Variables influencing condom use in a cohort of gay and bisexual men

Changes in substance use among HIV-negative MSM: A longitudinal analysis, 1995-2019

BACKGROUND

Research suggests shifting patterns of recreational drug consumption among MSM in recent decades. The present study evaluates population-level mean trajectories of substance use among HIV-negative MSM from 1995 to 2019.

METHODS

Using open cohort study data following MSM in the Netherlands (n=1495) since 1995, we applied generalized estimating equations to examine population-averaged estimates of five substances - alcohol, cannabis, ecstasy, cocaine, and poppers - from 1995 to 2019, as well as their use during sexual encounters.

RESULTS

Recent alcohol use decreased; predicted probabilities declined from 1995 to 2019 (.96 to .87). During the same period, cocaine and poppers use increased - (.10 to .23 and .37 to .47, respectively) and use during sex also increased (.05 to .16, and .32 to .41, respectively). Ecstasy use increased over time (.23 to .38), although not during sex. No significant changes in cannabis use occurred.

CONCLUSIONS

While changes in use of various substances were mixed, increases in cocaine and poppers use during sexual encounters occurred among HIV-negative MSM over time. Efforts to intervene on substance use in connection with sex remain critical for health promotion.

Safer sex practices among newly diagnosed HIV-positive men who have sex with men in China: results from an ethnographic study

The study reported here sought to understand the rationales of safer sex practices adopted by newly diagnosed HIV-positive men who have sex with men (MSM). Guided by a socio-ecological framework, an ethnography was conducted among newly diagnosed HIV-positive MSM. In-depth interviews and participant observation were employed to produce an account of the social and cultural settings that was faithful to the perspectives of participants. A total of 31 participants with diverse backgrounds were recruited in a southern city of China. Participant observation was conducted in local healthcare settings, MSM venues, and NGO offices. Most participants (24/31) reported stopping unprotected anal intercourse (UAI) immediately after being diagnosed as HIV-positive. Factors associated with safer sex practices were identified at both individual and environmental levels, including self-protection, establishment of self-esteem, dignity, altruism and reciprocity, disease experience as a source of personal growth, and organizational culture and values. Newly diagnosed HIV-positive MSM navigate their sexual practices within the context of multiple competing factors. Implications for sustained behaviour change enabling safer sex practices include stimulating survival instinct, facilitating safer sex decision making, motivating and facilitating personal growth, and encouraging volunteerism to promote intentional activities for safer sex practices.

Actions of female sex workers who experience male condom failure during penetrative sexual encounters with clients in Cape Town: Implications for HIV prevention strategies

Background

Condom failure has always been found to coexist with condom usage, especially among sex workers.

Objective

To describe the actions of female sex workers when they are faced with situations of condom failure.

Methods

Using the survey design, the participants were selected through the snowball sampling method. Their responses were obtained using a structured questionnaire. A total of 100 questionnaires were analysed.

Results

With respect to the immediate actions of sex workers after condom failure, 36% of the respondents continued with the sexual encounter after noticing that the condom was broken. Another 36% stopped immediately when they noticed that the condom had failed, but replaced the condom; 13% of the participants stopped the sexual encounter completely; 3% applied vaginal spermicidal foam; and 5% of the respondents stopped immediately and took a douche when they had the chance. For the actions within the next 24 hours of experiencing condom failure with a client, 53% of the participants did nothing; 4% sought counsel from a professional; 3% of the respondents took alcohol or drugs to forget the incident, 25% went to the clinic for assistance and 8% offered other responses.

Conclusion

While continuing the sexual encounter without replacing the condom, taking alcohol and drugs or doing nothing could increase the risk of contracting HIV; however, actions like stopping the sexual encounter completely and visiting a clinic or a professional could make a difference between staying HIV negative or seroconverting. There is a need for targeted intervention to address issues of inappropriate behaviours after experiencing condom failure.

Are Condom Instructions in Spanish Readable? Implications for AIDS Prevention Activities for Hispanics

Almost haylof the 10,544 cases of AIDS reported among Hispanics are associated with sexual transmission of the human immunodeficiency virus. As a result, the use of condoms has assumed a central role in the prevention of AIDS. In order to determine the readability of Spanish instructions provided with condoms, twentyfive brands were purchased in Los Angeles. Only half of the manufacturers of condoms available in Los Angeles provided instructions in Spanish. Seven different Spanish texts were identified from the thirteen marketed brands. Readability tests indicate that these texts pose difficulties in comprehension for anyone whose reading skills are below the ninth grade level. These instructions inadequately serve the majority of the Hispanic community whose limited reading skills inhibit comprehension of high school level materials. These results suggest the need to modify AIDS education and prevention materials to increase the level of information available to the Hispanic community.

