Situational predictors of sexual risk episodes among men with HIV who have sex with men

Self-rated health and quality of life in female sex workers with substance use disorders in Tehran, Iran

BACKGROUND

While self-rated health (SRH) and quality of life (QoL) has been associated with substance use disorders (SUDs) in sex-working populations, little is known about this association in Iran. This study aimed to assess QoL and SRH in Iranian female sex workers (FSWs) in Tehran.

METHOD

FSWs were recruited using convenience sampling methods from substance abuse treatment centers in Tehran that exclusively provided services for women. Participants completed an interviewer-administered demographic questionnaire in Persian and the Iranian version of the Short Form Health Survey (SF-36). Descriptive analyses, means and standard deviations; frequency and percentages, t-test and one-way ANOVA, and Chi-square tests were utilized to analyze the data.

RESULTS

The mean age among 161 participants clinically diagnosed with SUD was 34.09 years (SD 7.97; range: 18-57). The total mean QoL score was 41.03 (SD: 12.92). The highest and lowest mean scores were observed in the physical functioning (52.23) and role emotional (26.64) dimensions, respectively. Significant differences (p < 0.05) in QoL were observed according to education and marital status, and the average QoL score was lower in women who reported permanent marriages and women who were illiterate. The average score of QoL was significantly higher in employed women. Overall, 51.6% of the women rated their health as sub-optimal, with divorced participants and women who were illiterate more likely to rate their health as sub-optimal (p < 0.05).

CONCLUSION

Results emphasize the need for mental, physical, and sexual health screening and gender-specific interventions to improve QoL in this population. Further investigation may elucidate the consequences of poor SRH and QoL on SUD treatment adherence, sexual risk behavior, and morbidity and mortality in FSWs.

Measuring Sexual Risk-Taking: A Systematic Review of the Sexual Delay Discounting Task

The Sexual Delay Discounting Task (SDDT; Johnson & Bruner, 2012) is a behavioral economic task that assesses sexual risk-taking by measuring likelihood of immediate and delayed condom use. The SDDT is ecologically valid and has been used to test effects of various substances on sexual risk-taking. However, considerable variety in implementation, analysis, and reporting of the SDDT may limit rigor and reproducibility of findings. The current review synthesized studies that used the SDDT to evaluate these possible variabilities systematically. A two-step search (citation-tracking and keyword-based search) was conducted to identify studies that met inclusion criteria (i.e., used the SDDT). Eighteen peer-reviewed articles met inclusion criteria. The SDDT has been implemented primarily in three populations: individuals who use cocaine, men who have sex with men, and college students. Comparable results across diverse populations support the SDDT's validity. A few studies administered substances before the SDDT. Evidence suggests that while cocaine and alcohol increased sexual risk-taking under some conditions, buspirone decreased preference for immediate condomless sex. There was also heterogeneity in the determination of data orderliness (i.e., outliers) and inconsistent reporting of task design and analysis. Considerable differences present in methodologic approaches could influence results. Reducing variation in the administration, analysis, and reporting of the SDDT will enhance rigor and reproducibility and maximize the task's tremendous potential.

A Randomized Pilot Study of a Group-Delivered HIV Risk Reduction Intervention for At-Risk Urban Men Who Have Sex with Men Who Regularly Attend Private Sex Events

Across HIV prevention studies, as many as 25% of men who have sex with men (MSM) report meeting male partners at private sex events and attendance is associated with increased number of sexual partners, condomless anal sex (CAS), and HIV infection. Despite the need for effective HIV prevention interventions, no risk reduction interventions have been tested to reduce HIV sexual risk of MSM that regularly engage in sexual risk at private sex events. This randomized pilot study assessed the feasibility and acceptability of an HIV risk reduction intervention to reduce CAS among urban MSM (N = 14) reporting risk at a private sex event in the prior 12 months. The intervention arm received four group sessions (2 h/session) focusing on HIV risk reduction education and skills building. Both the intervention (n = 8) and control (n = 6) conditions received HIV testing and pre- and posttest risk reduction counseling and completed a sexual risk and psychosocial assessment visit at baseline and 3 months post-intervention. In addition, intervention participants completed a brief exit interview post-intervention. Mean age was 37 years, and 57% were racial/ethnic minorities. At follow-up, the intervention group reported greater reductions in sexual risk behavior in the past 3 months including number of CAS episodes, number of partners at private sex events, and CAS episodes at private sex events. The intervention group also reported reduced sexual compulsivity, increases in HIV disclosure, and reduced drug use at private sex events over study follow-up. Exit interviews revealed that participants found the intervention to be highly acceptable. Findings demonstrate feasibility of procedures, participant acceptability, and initial promise of a group-delivered HIV risk reduction intervention for MSM who attend and engage in CAS at private sex events. Further testing of this intervention in a larger pilot randomized controlled trial is warranted.

Sexual Risk Behaviors and Perceptions of Men Who Go to Gay Sex Parties in New York City: Comparisons Between Three HIV Groups

Men who have sex with men (MSM) who attend group-sex events often engage in risky sexual behaviors that contribute to the high human immunodeficiency virus (HIV) incidence among this population. We conducted an online survey with 211 New York City MSM who attended sex parties in the prior year and asked them to describe their behaviors and perceptions of risk. We compared responses from HIV-positive-undetectable men (n = 36), HIV-negative men on pre-exposure prophylaxis (PrEP; n = 62), and HIV-negative men never on PrEP (n = 113). In bivariate analyses, undetectable and on-PrEP men had been to more sex parties in the prior six months, had more anal sex partners there, and had higher rates of sexually transmitted infection (STI) diagnoses than men never on PrEP. Although less than the other groups, 43% of the presumably HIV-negative men never on PrEP reported condomless anal sex at a party in the prior six months. About half of participants agreed that, at sex parties, they made assumptions about others' HIV status, that they sometimes took more risks than intended, and that the atmosphere of these events was conducive to risk taking. Most disagreed that there was discussion of HIV status at sex parties. Implications for sexual health interventions are discussed.

