Individual and poly-substance use and condomless sex among HIV-uninfected adults reporting heterosexual sex in a multi-site cohort

BACKGROUND

We analyzed the association between substance use (SU) and condomless sex (CS) among HIV-negative adults reporting heterosexual sex in the Seek, Test, Treat, and Retain (STTR) consortium. We describe the impact of SU as well as person/partner and context-related factors on CS, identifying combinations of factors that indicate the highest likelihood of CS.

METHODS

We analyzed data from four US-based STTR studies to examine the effect of SU on CS using two SU exposures: 1) recent SU (within 3 months) and 2) SU before/during sex. Behavioral data were collected via 1:1 or self-administered computerized interviews. Adjusted individual-study, multivariable relative risk regression was used to examine the relationship between CS and SU. We also examined interactions with type of sex and partner HIV status. Pooled effect estimates were calculated using traditional fixed-effects meta-analysis. We analyzed data for recent SU (n = 6781; 82% men, median age = 33 years) and SU before/during sex (n = 2915; 69% men, median age = 40 years).

RESULTS

For both exposure classifications, any SU other than cannabis increased the likelihood of CS relative to non-SU (8-16%, p-values< 0.001). In the recent SU group, however, polysubstance use did not increase the likelihood of CS compared to single-substance use. Cannabis use did not increase the likelihood of CS, regardless of frequency of use. Type of sex was associated with CS; those reporting vaginal and anal sex had a higher likelihood of CS compared to vaginal sex only for both exposure classifications (18-21%, p < 0.001). Recent SU increased likelihood of CS among those reporting vaginal sex only (9-10%, p < 0.001); results were similar for those reporting vaginal and anal sex (5-8%, p < 0.01). SU before/during sex increased the likelihood of CS among those reporting vaginal sex only (20%; p < 0.001) and among those reporting vaginal and anal sex (7%; p = 0.002). Single- and poly-SU before/during sex increased the likelihood of CS for those with exclusively HIV-negative partners (7-8%, p ≤ 0.02), and for those reporting HIV-negative and HIV-status unknown partners (9-13%, p ≤ 0.03).

CONCLUSION

Except for cannabis, any SU increased the likelihood of CS. CS was associated with having perceived HIV-negative partners and with having had both anal/vaginal sex.

Gender roles and HIV sexual risk vulnerability of Roma (Gypsies) men and women in Bulgaria and Hungary: an ethnographic study

Roma, the largest ethnic minority group in Central and Eastern Europe, have cultures that are traditional, often closed, and autonomous of majority populations. Roma communities are characterized by pervasive social health problems, widespread poverty, limited educational opportunities, and discrimination. Although some evidence suggests high levels of HIV sexual risk behaviour among Roma, little is known about the cultural and social context in which risk behaviour occurs. In-depth interviews were used to elicit detailed information about types of sexual partnerships and sexual risk behaviour practices occurring in them, use and perception of protection, knowledge and beliefs about AIDS and STDs, and sexual communication patterns in a sample of 42 men and women aged 18-52 living in Roma community settlements in Bulgaria and Hungary. Analysis of the interview data revealed that men have great sexual freedom before and during marriage, engage in a wide range of unprotected practices with primary and multiple outside partners, and have much more relationship power and control. In contrast, women are expected to maintain virginity before marriage and then sexual exclusivity to their husbands. Condom use is not normative and is mainly perceived as a form of contraception. Although awareness of AIDS was common, it was generally not perceived as a personal threat. Misconceptions about how HIV is transmitted are widespread, and women - in particular - had very little knowledge about STDs, HIV transmission, and protective steps. There is an urgent need for the development of HIV prevention programs culturally sensitive to Roma populations in Eastern Europe, where HIV rates are rapidly rising.