Alcohol and Drug Use during Sexual Activity

The relation of alcohol and drug use during sexual activity to increased HIV risk-associated behavior was examined among 108 inner-city Black male adolescents who completed a self-administered questionnaire. Adolescents who reported a greater number of days in which they had sex while "high" reported more unprotected coitus, a greater number of coital partners, a greater number of risky coital partners, and more frequent insertive anal intercourse than did those who reported fewer days on which they had sex while high. For the most part, these relations remained significant when total frequency of sexY, a correlate of having sex while high, was included in the regression equation. The only exception was failure to use condoms. These results support the view that alcohol and drug use during sexual activity may affect the nature of the sexual behavior in which Black male adolescents engage, although it may not affect whether they use condoms.

Gay Men and HIV/AIDS Risk Management

This article presents a framework through which changes in the management of HIV/AIDS risks among British gay men may be conceptualized. Three distinct periods of risk management are outlined. First, a ‘confused’ period in which the aetiology of AIDS and its cultural impact were poorly understood. Second, a ‘somatic’ period is described in which discourses linking HIV risk to the body became prevalent (following the ‘discovery’ of the HIV virus). Finally a third, ‘technological’ period is described which stresses the impact of recent social and medical technologies in the contemporary management of both HIV and AIDS risks. The privatization, fluidity and development of HIV and AIDS ‘risks’ are discussed with particular reference to notions of surveillance medicine, processes of ‘othering’ and the attribution of both responsibility and blame.

Constructing Sexual Health

This article outlines the importance of conceptualizing ‘sexual health’ as a pluralistic and context-bound phenomenon. It explores gay men's sexual decision making in the particular context of public parks. Twenty gay men from Glasgow, Scotland, took part in semi-structured, in-depth interviews. Interpretative Phenomenological Analysis (IPA) was employed to analyse transcripts for recurrent themes—these represent shared understandings across participants. Risk reduction, danger and safety figured frequently in men's accounts of sex and sexual decision making. However, the risks men reported related more directly to the threat of attack or arrest rather than the avoidance of sexually transmitted infections. Indeed, danger itself was occasionally something to be sought and enjoyed. Given these findings, we discuss the appropriateness of traditional health psychological approaches to understanding sexual health. It is hoped that this approach can highlight some issues that a true psychology of sexual health must address in order to represent sexual decision making more accurately and to be useful with respect to both service provision and theoretical development.

Examining the relationship between use of sexually explicit media and sexual risk behavior in a sample of men who have sex with men in Norway

The purpose of this study was to investigate consumption patterns of gay-oriented sexually explicit media (SEM) among men who have sex with men (MSM) in Norway, with a particular emphasis on a possible relationship between gay SEM consumption and HIV risk behavior. Participants included 529 MSM living in Norway recruited online to complete a SEM consumption and sexual risk survey. Of the 507 participants who responded to the all items measuring exposure to SEM, 19% reported unprotected anal intercourse with a casual partner (UAI) in last 90 days, and 14% reported having had sero-discordant UAI. Among those with UAI experience, 23% reported receptive anal intercourse (R-UAI) and 37% reported insertive anal intercourse (I-UAI). SEM consumption was found to be significantly associated with sexual risk behaviors. Participants with increased consumption of bareback SEM reported higher odds of UAI and I-UAI after adjusting for other factors using multivariable statistics. MSM who started using SEM at a later age reported lower odds of UAI and I-UAI than MSM who started earlier. Future research should aim at understanding how MSM develop and maintain SEM preferences and the relationship between developmental and maintenance factors and HIV sexual risk behavior.

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

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

The effects of gay sexually explicit media on the HIV risk behavior of men who have sex with men

This study sought to study consumption patterns of gay-oriented sexually explicit media (SEM) by men who have sex with men (MSM); and to investigate a hypothesized relationship between gay SEM consumption and HIV risk behavior. Participants were 1,391 MSM living in the US, recruited online to complete a SEM consumption and sexual risk survey. Almost all (98.5 %) reported some gay SEM exposure over the last 90 days. While 41 % reported a preference to watch actors perform anal sex without condoms (termed "bareback SEM"), 17 % preferred to actors perform anal sex with condoms (termed "safer sex SEM") and 42 % reported no preference. Overall SEM consumption was not associated with HIV risk; however participants who watched more bareback SEM reported significantly greater odds of engaging in risk behavior. The results suggest that a preference for bareback SEM is associated with engaging in risk behavior. More research to understand how MSM develop and maintain preferences in viewing SEM, and to identify new ways to use SEM in HIV prevention, is recommended.

