Asian/Pacific Islander Men Who Have Sex With Men in Western Countries

Over the past two decades, there has emerged a body of literature documenting a number of risk factors associated with Asian/Pacific Islander men who have sex with men's unsafe sexual behaviors. This study aims to systematically review existing empirical studies and synthesize research results into a social-ecological framework using a mixed research synthesis. Empirical research articles published in peer-reviewed journals between January 1990 and June 2013 were identified in six databases, including PubMed, Ovid MEDLINE, PsycINFO, Social Work Abstract, CINAL, and Web of Knowledge. Both quantitative and qualitative studies were included. Two analysts independently reviewed the articles, and findings were organized on a social-ecological framework. Twenty-two articles were included in the analysis; among these 13 were quantitative, 8 were qualitative, and 1 was mixed-methods research. Results indicated that demographic characteristics, psychological resources, behavioral patterns, relationships with family and friends, dynamics with romantic or sexual partners, community involvement, culture, discrimination, and institutional factors were related to unprotected anal intercourse. This article presents a critique of this literature and discusses implications for future research with this population. It concludes with prevention/intervention initiatives based on review findings.

Modified social ecological model: a tool to guide the assessment of the risks and risk contexts of HIV epidemics

Background

Social and structural factors are now well accepted as determinants of HIV vulnerabilities. These factors are representative of social, economic, organizational and political inequities. Associated with an improved understanding of multiple levels of HIV risk has been the recognition of the need to implement multi-level HIV prevention strategies. Prevention sciences research and programming aiming to decrease HIV incidence requires epidemiologic studies to collect data on multiple levels of risk to inform combination HIV prevention packages.

Discussion

Proximal individual-level risks, such as sharing injection devices and unprotected penile-vaginal or penile-anal sex, are necessary in mediating HIV acquisition and transmission. However, higher order social and structural-level risks can facilitate or reduce HIV transmission on population levels. Data characterizing these risks is often far more actionable than characterizing individual-level risks. We propose a modified social ecological model (MSEM) to help visualize multi-level domains of HIV infection risks and guide the development of epidemiologic HIV studies. Such a model may inform research in epidemiology and prevention sciences, particularly for key populations including men who have sex with men (MSM), people who inject drugs (PID), and sex workers. The MSEM builds on existing frameworks by examining multi-level risk contexts for HIV infection and situating individual HIV infection risks within wider network, community, and public policy contexts as well as epidemic stage. The utility of the MSEM is demonstrated with case studies of HIV risk among PID and MSM.

Summary

The MSEM is a flexible model for guiding epidemiologic studies among key populations at risk for HIV in diverse sociocultural contexts. Successful HIV prevention strategies for key populations require effective integration of evidence-based biomedical, behavioral, and structural interventions. While the focus of epidemiologic studies has traditionally been on describing individual-level risk factors, the future necessitates comprehensive epidemiologic data characterizing multiple levels of HIV risk.

Convergence of HIV prevalence and inter-racial sexual mixing among men who have sex with men, San Francisco, 2004-2011

Disparity in HIV prevalence by race/ethnicity has been noted among men who have sex with men for almost 20 years. Research suggests that rather than individual risk behaviors, sexual networks play an important role in HIV prevalence disparity. This analysis uses data from the National HIV Behavioral Surveillance System collected at three time points using time-location sampling in 2004, 2008, 2011. We use Newman's coefficient to assess racial mixing among 1,207 observations. We found significant differences in HIV status across race groups in 2004 and 2008; yet in 2011, there were no significant differences of HIV status by race. Racial mixing across all races increased from 2004 to 2011; in other words, individuals were increasingly more likely to sexually partner outside their own race/ethnicities. Increased racial mixing may explain this convergence, although full social network studies are necessary in order to fully explain these findings.

