Variations in HIV Prevention Coverage in Subpopulations of Australian Gay and Bisexual Men, 2017-2021: Implications for Reducing Inequities in the Combination Prevention Era

Using repeated behavioural surveillance data collected from gay and bisexual men (GBM) across Australia, we assessed trends in HIV prevention coverage (the level of 'safe sex' achieved in the population by the use of effective prevention methods, including condoms, pre-exposure prophylaxis [PrEP] and having an undetectable viral load). We stratified these trends by age, country of birth/recency of arrival, sexual identity, and the proportion of gay residents in the participant's suburb. Among 25,865 participants with casual male partners, HIV prevention coverage increased from 69.8% in 2017 to 75.2% in 2021, lower than the UNAIDS target of 95%. Higher levels of coverage were achieved among older GBM (≥ 45 years), non-recently-arrived migrants, and in suburbs with ≥ 10% gay residents. The lowest levels of prevention coverage (and highest levels of HIV risk) were recorded among younger GBM (< 25 years) and bisexual and other-identified participants. Younger, recently-arrived, and bisexual GBM were the most likely to use condoms, while PrEP use was concentrated among gay men, 25-44-year-olds, and in suburbs with more gay residents. The use of undetectable viral load was most common among participants aged ≥ 45 years. Our analysis shows that high HIV prevention coverage can be achieved through a mixture of condom use, PrEP use, and undetectable viral load, or by emphasising PrEP use. In the Australian context, younger, bisexual and other-identified GBM should be prioritised for enhanced access to effective HIV prevention methods. We encourage other jurisdictions to assess the level of coverage achieved by combination prevention, and variations in uptake.

Understanding Motivations for Dating App Use Among Gay and Bisexual Men: Validation, Latent Profile Analysis, and Differences in Health Outcomes

While there has been a proliferation in gay dating app (GDA) use in China, research into their potential effects on health outcomes, particularly mental health outcomes, among gay and bisexual men is lacking. The motivations for GDA use are diverse, and understanding users' motivation profiles may provide a necessary starting point for exploring the heterogeneous effects of GDA use on health outcomes. A cross-sectional survey of the motivations for GDA use and other health outcome variables (i.e., condom use frequency, self-stigma, and subjective emptiness) was conducted among 366 Chinese gay and bisexual men. The results of exploration structure equation modeling indicate that the GDA Use Motivation Scale, with a four-factor first-order model, had strong psychometric properties. Then, latent profile analysis (LPA) based on the mean scores of four aspects of motivation was performed. The results of the LPA revealed the existence of four profiles: "Weak motivations" (30.9%), "Differentiated motivations" (17.8%), "Moderate motivations" (30.3%), and "Strong motivations" (21.0%). Differences in health outcomes among the motivation profiles were found by using the Bolck-Croon-Hagenaars approach. Overall, most participants (60.1%) tended to use condoms consistently, regardless of how strong their GDA use motivation was; however, stronger GDA use motivations were associated with higher levels of self-stigma and subjective emptiness. We call for more research to focus on the real needs behind and motivations for GDA use so that all such app users' voices can be heard, as well as to raise awareness about the potential health risks associated with GDA use among Chinese gay and bisexual men.

Testing the Effectiveness of a Motivational Interviewing Intervention to Reduce HIV Risk and Drug Use in Young Sexual Minority Men in a Community-Based Organization Setting

Younger sexual minority men (YSMM) remain at high risk for HIV infection and substance use increases this risk. This study evaluated the effectiveness of a (4-session) motivational interviewing (MI) intervention to reduce substance use and sexual risk taking when delivered at two community-based organizations (CBOs) in the New York City metropolitan area. Participants included 86 YSMM aged 15-29 who reported recent sexual HIV transmission risk and substance use. Overall, 86% of the sample identified as a racial or ethnic minority. Within each CBO, participants were randomized to receive either the MI intervention or enhanced treatment as usual (an HIV testing session plus PrEP information and referrals to CBO services). Contrary to hypotheses, results provided no indication that the MI intervention was associated with reductions in substance use (alcohol, cannabis, or other illicit drug use) or sexual risk taking or current PrEP use. Results are discussed in terms of challenges in real world intervention implementation, study enrollment, and the COVID-19 pandemic.

National Surveillance of Home-Based HIV Testing Among Australian Gay and Bisexual Men, 2018-2020: Uptake After Commercial Availability of HIV Self-Tests

HIV self-testing allows people to collect samples and test themselves at home, addressing known barriers to facility-based testing. We aimed to measure the uptake of home HIV testing among Australian gay and bisexual men (GBM). Using national cross-sectional data from the Australian Gay Community Periodic Surveys, we assessed trends in home HIV testing among non-HIV positive GBM between 2018 and 2020. Overall, the use of home HIV testing was low, but slightly increased during 2018-2020 (from 0.3 to 0.8%, RR = 1.54, 95%CI = 1.23-1.92, p-trend < 0.001). Testing at home was more likely among non-HIV-positive GBM who were born overseas and recently arrived in Australia, at higher risk of HIV, and infrequent HIV testers. Given the greater use of home testing by men at higher risk of HIV, recent migrants and infrequent testers, all priority groups in Australia's HIV epidemic, we recommend increasing access to HIV self-testing to enhance uptake in these and other groups of GBM.

Longitudinal associations of relationship support and strain and internalized homophobia with mental health among middle-aged and older gay and bisexual men

Objectives: Mental health concerns (e.g. depression, anxiety) that negatively impact gay, bisexual, and other men who have sex with men (GBMSM) persist over the life course and into old age, but less is known about potential contributors to GBMSM's mental health. Close relationships can be a source of risk or resilience from stress, exerting direct relationships on mental health, and may mediate well-established associations between minority stress and mental health. This study examined whether primary partner relationship support and strain were uniquely associated with, and mediated the association between internalized homophobia, and mental health among older GBMSM.Methods: GBMSM (N = 517, M age = 60) from the Multicenter AIDS Cohort Study, who were in primary relationships with men, provided self-report data at four timepoints. We used multilevel modeling to examine longitudinal associations among relationship support and strain and internalized homophobia with depression and anxiety.Results: Relationship strain, but not support, was positively associated with mental health concerns longitudinally. There was a significant, positive indirect effect of internalized homophobia on depression and anxiety through strain, but no support. Internalized homophobia was positively associated with relationship strain, which was positively associated with mental health symptoms longitudinally.Conclusions: Relationship strain was associated with depression and anxiety longitudinally among middle-aged and older GBMSM and mediated associations of internalized homophobia with mental health. The role of partner support warrants further investigation. Mental health interventions are critically needed for older GBMSM and, for partnered GBMSM, should include strategies for reducing relationship strain to foster well-being.

Experiences of care-seeking behaviour for sexually transmitted infections among gay and bisexual men: A phenomenological study

Gay and bisexual men (GBM) are stigmatized in the Ghanaian society and that negatively affect their care-seeking behaviour. We sought to understand the experiences of care-seeking behaviour (CSB) for STIs among gay and bisexual men in Sunyani, capital of Bono Region, Ghana. A respondent-driven sampling was used to collect data from 17 gay and bisexual men in Sunyani based on phenomenological qualitative approach. The data were thematically analysed using the Atlas.ti software. Results were presented under various themes with appropriate accompanying excerpts. Two broad themes emerged from the data - personal and health system experiences of treating STIs. Personal experiences such as economic conditions, knowledge on STI, marital experiences and bisexual's partner awareness of sexual orientation had influences on CSB. Experience with cost of treatment, stigmatisation by health care workers (HCW) and perceived quality healthcare were the health system factors found to influence CSB. To help improve STIs care-seeking behaviour, government need to encourage and economically empower GBM, while at the same time, improving their knowledge on STI prevention and control. The National Health Authority should intensify and monitor the implementation of the national health insurance at the private healthcare sectors without favour and discrimination for gay and bisexual men.