Is Sex with Older Male Partners Associated with Higher Sexual Risk Behavior Among Young Black MSM?

Participants at a sexual health clinic completed a survey with questions regarding sexual risk behavior and partner characteristics. Of 585 participants eligible for analysis, 124 reported generally having older male partners. These participants were significantly more likely to be HIV-infected (p < 0.001), have four or more sex partners as a "bottom" (p = 0.04), have concurrent partners (p = 0.01), and have partners suspected of having an sexually transmitted infection (p = 0.05) than participants without older partners. With analysis restricted to HIV- individuals, risk behaviors did not differ significantly between the groups. HIV- individuals with older partners may be at increased risk of HIV infection due to increased HIV prevalence among older sexual partners and not due to increased risk behaviors with these partners.

The Strategies of Heterosexuals from Large Metropolitan Areas for Assessing the Risks of Exposure to HIV or Other Sexually Transmitted Infections from Partners Met Online

Heterosexuals' use of the Internet for meeting romantic or sexual partners is rapidly increasing, raising concerns about the Internet's potential to facilitate encounters that place individuals at risk for acquiring HIV or other sexually transmitted infections (STIs). For example, online sharing of personal information and self-revelations can foster virtual intimacy, promoting a false sense of familiarity that might accelerate progression to unprotected sex. Therefore, it is critical to understand how those who meet sexual partners online attempt to assess the possible risk of acquiring HIV or STIs posed by having unprotected sex with a new partner and decide whether to use a condom. To investigate this issue, in-depth interviews were conducted with a diverse sample of heterosexual male and female participants from large metropolitan cities who had had unprotected vaginal or anal sex with at least two partners met online in the past 3 months. With few exceptions, participants relied on faulty strategies and heuristics to estimate these risks; yet, most engaged in unprotected sex at their first meeting or very soon afterward. While some seemed to try to make a genuine effort to arrive at a reliable assessment of the HIV risk posed, most appeared to be looking for a way to justify their desire and intention to have unprotected sex. The findings suggest the need for more HIV and sexual health education targeted at heterosexuals, especially for those who go online to meet partners.

The Use of Technology to Advance HIV Prevention for Couples

The majority of HIV prevention studies and programs have targeted individuals or operated at the community level. This has also been the standard approach when incorporating technology (e.g., web-based, smartphones) to help improve HIV prevention efforts. The tides have turned for both approaches: greater attention is now focusing on couple-based HIV prevention and using technology to help improve these efforts for maximizing reach and potential impact. To assess the extent that technology has been used to help advance HIV prevention with couples, a literature review was conducted using four databases and included studies that collected data from 2000 to early 2015. Results from this review suggest that technology has primarily been used to help advance HIV prevention with couples as a tool for (1) recruitment and data collection and (2) intervention development. Challenges and limitations of conducting research (e.g., validity of dyadic data) along with future directions for how technology (e.g., mHealth, wearable sensors) can be used to advance HIV prevention with couples are then discussed. Given the growing and near ubiquitous use of the Internet and smartphones, further efforts in the realm of mHealth (e.g., applications or "apps") and eHealth are needed to develop novel couple-focused HIV-preventive interventions.

The Feasibility and Acceptability of Using Technology-Based Daily Diaries with HIV-Infected Young Men Who have Sex with Men: A Comparison of Internet and Voice Modalities

This study delivered a daily diary to 67 HIV-infected men who have sex with men (MSM) between 16 and 24 years old for 66 days to measure HIV-risk behaviors and other psychosocial variables via two diary modalities: internet (accessible via any web-enabled device) and voice (accessible via telephone). Participants were randomized to complete one diary modality for 33 days before switching to the second modality for 33 days. The study was implemented in three urban HIV health care centers in the United States where participants were receiving services. Through diary data and qualitative interview data, we examined the feasibility and acceptability of the dairies and identified barriers and facilitators of dairy compliance. Results show high participant retention in the daily diary (93.4 %) and high compliance for the number of dairies completed (72.4 %). Internet diaries were preferred by 92 % of participants and completed at a significantly higher rate (77.5 %) than voice diaries (67.7 %). Facilitators included opportunities for self-reflection and cathartic sharing, monetary compensation, relationships with study staff, and daily reminders. Barriers included being busy or not having privacy at the time of reminders, forgetting, and falling asleep. Participants also described barriers and facilitators unique to each modality. Overall, both modalities were feasible and acceptable for use with our sample of HIV-infected MSM.

Findings from within-subjects comparisons of drug use and sexual risk behaviour in men who have sex with men in England

Epidemiological evidence for the encounter-level association between sexualised drug use and unprotected anal intercourse in men who have sex with men is unclear and has not examined men who have sex with men in England. To estimate this association, we compared dyadic sexual encounters within respondents. We used encounter-level data from a longitudinal online survey of men who have sex with men living in England and multilevel models to test univariate and multivariate associations between any respondent or partner drug use, specific respondent drug use, additional situational characteristics and unprotected anal intercourse. Based on 6742 encounters from 2142 men who have sex with men, respondent drug use and respondent use of certain specific drugs were associated with increased unprotected anal intercourse odds. In univariate models, partner drug use was associated with increased unprotected anal intercourse odds, but in multivariate models, only non-specific knowledge of partner drug use was associated with the same. Encounters with non-regular-and-steady partners or that were not HIV-seroconcordant were associated with decreased unprotected anal intercourse odds. This is the first within-subjects comparison of drug use and unprotected anal intercourse conducted on a sample from England, and the largest of its kind. Findings are consistent with other studies, though associations between drug use and unprotected anal intercourse are shaped by social contexts that may change over time.