Global epidemiology of HIV infection in men who have sex with men

Epidemics of HIV in men who have sex with men (MSM) continue to expand in most countries. We sought to understand the epidemiological drivers of the global epidemic in MSM and why it continues unabated. We did a comprehensive review of available data for HIV prevalence, incidence, risk factors, and the molecular epidemiology of HIV in MSM from 2007 to 2011, and modelled the dynamics of HIV transmission with an agent-based simulation. Our findings show that the high probability of transmission per act through receptive anal intercourse has a central role in explaining the disproportionate disease burden in MSM. HIV can be transmitted through large MSM networks at great speed. Molecular epidemiological data show substantial clustering of HIV infections in MSM networks, and higher rates of dual-variant and multiple-variant HIV infection in MSM than in heterosexual people in the same populations. Prevention strategies that lower biological transmission and acquisition risks, such as approaches based on antiretrovirals, offer promise for controlling the expanding epidemic in MSM, but their potential effectiveness is limited by structural factors that contribute to low health-seeking behaviours in populations of MSM in many parts of the world.

Risk of window period HIV infection in high infectious risk donors: systematic review and meta-analysis

The OPTN defines high risk donors (HRDs), colloquially known as 'CDC high risk donors', as those thought to carry an increased risk of HIV window period (WP) infection prior to serologic detectability. However, the true risk of such infection remains unknown. To quantify the risk of WP infection in each HRD behavior category, we performed a systematic review and meta-analysis of studies of HIV prevalence and incidence. Of 3476 abstracts reviewed, 27 eligible studies of HIV infection in HRD populations were identified. Pooled HIV incidence estimates were calculated for each category of HRD behavior and used to calculate the risk of WP HIV infection. Risks ranged from 0.09-12.1 per 10 000 donors based on WP for ELISA and 0.04-4.9 based on nucleic acid testing (NAT), with NAT reducing WP risk by over 50% in each category. Injection drug users had the greatest risk of WP infection (4.9 per 10 000 donors by NAT WP), followed by men who have sex with men (4.2:10 000), commercial sex workers (2.7:10 000), incarcerated donors (0.9:10 000), donors exposed to HIV through blood (0.6:10 000), donors engaging in high-risk sex (0.3:10 000) and hemophiliacs (0.035:10 000). These estimates can help inform patient and provider decision making regarding HRDs.

Epidemiology of HIV among Asians and Pacific Islanders in the United States, 2001-2008

BACKGROUND

Recent analyses have shown increases in combined annual HIV diagnosis rates for Asians and Pacific Islanders (API).

METHODS

Using surveillance data from 33 states and 4 dependent areas we investigated the epidemiology of HIV among API during 2001-2008.

RESULTS

HIV diagnoses for API during 2001-2008 were predominantly among persons age 30-39 years (40%) and males (78%). The primary risk factor for males was sexual contact with males (78%) and for females, heterosexual contact (86%). API were the only racial/ethnic groups with a statistically significant estimated annual percentage increase (4.4%) in HIV diagnoses over the time period. Thirty-seven percent of HIV diagnoses among API progressed to AIDS in <12 months, with significantly greater likelihood among those 30 years and older. Survival was lower among API with AIDS diagnosis after 49 years of age, and was higher among persons with AIDS whose primary risk factor for infection was heterosexual contact.

CONCLUSIONS

In contrast to other racial/ethnic groups, API were the only groups to show a significant increase in HIV diagnoses. A clearer understanding of the reasons for this trend is needed, so that appropriate interventions can be selected and adapted to prevent increased HIV prevalence among API in the U.S.

Lower HIV prevalence among Asian/Pacific Islander men who have sex with men: a critical review for possible reasons

We conducted a critical literature review for possible reasons that may explain the lower HIV prevalence observed among API MSM compared to MSM of other races/ethnicities. Trends emerging from the literature suggest that traditional individual-level factors-unprotected anal intercourse, substance use, STD prevalence, rates and frequency of HIV testing, and utilization of HIV prevention services-do not appear to be related to the lower HIV prevalence among API MSM. Some evidence suggests that socio-cultural and structural factors might be the more critical forces in determining racial/ethnic disparities of HIV among MSM. For API MSM, these factors include structures of sexual networks, access to and reception of medical care and treatment among HIV-positive MSM, and influences of different levels and types of acculturation. Moreover, emerging risk reduction strategies, such as seroadaptive behaviors, could play a role. Future research should address these factors in intervention design. In addition, better theories of resilience and measurement of strengths and protective factors are needed to enhance the efficacy of HIV interventions.