Attitudes Towards Treatment as Prevention Among PrEP-Experienced Gay and Bisexual Men in Australia

The introduction of HIV pre-exposure prophylaxis (PrEP) has the potential to impact the attitudes gay and bisexual men (GBM) who consequently choose to take PrEP have towards treatment as prevention (TasP), and the extent to which they are willing to have condomless anal intercourse (CLAI) with an HIV-positive sexual partner who has an undetectable viral load (UVL). Using a cross-sectional sample from an observational cohort study conducted from August 2018 to March 2020, we examined the extent to which PrEP-experienced GBM are willing to have CLAI with a partner who has a UVL. Simple and multiple logistic regression models were used to identify associated variables. Of the 1386 participants included in the analyses, 79.0% believed in the effectiveness of TasP, and 55.3% were willing to have CLAI with a partner who has a UVL. Wiling participants were less worried about getting HIV when taking PrEP and more likely to believe in TasP. Further research is needed to better understand the gap between belief in TasP and willingness to have CLAI with a partner who has a UVL among PrEP-experienced GBM.

Identifying Patterns of Discontinuing and Recommencing Pre-exposure Prophylaxis in the Context of Sexual Behavior Among Gay and Bisexual Men in Australia

We mapped gay and bisexual men's (GBM) patterns of using pre-exposure prophylaxis (PrEP) over time and explored sexual behavior as PrEP use changed. We conducted semi-structured interviews between June 2020 and February 2021 with 40 GBM living in Australia who had changed their PrEP use since initiating. There was considerable diversity in patterns of discontinuation, suspension, and recommencement of PrEP. Reasons for changing PrEP use mostly centered on accurate perceived changes to HIV risk. Twelve participants reported condomless anal intercourse with casual or fuckbuddy partners after discontinuing PrEP. These sex events were unanticipated, condoms were not a preferred option, and other risk reduction strategies were applied inconsistently. Service delivery and health promotion can support safer sex among GBM when PrEP use fluctuates by promoting event-driven PrEP and/or non-condom-based risk reduction methods during periods off daily PrEP, and guiding GBM to better recognize changing circumstances of risk and when to recommence PrEP.

Gay, Bisexual, and Other Men Who Have Sex With Men Who Are Not on Oral PrEP may be Less Interested in Available Injectable Products than in Oral PrEP: Examining Individual-Level Determinants of Interest and Barriers Across Products

Approval of the first injectable PrEP product (cabotegravir) provides an exciting addition to oral PrEP that could encourage those not currently on PrEP to use it. However, few studies have explored interest in injectable cabotegravir among those at increased risk who are not currently on PrEP. We conducted an online survey with 327 gay, bisexual, and other men who have sex with men (GBM) with limited PrEP history to explore their interest and intentions to use oral and injectable PrEP (cabotegravir), and examine barriers and individual-level predictors of both product types. Results showed that 17% of participants who reported being uninterested/neutral about oral PrEP expressed interest in injectable PrEP. Slightly more racial/ethnic minority GBM who were uninterested/neutral for oral PrEP expressed interest in injectable PrEP than White GBM (23% vs. 14%). Determinants were similar across PrEP types. Findings can directly inform interventions encouraging use of both PrEP products.

Next Generation Pre-Exposure Prophylaxis for Young Men who have Sex with Men: Lessons from System and Provider-level barriers to oral PrEP

Next generation pre-exposure prophylaxis (PrEP) modalities that do not require daily regimens may address some of the barriers to daily oral PrEP among young men who have sex with men (YMSM). We conducted online semi-structured interviews with 30 YMSM to examine experiences and preferences related to HIV prevention care that may inform implementation of next generation PrEP. Barriers to PrEP care included initiating conversations about sexuality with providers; confidentiality concerns regarding disclosure of sexual practices and PrEP use to family; gaps in access to healthcare; and limited availability of affordable health services. Future implementation of next generation PrEP may benefit from providers addressing confidentiality concerns when discussing PrEP with YMSM; PrEP programs accounting for discontinuities in healthcare access among YMSM while strengthening access to affordable services; and collaborations between generalist providers and specialized clinics and providers to address providers' education needs, which may increase as next generation PrEP becomes available. We have linked affiliation 9 to author name "Katie B. Biello". Please check and confirm. Okay!

Online Sexual Health Information Seeking Patterns Differentiated by Social Location and Physical Location among Gay and Bisexual Men in Ontario, Canada

Objective

This research aimed to understand the varying needs of diverse gay and bisexual men (GBM) in relation to online sexual health information-seeking dependent upon differing social sociodemographic variables and geographic location.

Methods

A total of 1802 GBM in Ontario participated in this study. Multivariable regressions were conducted to analyze differences in information-seeking based on ethnicity group, HIV status, recent sexual behavior and regionality (urban and rural location).

Results

There were significant differences in online sexual health information-seeking content based on these demographic variables.

Conclusions

Implications for sexual health outreach and service provision for diverse GBM are discussed as well.

Switching to Non-daily Pre-exposure Prophylaxis Among Gay and Bisexual Men in Australia: Implications for Improving Knowledge, Safety, and Uptake

INTRODUCTION

Preexposure prophylaxis (PrEP) dosing options such as event-driven PrEP hold promise to increase PrEP uptake among gay, bisexual, and queer men (GBQM), but their impacts have not yet been realized and uptake by GBQM suitable for PrEP remains slow in countries where it is only considered an alternative option to daily PrEP.

METHODS

We conducted semi-structured interviews between June 2020 and February 2021 with 40 GBQM in Australia to understand PrEP dosing behaviors, knowledge, and preferences.

RESULTS

All participants commenced PrEP daily; 35% had ever switched to non-daily PrEP, mostly taking it event-driven. GBQM who preferred non-daily PrEP had infrequent or predictable sex, were concerned about cost given infrequency of sex, and/or wanted to minimize unnecessary drug exposure. Accurate knowledge of event-driven PrEP was poor. However, reflecting concepts underpinning critical pedagogy, having accurate knowledge was supported by access to consistent messaging across clinical, social, community, and public settings. Several participants who switched to event-driven PrEP had condomless sex events in which they were unable to adhere to pills due to unanticipated sex.

CONCLUSIONS AND POLICY IMPLICATIONS

Implementation of comprehensive and consistent education about correct dosing for event-driven PrEP across multiple settings is needed to ensure increased uptake and safe use. GBQM require messaging about non-condom based HIV prevention strategies when they cannot access daily or event-driven PrEP.

Latent Class Analysis of Sexual Behaviours and Attitudes to Sexually Transmitted Infections Among Gay and Bisexual Men Using PrEP

Gay and bisexual men (GBM) who use pre-exposure prophylaxis (PrEP) are at increased risk of sexually transmitted infections (STIs) compared to those who don't use PrEP. Since the implementation of PrEP in Australia, it is possible that attitudes towards STIs have shifted in line with changes in risk and transmission dynamics in the context of increased screening. As the extent to which GBM utilise STI prevention strategies likely depends on their attitudes towards STIs and STI prevention, the aims of this study were to use latent class analysis (LCA) to classify GBM using PrEP on the basis of their attitudes towards STIs and reported risk behaviours, and examine how these categorisations relate to risk of STI acquisition. 1225 GBM who were previously enrolled in a PrEP implementation study (The PrEPX Study) completed a survey focused on sexual behaviours and attitudes towards STIs 1 year post-study follow-up. Data on chlamydia, gonorrhoea and syphilis testing and positivity were available through a sentinel network of participating study clinics. Using LCA, participants were allocated into four classes; Class 1, "Some concern and lowest risk"; Class 2, "Low concern and lower risk"; Class 3, " High concern and higher risk"; and Class 4, "Low concern and highest risk". The majority (78%) of participants were classified into Class 3 or Class 4, two groups which were distinguished by highly disparate attitudes towards STIs but with a similar proportion of participants diagnosed with a bacterial STI in the last 12 months (48% and 57%, respectively). Findings suggest that attitudes towards STIs among GBM using PrEP in Australia vary considerably, and this will likely influence their receptivity to different STI prevention strategies.

PrEParing for NextGen: Cognitive Interviews to Improve Next Generation PrEP Modality Descriptions for Young Men Who have Sex with Men

Next generation PrEP formulations may circumvent factors that impede daily oral pre-exposure prophylaxis (PrEP) use among young men who have sex with men (YMSM). We conducted video-based cognitive interviews with 20 YMSM (age 16-24) recruited in the US Northeast to assess participants' attitudes and comprehension of written descriptions of next generation PrEP modalities. Participants were predominately racial/ethnic minorities and half used daily oral PrEP. We identified four main areas for improvement of descriptions: defining scientific terms and balancing medical jargon and casual language; referencing more established products to contextualize PrEP formulations (e.g., hormonal implants); ensuring clarity and reducing redundancy; and including imagery (e.g., rectal douche applicator). The refined descriptions serve as exemplar text that may be used in future studies examining YMSM's preferences across next generation PrEP modalities. Accurate descriptions of next generation PrEP products strengthen measurement accuracy and can help roll-out products that become approved for clinical use.