Individual-Level, Partnership-Level, and Sexual Event-Level Predictors of Condom Use During Receptive Anal Intercourse Among HIV-Negative Men Who Have Sex with Men in Los Angeles

We examined individual-level, partnership-level, and sexual event-level factors associated with condom use during receptive anal intercourse (RAI) among 163 low-income, racially/ethnically diverse, HIV-negative men who have sex with men (MSM) in Los Angeles (2007-2010). At baseline, 3-month, and 12-month visits, computer-assisted self-interviews collected information on ≤3 recent male partners and the last sexual event with those partners. Factors associated with condom use during RAI at the last sexual event were identified using logistic generalized linear mixed models. Condom use during RAI was negatively associated with reporting ≥ high school education (adjusted odds ratio [AOR] = 0.32, 95 % confidence interval [CI] 0.11-0.96) and methamphetamine use, specifically during RAI events with non-main partners (AOR = 0.20, 95 % CI 0.07-0.53) and those that included lubricant use (AOR = 0.20, 95 % CI 0.08-0.53). Condom use during RAI varies according to individual-level, partnership-level, and sexual event-level factors that should be considered in the development of risk reduction strategies for this population.

Is Location of Sex Associated with Sexual Risk Behaviour in Men Who Have Sex with Men? Systematic Review of Within-Subjects Studies

To understand associations between location of sex and sexual risk, it is most helpful to compare sexual encounters within persons. We systematically reviewed within-subjects comparisons of sexual encounters reported by men who have sex with men (MSM) with respect to location of sex. Within-subjects comparisons of sexual risk and location of sex were eligible if they collected data post-1996 from samples of MSM. We independently screened results and full-text records in duplicate. Of 6,336 deduplicated records, we assessed 138 full-text studies and included six, most of which compared unprotected anal intercourse against other anal intercourse. This small, but high quality, body of evidence suggests that associations between attendance at sex-on-premises venues and person-level sexual risk may be due to overall propensity towards unprotected sex. However, there may be some location factors that promote or are associated with serononconcordant unprotected anal intercourse. Health promoters may wish to focus on person-level characteristics.

Sexual identity and HIV status influence the relationship between internalized stigma and psychological distress in black gay and bisexual men

Experiences of internalized homophobia and HIV stigma in young Black gay and bisexual men (GBM) may lead to psychological distress, but levels of distress may be dependent upon their sexual identity or HIV status. In this study, we set out to explore the associations between psychological distress, sexual identity, and HIV status in young Black GBM. Participants were 228 young Black GBM who reported on their psychological distress, their HIV status, and their sexual identity. Results indicated that internalized homophobia was significantly related to psychological distress for gay men, but not for bisexual men. HIV stigma was related to psychological stress for HIV-positive men, but not for HIV-negative men. Results indicate a need for more nuanced examinations of the role of identity in the health and well-being of men who have sex with men.

Nested Event-Level Case-Control Study of Drug Use and Sexual Outcomes in Multipartner Encounters Reported by Men Who Have Sex with Men

Previous event-level analyses have often, but not always, found significant associations between drug use and sexual risk behaviour in men who have sex with men (MSM), but these analyses have rarely considered either multipartner encounters specifically, or other sexual outcomes such as pleasure and control. Using data from an internet-based longitudinal survey of MSM, we tested the association between drug use by respondent and by partners and unprotected anal intercourse (UAI), pleasure and control over sexual activity. Overall respondent substance use was significantly associated with increased odds of UAI, though not with pleasure or control. Respondent use of crystal methamphetamine was significantly associated with both increased odds of UAI and decreased odds of control over sexual activity. This analysis agrees with previous studies of dyadic encounters, and specifically suggests that the association between crystal methamphetamine and sexual risk behaviour may be mediated by loss of control.

Sexual health risks, service use, and views of rapid point-of-care testing among men who have sex with men attending saunas: a cross-sectional survey

Guidelines highlight the need to increase HIV testing among men who have sex with men (MSM) and novel point-of-care testing provides new possibilities for delivery of care. However, it is unclear how point-of-care testing should be used to best effect. This study aimed to increase understanding of sexual risk-taking behaviour, service use, and attitudes to point-of-care testing among MSM sauna clients. Data were collected within two saunas for MSM in south west England using a self-completion survey (n = 134). Though this sample of MSM sauna clients are at high risk of acquiring a sexually transmitted infection, the testing frequency among the majority of those reporting unprotected anal intercourse is not in keeping with national guidelines. For almost all participants the introduction of rapid point-of-care testing for both genital and blood-borne infection was likely to increase testing and for the majority NHS specialist services was the preferred setting.

Correlates of Seroadaptation Strategies Among Black Men Who have Sex with Men (MSM) in 4 US Cities

We assessed associations of demographic, psychosocial, and substance use factors with seroadaptation strategies among 835 BMSM in four US cities. Seroadaptation strategies were practiced by 59.8 % of men, with 10.5 % practicing 100 % condom use, 26.5 % serosorting, 7.2 % condom serosorting, and 15.6 % seropositioning. In multivariable analyses, compared to men who used no seroadaptation strategies, serosorters were older, were less likely to be HIV infected, had fewer male sex partners, and had higher levels of social support and sexual self-efficacy. Condom serosorters had less psychological distress, were more likely to use methamphetamine, and had higher levels of sexual self-efficacy. Seropositioners were older, were less likely to be HIV infected, to have a main partner, and report alcohol/drug use with sex, while having higher levels of sexual self-efficacy. Seroadaptation practices among BMSM need to be considered to address perceived safer sex strategies and strengthen access to a broader reach of culturally-relevant prevention efforts.

Drug use moderates associations between location of sex and unprotected anal intercourse in men who have sex with men: nested cross-sectional study of dyadic encounters with new partners

OBJECTIVES

This nested cross-sectional study of dyadic sexual encounters with new male partners reported by men living in England who have sex with men tested moderation between drug use and location of sex in associations with unprotected anal intercourse (UAI).

METHODS

Data were drawn from two waves of a longitudinal monthly internet survey of men living in England who have sex with men conducted in 2011. Using generalised estimating equations and logit link, we tested the relationship with UAI of any respondent drug use before sex, specific respondent drug use before sex, location of sex (distinguishing private, sex-on-premises venue and cruising locations) and location-drug use interactions.