Syphilis-related perceptions not associated with risk behaviors among men who have sex with men having regular male sex partner(s) in Nanjing, China

The prevalence of HIV among men who sex with men (MSM)has been increasing sharply in China. The prevalence of unprotected anal intercourse (UAI)among them is very high, especially when male regular sex partners are involved. Many MSM having regular sex partners are engaged in multiple sex partnerships, which often involved UAI. This study interviewed 168 MSM in Nanjing, China, having had anal intercourse with at least one male regular sex partner in the last six months. Amongst the participants, 52.4% reported having had UAI with male regular sex partners whilst 50.0% reported multiple male sex partnerships in the last six months. Multivariate analysis showed that monthly personal income higher than 2000 RMB (multivariate OR = 0.49, 95% CI: 0.26-0.96), HIV antibody testing in the last year (multivariate OR = 0.19, 95% CI: 0.06-0.60), sexual position being both insertive and receptive during anal sex with male sex partners in general (multivariate OR = 0.43, 95% CI: 0.18-0.99; reference group: with receptive position only) were associated with lower likelihoods of UAI. Syphilis-related perceptions, including knowledge, cognitions (perceived susceptibility, perceived severity, self-efficacy in avoiding syphilis infection and perceived infectivity and perceived syphilis-related norms among MSM in general)were not associated with risk behaviors (UAI and multiple male sex partnerships). Our sampled MSM are exposed to very high risk of HIV/STD transmission. We found no association between syphilis-related perceptions and the two types of risk behaviors. Future studies are warranted to understand such associations in the context of sexual intercourse with non-regular sex partners among MSM.

Operating without a safety net: gay male adolescents and emerging adults' experiences of marginalization and migration, and implications for theory of syndemic production of health disparities

Health disparities among gay men (HIV, substance use, depression) have been described as a mutually occurring "syndemic" that is socially produced through two overarching dynamics: marginalization and migration. Although the syndemic theory proposes a developmental trajectory, it has been largely based on epidemiological studies of adult gay men and has not been examined using qualitative data from gay male adolescents and emerging adults describing their developmental experience. We conducted interviews with 54 HIV-positive gay and bisexual male adolescents and emerging adults at four sites in the United States. This study provides examples of developmental trajectories that help explain the early onset of socially produced health disparities among some gay male adolescents and emerging adults, but also the development of risk factors that may follow some gay men into adulthood.

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.

Development and validation of the sexual agreement investment scale

Sexual agreements are ubiquitous among gay men. Lower levels of investment in these agreements may be associated with breaking them or engaging in risky sexual behavior. A scale was developed to measure agreement investment levels among gay men. Qualitative data from 78 gay men in committed relationships were analyzed to inform item development, followed by quantitative analyses of two larger samples (n = 380, n = 1,001) to assess construct, convergent, and discriminant validity. The Sexual Agreement Investment Scale (SAIS) is a psychometrically sound measure of the level of investment in sexual agreements among gay men in relationships. Men with higher agreement investment were less likely to break agreements and less likely to engage in unprotected anal intercourse with outside partners. The SAIS can be used to measure investment in sexual agreements and its impact on sexual behavior in a wide variety of settings, including research on relationships, sexuality, couples therapy and HIV prevention.

Stigmatization, Substance Use, and Sexual Risk Behavior among Latino Gay and Bisexual Men and Transgender Persons

Following the minority stress model as a framework, we examine the associations between racial and homosexual stigma, substance use, and sexual risk behavior among a respondent-driven sample of Latino gay and bisexual men and male-to-female transgender persons (GBT) in Chicago and San Francisco (N = 643). We use structural equations to test such a model and disentangle the possible effects of the different stigmas and their corresponding dimensions (i.e., perception, experience, internalization). Findings revealed distinct pathways to sexual risk. Two are typified by experienced homosexual stigma and internalized racial stigma via multiple drug use, and two are characterized by experienced racial stigma and internalized homosexual stigma via alcohol use.

Diferenças nas situações de risco para HIV de homens bissexuais em suas relações com homens e mulheres

OBJETIVO: Descrever o comportamento bissexual masculino quanto à identidade sexual, uso de preservativo, freqüência de relações sexuais e tipos de parceria e verificar diferenças entre práticas protegidas nas suas relações com homens e mulheres. MÉTODOS: Estudo transversal aninhado em coorte de homossexuais e bissexuais HIV negativos implantada em 1994 em Belo Horizonte (Projeto Horizonte). Dos 1.025 voluntários recrutados entre 1994 e 2005, foram selecionados 195 que relataram, na admissão, ter tido relações sexuais com homens e mulheres nos seis meses anteriores à entrevista. Foi criado índice de risco comportamental, designado Índice de Risco Horizonte, que incorpora uma constante para cada prática sexual não protegida, ajustada segundo o número de encontros sexuais. RESULTADOS: Houve predomínio de atividade sexual com homens; a maioria se auto-referiu como bissexual (55%) e homossexual (26%). A mediana do número de parceiros homens ocasionais nos últimos seis meses (4) foi superior ao de parceiras ocasionais (2) e de parceiros fixos de ambos os sexos (1). No sexo vaginal com parceira fixa, o uso inconsistente do preservativo foi de 55%, comparado com 35% e 55% no sexo anal insertivo e receptivo com parceiros fixos. O índice foi maior para os que relataram terem tido sexo com homens e mulheres comparado com os que tiveram sexo exclusivamente com mulheres ou homens. CONCLUSÕES: As situações de risco para HIV foram mais freqüentes entre os homens que relataram atividade sexual com homens e mulheres. Os comportamentos sexuais e de proteção dos bissexuais diferem conforme gênero e estabilidade da parceria, havendo maior desproteção com parceiras fixas mulheres.