Relationship Between Sexual Behaviors with Non-committed Relationship Partners and COVID-19 Restrictions and Notification Rates: Results from a Longitudinal Study of Gay and Bisexual Men in Australia

Introduction

COVID-19 related lockdowns have impacted the sexual activity of gay and bisexual men (GBM). We investigated trends in sexual behaviors and the COVID-19 context in which they occurred (COVID-notification rates and jurisdictional restrictions) to understand changes in the duration and severity of periods of lockdown on the sexual behavior of Australian GBM.

Methods

In an online, prospective observational study of 831 GBM from May 2020 to May 2021, we investigated associations between changes in sexual behavior among Australian GBM, lockdowns, and COVID-19 notification rates through weekly surveys from May 2020 to May 2021.

Results

The mean age was 45.71 years (SD: 13.93). Most identified as gay (89.0%) and 10.2% were living with HIV. There was an overall increase in the mean weekly number of non-committed relationship partners (0.53-0.90, p < 0.001). The state of Victoria experienced a significant extended COVID-19 outbreak, accompanied by severe lockdown restrictions. In response, Victorian men's partner numbers shifted three times, while elsewhere there was an overall gradually increasing trend.

Conclusions

Less severe outbreaks with shorter lockdown periods, involving fewer and geographically contained, COVID-19 notifications were accompanied by non-significant changes in sex with non-relationship partners than more severe outbreaks over extended periods and larger geographical areas.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13178-022-00733-8.

"It's not just the hit itself": the social practice of injecting drug use among gay and bisexual men in Australia

BACKGROUND

Injecting drug use is purportedly more common among gay and bisexual men (GBM) than the general Australian population. Approaches designed to support the wellbeing of people who inject drugs may not be effective for GBM who inject, due to divergent settings, substances, and/or symbolism. We sought to identify the critical elements shaping injecting among GBM as a social practice and the implications for health and psychosocial wellbeing.

METHODS

We conducted 19 in-depth interviews with GBM in Australia with lifetime experience of injecting drug use, adopting the Frameworks Method for data analysis. Framed by social practice theory, transcripts were coded to delineate the constituent material, competency, and meaning elements of GBM's injecting practices. We developed themes encompassing the dynamic interrelationship between practice elements and wellbeing aspects.

RESULTS

Of 19 participants interviewed (aged 24-60 years), 17 identified as gay, two as bisexual. Injecting histories ranged from 2-32 years; most injected methamphetamine (n = 18). Injecting involved the integration of sexual function with substances and injecting skills in dyadic/communal settings. Beyond traditional harm reduction aspects, 'safe injecting' concerned trustworthiness of fellow practitioners, preventing addiction, and maintaining a solid self-concept. Injecting occurred as a dyadic/communal practice, in which an uneven distribution of materials (substances, sexual capital) and competencies (self-injecting) influenced risk and power dynamics. Pleasurable meanings of belonging, desirability and self-actualisation - gained from communities of practice - conflicted with injecting-related stigma, social dependencies, and fear of harms to body, mind, and sense of self.

CONCLUSION

Injecting is a heterogenous practice, including among GBM. Shifting configurations of its composite elements influence GBM's perceptions and experiences of pleasure, risk, and harms. Efforts to support their wellbeing should take a dyadic/communal approach and seek to rectify the uneven distribution of material and competency elements in these settings.

COVID-19 Vaccine Uptake and Its Impacts in a Cohort of Gay and Bisexual Men in Australia

Successful use of biomedical forms of HIV risk-reduction may have predisposed many gay and bisexual men (GBM) to vaccination against COVID-19, which may, in turn, affect their sexual behavior. A total of 622 Australian GBM provided weekly data on COVID-19 vaccination history and sexual behaviour between 17 January 2021 and 22 June 2021. We identify factors associated with COVID-19 vaccination, and compare sexual behavior before and since vaccination. Mean age was 47.3 years (SD 14.0). At least one-dose vaccination coverage had reached 57.2%, and 61.3% reported that the majority of their friends intended to be vaccinated. Vaccinated men reported a mean of 1.11 (SD 2.10) weekly non-relationship sex partners before vaccination and 1.62 (SD 3.42) partners following vaccination. GBM demonstrated high confidence in COVID-19 vaccines. Their sexual activity increased following vaccination suggesting that greater sexual freedom may be a specific motivation for vaccine uptake among some men.

Pilot Randomized Controlled Trial of Motivational Interviewing with Sexual Minority Male Couples to Reduce Drug Use and Sexual Risk: The Couples Health Project

A randomized controlled trial evaluated the preliminary efficacy of a dyadically-delivered motivational interviewing (MI) intervention to reduce drug use and sexual risk in a sample of 50 sexual minority (cis)male (SMM) couples. In each couple, at least one partner was aged 18–29; reported drug use and sexual HIV transmission risk; and was HIV-negative. Couples were randomized to either the three-session MI intervention or an attention-matched control, with follow-up surveys completed at 3- and 6-months post-baseline. Between-group differences for all outcomes were non-significant in the overall sample. Subsequent moderation analyses indicated the intervention significantly reduced illicit drug use (excluding marijuana) at 3-month follow-up when either respondents (B = − 1.96; interval rate ratio—IRR 0.02–1.22; p = .001), their partners (B = − 2.60; IRR 0.01–0.64; p = .004), or both (B = − 2.38; IRR 0.01–0.80; p = .001) reported high levels of baseline use. The intervention also reduced condomless anal sex (CAS) with casual partners when both partners reported high frequency baseline CAS (B = − 2.54; IRR 0.01–0.83; p = .047). Findings provide initial evidence of the potential for MI to address drug use and sexual risk-taking among SMM couples at highest risk.

Trial Registration ClinicalTrials.gov (NIH U.S. National Library of Medicine) Identifier: #NCT03386110.

PrEP uptake as a social movement among gay and bisexual men

Despite PrEP's effectiveness as an HIV prevention intervention, uptake among gay and bisexual men remains low. Historical involvement in AIDS activism may reveal important ways of mobilising gay and bisexual men to increase PrEP uptake. Data come from a qualitative study to understand New York City gay and bisexual men's experiences with PrEP. Informed by a constructivist grounded theory approach, we assessed ways in which gay and bisexual men's relational experiences concerning PrEP were congruent with features of past AIDS activism. Participants' mean age was 32.5 years, half were men of colour, and over half had been taking PrEP for less than one year. Analysis revealed three primary themes related to AIDS activism strategies: (1) framing, which referenced how participants referred to PrEP as an empowering, liberatory and community-building intervention (2) reactions, which encompassed positive to negative expressions about PrEP and sex; and (3) innovation, which conveyed ways that participants engaged in processes of transferring lay knowledge about PrEP through leadership roles across social and digital encounters. Findings suggest that the ways in which gay and bisexual men communicate about PrEP with peers are consistent with features of AIDS activism. Deploying lay knowledge using framing strategies through peer-based intervention could expand PrEP uptake. However, elements of PrEP stigma must be addressed to engage with the wide-ranging HIV prevention needs of gay and bisexual men.

Pilot Randomized Trial of an Expressive Writing Intervention to Reduce Sexual HIV-Transmission Risk and Substance Use Among Emerging Adult Gay and Bisexual Men

This pilot randomized controlled trial evaluated the feasibility, acceptability, and preliminary efficacy of expressive writing to reduce HIV-related sexual risk taking and symptoms of drug dependence among emerging adult gay and bisexual men (EAGBM) through linguistic mechanisms involving use of words associated with cognitive processing (e.g., think, cause), positive emotion (e.g., love, nice), and negative emotion (e.g., hurt, shame). Between 2014 and 2015, EAGBM (n = 78; aged 18-29) completed a baseline survey and were randomized to complete three 15-min expressive writing or equivalent control-group writing sessions and follow-up assessments 2 months post-baseline. EAGBM in the expressive writing condition utilized significantly more positive emotion, negative emotion, and cognitive processing words. Path model results indicated the intervention condition resulted in significant reductions in symptoms of drug dependence and frequency of condomless anal sex (CAS) through paths mediated by positive emotion words, and significant increases in CAS through a path mediated by negative emotion words.