RESULTS

Any respondent drug use (OR 1.57, 95% CI 1.31 to 1.88) was associated with increased odds of UAI. Relative to encounters in private locations, encounters in sex-on-premises venues (0.69, 95% CI 0.52 to 0.91), but not cruising locations, were associated with decreased odds of UAI. Any respondent drug use, respondent use of poppers and respondent use of alcohol were each associated with increased UAI in sex-on-premises venues.

DISCUSSION

This analysis presents evidence of moderation between drug use and location of sex in associations with UAI. Though this analysis used a large sample, it relied on community-recruited respondents. Our findings may reflect either 'totalising' effects of drug use across venues or site-specific use of drugs as a mechanism for cognitive escape. Additional qualitative research is necessary to understand these findings in context.

Molecular Epidemiology of HIV-1 Infection among Men who Have Sex with Men in Taiwan in 2012

The number of men who have sex with men (MSM) infected with HIV-1 in Taiwan has increased rapidly in the past few years. The goal of this study was to conduct a molecular epidemiological study of HIV-1 infection among MSM in Taiwan to identify risk factors for intervention. Voluntary counseling program and anonymous testing were provided to patrons at 1 gay bar, 7 night clubs and 3 gay saunas in Taipei and New Taipei Cities in 2012. HIV-1 subtypes were determined using gag subtype-specific PCR and phylogenetic analysis by env sequences. Recent HIV-1 infection was determined using LAg-Avidity EIA. In-depth interviews and questionnaires were used to identify risk factors. The prevalence and incidence of HIV-1 among MSM in Taiwan were 4.38% (53/1,208) and 3.29 per 100 person-years, respectively. Of 49 cases genotyped, 48 (97.9%) were infected with subtype B and 1 with CRF01_AE (2%). Phylogenetic analysis of 46 HIV-1 strains showed that 25 (54.4%) subtype B strains formed 9 clusters with each other or with other local strains. The CRF01_AE case clustered with a reference strain from a Thai blood donor with bootstrap value of 99. Multivariate logistic regression analysis showed that risk factors associated with HIV-1 infection included use of oil-based solution as lubricant (vs. saliva or water-based lubricants, OR= 4.23; p <0.001); exclusively receptive role (vs. insertive role, OR= 9.69; p <0.001); versatile role (vs. insertive role, OR= 6.45; p= 0.003); oral sex (vs. insertive role, OR= 11.93; p= 0.044); times of sexual contact per week (2-3 vs. zero per week, OR= 3.41; p= 0.021); illegal drug use (OR= 4.12; p <0.001); and history of sexually transmitted diseases (OR= 3.65; p= 0.002). In conclusion, there was no new HIV-1 subtype or circulating recombinant form responsible for the increase of HIV-1 among MSM in Taiwan in 2012. Misuse of oil-based solution as lubricant is a new risk factor identified among MSM in Taiwan. The Taiwan's Centers for Disease Control has created a video (www.youtube.com/watch?v=BinExvvOTMM&feature=iv&src_vid=BW81-PfmY3E&annotation_id=annotation_2436493705) to correct such misconception in its AIDS prevention campaign.

Drug Use, Sexual Risk, and Syndemic Production Among Men Who Have Sex With Men Who Engage in Group Sexual Encounters

OBJECTIVES

We surveyed men who have sex with men (MSM) to determine whether sexual risk behaviors, recent drug use, and other psychosocial problems differed between men who engaged in one-on-one and group sexual encounters.

METHODS

We conducted an Internet-based cross-sectional survey of 7158 MSM aged 18 years or older in the United States recruited from a gay-oriented sexual networking Web site in 2008. Among MSM who engaged in group sexual encounters, we compared their past-60-day sexual behaviors in one-on-one encounters and group sexual encounters. We also compared risk profiles and syndemic production between men who did and did not participate in group sex.

RESULTS

Men reporting a group-sex encounter had significantly higher polydrug use and sexual risk than did the men not reporting group sex in the past 60 days. The odds of engaging in group sex with 4 or more sexual partners significantly increased with the number of psychosocial problems, supporting evidence of syndemic production.

CONCLUSIONS

We identified a particularly high-risk subgroup in the MSM population with considerable psychosocial problems that may be reached online. Research is needed on how to engage these high-risk men in combination prevention interventions.

Partners met via sex parties present significantly greater odds for condomless anal sex among MSM: an event-level analysis of venues where male partners are met

One hundred forty-seven men who have sex with men completed time-line follow-back interviews about the venues where they met their male partners (n = 1180 sexual events with first-time partners, <30 days). We ran multivariate models to determine the association between venues and condomless anal sex (CAS). After adjusting for known correlates of CAS, partners met at sex parties presented significantly greater odds for CAS compared with meeting a partner at a gay bar/club (adjusted odds ratio = 0.44), online (adjusted odds ratio = 0.42), bathhouse (adjusted odds ratio = 0.35), or via "other" venues (adjusted odds ratio = 0.35), all P < 0.01. These findings highlight the need to develop innovative HIV/sexually transmitted infection prevention initiatives for men who attend sex parties.

Sources of racial/ethnic differences in awareness of HIV vaccine trials

OBJECTIVES

We explored the relative effects of 2 awareness components-exposure and attention-on racial/ethnic differences in HIV vaccine trial awareness among men who have sex with men (MSM).

METHODS

Surveys assessing awareness of and attitudes toward HIV vaccine trials were administered to 1723 MSM in 6 US cities. Proxy measures of exposure included use of HIV resources and other health care services, community involvement, income, and residence. Attention proxy measures included research attitudes, HIV susceptibility, and HIV message fatigue. Using logistic regression models, we assessed the extent to which these proxies accounted for racial/ethnic differences in vaccine trial awareness.

RESULTS

White MSM reported significantly (P < .01) higher rates of HIV vaccine trial awareness (22%) compared with Latino (17%), Black (13%) and "other" (13%) MSM. Venue-based exposure proxies and research-directed attitudinal attention proxies were significantly associated with awareness, but only accounted for the White-Latino disparity in awareness. No proxies accounted for the White-Black or White-"other" differentials in awareness.