Male bisexuality and condom use at last sexual encounter: results from a national survey

Relatively little is known about condom use among bisexual men as separate and distinct from exclusively homosexual and heterosexual men. Most previous research on bisexual men has relied on non-probabilistic, high risk samples with limited generalizability. We examined the relationship between male behavioral bisexuality and condom use in the 2002 cycle of the National Survey of Family Growth (NSFG). Bisexually-active men positively differed from heterosexually- and homosexually-active men on every indicator of confounding risk. However, bisexually-active men did not report using condoms less often than other men during their last sexual encounters with males and females. Indeed, with female partners, bisexually-active men reported higher rates of condom use than other men. These relationships remained when all sociodemographic and confounding risk factors were held constant. Our results suggest that caution must be used when making assumptions about condom use in the general population of bisexual men from non-probabilistic samples.

Unprotected anal intercourse and substance use before and after HIV diagnosis among recently HIV-infected men who have sex with men

OBJECTIVE

The objective of this study was to assess associations between unprotected anal intercourse (UAI) and substance use before and after HIV diagnosis among recently HIV-infected MSM.

STUDY DESIGN

Two hundred seven MSM completed computer-assisted self-interviews regarding type and timing of sexual activity and substance use with their last 3 partners. Date of HIV diagnosis was extracted from medical records. Generalized estimating equations, including interaction terms, were used to assess associations between substance use and UAI before and after HIV diagnosis.

RESULTS

Among partners with whom sexual activity occurred before diagnosis, UAI was associated with methamphetamine use alone (odds ratio = 7.12) and a combination of methamphetamine and other substances (odds ratio = 4.06). However, after HIV diagnosis, UAI was associated with use of substances other than methamphetamine (odds ratio = 3.36), but not methamphetamine alone.

CONCLUSIONS

Use of illicit substances may be differentially associated with UAI based on knowledge of HIV status and could have implications for prevention of HIV transmission.

Examining the role of partner status in an HIV prevention trial targeting HIV-positive gay and bisexual men: the seropositive urban men's intervention trial (SUMIT)

The goal of this analysis was to examine whether partner status impacted behavioral outcomes from the Seropositive Urban Men's Intervention Trial (SUMIT). We contrasted sample characteristics of HIV-positive gay and bisexual men with and without main partners and then examined differences in sexual behaviors among men participating in an enhanced HIV prevention intervention compared to those in a standard condition. Logistic regression analyses were performed to differentiate characteristics of men with and without main partners and mixed-model logistic regression analyses were performed to test for intervention effects. Men with main partners showed a greater likelihood of having unprotected anal sex with any partner, although the number of male sexual partners was higher for men without a main partner. SUMIT generally produced few differences in sexual risk behaviors and did not affect several potential mediator variables of the relationship between the intervention and sexual behaviors with main and nonmain partners.

Characteristics of gay, lesbian, and bisexual Asians, Asian Americans, and immigrants from Asia to the USA

An exploratory study of self-identified lesbian, gay, and bisexual Asians and Asian Americans surveyed respondents (60 women and 254 men) using a questionnaire in four languages from nineteen different sources in Korea, Japan, China, and the US. Respondents were compared in terms of country of residence, whether they immigrated to the US, having a same-sex lover, living with the lover, being open about their sexual orientation to the family, and age. Respondents in the US were generally more open about their sexual orientation. Openness to the family was related to other variables suggesting an affirmative lesbian, gay, or bisexual identity.