Targeted expansion project for outreach and treatment for substance abuse and HIV risk behaviors in Asian and Pacific Islander communities

Access to culturally competent HIV/AIDS and substance abuse treatment and prevention services is limited for Asian and Pacific Islanders (APIs). Based on the intake data for a community outreach project in the San Francisco Bay Area (N = 1,349), HIV risk behaviors were described among the targeted API risk groups. The self-reported HIV prevalence was 6% among MSM. Inconsistent condom use for vaginal sex with casual partners in the past 6 months was reported among substance users (43%) and incarcerated participants (60%), whereas 26% of men who have sex with men reported inconsistent condom use for anal sex with casual partners. Overall, 56% and 29% had engaged in sex with casual partners under the influence of alcohol and drugs in the past 6 months, respectively. Although API organizations in the Bay Area have spearheaded HIV prevention, future programs must address substance use issues in relation to sexual risk behaviors, specific to API risk groups.

Stable sexual risk behavior in a rapidly changing risk environment: findings from population-based surveys of men who have sex with men in Seattle, Washington, 2003-2006

We assessed trends in behavioral risk for HIV infection among men who have sex with men (MSM). Seattle MSM participated in random digit dial telephone surveys in 2003 (n = 400) and 2006 (n = 400). Fourteen percent in 2003 and 9% in 2006 reported unprotected anal intercourse with a partner of different or unknown HIV status (non-concordant UAI; odds ratio [OR] = 0.7; 95% confidence interval [CI]: 0.5, 1.2). Compared to participants in 2003, participants in 2006 met a greater proportion of their anal sex partners through the Internet (OR = 2.0; 95% CI: 1.2, 3.1). Although the proportion of anal sex partnerships formed online increased between 2003 and 2006, Internet partnerships were not more risky than those initiated elsewhere. While the emergence of the Internet as a venue through which men meet partners demonstrates that sexual risk among MSM remains highly dynamic, our findings suggest that sexual risk behavior among MSM is currently stable.

HIV and hepatitis B and C incidence rates in US correctional populations and high risk groups: a systematic review and meta-analysis

BACKGROUND

High Human Immunodeficiency Virus (HIV) prevalence and high risk behaviors have been well documented within United States (US) correctional systems. However, uncertainty remains regarding the extent to which placing people in prison or jail increases their risk of HIV infection, and regarding which inmate populations experience an increased incidence of HIV. Describing these dynamics more clearly is essential to understanding how inmates and former detainees may be a source for further spread of HIV to the general US population.

METHODS

The authors conducted a systematic review and meta-analysis of studies describing HIV incidence in US correctional facility residents and, for comparison, in high risk groups for HIV infection, such as non-incarcerated intravenous drug users (IVDU) and men who have sex with men (MSM) in the US. HIV incidence rates were further compared with Hepatitis B and Hepatitis C Virus rates in these same populations.

RESULTS

Thirty-six predominantly prospective cohort studies were included. Across all infection outcomes, continuously incarcerated inmates and treatment recruited IVDU showed the lowest incidence, while MSM and street recruited IVDU showed the highest. HIV incidence was highest among inmates released and re-incarcerated. Possible sources of heterogeneity identified among HIV studies were risk population and race.

CONCLUSIONS

Although important literature gaps were found, current evidence suggests that policies and interventions for HIV prevention in correctional populations should prioritize curtailing risk of infection during the post-release period. Future research should evaluate HIV incidence rates in inmate populations, accounting for proportion of high risk sub-groups.

Group sex events amongst non-gay drug users: an understudied risk environment

This article discusses relevant literature on group sex events--defined as events at which some people have sex with more than one partner--as risk environments, with a particular focus on group sex events where people who take drugs by non-injection routes of administration participate and where the event is not primarily LGBT-identified, at a "classic" crack house, nor in a brothel. It also briefly presents some findings from a small ethnography of such events. Group sex participation by people who take drugs by non-injection routes of administration seems to be widespread. It involves both behavioural and network risk for HIV and STI infection, including documented high-risk behaviour and sexual mixing of STI- and HIV-infected people with those who are uninfected. Indeed several HIV and STI outbreaks have been documented as based on such group sex events. Further, group sex events often serve as potential bridge environments that may allow infections to pass from members of one high-risk-behavioural category to another, and to branch out through these people's sexual and/or injection networks to other members of the local community. The ethnographic data presented here suggest a serious possibility of "third party transmission" of infectious agents between people who do not have sex with each other. This can occur even when condoms are consistently used since condoms and sex toys are sometimes used with different people without being removed or cleaned, and since fingers and mouths come into contact with mucosal surfaces of other members of the same or opposite sex. In addition to being risk environments, many of these group sex events are venues where risk-reducing norms, activities and roles are present--which lays the basis for harm reduction interventions. Research in more geographical locations is needed so we can better understand risks associated with group sex events in which drug users participate--and, in particular, how both participants and others can intervene effectively to reduce the risks posed to participants and non-participants by these group sex events. Such interventions are needed and should be developed.