CONCLUSIONS

Sources of disparities in awareness of HIV vaccine trials remain to be explained. Future trials seeking to promote diverse participation should explore additional exposure and attention mediators.

The use of web-based diaries in sexual risk behaviour research: a systematic review

BACKGROUND

An increasing number of studies have used the diary method, which provides quantitative event-level data about sexual encounters. Diaries are an attractive tool for sexual behaviour research, yet little is known about the range of uses, methodological issues and best practices associated with this technology.

OBJECTIVES

To conduct a systematic review of the literature regarding the use of web-based diaries in sexual risk behaviour studies.

DESIGN

Systematic review.

DATA SOURCES

Five bibliographical databases, supplemented by references from previous reviews.

METHODS

Eligible studies were published in English before August 2013, used the internet to transmit data from collection device to study staff, and measured behaviours affecting HIV or sexually transmitted infection transmission risk. The primary author conducted an initial screen to eliminate irrelevant articles. Both authors conducted full-text reviews to determine final articles. We abstracted data on diary methodology, validity and reactivity (behaviour change caused by diary completion).

RESULTS

Twenty-three articles representing 15 studies were identified. Most diaries were collected daily for 1 month via websites, and completion was generally high (>80%). Compensation varied by study and was not associated with completion. Studies comparing diary with retrospective survey data demonstrated evidence of over-reporting on retrospective tools, except for the least frequent behaviours. Most studies that assessed reactivity as a result of diary completion demonstrated some change in behaviour associated with frequent monitoring.

CONCLUSIONS

Web-based diaries are an effective means of studying sexual risk behaviour. More uniform reporting and further research on the extent of reactivity are needed.

Men who have sex with men's attitudes toward using color-coded wristbands to facilitate sexual communication at sex parties

Sex parties are environments where men who have sex with men (MSM) have the opportunity to have sex with multiple partners over a brief period of time. Dim lighting and non-verbal communication are characteristics of sex parties that make sexual communication more challenging. We report on qualitative data from 47 MSM who attended sex parties in New York City. Participants responded to distinct hypothetical scenarios involving the use of color-coded wristbands to communicate (1) condom use preferences, (2) sexual position (e.g., top, bottom) and (3) HIV status at sex parties. The majority had positive-to-neutral attitudes toward color-coded wristbands to indicate (1) condom use preference and (2) sexual position (70.8%, 75.0% HIV-positive; 63.6%, 81.8%, HIV-negative respectively). These men cited that wristbands would facilitate the process of pursuing partners with similar interests while also avoiding the discomforts of verbal communication. In contrast, 41.7% of HIV-positive and 50.0% of HIV-negative men expressed unfavorable attitudes to using wristbands to communicate HIV status. These men cited the potential for HIV-status discrimination as well as suspicions around dishonest disclosure. Although participants were receptive to utilizing color-coded wristbands at sex parties to convey certain information, it may be unfeasible to use wristbands to communicate HIV status.

Sexual sensation seeking and Internet sex-seeking of Middle Eastern men who have sex with men

Despite recent evidence of stabilization in many developed nations, new human immunodeficiency virus (HIV) infections remain a public health concern globally. Efforts remain fragile in a number of world regions due to incomplete or inconsistent social policies concerning HIV, criminalization of same-sex encounters, social stigma, and religious doctrine. Middle Eastern men who have sex with men (MSM) remain one of the most hidden and stigmatized of all HIV risk groups. High-risk sexual bridging networks from these men to low prevalence populations (e.g., to spouse to offspring) are emerging HIV transmission pathways throughout the region. This cross-sectional, exploratory study investigated Sexual Sensation Seeking Scale (SSSS) scores to predict numbers of recent MSM sexual activities and to predict any recent unprotected receptive anal intercourse (URAI) activities in 86 Middle Eastern MSM who resided in the Middle East and who used the Internet to sex-seek. In a multivariate hierarchical regression, higher SSSS scores predicted higher numbers of recent MSM sexual activities (p = .028) and URAI (p = .022). In a logistic regression, higher SSSS scores increased the likelihood of engaging in URAI activities threefold (OR 3.0, 95 % CI 1.15-7.85, p = .025). Age and drug/alcohol use during sexual activities served as covariates in the regression models and were not significant in any analyses. Despite numerous hurdles, adopting Internet-based, non-restricted HIV education and prevention public health programs in the Middle East could instrumentally enhance efforts toward reducing the likelihood of new HIV transmissions in MSM and their sexual partners, ultimately contributing to an improved quality of life.

Overcoming biological, behavioral, and structural vulnerabilities: new directions in research to decrease HIV transmission in men who have sex with men

Men who have sex with men (MSM), including transgender women, comprise a heterogeneous group of individuals whose sexual behaviors and gender identities may vary widely between cultures and among individuals. Their sources of increased vulnerability to HIV are diverse, including the increased efficiency of HIV transmission via unprotected anal intercourse, sexual role versatility, asymptomatic sexually transmitted infections, and behavioral factors that may be associated with condomless sex with multiple partners. Societal stigmatization of homosexual behavior and gender nonconformity may result in internalized negative feelings that lead to depression, other affective disorders, and substance use, which in turn are associated with increased risk-taking behaviors. Social stigma and punitive civil environments may lead to delays in seeking HIV and sexually transmitted disease screening, and later initiation of antiretroviral therapy. The iPrEX study demonstrated that chemoprophylaxis can decrease HIV acquisition in MSM, and the HIV prevention trials network 052 study established the biological plausibility that earlier initiation of highly active antiretroviral therapy can decrease HIV transmission to uninfected partners. Despite these advances, MSM remain among the most significantly HIV-affected population in resource-rich and limited settings. New studies will integrate enhanced understanding of the biology of enhanced rectal transmission of HIV and the focused use of antiretrovirals for prevention with culturally tailored approaches that address the potentiating social and behavioral factors associated with enhanced HIV spread among MSM.