COVID-19 Vaccination Uptake and Hesitancy in a National Sample of Australian Gay and Bisexual Men

Minority groups may face additional barriers to vaccination. In April-June 2021, we assessed the level of COVID-19 vaccination and willingness to be vaccinated in a national, online survey of 1280 gay and bisexual men in Australia. Over a quarter of the sample (28.0%) had been partially or fully vaccinated, and 80.0% of the unvaccinated were willing to be vaccinated. Vaccination was independently associated with older age, being university educated, and HIV status (with HIV-positive participants being more likely and untested participants less likely to be vaccinated). Willingness to be vaccinated was independently associated with living in a capital city and being university educated. Those who had lost income or their job due to COVID-19 were less willing to be vaccinated. Our results suggest encouraging COVID-19 vaccination among those with lower levels of health literacy and supporting those who have experienced financial stress because of the pandemic.

Mindfulness for Reducing Minority Stress and Promoting Health Among Sexual Minority Men: Uncovering Intervention Principles and Techniques

Objectives

Tailored, evidence-based interventions are in high need for sexual minority men (gay, bisexual, and queer men who have sex with men) to address prevalent mental health issues and HIV/STI risk. This study describes the formative research that informed the development of Mindfulness-Based Queer Resilience (MBQR): a mindfulness-based intervention for health promotion among sexual minority men.

Methods

Guided by the ADAPT-ITT model, we conducted a series of interviews with community stakeholders, including sexual minority men with anxiety and depressive symptoms (n = 15) and mindfulness service providers with experience working with sexual minority men (n = 11). Thematic analysis was used for data analysis.

Results

Six intervention principles and seven key techniques/delivery considerations emerged relevant to intervention development. Principles included (a) reducing minority stress as a key theoretical guide, (b) affirming LGBTQ + identity and facilitating healthy identity development, (c) attending to intersectionality, (d) facilitating resilience and self-empowerment, (e) trauma sensitivity, and (f) promoting healthy relationships and a healthy community. Key techniques represent the pathways through which MBQR may address the adverse impacts of minority stress, including through attention control practice to facilitate agency and self-awareness, enhancing emotion regulation, reducing reactivity to minority stress-informed thoughts, self-compassion to increase self-acceptance, and reducing behavioral avoidance. Delivery considerations also included careful navigation regarding mindfulness and religion, as well as using modern technology to increase reach, access, and engagement.

Conclusions

If proven to be feasible and efficacious, MBQR may offer the potential to alleviate adverse impacts of minority stress and improve mental and sexual health of sexual minority men.

Increase in Depression and Anxiety Among Australian Gay and Bisexual Men During COVID-19 Restrictions: Findings from a Prospective Online Cohort Study

We examined depression and anxiety prior to and during COVID-19 restrictions in Australian gay and bisexual men (GBM). In an online cohort, a COVID-19-focused survey was conducted in April 2020. During 2019 and in April 2020, 664 GBM completed the Patient Health Questionnaire (PHQ-9, measuring depression) and Generalized Anxiety Disorder Assessment (GAD-7, measuring anxiety). Increased depression and anxiety were defined as a ≥ 5 point increase on the respective scales. Mean PHQ-9 and GAD-7 scores increased between 2019 and 2020 (PHQ-9: from 5.11 in 2019 to 6.55 in 2020; GAD-7: from 3.80 in 2019 to 4.95 in 2020). The proportion of participants with moderate-severe depression (PHQ-9 ≥ 10) increased from 18.8% (n = 125) to 25.5% (n = 169), while the proportion of participants with moderate-severe anxiety (GAD-7 ≥ 10) increased from 12.7% (n = 84) to 17.3% (n = 115). Almost one-quarter of participants (n = 158, 23.8%) had increased depression; in these men, mean PHQ-9 increased from 2.49 in 2019 to 11.65 in 2020 (p < 0.001). One-in-five (20.6%) participants (n = 137) had increased anxiety; among these men, mean GAD-7 increased from 2.05 in 2019 to 10.22 in 2020 (p < 0.001). Increases were associated with concerns about job security, reduction in social and sexual connections and opportunities, and being personally concerned about COVID-19 itself. COVID-19 appeared to have a sudden and pronounced impact on depression and anxiety in Australian GBM, with a significant minority showing sharp increases. Ongoing monitoring is required to determine longer-term impacts and GBM need access to appropriate and sensitive supports both during and after the COVID-19 pandemic.

Switching to Non-daily Pre-exposure Prophylaxis Among Gay and Bisexual Men in Australia: Implications for Improving Knowledge, Safety, and Uptake

INTRODUCTION

Preexposure prophylaxis (PrEP) dosing options such as event-driven PrEP hold promise to increase PrEP uptake among gay, bisexual, and queer men (GBQM), but their impacts have not yet been realized and uptake by GBQM suitable for PrEP remains slow in countries where it is only considered an alternative option to daily PrEP.

METHODS

We conducted semi-structured interviews between June 2020 and February 2021 with 40 GBQM in Australia to understand PrEP dosing behaviors, knowledge, and preferences.

RESULTS

All participants commenced PrEP daily; 35% had ever switched to non-daily PrEP, mostly taking it event-driven. GBQM who preferred non-daily PrEP had infrequent or predictable sex, were concerned about cost given infrequency of sex, and/or wanted to minimize unnecessary drug exposure. Accurate knowledge of event-driven PrEP was poor. However, reflecting concepts underpinning critical pedagogy, having accurate knowledge was supported by access to consistent messaging across clinical, social, community, and public settings. Several participants who switched to event-driven PrEP had condomless sex events in which they were unable to adhere to pills due to unanticipated sex.

CONCLUSIONS AND POLICY IMPLICATIONS

Implementation of comprehensive and consistent education about correct dosing for event-driven PrEP across multiple settings is needed to ensure increased uptake and safe use. GBQM require messaging about non-condom based HIV prevention strategies when they cannot access daily or event-driven PrEP.

A full-factorial randomized controlled trial of adjunct couples HIV testing and counseling components addressing drug use and communication skills among sexual minority male couples

Background

The past decade has seen increasing attention directed to the development of HIV prevention interventions for male couples, driven by epidemiological data indicating that main or primary – rather than causal – partnerships account for a substantial number of HIV infections in this population. Couples HIV testing and counseling (CHTC) has emerged as a standard of care in the US. This protocol describes a study that aims to evaluate the efficacy of two adjunct components to CHTC – communication training (CT) videos and a substance use module (SUM) – to reduce drug use and sexual HIV transmission risk behavior.

Methods

Eligible couples must include one participant who is aged 17-29, HIV-negative, and reports recent drug use. Both partners must be aged 17 or older, identify as cismale (assigned male sex at birth and currently identify as male gender), and communicate in English. Couples are randomized post-baseline to one of four conditions (CHTC as usual, CHTC plus CT video; CHTC + SUM and CHTC + CT video + SUM) in a full-factorial design. Follow up assessments are completed at 3-, 6-, 9- and 12-months post baseline.

Discussion

Results of this trial will enhance the application of CHTC. If found effective, adjunct components would comprise a brief and scalable drug use intervention that could be readily integrated into existing HIV testing settings.

Trial registration

ClinicalTrials.gov Protocol Registration; NCT05000866; completed August 3, 2021; https://register.clinicaltrials.gov/

Protocol version 1.0; September 1, 2021.

Sustaining success: a qualitative study of gay and bisexual men's experiences and perceptions of HIV self-testing in a randomized controlled trial

Background

HIV self-testing was proved as an effective tool for increasing testing frequency in gay and bisexual men at high risk of infection. Questions remain about understanding why HIVST encouraged testing and how such success can be translated to programmatic implementation.

Methods

We conducted a qualitative investigation of how FORTH participants experienced and perceived HIVST. Stratified sampling was used to recruit gay and bisexual men participating in the FORTH HIVST intervention to take part in interviews, focusing on infrequent testers and those who had received inaccurate HIVST results.