Personality characteristics of condom users

The California Psychological Inventory (CPI) and a survey of sexual behavior and condom use specifically developed for this descriptive study were administered to 132 sexually active, heterosexual male university students (mean age = 19.2 years; 75% Caucasian). Condom "users" (44% of this sample) were defined as those who reported using a condom in their last sexual encounter to ejaculation. "Sexually active" men were defined as those who reported some form of intercourse with a partner to ejaculation within the past 3 months. On the CPI, the condom users scored significantly higher than nonusers on the Achievement via Independence scale and marginally higher on the Socialization and the Social Presence scales. The mean CPI profile for the condom users yielded the Gamma personality type which denotes an externally-oriented, norm questioning personality. Gammas tended to be uninhibited, clever, witty, pleasure-seeking risk takers. Those men who did not use a condom in their last sexual encounter offered their reasons for not doing so. The most common reasons were not expecting intercourse to occur and they were not available. In terms of perceived risk for HIV-infection, only 12.3% of the men had taken the antibody test and 75% considered themselves to be at zero or low risk. Several suggestions were made for counseling strategies in promoting condom use in college-age populations.

Management of psychiatric disorders in patients infected with human immunodeficiency virus

Psychiatric disorders increase the risk of acquiring human immunodeficiency virus (HIV) and increase morbidity from HIV-related illness by impeding treatment. The response to highly active antiretroviral therapies is impaired by poor patient adherence, a substantial component of which is related to mental illness and substance use disorders. The recognition of psychiatric disorders in most HIV clinics is an issue of utmost importance. We outline diagnostic and treatment issues for major depression, bipolar disorder, personality disorder, substance use disorders, and demoralization as seen in patients with HIV. Our experience at the Johns Hopkins Moore (HIV) Clinic has led us to conclude that treatment of these disorders greatly improves patient adherence to treatment and outcomes of HIV infection.

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

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

Early initiation of sex, drug-related risk behaviors, and sensation-seeking among urban, low-income African-American adolescents

The purpose of this study was to examine the relationship of early initiation of sex, drug-use, drug-trafficking, and sensation-seeking among urban, African-American adolescents. A longitudinal follow-up of 383 youth ages 9 to 15 years at baseline over four years with serial risk-assessments was used. Sexual experience and several drug-related risk behaviors increased significantly during the four-year study interval. Sensation-seeking scores were higher after the baseline assessment among youth reporting tobacco, alcohol, and marijuana use and were higher, both at baseline and through several follow-up assessments, among youth reporting drug-selling and sexual activity. At baseline, the correlations among drug-related risk behaviors were all strong, except those between initiation of sex and drug-related risk behaviors. However, over time, early initiators of sex were significantly more likely to report involvement in substance use and drug-delivery/sales than were late initiators. Youth reporting repeated involvement in drug-related activities were more likely to report intensive sexual involvement than they were to report experimental sex or no sex. Sensation-seeking scores were lower among youth reporting no involvement in risk behaviors. However, scores did not differ between youth exhibiting experimental behavior compared to youth demonstrating repeated risk involvement. These results support the need for alternative experiences for youth exhibiting high levels of sensation-seeking and the need for early drug/sexual risk prevention programs.

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

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

Safer sex decision-making among men with haemophilia and HIV and their female partners

An exploratory qualitative study of adult heterosexual men with haemophilia and HIV and women who were their sexual partners was conducted as formative research to better understand cognitive factors involved in behavioural intentions and practices which comprise HIV risk-reduction for sexual transmission. The study sought to generate hypotheses, uncover themes, and develop a broad perspective on possible determinants of behaviours related to HIV transmission risk reduction. Qualitative analysis of these data served as a basis for developing a subsequent quantitative, hypothesis-testing survey and an intervention. Face-to-face interviews were conducted with 23 single men and 28 married men with haemophilia and HIV infection, and 28 married women partners selected through stratified, purposeful sampling. The interviews identified beliefs, attitudes, and values underlying decisions regarding target behaviours related to preventing sexual transmission of HIV, including (1) using condoms consistently during vaginal intercourse and (2) talking to partners about risk reduction. The interviews elicited information about perceived advantages and disadvantages of performing each of the targeted behaviours, and factors that facilitate or prevent performing them. Qualitative analysis of coded responses yielded important themes regarding how choices are made about sexual activity and safer sex. Most notably, communication between partners (1) plays a direct, key role in facilitating condom use and (2) forms the basis for maintaining emotional intimacy in these relationships. The link between condom use and communicating about safer sex was viewed as pivotal in achieving HIV prevention for individuals in serodiscordant couples. Recommendations for risk reduction intervention development are discussed.

Patterns of initiation of sex and drug-related activities among urban low-income African-American adolescents

PURPOSE

To examine the pattern of adolescent's involvement in drug-related behaviors and sexual initiation, and its relationship with: (a) age and gender, (b) sensation- seeking, (c) perceptions of peer and family risk involvement, and (d) involvement in high-risk sexual behavior.

SUBJECTS

Two hundred and sixty-one urban African-American youth, aged 9 to 15 years at baseline, who were sexually experienced by the end of the 4-year study interval. The longitudinal assessment (4 years) was focused on: (a) alcohol use, illicit drug use, and drug trafficking; (b) high-risk sex; (c) propensity to sensation seeking; and (d) perceived peer and family risk involvement.