Exploring the venue's role in risky sexual behavior among gay and bisexual men: an event-level analysis from a national online survey in the U.S

Venue-based characteristics (e.g., alcohol in bars, anonymous chat online, dark/quiet spaces in bathhouses) can impact how men who have sex with men (MSM) negotiate sex and HIV-associated risk behavior. We sought to determine the association between HIV-associated risk factors and the venues where MSM met their most recent new (first-time) male sex partner, using data from a 2004 to 2005 national online anonymous survey of MSM in the U.S. (n = 2,865). Most men (62%) met their partner through the Internet. Among those reporting anal sex during their last encounter (n = 1,550), half had not used a condom. In multivariate modeling, and among men reporting anal sex during their last encounter, venue where partner was met was not significantly associated with unprotected anal intercourse (UAI). Nevertheless, venue was related to other factors that contextualized men's sexual encounters. For example, HIV status disclosure was lowest among men who met their most recent partner in a park, outdoors, or other public place and highest among men who met their most recent partner online. Alcohol use prior to/during the last sexual encounter was highest among men who met their most recent partner in a bathhouse or a bar/club/party/event. These data suggest it is possible to reach men online who seek sex in many different venues, thus potentially broadening the impact of prevention messages delivered in virtual environments. Although not associated with UAI, venues are connected to social-behavioral facets of corresponding sexual encounters, and may be important arenas for differential HIV and STI education, treatment, and prevention.

Participation in research involving novel sampling and study designs to identify acute HIV-1 infection among minority men who have sex with men

HIV-1 infection disproportionally affects African-American and Latino men who have sex with men (MSM). Their inclusion in biomedical and behavioral research is critical to understanding and addressing HIV vulnerability. Using focus groups, we sought to understand the perceptions related to participating in biomedical research of acute/recent HIV-1 infection (AHI) using complex sampling and data collection methods to reach this hidden group at highest risk of acquiring and transmitting HIV. Given the potential impact of AHI on HIV transmission in MSM, it is important to understand this intersection for HIV prevention, care, and treatment purposes. The aim of this study was to understand how recruitment and data collection methods affect AHI research participation willingness particularly among MSM of color. Findings suggest that major barriers to research participation with complex sampling to identify AHI and intensive risk behavior collection such as diary methods are lack of anonymity, partner disclosure, and study fatigue. The authors explore implications for future study designs and development based on these findings.

Alcohol use predicts sexual risk behavior with HIV-negative or partners of unknown status among young HIV-positive men who have sex with men

Although the relationship between substance use and heightened sexual risk behaviors have been documented in samples of young men who have sex with men (YMSM) and HIV-positive adult men who have sex with men (MSM), there is a dearth of research on the role of substance use in the sexual risk behaviors of HIV-positive YMSM. We examined associations between alcohol and other drug use with sexual risk behaviors among a sample of HIV-positive YMSM (N=200). There were no significant predictors of either receptive or insertive unprotected anal intercourse (UAI) with HIV-positive partners among the substance use variables. Failure to use a condom after drinking alcohol (β=2.00, p<0.01) was significantly associated with insertive UAI with HIV-negative partners or partners of unknown status. Failure to use a condom after drinking alcohol (β=1.36, p<0.05) and age (β=0.35, p<0.05) were significantly associated with receptive UAI with HIV-negative partners or partners of unknown status. Findings from this article underscore the role of alcohol in facilitating UAI among HIV-positive YMSM and their HIV-negative and status-unknown partners.

A review of the literature on event-level substance use and sexual risk behavior among men who have sex with men

In the United States, there continues to be high incidence of HIV infection among men who have sex with men (MSM), who represent 57% of new infections in 2009. While many studies report associations between non-injection substance use and sexual risk behavior among MSM, overall results are mixed. Summarizing these studies is difficult because researchers have used a variety of assessment periods for substance use and sexual behavior. We review the scientific literature on event-level measures, which assess substance use and sexual risk behavior immediately before or during a sexual encounter and provide the most precise link between these two behaviors. From January 2009 through March 2010, we searched four databases: Ovid (MEDLINE and PsycINFO), Web of Knowledge, and Sociofile. Across studies, results varied by substance with little within substance consistency or a lack of research except for two notable exceptions: methamphetamine and binge alcohol use. The findings underscore the importance of providing HIV risk-reduction interventions for substance-using MSM.

Sexually transmitted diseases in men who have sex with men

Men who have sex with men (MSM) have increased rates of human immunodeficiency virus (HIV) infection and sexually transmitted diseases (STDs) compared with demographically matched controls. The reasons for the disproportionate infection burden are complex, including biological, behavioral, and sociocultural factors. HIV and syphilis may often be coprevalent among MSM. The use of nucleic acid amplification testing has enhanced the ability to detect frequently asymptomatic gonococcal and chlamydial infections of the rectum and other sites. Lymphogranuloma proctitis outbreaks among MSM were noted in the developed world several years ago but have not been common recently. MSM are at increased risk for viral hepatitis and anal human papillomavirus disease. Preventive interventions include vaccination for the former and anal cytologic screening for the latter. Because of the diverse ways in which MSM may be exposed to STDs, it is essential for clinicians to obtain a thorough sexual history in a culturally competent manner.

Predictors of HIV Sexual Risk Behavior among Men Who Have Sex with Men, Men Who Have Sex with Men and Women, and Transgender Women

Men who have sex with men, men who have sex with men and women, and transgender women are at high risk for HIV infection. This study seeks to clarify which known HIV risk factors (partner type, sex location, serodiscordance, multiple sex partners, substance use during sex) contribute to engagement in high-risk (unprotected receptive anal) sex in each population. Data collected from June 2005 through June 2008 indicate all three populations display different HIV sexual risk profiles. The data suggest that HIV-prevention interventions should be individually tailored to address the specific needs of these three highly vulnerable and impacted populations.