Results

Our analysis identified several prominent themes organized into two overarching domains from the 15 interviews: (i) aspects of HIVST contributing to HIV testing frequency, and (ii) sustaining HIVST into the future. Participants also believed that their use of HIVST in the future would depend on the test kit’s reliability, particularly when compared with highly reliable clinic-based testing.

Conclusion

HIVST increases the frequency of HIV testing among gay and bisexual men due, in part, to the practical, psychological, and social benefits it offers. To capitalize fully on these benefits, however, strategies to ensure the availability of highly reliable HIVST are required to sustain benefits beyond the confines of a structured research study.

Demographic and Geographic Differences in Facial Masculinity Preferences Among Gay and Bisexual Men in China

This study examined demographic and geographic differences in facial masculinity preferences among gay and bisexual men in China. The final sample included 2595 participants whose data were obtained from four published data sets and one unpublished data set. Demographic variables included sexual self-label, sexual orientation, age, educational level, and occupational status. Geographic variables were classified based on the IP addresses of respondents including North-South division, administrative division, economic regional division, and modernization division. There were significant differences in facial masculinity preferences in demographic variables. Gay men preferred more masculinized faces than did bisexual men. "Tops" preferred feminized faces, whereas "bottoms" and "versatiles" preferred masculinized faces. Participants aged 20-29 years preferred more masculinized faces than did those aged 16-19 years and older than 30. Also, the results indicated significant differences in facial masculinity preferences in geographic variables. Participants living in South China preferred more masculinized faces than did those living in North China. Concerning administrative division, individuals living in South China (Guangdong, Guangxi, Fujian, and Jiangxi) preferred more masculinized faces than did those living in other regions. Participants living in first-tier cities (Beijing, Shanghai, Guangzhou, and Shenzhen) preferred more masculinized faces than did those living in other cities. The findings implicated context-dependent variability in facial masculinity preferences among gay and bisexual men; facial trait-attribution processes may contribute to these individual differences.

The longer-term effects of access to HIV self-tests on HIV testing frequency in high-risk gay and bisexual men: follow-up data from a randomised controlled trial

Background

A wait-list randomised controlled trial in Australia (FORTH) in high-risk gay and bisexual men (GBM) showed access to free HIV self-tests (HIVSTs) doubled the frequency of HIV testing in year 1 to reach guideline recommended levels of 4 tests per year, compared to two tests per year in the standard-care arm (facility-based testing). In year 2, men in both arms had access to HIVSTs. We assessed if the effect was maintained for a further 12 months.

Methods

Participants included GBM reporting condomless anal intercourse or > 5 male partners in the past 3 months. We included men who had completed at least one survey in both year 1 and 2 and calculated the mean tests per person, based on the validated self-report and clinic records. We used Poisson regression and random effects Poisson regression models to compare the overall testing frequency by study arm, year and testing modality (HIVST/facility-based test).

Findings

Overall, 362 men completed at least one survey in year 1 and 343 in year 2. Among men in the intervention arm (access to HIVSTs in both years), the mean number of HIV tests in year 2 (3⋅7 overall, 2⋅3 facility-based tests, 1⋅4 HIVSTs) was lower compared to year 1 (4⋅1 overall, 1⋅7 facility-based tests, 2⋅4 HIVSTs) (RR:0⋅84, 95% CI:0⋅75-0⋅95, p=0⋅002), but higher than the standard-care arm in year 1 (2⋅0 overall, RR:1⋅71, 95% CI:1⋅48-1.97, p<0⋅001). Findings were not different when stratified by sociodemographic characteristics or recent high risk sexual history.

Interpretation

In year 2, fewer HIVSTs were used on average compared to year 1, but access to free HIVSTs enabled more men to maintain higher HIV testing frequency, compared with facility-based testing only. HIV self-testing should be a key component of HIV testing and prevention strategies.

Funding

This work was supported by grant 568971 from the National Health and Medical Research Council of Australia.

Variations in Sexual Behaviors by Use of Specific Substances Among Vancouver Gay, Bisexual, and Other Men Who Have Sex with Men: An Event-Level Analysis

Event-level studies measure substance use and sexual behaviors happening during a specific sexual encounter, ensuring that both variables are temporally paired. This study explored the event-level associations between a range of sexual behaviors (masturbation, anal sex, oral sex, rimming, fisting, sex toys, and group sex) and five sexualized substances (poppers, methamphetamine, GHB, ecstasy/MDMA, and ketamine) used during 11,582 sexual events reported by 762 gay, bisexual, and other men who have sex with men (GBMSM) in Vancouver, Canada. Data were obtained from a prospective cohort of GBMSM who self-reported their behaviors via computer-based questionnaires on their last sexual encounter with up to five of their most recent partners in the past six months. These clustered data were analyzed with multivariable generalized linear mixed models. Participants reported popper use in 16.1% of sexual encounters, methamphetamine in 8.6%, gamma-hydroxybutyrate (GHB) in 4.1%, ecstasy/3,4-methylenedioxymethamphetamine (MDMA) in 3.3%, and ketamine in 1.5%. Condomless receptive anal sex (25.0% of events) was associated with increased odds of using poppers, methamphetamine, GHB, and ecstasy/MDMA. Group sex (13.1% of events) and sharing sex toys (2.0% of events) were more likely with the use of all five substances. Receiving money/drugs/goods in exchange for sex (2.5% of events) was associated with increased odds of poppers, methamphetamine, GHB, and ecstasy/MDMA use. GBMSM living with HIV (29.9% of participants) had higher odds of using poppers, methamphetamine, and GHB, but lower odds of using ecstasy/MDMA. In conclusion, these event-level results suggest public health strategies are needed to address the possible negative impacts of sexualized substance use among GBMSM.

Associations of prescription stimulant misuse with subsequent methamphetamine use among a U.S. cohort of HIV-vulnerable sexual and gender minorities who have sex with men

INTRODUCTION

Prescription stimulants and methamphetamine have similarities in chemical structure and impact on biological functioning. However, there is limited literature on prescription stimulant misuse among sexual and gender minorities as well as how prescription misuse may impact later methamphetamine use.

METHODS

We used data collected from a HIV prevention cohort to describe (e.g., frequencies, percentages) prescription stimulant use/misuse and methamphetamine use at baseline and 12-month follow-up (n = 4857). We then used multivariable logistic regression models to determine the impact of baseline prescription stimulant misuse and methamphetamine use on 12-month prescription stimulant misuse and methamphetamine use.

RESULTS

At baseline, 10.2 % of participants misused prescription stimulants and 12 % of participants used methamphetamine in the past 3 months, while at 12-month follow-up 11.6 % of participants misused prescription stimulants and 11.2 % of participants used methamphetamine in the past 3 months. Multivariable regression analyses indicated that participants who misused prescription stimulants (in the absence of methamphetamine) at baseline had 2.51 (95 % CI: 1.44-3.59, ref. no stimulant or methamphetamine use) times the odds of using methamphetamine at 12-month follow-up.

DISCUSSION

Findings suggest that prescription stimulant use is a risk factor for continued meth use. Therefore, earlier and targeted public health interventions could reduce methamphetamine use by disrupting the progression from prescription stimulant misuse to methamphetamine use through early screening and interventions for prescription stimulant misuse.

Sexual Behavior Change Among Gay and Bisexual Men During the First COVID-19 Pandemic Wave in the United States

Background

After decades of navigating HIV and other sexually transmitted infections, gay and bisexual men are responding to new and uncertain risks presented by the coronavirus (COVID-19) pandemic by adapting their sexual behavior.

Methods

This paper uses data from a national sample of 728 gay and bisexual men collected from April 10 to May 10, 2020, to examine changes to sexual behavior in response to the first wave of the pandemic in the USA. We also assess whether behavior modifications are associated with exposure to statewide public health measures, including Stay-at-Home orders.

Results

Sexual minority men report significant changes to their sexual behavior and partner selection during the first wave. Nine out of 10 men reported having either one sexual partner or no sexual partner in the last 30 days at the time of interview, a decrease compared to just before the pandemic for nearly half of men surveyed. Reporting no sexual partners in the last 30 days was significantly predicted by increased exposure to a Stay-at-Home order. Sexual minority men also reduced interactions with casual partners, increased no-contact sexual behaviors (e.g., masturbation and virtual sex), and engaged in new strategies to reduce their risks of infection from partners. HIV-positive men were particularly likely to adopt strategies including avoiding casual partners and avoiding public transportation to meet sexual partners.