RESULTS

Involvement increased over the 4-year study interval such that over half of the adolescents reported use of alcohol and/or use of marijuana in the final assessment period. For each of the three drug-related activities examined, the largest proportion of youth who engaged in sexual intercourse never engaged in drug-related activity, and the next largest proportion initiated sexual involvement before drug use. Sensation-seeking scores, which were relatively stable across time, were lower among girls, and also were lower among youth who remained uninvolved in drug-related behaviors. For all three drug-related behaviors, rates of high-risk sex were higher among youth who initiated both sex and drugs, and were lower among youth who reported engaging only in sex. Although youth who did eventually initiate drug use had higher perceived levels of family and peer drug use compared to those who remained uninvolved, these perceptions did not contribute directly to high-risk sexual behavior.

CONCLUSIONS

Youth who will become both sexually active and involved with drugs during adolescence are especially vulnerable to involvement in high-risk sexual behavior.

A double epidemic: crystal methamphetamine drug use in relation to HIV transmission among gay men

Emerging research on methamphetamine use among gay men suggests that growth in the use of this drug could present serious problems for HIV/AIDS prevention within the gay community. This article summarizes current studies on the extent, role, and context of methamphetamine use among gay men and its relationship to high risk sexual behaviors related to HIV transmission. Methamphetamine is often used by gay men to initiate, enhance, and prolong sexual encounters. Use of the drug is, therefore, associated with particular environments where sexual contact among gay men is promoted, such as sex clubs and large "circuit" parties. Research with gay and bisexual men indicates that methamphetamine use is strongly associated with risky sexual behaviors that may transmit HIV. This relationship, coupled with emerging evidence that methamphetamine use is on the rise among gay men, suggests that the drug could exacerbate the HIV/AIDS epidemic among this community. The article offers recommendations for further research and suggestions for prevention programs regarding methamphetamine use by gay men.

Correlates of risky behaviors among young and older men having sexual relations with men in Montréal, Québec, Canada. Omega Study Group

OBJECTIVE

To assess characteristics associated with 1) age and 2) recent unprotected anal sex with casual partners among men having sexual relations with men (MSM) participating in the Omega Cohort, Montréal, Québec, Canada.

METHODS

The Omega Cohort is a study of the incidence and psychosocial determinants of HIV infection among MSM living in Montréal. MSM complete a questionnaire and are tested for HIV every 6 months.

RESULTS

Thirteen percent of young MSM (< 30 years of age, n = 355) and 12% of older MSM (> or = 30 years of age, n = 455) reported recent unprotected anal sex with casual partners. The predictors of this latter behavior were: not living with a male sexual partner, unprotected anal sex with regular partner, > 5 casual partners, alcohol/drug use before anal sex, and having difficulties with procedures needed for safe sex. Among young MSM, additional predictors were: to have been living in Montreal for less than 1 year and to have exchanged money for sex. Among older MSM, additional predictors were: female sexual partners, unprotected anal sex with an HIV-infected partner, and feeling invulnerable to AIDS.

CONCLUSION

Young Omega participants do not have more risky behaviors than older participants. Some predictors of recent risk behaviors with casual partners were different between the two groups. Prevention programs should be adapted consequently.

Does alcohol lead to sexual risk behavior? Findings from event-level research

The belief that alcohol use leads to sexual risk behavior is nearly ubiquitous. To determine if this belief is warranted, we identify theory and research regarding the alcohol, risky-sex link. We focus our review on studies that use the event-level methodology because this approach provides a particularly sensitive but stringent test of the situational alcohol, risky-sex connection. Overall, the data from available event-level studies indicate that people who use condoms when they are sober also tend to use them when drinking; people who fail to use condoms when drinking probably also fail to use them when sober. We recognize several empirical exceptions to this rule and provide suggestions for future research.

Knowledge of HIV serostatus and preventive behaviour among European injecting drug users: second study. European Community Study Group on HIV in Injecting Drug Users