Determinants of condom use among HIV-positive men who have sex with men

The main objectives of this study were to identify the determinants of condom use among HIV-positive men having anal sex with HIV-negative men or men of unknown HIV status and moderators of the intention-behaviour relationship. A cohort of 237 sexually active HIV-positive men having sex with men was followed over a period of six months. The cognitive variables measured were guided by an extended version of the theory of planned behaviour. Results indicated that past behaviour (odds ratio [OR] = 9.75; 95% confidence interval [CI]: 4.48-21.26), intention (OR = 3.13; 95% CI: 1.25-7.81), self-efficacy (OR = 3.62; 95% CI: 1.40-9.37) and use of sex drugs (OR = 0.16; 95% CI: 0.06-0.45) contributed to the prediction of 100% condom use. Self-efficacy also interacted with intention as a significant moderator of the intention-behaviour relationship (OR = 20.96; 95% CI: 2.90-151.51). Interventions promoting condom use should increase self-efficacy to use condoms and target users of sex drugs.

Sexual contexts and the process of risk reduction

Understanding the dynamics of sexual risks for HIV among men who have sex with men has been one of the ongoing challenges of HIV prevention. While the majority of HIV-prevention interventions target individual behaviour and decision making, multiple studies point to the importance of social context in shaping risk behaviour. Analysis of qualitative data from a study of men who have sex with men, drug use and sex found that sexual encounters were made up multiple contextual and interpersonal elements, which interacted to shape sexual practices and risk reduction strategies. Semi-structured interviews were conducted with 60 racially diverse men who have sex with men in NYC, recruited from multiple venues. The majority of respondents were gay-identified and half were 40 or older. Respondents described risk assessment and risk-reduction processes that develop throughout a sexual encounter, embedded in ongoing negotiations of sexual practices. Strategies of risk assessment and reduction draw on probability-based approaches to HIV prevention, presenting a challenge to health education.

Sexual agreement classifications for gay and bisexual men and implications for harm reduction HIV prevention

HIV prevention educators frequently encourage gay and bisexual men (GBM) to negotiate condom use prior to sexual engagement. Identifying groups of GBM based on their presexual agreements can aid efforts to tailor interventions. Using cross-sectional data from 1,188 GBM who reported having sex with a nonprimary sex partner in the 90 days prior to the survey, the authors identified presexual agreement patterns. For both HIV-positive and HIV-negative GBM, two groups existed: men agreeing to no anal sex and men agreeing to anal sex with condoms. Among HIV-negative participants, there was a group agreeing to anal sex without specifying condom use. Among HIV-positive participants, there was a group agreeing to anal sex without condoms; this was the largest group of HIV-positive participants. Despite a presexual agreement to use condoms, substance use during sex increased the risk of unprotected anal sex. Suggestions for applying harm reduction to HIV prevention based on agreement classifications are discussed.

Sex parties among urban MSM: an emerging culture and HIV risk environment

Private sex parties are an emerging risk environment for HIV among men who have sex with men (MSM). In 2009, 103 participants who reported attending at least one sex party in Massachusetts in the prior 12 months completed an in-depth, interviewer-administered quantitative assessment. Multivariable logistic regression analyses were conducted to examine associations with having engaged in one or more serodiscordant unprotected anal sex (SDUAS) acts at the most recent sex party attended. Nearly one-third (32%) of the sample reported engaging in SDUAS at the most recent sex party attended. Adjusting for age, race/ethnicity, and educational attainment, variables associated with an increased odds of engaging in SDUAS at the most recent sex party were: total number of unprotected anal receptive sex acts at sex parties in the past 12 months, self-perception of being at-risk for transmitting or acquiring HIV, and sexual sensation seeking. Examined in the same model, if condoms were provided/available at the most recent sex party attended, participants were at a decreased odds of engaging in SDUAS at that sex party. The majority (80%) expressed an interest in HIV prevention activities for MSM who attend sex parties. HIV prevention interventions are needed to reach MSM who attend sex parties and should take into account individual and contextual factors that may contribute to sexual risk. Environmental factors in the sex party setting, in particular the presence and availability of condoms, may potentially mitigate individual-level factors such as unprotected anal sex.

Reasons for non-use of condoms among men who have sex with men: a comparison of receptive and insertive role in sex and online and offline meeting venue

This study examined reasons for non-use of condoms among an online survey sample of 462 non-condom using men who have sex with men to: (1) identify major domains, themes and categories encompassing reasons for non-use of condoms and (2) examine whether reasons varied by role-in-sex (insertive or receptive) and meeting venue (online or offline). A thematic analysis was completed on participant responses to an open-ended question about reasons for non-condom use. Preference for not using condoms and contextual factors were the top two reasons given for not using condoms, followed by a reasoned judgment based on risk assessment, relationship status and interpersonal communication. No major differences were found between men who reported non-condom use at last receptive and insertive anal intercourse. By contrast when meeting online, men were more likely to report reasons for non-condom use that corresponded to individual preference and mutual agreement not to use condoms. When meeting offline, men were more likely to cite reasons related to context and relationships. In developing HIV-prevention interventions for this population, researchers should address both venues separately, as reasons why men engage in non-use of condoms appear to differ.

Reconsidering the internet as an HIV/STD risk for men who have sex with men

Previous studies linking online sexual partnerships to behavioral risks among men who have sex with men (MSM) may be subject to confounding and imprecise measurement of partnership-specific risks. We examined behavioral risks associated with having only online, only offline, or both online and offline partners in the past year, the confounding effects of multiple partnerships, and partnership-specific risks among a sample of MSM from New York City recruited offline in 2008. Overall, 28% of 479 participants had an online partner in the past year, but most of those (82%) also had an offline partner. Having an online partner was associated with past-year unprotected anal intercourse (UAI) and other risks, but not after controlling for multiple partnerships. There were slightly higher levels of risk within offline partnerships, but differences were largely attributable to MSM who had both offline and online partners. Last sex partners met offline were more likely to be HIV-serodiscordant and engage in concurrent substance use with the participant. This suggests that online partnerships may not be an independent cause of behavioral risks, but a marker for risks occurring independent of Internet use.