Conclusion

Sexual minority men's behavior changes during the first wave may have reduced the impact of the coronavirus pandemic on their communities. Despite substantial changes in sexual behavior for most men in our sample during the initial first wave, we identify some concerns around the sustainability of certain behavioral changes over time and nondisclosure of COVID-19 symptoms to partners.

Insurance- and medical provider-related barriers and facilitators to staying on PrEP: results from a qualitative study

Pre-exposure prophylaxis (PrEP) is a highly effective biobehavioral strategy for preventing HIV acquisition. Although PrEP uptake has increased steadily, discontinuation rates are high among members of key populations like gay and bisexual men (GBM). Understanding the challenges that arise for PrEP users is key to better PrEP implementation and sustained use over time. We report on barriers that arose for PrEP-using GBM, as well as facilitating factors that aided PrEP persistence, with the goal of informing PrEP implementation efforts. In 2015-2016, 103 PrEP-using GBM in NYC completed qualitative interviews about their engagement with PrEP, including their experiences navigating PrEP-related medical care. Interviews were transcribed verbatim, coded, and analyzed thematically. Over half of participants (53%) received their PrEP-related care from their primary care provider (PCP), one-third (33%) from a community-based health clinic, and 13% from multiple medical providers. Emergent themes regarding the barriers and facilitators to PrEP persistence fell into two categories: insurance- and medical appointment-related barriers and facilitators to continued PrEP use. The experiences of PrEP-using GBM can provide useful insights for providers, program developers, and policymakers aiming to improve the implementation of PrEP. To support PrEP persistence, reliable insurance coverage, cost-assistance, and easy appointment scheduling are key to maintenance. Removing insurance- and appointment-related barriers to persistence may prove essential for sustaining use among GBM.

The role of disclosure & perceptions about providers in health discussions among gay and bisexual young men

OBJECTIVES

Gay and bisexual men may feel discomfort discussing sensitive topics such as sexual behaviors and substance use with their health providers, which may prevent them from receiving important health information. This study investigates whether patients' perceptions of their provider's sexual orientation predicts patient-provider discussions of sexual and general health topics, and whether this relationship is moderated by patients' disclosure of sexual orientation to providers.

METHODS

Data were collected online from a sample of 576 gay and bisexual men living in the USA, aged 18-26. Adjusted risk ratios were estimated by using modified Poisson regression with robust error variance.

RESULTS

Participants who believed their providers were gay or bisexual were more likely to have discussed sexual health topics, but not general health topics; simple slopes analyses revealed that this effect was stronger among those who had not disclosed to their providers. Disclosure was also consistently associated with increased likelihood of discussing almost all topics.

CONCLUSIONS

Findings highlight differences in communication based on disclosure and perceived sexual orientation of provider, suggesting the need to further explore how these differences influence young gay and bisexual men's health.

PRACTICE IMPLICATIONS

Dyads may be more likely to discuss sexual health topics when patients believe their providers are sexual minorities themselves. In addition, patient-provider dyads may be likelier to discuss various health topics when providers are aware of patients' sexual minority statuses.

A Structural Equation Model of the Effect of Masculinity and Avoidant Coping on Gay and Bisexual Men's Sexual Risk-Taking

This study aims to extend the scientific knowledge base on the association between masculine norm adherence and sexual risk-taking, in the context of gay and bisexual men, by examining emotional suppression, social support seeking, and avoidant coping as potential mediating pathways. A sample of 482 gay and bisexual men was recruited. Structural equation modeling was used to assess for mediation. Findings revealed that although gender role conflict and conformity to masculine norms (i.e., the two masculine norm adherence predictor variables) did not have a direct effect on sexual risk-taking, a significant indirect effect was observed for gender role conflict on sexual risk-taking via increased avoidant coping. Accordingly, gender role conflict and avoidant coping may create a unique effect on sexual risk-taking whereby the effect of gender role conflict on sexual risk-taking is not transmitted directly but only indirectly through the mediating role of avoidant coping. Future research directions are discussed.

Marketing of Tenofovir Disoproxil Fumarate (TDF) Lawsuits and Social Media Misinformation Campaigns' Impact on PrEP Uptake Among Gender and Sexual Minority Individuals

There has been an influx of ads on social media seeking plaintiffs in lawsuits for harms/side-effects caused by tenofovir disoproxil fumarate/Emtricitabine (TDF/FTC, Truvada) for PrEP. Community groups and researchers have suggested these ads may be undermining efforts to disseminate PrEP to key populations. In October 2019, we began assessing the impact of injury lawsuit ads on social media platforms in an ongoing U.S. national cohort study of HIV-negative cis men, trans men, and trans women who have sex with men. Although assessments are ongoing, given the alarming nature of our findings, we report data collected as of March 2020 (n = 2078). Most (59.9%) said they had seen ads for TDF-related lawsuits on social media. Twenty-eight percent said they would probably or definitely not start PrEP and 22.1% said they would not stay on PrEP (were they on it) as a result of seeing these ads. Next, 38.2% agreed or strongly agreed that seeing these ads made them think that TDF/FTC for PrEP was not safe. Black, Latinx, and/or multiracial individuals were most likely to be negatively impacted by the ads including perceptions that these ads made them think PrEP is not safe. In contrast, past year experience taking PrEP was positively associated with intentions to start and/or stay on PrEP despite seeing the ads. Due to forthcoming affordable/generic options, TDF/FTC is projected to become the most scalable option for disseminating PrEP to key populations. Results suggest that ads for TDF lawsuits on social media are having a negative impact on individual PrEP decision-making. Our findings highlight the urgency for accurate and balanced messaging on the benefits and risks of PrEP, so that individuals can make informed choices about whether PrEP is right for them.

An exploratory study of factors associated with difficulties in accessing HIV services during the COVID-19 pandemic among Chinese gay and bisexual men in Hong Kong

Background

The coronavirus disease 2019 (COVID-19) pandemic has resulted in the disruption of provision of human immunodeficiency virus (HIV) services. This study examined the factors associated with difficulties in accessing HIV services during the COVID-19 pandemic.

Methods

An online survey of 236 Chinese-speaking gay and bisexual men in Hong Kong conducted in 2020.

Results

Among those who expressed a need to access HIV services during the COVID-19 pandemic, 22.9%, 33.9% and 43.2% indicated moderate-to-high, mild and no difficulties in accessing these services, respectively. Difficulties in accessing HIV services were positively related to concerns about potential COVID-19 infection, experience of actual impact on health because of COVID-19, disruption in work/studies, and reduced connection to the LGBT+ community during the pandemic. It was also found that difficulties in accessing HIV services were positively associated with frequency of having sex with casual partners, but were not significantly associated with frequency of having sex with regular partners.

Conclusions

This study provides novel empirical evidence for understanding difficulties in accessing HIV services during the COVID-19 pandemic. It found that disruption in work/studies and frequency of having sex with casual partners were associated with difficulties in accessing HIV services.

Lifetime Exposure to Conversion Therapy and Psychosocial Health Among Midlife and Older Adult Men Who Have Sex With Men

BACKGROUND AND OBJECTIVES

Conversion therapies to minimize same-sex attractions are classified as a dangerous practice by numerous scientific institutions in the United States. These practices may contribute to poor long-term psychosocial health, thereby interrupting processes of healthy aging. Few studies have examined psychosocial differences between persons with and without prior experiences of conversion therapy. We assessed associations between prior conversion therapy experiences and psychosocial health among midlife and older men who have sex with men (MSM; age 40+ years).

RESEARCH DESIGN AND METHODS

Participants included a multicity sample of MSM (N = 1,156) enrolled in the Multicenter AIDS Cohort Study who completed health surveys (2016-2019) as part of their biannual study visits. Using multivariable regressions, we investigated the associations of prior conversion therapy with current depressive symptoms, internalized homophobia, post-traumatic stress, and cumulative psychosocial conditions. Using a trait-level measure (e.g., life purpose and perseverance), we tested whether resilience moderated these associations.