Using social networks to recruit an HIV vaccine preparedness cohort

OBJECTIVES

To evaluate a social network approach to develop an adolescent cohort for HIV vaccine preparedness and investigate characteristics that influence recruitment.

METHODS

We summarize baseline data from a prospective cohort study that included 4 sessions over 6 months. Fifty-nine HIV-infected adolescent and adult patients of a family-based HIV clinic named significant others and indicated willingness to involve them in this study. Sixty-two adolescent and adult significant others not known to be HIV infected were enrolled. Logistic regression was used to estimate factors associated with willingness.

RESULTS

Participants identified 624 social network members including 276 adolescents (44%). Network member's awareness of the index's HIV positivity (P < 0.01) and older age (P = 0.05) affected willingness. Respondents were less willing to invite drug-risk alters (P = 0.006). Adolescents were willing to invite more adolescents than were adults (P < 0.0001). Adolescents younger than 18 years old reported fewer sexual and drug-using risk behaviors than expected.

CONCLUSIONS

HIV-infected patients are willing to recruit their social networks, provided concerns about disclosure of HIV status are addressed. Using social networks to identify and recruit adolescent populations is appropriate and feasible for vaccine preparedness activities, future vaccine trials, and other prevention programs, but procedures are needed to selectively identify and retain high-risk youth.

Prediction of HIV acquisition among men who have sex with men

OBJECTIVE

To develop and validate an easy-to-use prediction model for HIV acquisition among men who have sex with men (MSM).

METHODS

We developed prediction models using medical records data from an STD clinic (2001-2008) and validated these models using data from the control arm of Project Explore, an HIV prevention trial (1999-2003).

RESULTS

Of 1903 MSM who tested for HIV more than once in the development sample, 101 acquired HIV over 6.7 years of follow-up. Annual HIV incidence was 2.57% (95% confidence interval [CI]: 2.09%, 3.12%). During 4 years of follow-up of 2081 Project Explore control arm participants, 144 acquired HIV for an incidence of 2.32% (95% CI: 1.96%, 2.73%). A prediction model that included variables indicating use of methamphetamine or inhaled nitrites in the prior 6 months, unprotected anal intercourse with a partner of positive or unknown HIV status in the prior year, > or =10 male sex partners in the prior year, and current diagnosis or history of bacterial sexually transmitted infection was well calibrated overall (expected-observed ratio = 1.01; 95% CI: 0.97, 1.05) and had modest discriminatory accuracy at 1 year (area under the receiver-operator characteristic curve = 0.67; 95% CI: 0.60, 0.75) and at 4 years (area under the receiver-operator characteristic curve = 0.66; 95% CI: 0.61, 0.71). Over 4 years, cumulative incidence ranged from 3.9% to 14.3% for groups of men defined by the prediction model.

CONCLUSIONS

A new risk score was predictive of HIV acquisition and could assist providers in counseling MSM and in targeting intensified prevention to MSM at greatest risk for HIV infection. Its accuracy requires further evaluation.

Running in place: implications of HIV incidence estimates among urban men who have sex with men in the United States and other industrialized countries

Attempts to document changing HIV incidence rates among MSM are compromised by issues of generalizability and statistical power. To address these issues, this paper reports annualized mean HIV incidence rates from the entire published incidence literature on MSM from Europe, North America and Australia for the period 1995-2005. Publications that met the entry criteria were coded for region of the world, sampling method and year of study. From these reports, we calculated a mean incidence rate with confidence intervals for these variables. Although no differences in mean incidence rates were found for MSM from 1995 to 2005, HIV incidence rates are lower in Australia than either North America or Europe. We calculated a mean incidence rate of 2.39% for MSM in the United States, which if sustained within a cohort of MSM, would yield HIV prevalence rate of approximately 40% at age 40. These extrapolations overlap published HIV prevalence rates for MSM younger than age 40 in the United States. HIV incidence rates in the 2-3% range will adversely affect the health of gay male communities for decades to come. This analysis suggests that greater attention should be devoted to the question of how best to design prevention interventions that will lower HIV incidence rates among gay men.