Sexual Behavior, Mental Health, Substance Use, and HIV Risk Among Agency-Based Male Escorts in a Small U.S. City

Relatively little research has examined the personal sex lives of indoor male sex workers (MSWs) or possible connections in this group between sexual behavior and factors related to HIV risk. As part of a larger project, this study collected data from 30 agency-based indoor MSWs (mean = 22.4 years) about their sexual behavior, mental health, and substance use. Few HIV risk behaviors with clients occurred. Drug use and mental health problems were relatively frequent, but not related to increased risk behavior. Instead, MSWs appeared to employ rational decision-making and harm-reduction strategies. Conceptualization of MSW sexual behavior may be required where HIV risk is not attributed to sex work per se, but to other influences such as economic and relational factors.

A longitudinal, qualitative analysis of the context of substance use and sexual behavior among 18- to 29-year-old men after their release from prison

Substance use, sexual behavior, and reincarceration among 89 men from 5 state prisons across the USA, aged 18-29 years, were examined in relation to individual patterns of coping with community reintegration after their release from prison. Analyses of a series of qualitative interviews conducted over a 6-month period post-release revealed three global reintegration coping patterns: moving toward successful reintegration, resuming behavioral patterns that preceded incarceration, and reintegrating through withdrawal or isolation. Four key contextual factors that differentiated these three coping patterns were the consistency and extensiveness of social relationships, the nature of social support, and the degree of structural stability (e.g., stable employment and housing). Participants were assigned a Likert scale score (1 for poor rating to 3 for better rating) for their pattern of global reintegration and for their rating on each of the four contextual factors across the longitudinal qualitative interviews. Collectively, these five factors differentiated the prevalence and frequency of substance use, patterns of sexual behavior, and incidence of reincarceration as assessed by a quantitative survey administered 6 months post-release. Poorer ratings on all five contextual indices were related to the use of substances other than marijuana and alcohol. Men with less consistent social relationships reported more sexual partners. However, vaginal or anal sex without a condom was associated with greater social consistency and greater structural stability, possibly due to the presence of a steady main partner. Reincarceration was significantly associated with poorer global reintegration ratings, more negative social support, and less structural stability. These findings highlight the need to consider the role of social and structural support systems in HIV and sexually transmitted infection risk reduction interventions for men after their release from prison.

Screening for sexually transmitted diseases and hepatitis in 18-29-year-old men recently released from prison: feasibility and acceptability

Men entering prisons have high rates of sexually transmitted disease (STD), hepatitis, and HIV. This study sought to determine the acceptability and feasibility of screening for STD and hepatitis in young men released from prison. Participants were interviewed six months after release and offered free screening. Of 42 (56%) eligible men who participated in the qualitative interview, 33 (79%) provided at least a blood or urine specimen. Eight of 33 (24%) men tested had chlamydia, trichomoniasis, hepatitis B or C virus (HBV or HCV). Three of 32 (9%) had chlamydia, three of 32 (9%) had trichomoniasis, two of 28 (7%) had prior syphilis, and two of 28 (7%) had HCV. Of 28 tested for HBV, six (21%) were immune, two (7%) had chronic infection, and 20 (71%) were susceptible. Barriers to screening included lack of forewarning, inconvenience, and insufficient incentive. In conclusion, screening for STD and hepatitis among former inmates can be acceptable and feasible. Forewarning, reducing the time burden, and providing monetary incentives may increase screening rates.

HIV prevention with young men who have sex with men: what young men themselves say is needed. Medical College of Wisconsin CITY Project Research Team

Young men who have sex with men (YMSM), and particularly ethnic minority YMSM, experience high incidence HIV infection due to continued patterns of high-risk sexual behaviour. The intent of this research was to systematically solicit input and recommendations from YMSM themselves concerning the kinds of HIV prevention programmes that would best meet their needs and would address risk issues they believed are critical. In-depth qualitative interviews were conducted with a sample of 72 purposively selected YMSM to identify necessary components of HIV prevention targeting YMSM. Respondents noted a need for comprehensive HIV prevention programmes that addressed issues related to dating and intimacy, sexuality and arousal, drugs and alcohol, self-esteem and self-worth, abuse and coercion, and sexual identity. Respondents emphasized the importance of keeping programmes confidential, fun, comfortable, accepting and open to all YMSM regardless of sexual identity. Identified community resource needs included safe havens for youth, more peer educators and older MSM mentors, increased school-based sexuality education, and greater support from the society at large as well as from churches, the gay community and communities of Color. Implications of these findings for HIV prevention are discussed.