RESULTS

The full sample was predominantly non-Hispanic white with a mean age of 62.6 years. Fifteen percent of men (n = 171/1,156) reported prior conversion therapy. In multivariable models, men exposed to conversion therapy were more likely to have depressive symptoms and above-average internalized homophobia. Men exposed to conversion therapy had 2-2.5 times the odds of reporting 1 and ≥2 psychosocial conditions, respectively, compared with those who reported 0 conditions. Resilience did not moderate these associations.

DISCUSSION AND IMPLICATIONS

Conversion therapies are nonaffirming social stressors for MSM and may compromise critical psychosocial aspects of healthy aging among MSM.

Stigma as understood by key informants: A social ecological approach to gay and bisexual men's use of crystal methamphetamine for sex

This paper explores the perceptions of 35 key informants (KIs) in a range of relevant health and community sectors regarding the stigmatisation of GBM's crystal methamphetamine use and sexual practice with view to informing stigma reduction efforts. A modified social ecological model was used to guide analysis and interpretation. At the individual level, KI participants indicated that crystal methamphetamine was used by some GBM to reduce the effects of internalised stigma. At the network level, KIs thought that some drugs and types of use could attract more stigma and that this could erode support from GBM networks for men who use crystal. KIs felt that few "mainstream" organisations could provide appropriate services for GBM who use crystal and furthermore, that there was significant work to "undo" misperceptions of the harms of crystal use. At the policy level, mass media anti-drug campaigns were seen to be a significant generator of stigma with irrelevant and patronising messages that lacked useful information. Efforts to reduce stigma about crystal methamphetamine use amongst GBM must address individual, network, organisation and policy issues and be underpinned by understandings of social power in relation to sex, sexuality, drug use, infectious status and sexual minorities.

Perspectives from Young Partnered Gay, Bisexual, and Other Men Who Have Sex with Men on the Adaptation of Couples HIV Testing and Counseling (CHTC)

Young gay, bisexual, and other men who have sex with men (YGBMSM) are a priority population for HIV prevention efforts. Although there has been a growing focus on dyadic HIV prevention interventions for same-gender male couples, the unique needs of partnered YGBMSM have been largely overlooked. In this qualitative study, we explored partnered YGBMSM's perceptions of existing HIV prevention interventions to inform the design of a relationship-focused HIV prevention intervention. Between July and November 2018, we conducted in-depth interviews with 30 young partnered YGBMSM (mean age = 17.8, SD = 1.1). Participants described that interventions were needed to address skills regarding: (1) implicit versus explicit communication about sexual agreements; (2) boundary setting and identifying signs of abusive relationships; and (3) relationship dynamics (e.g., trust). Participants noted the absence of inclusive sexual education for them; thus, findings suggest that the provision of relationship skills training are requisites for HIV prevention interventions with YGBMSM in the US.

Priorities and practices of risk reduction among gay and bisexual men in Australia who use crystal methamphetamine for sex

Crystal methamphetamine (hereafter crystal) is associated with deleterious health outcomes, such as drug dependence and physical and mental health disorders. While some harms from crystal use can affect all users, there may be additional risks for people who combine the use of drug with sex. Compared with the broader population, gay and bisexual men in Australia report a higher prevalence of methamphetamine use, and crystal is the most commonly injected illicit drug among this population. The Crystal, Pleasures and Sex between Men research project was conducted between 2017 and 2019 and examined gay and bisexual men's crystal use in four capital cities in Australia, with the aim of identifying how to best support men who use crystal for sex. In this article, we examine how risk is understood and prioritised by gay and bisexual men who combine crystal use and sex and identify the range of risk reduction practices that they used. We classified these risks as those associated with the transmission of HIV, HCV and STIs, and those associated with dependence on either crystal or the sex it facilitated. Gay and bisexual men overwhelmingly prioritised the risk of dependence over any other risks associated with crystal-enhanced sex, and this prioritization was reflected in the risk reduction practices they employed. While some of the strategies that gay and bisexual men have adopted may contradict anticipated public health principles, they derive from a carefully considered and shared approaches to the generation of pleasure, the maintenance of a controlled form of feeling "out of control", and the negotiated reduction of risk. The consolidation of these strategies effectively constitutes a "counterpublic health" underpinned by forms of "sex-based sociality", which gives primacy to the priorities and practices of gay and bisexual men in Australia who combine crystal and sex.

Australian Gay and Bisexual Men Who Use Condoms, PrEP or Rarely Practise HIV Risk Reduction with Casual Sex Partners: An Analysis of National, Behavioural Surveillance Data, 2017-2018

Recent increases in the availability of pre-exposure prophylaxis (PrEP) internationally have widened the range of HIV prevention strategies available to gay and bisexual men. This paper aimed to quantify the use of different risk reduction strategies and compare characteristics of men who rarely use any strategies with those who regularly use condoms or PrEP. Using national cross-sectional data from the Gay Community Periodic Surveys in Australia, comparisons were made between regular condom users (37.1% of participants), PrEP users (50.1%), and men who infrequently used any risk reduction strategies (12.8%). The proportion of gay and bisexual men reporting infrequent use of HIV risk reduction strategies has decreased in recent years. These men reported less frequent high-risk sexual practices than PrEP users and also reported less recent HIV testing than either PrEP or condom users. Men who infrequently use HIV risk reduction strategies should be encouraged to test for HIV more regularly and to utilise prevention strategies that align with their infrequent high-risk behaviour.

Disclosing sexuality: Gay and bisexual men's experiences of coming out, forced out, going back in and staying out of the 'closet' in prison

Many papers have been written on the process of coming out by individuals with predominantly same-sex sexual orientation but few of these papers have explored the concept of how people negotiate the idea of coming out in prison. We conducted in-depth interviews with 13 prisoners and one ex-prisoner in New South Wales, Australia, who self-identified as gay, homosexual or bisexual men. Data was collected and analysed using an inductive or grounded theory framework since very little was known on the sexual behaviours and identities of Australian prisoners prior to the study and elsewhere. We examined and discussed the lived experiences of prisoners whose disclosure stories were seen to fall under four thematic categories: 'coming out', 'forced out', 'going back in' and 'staying out of the closet' on entering prison. Respondents were required continuously and contextually to manage their sexual identities and disclosure to different audiences while incarcerated. Findings suggest that the prison environment and its attendant heteronormative values and hyper-masculine culture, apply significant pressure on gay and bisexual men on how to manage their sexual identities and disclose their sexuality in prison.

Poor sleep health is associated with increased mental health problems, substance use, and HIV sexual risk behavior in a large, multistate sample of gay, bisexual and other men who have sex with men (GBMSM) in Nigeria, Africa

BACKGROUND

Poor sleep health has been linked to mental health problems, substance use, and sexual risk-taking among gay, bisexual, and other men who have sex with men (GBMSM). No known published study has examined these relationships among African GBMSM. Consequently, we investigated poor sleep health and associated health-related factors among a large multistate sample of Nigerian GBMSM.

METHODS

Between March and June 2019, 406 GBMSM were recruited from Abuja, Delta, Lagos, and Plateau and asked to complete an interviewer-administered survey. Bivariate and multivariable logistic regression models were constructed to examine the relationship between poor sleep health and other health-related factors.

RESULTS

In the past month, 45.5% of participants reported sleeping an average of 6 hours or less every night, and 30.7% reported experiencing a sleep problem. Factors associated with increased odds of reporting short sleep included: residing in Delta [adjusted odds ratio (aOR) 2.16; 95% confidence interval (CI): 1.15 to 4.04] and Lagos (aOR 2.40; 95% CI: 1.29 to 4.45), depressive symptoms (aOR 1.94; 95% CI: 1.13 to 3.32), and reporting lifetime history of using four or more drugs (aOR 2.52; 95% CI: 1.06 to 6.01). Reporting condom use at last anal sex was associated with decreased odds of reporting short sleep in the last month (aOR 0.54; 95% CI: 0.31 to 0.92). Factors associated with increased odds of reporting sleep problems included: reporting an STI diagnosis in the last year (aOR 1.79; 95% CI: 1.05 to 3.05) and reporting monthly or higher polydrug use in the last 3 months (aOR 2.19; 95% CI: 1.14 to 4.24).

DISCUSSION

Sleep health interventions should be developed for Nigerian GBMSM, which may improve mental health and reduce substance use and sexual risk-taking.