A qualitative exploration of the relationship between racism and unsafe sex among Asian Pacific Islander gay men

Although reported cases of HIV/AIDS among gay Asian Pacific Islander (API) American men and API men who have sex with men (MSM) are still relatively low, current research findings indicate that incidences of unsafe sexual activity may be higher for this group than for any other group. Among the explanations offered to explain the levels of increasing unsafe sex among gay API men have been sexual norms found in Asian cultures, the lack of culturally relevant and/or linguistically appropriate intervention material, lack of integration into the mainstream gay community, and internalized homophobia. What are often ignored in these analyses are the contextual norms in which sexual behavior for gay API men occur. In this article, I develop the argument that racism within the gay community leads to socially and contextually prescribed sexual roles for gay API men that may also contribute to the practice of unsafe sex among this group.

COMPARING THE EFFECTIVENESS OF TWO FORMS OF TIME-SPACE SAMPLING TO IDENTIFY CLUB DRUG-USING YOUNG ADULTS

Time-space sampling has been used to generate representative samples of both hard-to-reach and location-based populations. Because of its emphasis on multi-tiered randomization (i.e., time, space, and individual), some have questioned the feasibility of time-space sampling as a cost-effective strategy. In an effort to better understand issues related to drug use among club-going young adults (ages 18 to 29) in the New York City nightlife scene, two variations of time-space sampling methods were utilized and compared (Version 1: randomized venue, day, and individuals within venues: Version 2: randomized venue and day). A list of nightlife venues were randomized and survey teams approached potential participants as they entered or exited venues to conduct brief anonymous surveys. Over the course of 24 months, 18,169 approaches were conducted and 10,678 consented to complete the brief questionnaire (V1 response rate = 46.0%, V2 response rate = 62.5%). Drug use was fairly common, with nearly two-thirds of the sample reporting having ever tried an illegal drug and more than half of drug users specifically tried either MDMA/ecstasy and/or cocaine. There were few differences between young adults surveyed during Version 1 and Version 2. Time-space sampling is an effective strategy to quickly detect and screen club drug users. Although caution is urged, elimination of the third tier of randomization (i.e., individual level counting) from time-space sampling may significantly improve response rates while only minimally impacting sample characteristics.

Surveillance of HIV risk and prevention behaviors of men who have sex with men--a national application of venue-based, time-space sampling

In collaboration with the Centers for Disease Control and Prevention, participating state and local health departments, universities, and community-based organizations applied venue-based, time-space sampling methods for the first wave of National HIV Behavioral Surveillance of men who have sex with men (NHBS-MSM). Conducted in 17 metropolitan areas in the United States and Puerto Rico from November 2003 through April 2005, NHBS-MSM methods included: (1) formative research to learn the venues, times, and methods to recruit MSM; (2) monthly sampling frames of eligible venues and day-time periods that met attendance, logistical, and safety criteria; and (3) recruitment of participants in accordance with randomly generated venue calendars. Participants were interviewed on HIV risk and prevention behaviors, referred to care when needed, and compensated for their time. By identifying the prevalence and trends of HIV risk and prevention behaviors, NHBS-MSM data may be used at local, state, and federal levels to help obtain, direct, and evaluate HIV prevention resources for MSM.

National-level Capacity-building Assistance Model to Enhance HIV Prevention for Asian & Pacific Islander Communities

OBJECTIVES

Asian & Pacific Islander (A&PI) communities in the United States face increasing risk for HIV, yet have limited access to US culturally competent HIV prevention services. We describe a national HIV prevention capacity-building program for A&PI communities using a multitiered approach addressing systems, institutional, and individual level outcomes.

METHODS

The program developed a national network of A&PI HIV and health-focused institutions, and conducts regional-level replication and dissemination of this model to support four areas of capacity building. This network is led by two national organizations coordinating the planning, implementation, and evaluation of the National Capacity-Building Assistance Program.