Dilemmas in conducting qualitative sex research in applied field settings

Although resources are available to inform researchers of the many technical skills necessary to conduct qualitative research, individuals working in applied field settings often encounter ethical, moral, and sociopolitical dilemmas that cannot be resolved through the application of technical skills. The purpose of this article is to present examples of dilemmas faced by qualitative research methodologists studying sexual behavior in applied field settings. Possible solutions to these dilemmas are discussed within a theoretical and conceptual framework. The examples and discussion are organized around four broad topic areas: informed consent, privacy, confidentiality, and personal relationships.

Heterosexual men's attitudes toward the female condom

This article addresses heterosexual men's familiarity with the female condom and their attitudes toward this barrier method. Qualitative interviews were conducted with 71 ethnically diverse and heterosexually active men who were recruited in sexually transmitted disease (STD) clinics or through word of mouth in communities with high HIV/STD seroprevalence in New York City during fall 1994 to fall 1995. Only one man reported previous experience with the female condom. The large majority of men had no or limited knowledge of the female condom. Men's reactions to learning about this method ranged from positive to negative, although most men reported willingness to have sex with a partner who wanted to use the female condom. Positive reactions included: endorsement of a woman-controlled condom and her right to use it, the potential for enhancing one's sexual pleasure, and an eagerness to have a new sexual experience. Negative reactions centered on the "strangeness" and "bigness" of the female condom, concerns about prevention efficacy, and concerns about reductions in sexual pleasure. Our findings highlight the need for HIV prevention programs that target heterosexual men and promote the use of the female condom.

College students' perceptions of the prevalence of risky sexual behaviour

In contrast to previous research which has largely focused on students' perceptions of other students' risk for contracting HIV/STDs, this study assessed single heterosexual college students' (96 men, 121 women) perceptions of the prevalence of different sexual behaviours which increase a person's risk for HIV/STD infection (e.g. multiple sexual partners, unprotected sexual intercourse, one-time sexual encounters). Consistent with previous research which has demonstrated an overestimation bias in judging others' risk for HIV/STD infection, students' estimates about the prevalence of sexual behaviours increasing a person's risk for HIV/STD infection were similarly overestimated relative to reported base rates. Gender differences were also observed. Although women generally tended to give higher prevalence estimates than men, overall, participants gave higher estimates when judging the behaviour of men compared to women. Both motivational and cognitive explanations of our data are discussed. Our findings highlight the importance of developing sexual risk reduction programmes which (a) enable students to make more accurate personal risk judgements, (b) increase students' awareness of the riskiness of their own sexual behaviours, and (c) promote positive health changes (e.g. increased condom use) in normative sexual behaviour among college students.

Individual differences associated with high-risk sexual behaviour: implications for intervention programmes

Simpson & Gangestad's (1991) sociosexual orientation inventory measures people's willingness to engage in uncommitted sexual relations. People with unrestricted sociosexual orientations report more casual sex encounters, and multiple and concurrent sexual partners, factors known to increase the risk for exposure to human immunodeficiency virus (HIV). This study investigated the relationship of sociosexuality to an 'impulsive' personality profile characterized by impulsivity in decision-making, general risk-taking tendencies, and greater responsiveness to situational cues. It was found that an unrestricted sociosexual orientation was associated with greater impulsivity in decision-making on Tellegen's (1982) multidimensional personality questionnaire (MPQ) Control subscale, greater risk-taking tendencies on Tellegen's (1982) MPQ Harm-Avoidance subscale, and a greater responsiveness to situational cues as measured on Snyder's (1974) self-monitoring scale. Although unrestricted individuals had more knowledge about safe sex behavioural practices, they were more likely to engage in unprotected sexual intercourse (i.e. no condom use). Implications for HIV risk reduction educational programs targeting this population are discussed.