The objective of the study was to analyse the effect of knowledge of HIV serostatus on behaviours preventing the acquisition or transmission of HIV among European IDU, and to compare results with a previous similar study conducted 3 years before. Data were gathered in 1992-1993 during a retrospective multicentre cross-sectional study of IDU recruited in 11 European countries, in specialized centers and on the street. We compared, between groups with different HIV serological status (IDU who knew well before their HIV-positive serological status, IDU who knew their HIV-negative serostatus and IDU who did not know before their serological status), the respective proportions of IDU who reported that, during the six months prior to interview, (1) always used condoms, (2) never gave their used injecting equipment to other IDU, (3) always injected drugs safely. We only included IDU who had known their serological status for at least six months prior to interview. Results were compared to the similar survey conducted in 1990. From 2171 IDU recruited, data of 1334 IDU were included in the analysis. Compared with IDU who did not know their HIV serostatus, only IDU knowing their HIV-positive serostatus used condoms significantly more often (37% compared to 15%, rate ratio (RR): 2.4; 95% confidence interval (CI): 1.8-2.3) and never gave their used injecting equipment to other IDU (69% compared to 53%, RR: 1.3; 95% CI: 1.2-1.4). In comparison with the 1990 study, only condom use significantly improved and only for IDU who knew their HIV-negative serostatus (13% compared to 9%, RR: 1.6; 95% CI: 1.1-2.3). This study confirms among European IDU the relation between knowing own HIV serological status to preventive behaviours. However, there were only minor improvements between 1990 and 1992-1993, indicating that prevention of HIV transmission among IDU must be reinforced.

Perception of vulnerability to HIV infection in a cohort of homosexual/bisexual men in Rio de Janeiro, Brazil. Oswaldo Cruz Foundation STD/HIV Prevention Group

The present study addresses sociodemographic characteristics, knowledge and attitudes regarding HIV/AIDS, as well as risk behaviour and perception of vulnerability to HIV infection, in the first 295 homosexual and bisexual volunteers (excluding male commercial sex workers and transvestites) taking part in a cohort study in Rio de Janeiro. The sample has a higher socio-economic level than the remainder of the cohort, and than comparable strata of the general population, and a sound knowledge about how to protect themselves against HIV infection. In addition, an association between perception of vulnerability to infection and the practice of unprotected anal sex was observed. An association was also observed between higher levels of formal education and perception of vulnerability; however no association was found with markers for past and recent exposure to sexually transmitted infections (hepatitis B, HbsAG and syphilis). The results of the present study suggest that knowledge and awareness of risk do not easily translate into behaviour change, since significant proportions of the cohort continue to practise unprotected sex with both principal and casual partners, despite their awareness of HIV infection risks as well as preventive measures.

The influence of psychosocial factors, alcohol, drug use on African-American women's high-risk sexual behavior

OBJECTIVE

The present study examines psychosocial and behavioral influences, particularly drug and alcohol use, as correlates of inconsistent condom use and having multiple sexual partners during the past months among African-American women.

METHODS

The cross-sectional study, conducted between May and June 1996, recruited a convenience sample of 180 African-American women in Birmingham, Alabama. Women completed a face-to-face interview that assessed alcohol and drug use, sexual behaviors, depression, condom use, and negotiation skills.

RESULTS

The majority of women, 51.6% (n = 93), had used either alcohol or drugs during the previous month. Many women, 31.1%, consumed alcohol, 18.3% used marijuana, and 8.3% had smoked crack within the past month. Nearly 42.7% of women used condoms inconsistently in the past month and 13.3% of women had multiple sexual partners within the past month. A logistic regression model predicting inconsistent condom use indicated that women were less likely to use condoms if they consumed alcohol between 20 and 30 days of the month (OR = 2.8, 90% CI = 1.3-5.9) and if they had not negotiated condom use (OR = 32.4, 90% CI = 7.9-131.6). The logistic regression model predicting multiple sexual partners indicated that women were more likely to have multiple sexual partners if they had smoked crack in the past month (OR = 5.3, 90% CI = 1.6-18.2).

CONCLUSION

HIV sexual risk-reduction interventions for African-American women need to address the overlapping epidemics of drugs, alcohol, and STDs. Additionally, HIV sexual risk reduction efforts should be incorporated into existing drug and alcohol treatment programs and STD clinics.

Unsafe sex in men who have sex with both men and women

The sexual behaviors of bisexually active men, defined as men having sex with a man and a woman in previous 6 months, were compared with men who had sex with men only. Differential sexual practices associated with HIV risk between the two groups of men, as well as in the bisexual men with their male and female partners, were evaluated. Cross-sectional analyses were performed on baseline data from a prospective cohort of 508 young gay men recruited from bars, college campuses, and a health center in Boston from 1993 to 1994. Odds ratios (OR) and 95% confidence intervals (CI) were calculated on categorical variables, and McNemar's chi2 was used to compare the behaviors of bisexual men with their male versus female sex partners. Six months before the interview, 47 (10%) men had male and female sex partners, and 383 men had only male sex partners during the past year or ever. Fifty-eight percent of the men in the study had a female sexual partner in their lifetime, and 18% during the past year. Bisexual men were more likely to have drinking problems as identified by the Michigan Alcoholism Screening Test (MAST; OR = 3.96, 95% CI = 1.54-10.20), and fewer male partners over their lifetime (mean +/- standard deviation [SD], 24+/-42; median, 7; versus mean +/- SD, 69+/-516; median, 12), although this difference was not statistically significant. The two groups had similar levels of unprotected anal intercourse (25.5% versus 29.5%); however, bisexual men were half as likely to have anal sex as homosexual men (OR = 0.50; 95% CI = 0.27-0.93). Bisexual men were three times as likely to have unprotected sex with their female partner as their male partner (OR = 3.0; 95% CI = 1.02-8.8). Stratified analysis revealed similar discordant behavior while sober (OR = 4.0), drinking (OR = 7.0), and while drinking with concurrent drug use (OR = 8.0). Among this cohort of men who have sex with men (MSM), a sizable proportion also had vaginal sex with female partners in the previous 6 months. Bisexually active men were more likely to have unprotected sex with their female partners compared with their male partners, potentially increasing the risk for HIV and other sexually transmitted diseases. Behavioral interventions directed toward MSM need to address bisexual behaviors.