RESULTS

Baseline data are compared with the last 2 years of preliminary data that show increased capacity among community-based organizations and health departments to strengthen culturally competent models of HIV prevention. Systems-level outcomes so far show enhanced leadership skills for HIV-related advocacy efforts, increased ability to leverage the media, and stronger partnerships between peer providers, health departments, and community leaders.

CONCLUSION

This program model preliminarily demonstrates that national capacity-building initiatives can foster coalition development, replication of program models, materials sharing, and new leadership that improve HIV-related prevention services for A&PI communities.

HIV and AIDS in suburban Asian and Pacific Islander communities: factors influencing self-efficacy in HIV risk reduction

Though AIDS case rates among Asian Pacific Islander Americans (APIs) in the United States remain relatively low, the number has been steadily increasing. Scholars, policy makers, and service providers still know little about how confident APIs are in carrying out different HIV risk reduction strategies. This article addresses this gap by presenting an analysis of a survey of API women and youth in Orange County, California (N = 313), a suburban county in southern California with large concentrations of Asian residents. Multivariate logistic regression models using subsamples of API women and API youth respondents were used. Variations in reported self-efficacy for female respondents were explained by acculturation, comfort in asking medical practitioners about HIV/AIDS, and to a lesser degree, education, household size, whether respondents were currently dating, HIV knowledge, and whether respondents believed that HIV could be identified by physical appearance. For respondents younger than 25 years, variations in self-efficacy were related to gender, age, acculturation, HIV knowledge, taking-over-the-counter medicines for illness, whether respondents were dating, and to a lesser degree, employment, recent serious illness, whether they believe that one could identify HIV by how one looks, and believing that illness was caused by germs. Implications for HIV prevention programs and future research are provided.

Prevalence and correlates of substance use among young Asian Pacific Islander men who have sex with men

We examined patterns of substance use among young Asian Pacific Islander (API) men who have sex with men (MSM). Participants (N = 496) were recruited from sampled venues and were interviewed on substance use, sexual behaviors, and attendance at MSM social venues. Substance use prevalence was highest for alcohol (94% lifetime, 89% past 6 months), marijuana (61% lifetime, 44% past 6 months), and methylenedioxymethamphetamine or ecstasy (58% lifetime, 47% past 6 months). During the past 6 months, 24% used an illicit substance weekly or more often, 51% used club drugs, and 44% used 3 or more illicit substances. Multivariate models identified common and unique correlates of frequent drug use, club drug use, and polydrug use. Associations between substance use and sexual risk behaviors also emerged. These findings suggest a need to improve substance use and HIV prevention intervention efforts for young API MSM.

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.

HIV testing trends and correlates among young Asian and Pacific Islander men who have sex with men in two U.S. cities

We sought to determine the prevalence, trends, and correlates of recent HIV testing (within the past year) among young Asian and Pacific Islander men who have sex with men (API MSM) in two U.S. cities. We conducted serial, cross-sectional, interviewer-administered surveys of 908 API MSM aged 15-25 years, sampled from randomly selected MSM-identified venues annually from 1999 to 2002. The prevalence of recent testing increased from 63% to 71% between the first and fourth year. Recent testing was most significantly associated with ethnicity and with knowledge of testing sites to which respondents felt comfortable going. Other correlates of recent testing included gay identity, comfort with sexual and API identity, having a main partner, social support, and recent unprotected anal intercourse. API MSM who had ever traded sex for material goods or shelter were as likely to have tested recently. HIV prevention campaigns should increase the awareness and availability of culturally appropriate testing sites and urge more frequent testing by young API MSM.

HIV testing patterns and unrecognized HIV infection among young Asian and Pacific Islander men who have sex with men in San Francisco

The HIV epidemic is rising in Asian and Pacific Islander men who have sex with men (API MSM), who are often first diagnosed with HIV at a late stage of disease. We investigated the HIV testing patterns, correlates of prior testing, and awareness of HIV infection of 495 API MSM aged 18-29 years recruited from venues in San Francisco, using standardized face-to-face interviews. One quarter of participants had never tested for HIV, citing reasons such as perceived low risk, fear of results, and fear of needles. Older age, gay sexual orientation, history of sexually transmitted disease, higher lifetime number of sexual partners, and higher acculturation were significantly and independently associated with prior testing. Thirteen (2.6%) tested HIV-positive, of whom eight were unaware of their infection, five perceived themselves to be at low risk for HIV, and five reported recent UAI. These findings underscore the need to increase access to culturally appropriate and targeted HIV testing and to change perceptions of risk in this population.