“It's a quick way to get what you want”: a formative exploration of HIV risk among urban Massachusetts men who have sex with men who attend sex parties

Community-based studies with men who have sex with men (MSM) suggest that between 8% and 25% of MSM have met recent male sexual partners at private sex parties. Little is known about HIV sexual risk behaviors of MSM who attend sex parties and whether risk reduction interventions can be delivered in this setting. In 2008, 40 MSM who reported attending and/or hosting sex parties in Massachusetts in the past 12 months completed a qualitative interview and quantitative assessment. Participants reported attending a mean number of 10 sex parties in Massachusetts in the past 12 months. A significant percentage (43%) reported also hosting sex parties. Participants had made sexual partner connections across multiple venues, including public cruising areas, bars/clubs, and the Internet. At the most recent sex party attended, the majority had used alcohol (58%) and/or drugs (50%), and one quarter (25%) put themselves at risk of acquiring or transmitting HIV or other sexually transmitted infections (STIs) by having unprotected anal sex with a mean number of three serodiscordant male sex partners. Although many participants perceived that communicating about sexual health in the sex party context would “ruin the mood,” the majority (80%) considered some form of HIV prevention at sex parties to be appropriate and necessary, as well as acceptable. Nonintrusive prevention and education activities were especially endorsed (i.e., condoms, lubricants, and coupons for free HIV/STI testing). The majority of participants (75%) expressed some interest in “safer sex” parties. MSM attending sex parties appear to be a subpopulation at high risk for HIV and STI acquisition and transmission. Risk reduction interventions responsive to the needs of MSM who attend sex parties are warranted.

Internet advertisements for public sexual encounters among men who have sex with men: are safe behaviors communicated?

Public and commercial sex venues typically provide easy access to sexual encounters that are often anonymous and, therefore, may facilitate HIV/STD transmission among those men who attend. Recently, researchers have suggested that men who have sex with men may be using the Internet to search for sexual encounters to occur within sex venues. The current study explored the extent to which men who advertise for public or commercial sexual encounters initially communicate to potential partners their safe-sex intentions. Advertisements for sexual encounters (n = 99) were collected from a publicly accessible website and examined for content related to venue type, sexual behavior, and indications of sexual safety or risk. Word frequencies were calculated to provide a closer investigation of how individuals negotiate safe sex within these communications. The findings revealed that approximately half of the men who advertised for sex in a public or commercial sex venue failed to communicate to potential partners in their initial advertisement a desire to be safe during sexual encounters involving oral and anal practices. Additionally, a small percentage of men advertised specifically for risky encounters (e.g., barebacking). Together, these findings suggest that men do use the Internet to coordinate public sexual encounters, some of which may be unprotected from HIV/STD transmission. Future research should address the process of condom negotiation among men who initially meet their male sex partners on the Internet for subsequent encounters in sex venues.

Sexual Risk Behaviors with Female and Male Partners Met in Different Sexual Venues Among Non-Gay-Identified, Non-Disclosing MSMW

Despite considerable interest in the sexual behavior of non-disclosing men who have sex with men and women (MSMW), little is known about where they meet their male and female partners and whether their sexual risk behavior differs with partners met in different sexual venues (e.g., bars, Internet, parks). These issues were examined among 46 non-gay-identified MSMW who had not disclosed their same-sex behavior to female partners (i.e., men on the "down low"). The prevalence of unprotected vaginal sex was nearly identical with women met in bars/clubs as with women met through friends, work, or the neighborhood. In contrast, the prevalence of unprotected anal sex was higher with male partners met on the Internet, in bars/clubs, and through friends/work/neighborhood as compared with partners met in parks/restrooms or gyms. This is largely due to MSMW avoiding anal sex in parks, restrooms, and gyms, in favor of oral sex. These findings provide important insights into the role of venues on sexual risk and the locations where risk reduction interventions for MSMW may be provided.

Social network methodology for studying HIV epidemiology in men having sex with men

A self-administered network-based questionnaire survey was conducted on 91 HIV-positive Chinese men having sex with men (MSM). Affiliation matrices were created to assess their networking pattern. The individuals' preferential use of venues for sex partnership before HIV infection has changed over three time periods of 1997-2000, 2001-2003 and 2004-2006. Over time, there was a parallel increase in network density (density scores from 0.26, through 0.36, to 0.53) and degree centrality (from a median score of 9, through 12, to 16), suggesting that connectivity of MSM was becoming higher through sexual networks. The overall practice of unprotected sex has, however, remained the same. The study demonstrated how the application of social network analysis could enrich the epidemiologic description of HIV infection in the population.

Drug use, interpersonal attraction, and communication: situational factors as predictors of episodes of unprotected anal intercourse among Latino gay men

It is important to understand situational factors linked to episodes of unprotected sexual intercourse among Latino gay men (LGM), who are disproportionately affected by HIV/AIDS in the U.S. Past research has suggested that participation in difficult sexual situations mediates the relationship between socio-cultural factors and sexual risk behaviors among LGM. This study examined drug use by self and sex partners, interpersonal factors, and other key variables, each examined at the situation-level of analysis, as predictors of episodes of unprotected anal intercourse (UAI) among LGM. Study participants included 270 LGM living in New York City, Miami, and Los Angeles who reported inconsistent condom use during anal intercourse in the last year. Men participated in structured interviews in which they were asked sets of detailed questions about their most recent episode of anal intercourse in which they used condoms, and their most recent anal intercourse episode in which they did not use condoms. Conditional logistic regression was used to compare the relevance of specific situational factors to participants' episodes of UAI and protected anal intercourse. We found that drug use by a sex partner and lacks of discussions about condom use with partners, among other situational factors, were significantly related to episodes of UAI. The findings highlight the importance of considering the impact of sexual situations and interactions with sex partners when studying HIV risk among LGM and when designing interventions.