Reliability of the timeline follow-back sexual behavior interview

The reliability of self-reported sexual behavior is a question of utmost importance to human immunodeficiency virus (HIV) prevention research. The Timeline Follow-Back (TLFB) interview, which was developed to assess alcohol consumption on the event level, incorporates recall-enhancing techniques that result in reliable information. In this study, the TLFB interview was adapted to assess HIV-related sexual behaviors and their antecedents, and its reliability was assessed. The interview was administered to 110 participants (46% women, M age = 19.7; range = 18-41), and 58 participants who reported sexual behavior during the previous three months returned one week later for a second interview. Test-retest intraclass correlations (rho) from the TLFB protocol showed that all sexual behaviors were reported reliably (rho range = .86 to .97, median = .96). Bootstrapping, a nonparametric statistical technique, was used for significance testing in the reliability analyses. Reliability was equivalent across each of the three months assessed with the TLFB and was equivalent to conventional assessment methods (i.e. single-item questions). These findings show that the TLFB sexual behavior interview provides reliable reports of sexual behavior over three months and yields event-level data that are extremely valuable for sexual behavior and HIV-prevention research.

[Is there a correlation between alcohol drinking and sexual risk taking? A discussion of conceptional aspects exemplified by HIV infected men with homosexual behavior]

Does sexual risk behavior and alcohol consumption correlate or is sexual risk behavior due to alcohol consumption? These questions are controversially discussed in the literature. We investigated whether the two different methodological concepts (global association, e.g. not specific to the critical incident and situational association) cause these discrepancies in a sample of 64 HIV-infected gay men. There was no significant global association between alcohol consumption and sexual risk behavior. Using the situational approach, drinking was not related to sexual risk behavior. The combination of these two concepts may help to identify persons at risk.

Correlates of condom use in the young adult population in Ontario

OBJECTIVES AND METHODS

Data from the Ontario Health Survey were used to identify sociodemographic, lifestyle and sexual history characteristics associated with the use of condoms for protection against sexually transmitted diseases (STDs) in randomly selected adults between the ages of 16 and 44 years who had had two or more sexual partners in the 12 months before the survey (n = 2,699).

RESULTS

Forty-two percent reported not having used condoms for protection against STDs. Those most likely to use condoms were 16 to 24 years of age, males, students, non-binge-drinkers, urban residents, and those at higher risk for HIV/AIDS. Of those who used condoms, 68% did not use them consistently. Individuals most likely to always use condoms were 16 to 24 years of age, males, students, non-binge-drinkers, and those with secondary school education. Age, gender, occupational activity, and non-binge-drinking were common correlates of both condom use and consistent use.

CONCLUSIONS

Public health messages should be focused on people with multiple sex partners who are not using condoms for STD protection, including rural residents, those with high levels of education, and those over 34 years of age.

Correlates of condom use in the young adult population in Ontario

OBJECTIVES AND METHODS

Data from the Ontario Health Survey were used to identify sociodemographic, lifestyle and sexual history characteristics associated with the use of condoms for protection against sexually transmitted diseases (STDs) in randomly selected adults between the ages of 16 and 44 years who had had two or more sexual partners in the 12 months before the survey (n = 2,699).

RESULTS

Forty-two percent reported not having used condoms for protection against STDs. Those most likely to use condoms were 16 to 24 years of age, males, students, non-binge-drinkers, urban residents, and those at higher risk for HIV/AIDS. Of those who used condoms, 68% did not use them consistently. Individuals most likely to always use condoms were 16 to 24 years of age, males, students, non-binge-drinkers, and those with secondary school education. Age, gender, occupational activity, and non-binge-drinking were common correlates of both condom use and consistent use.

CONCLUSIONS

Public health messages should be focused on people with multiple sex partners who are not using condoms for STD protection, including rural residents, those with high levels of education, and those over 34 years of age.