Substance use, substance choice, and unprotected anal intercourse among young Asian American and Pacific Islander men who have sex with men

Substance use has been shown to be an important factor associated with having unprotected anal intercourse (UAI) among Asian and Pacific Islander (API) men who have sex with men (MSM). However, little is known about which substances are used in conjunction with sexual activity and whether having UAI varies by substance choice in this population. From January 2000 to September 2001, we sampled API MSM aged 18-29 years from 30 gay-identified venues in San Francisco, California, and interviewed 496 API men face-to-face using a standardized questionnaire. Overall, 47% of the sample reported UAI in the past 6 months. During the same time period, 32% and 34% reported being "high" or "buzzed" on alcohol and drugs during sex, respectively. The most common drugs used in conjunction with sex were methylenedioxymethamphetamine ("ecstasy"; 19%), followed by marijuana (14%), inhalant nitrites ("poppers"; 11%), and crystal methamphetamine ("crystal"; 10%). In a multivariate model, we observed associations between UAI and being high or buzzed on ecstasy (odds ratio [OR] = 2.62; 95% confidence interval [CI] = 1.37, 5.02) and poppers during sex (OR = 3.29; 95% CI = 1.50, 7.25). However, being high or buzzed on alcohol, marijuana, gamma-hydroxybutyrate (GHB), and crystal methamphetamine during sex had no association with UAI. One third of sampled young API MSM used drugs or alcohol during sex. The co-occurrence of ecstasy and popper use and unprotected sex underscores the need to develop HIV prevention programs focusing on particular drugs.

Epidemiology of HIV/AIDS among Asians and Pacific Islanders in the United States

Although the percentage of overall AIDS diagnoses remains low among Asian and Pacific Islanders (APIs) in the United States compared with other racial/ethnic groups, research on API risk behaviors and health status suggest that the low number of AIDS cases may not provide a full picture of the epidemic and issues faced by this understudied and underserved population. Data from national HIV/AIDS surveillance systems and the Behavioral Risk Factor Surveillance System (BRFSS) were examined to delineate the magnitude and course of the HIV/AIDS epidemic among APIs in the United States. Same-sex sexual activity is the main HIV risk for API men, whereas heterosexual contact is for API women. APIs are significantly less likely to report being tested for HIV despite the fact that a similar proportion of APIs and other racial/ethnic groups reported having HIV risk in the past 12 months. Given the enormous diversity among APIs in the United States it is important to collect detailed demographic information to improve race/ethnicity and HIV risk classification, conduct better behavioral and disease monitoring for informing prevention planning, and addressing cultural, linguistic, economic and legal barriers to HIV prevention among APIs.

Sexual risk behavior and substance use among a sample of Asian Pacific Islander transgendered women

We examined the prevalence and correlates of HIV-related sexual risk and substance use behaviors among Asian Pacific Islander (API) male-to-female (MTF) transgendered individuals, referred to here as API transgendered women. As part of a larger study on HIV risk among transgendered women of color (Nemoto, Operario, Keatley, Han, & Soma, 2004), a sample of 110 API transgendered women in San Francisco completed individual interviews, of which 13% reported being HIV-positive. In the past 30 days, one fifth of the sample engaged in unprotected receptive anal intercourse (URAI) with any male partner, nearly one half had sex while under the influence of substances, and over half used illicit drugs. In multivariate models, URAI was associated with commercial sex work (odds ratio [OR] = 4.23, 95% confidence interval [CI] = 1.10, 16.25) and previous attempted suicide (OR = 5.83, 95% CI = 1.02, 33.44). Sex under the influence of substances was associated with commercial sex work (OR = 3.35, 95% CI = 1.11, 10.13) and having a college degree (OR = 5.32, 95% CI = 1.34, 21.18). Illicit drug use was associated with commercial sex work (OR = 7.15, 95% = 2.26, 22.63). Findings suggest that API MTF transgenders are on the front line of HIV risk for the API community, and provide insight into factors within this group that might contribute to unsafe sex and substance use.