Increases in HIV Testing Frequency in Australian Gay and Bisexual Men are Concentrated Among PrEP Users: An Analysis of Australian Behavioural Surveillance Data, 2013-2018

Increasing HIV testing frequency in gay and bisexual men (GBM) is critical to reducing the time between HIV infection and diagnosis. Using anonymous national behavioural surveillance data (2013-2018) from 43,753 surveys of Australian GBM, we examined HIV testing frequency trends and factors differentiating PrEP-users, non-PrEP-users reporting two or more tests in the previous year, and non-PrEP-users reporting less frequent testing. The proportion tested at least annually increased from 64.4% in 2013 to 70.8% in 2018 (p-trend < 0.001), and from 73.9% to 84.6% among the 51.6% of men classified as higher-risk. Among higher-risk men, having two or more tests in the previous year increased from 48.0% to 69.3% (p-trend < 0.001). Among higher-risk non-PrEP-users, it increased from 47.2% to 54.8% (p-trend < 0.001), however, there was a decrease since 2016 (p-trend < 0.001). Among PrEP-users, it increased from 82.1% in 2013 to 97.3% in 2018 (p-trend < 0.001). Non-PrEP-using higher-risk men having less frequent tests reported lower risk than PrEP-users and non-PrEP-using men reporting two or more tests in the previous year. However, recent risk behaviour was not uncommon: nearly half reported condomless sex; one-fifth reported receptive condomless sex with ejaculation; over half reported group sex; one-quarter used drugs for the purposes of sex; and one-fifth had more than ten sex partners. Efforts are needed to encourage frequent testing and PrEP use among non-PrEP-users who are at higher-risk.

Gay and Bisexual Men's Perceptions of Pre-exposure Prophylaxis (PrEP) in a Context of High Accessibility: An Australian Qualitative Study

We report on Australian gay and bisexual men's (GBM) perceptions of preexposure prophylaxis (PrEP). Drawing on an online longitudinal cohort study, 1,404 free-text responses from HIV-negative or untested Australian GBM were qualitatively analysed. The chi-square statistic was then used to assess differences regarding PrEP-perceptions by participants' demographic and behavioral characteristics. Positive views of PrEP were twice more common than negative. Those with positive views thought PrEP helped overcome HIV fear and anxiety, enhanced sexual pleasure, and was a 'socially responsible' course of action. Those with negative views believed that people without medical conditions did not need medication and expressed concern that PrEP was replacing condoms, representing 'dangerous' behavior. Descriptive statistics revealed differences in PrEP-perceptions relating to age, recency of HIV testing, and PrEP eligibility. This study is the first to use free-text data to examine the frequency of Australian GBM's PrEP-perceptions, highlighting the potential benefits and challenges to its promotion.

Willingness to Distribute HIV Self-Testing Kits to Recent Sex Partners Among HIV-Negative Gay and Bisexual Men and an Examination of Free-Response Data from Young Men Participating in the Nationwide Cohort

Sexual minority men (SMM)-and young SMM in particular-are disproportionately affected by HIV. Secondary distribution of HIV self-testing (HIVST) kits-wherein patients deliver kits to partners-is a novel strategy to increase HIV testing access. Using quantitative data, we assessed willingness to distribute HIVST kits to recent sex partners among a U.S. national sample of HIV-negative SMM (n = 786). A thematic analysis was then conducted to identify barriers and facilitators of kit distribution to partners among young SMM (M age = 25.75 years; range: 20-29; n = 165). Overall, 93.5% of SMM (and 97.0% of young SMM) were willing to deliver HIVST kits to recent sex partners. Among young SMM, main barriers and facilitators included concerns about their partners' reaction, availability and cost, protection beliefs for others, HIV stigma and perceived infidelity, packaging and support, communication skill needs, inability to contact partners, requests for anonymity, and dyadic self-testing with their partners. The findings highlight the need for supportive intervention strategies such as informational content for HIVST, using motivational interviewing when providing the testing kits to index clients and providing skills-based training through role-playing exercises. Secondary distribution of HIVST kits through index patients is a potentially acceptable approach that could be used to expand access to HIV testing and aid in efforts to end the HIV epidemic in the U.S.

The Sexual Functioning of Gay and Bisexual Men Following Prostate Cancer Treatment: Results from the Restore Study

Prostate cancer is the second most common cancer in gay, bisexual, and other men who have sex with men (GBM). Few studies have assessed the effects of treatment on GBM's sexual behavior. For an online survey, 193 gay and bisexual men with prostate cancer were recruited from the North American's largest online cancer support group. Sexual functioning was measured using the Expanded Prostate Cancer Index Composite (EPIC) and a tailored Gay Sexual Functioning Inventory (GSFI). GBM have worse EPIC urinary and hormonal function and worse hormonal bother, but better sexual function and bother scores than published norms. In the GSFI, two-thirds of participants described their sexual functioning, post-treatment, as fair to poor. Only 22% reported erections sufficient for insertive anal sex. For receptive anal sex, one-third met criteria for anodyspareunia. Over half reported urination problems during sex or at orgasm. Erectile difficulties were common, severe, and a reason cited for not using condoms. Three men HIV seroconverted post-prostate cancer treatment. Differences in function and bother scores were observed by type of treatment, age, race/ethnicity, sexual orientation, but not relationship status. Sexual functioning significantly predicted long-term mental and physical health. GBM scored significantly worse on mental health and better on physical health than published norms. Sexual recovery after prostate cancer treatment is problematic for most GBM. Research to develop more effective sexual recovery, tailored to the needs of GBM treated for prostate cancer, is needed. Six implications for clinicians treating GBM with prostate cancer are identified.

Validation of depressive symptoms, social support, and minority stress scales among gay, bisexual, and other men who have with men (GBMSM) in Nigeria, Africa: a mixed methods approach

BACKGROUND

Gay, bisexual, and other men who have sex with men (GBMSM) in Nigeria experience social marginalization, discrimination and violence due to their sexual identity, which may negatively impact physical, mental, and sexual health outcomes. Studies on GBMSM in Africa utilize measurement scales developed largely for populations in the Global North. The validity and reliability of these instruments-to our knowledge-have never been thoroughly investigated among GBMSM in Nigeria. The aim of the current study was to determine the validity and reliability of the English versions of the Center for Epidemiologic Studies Depression Scale (CESD-R), Multidimensional Scale of Perceived Social Support (MSPSS), and LGBT Minority Stress Measure among a large multi-state sample of GBMSM Nigeria.

METHODS

Between January and June 2019, we conducted cognitive interviews (N = 30) and quantitative assessments (N = 406) with GBMSM in Nigeria. The cognitive interviews assessed comprehension of scale items and elicited suggestions for scale modifications. The quantitative assessment was used to gather psychosocial health data and to evaluate psychometric properties and construct validity of the modified scales. We utilized confirmatory factor analysis to assess factor structure, correlation coefficients, and Cronbach's alpha to examine scale validity and internal consistency.

RESULTS

Based on participant feedback from the cognitive interviews, we made slight modifications (i.e., culturally appropriate word substitutions) to all three scales. Results of quantitative analyses indicated good psychometric properties including high factor loadings, internal consistency and construct validity among the CESD-R, MSPSS, and LGBT Minority Stress Measure among GBMSM in Nigeria.

CONCLUSION

These results suggests that modifying research scales to be more culturally relevant likely do not jeopardize their validity and reliability. We found that modified scales measuring depressive symptoms, perceived social support, and minority stress among GBMSM in Nigeria remained valid. More research is needed to explore whether the psychometric properties remain if the scales are translated into broken English (Pidgin) and other traditional Nigerian languages (Yoruba, Igbo and Hausa).

Awareness of and intention to use an online sexually transmitted and blood-borne infection testing service among gay and bisexual men in British Columbia, two years after implementation

Objectives

This study assessed gay, bisexual, and other men who have sex with men’s (GBMSM) awareness of and intention to use GetCheckedOnline, an online sexually transmitted and blood-borne infection (STBBI) testing service.

Methods

A cross-sectional study was conducted two years after launch among GBMSM > 18 years of age in British Columbia, Canada. Participants were recruited through community venues, clinics, websites, and apps.

Results

Of 1272 participants, 32% were aware of GetCheckedOnline. Gay identity, regularly testing at an STBBI clinic, being out to one’s healthcare provider, attending GBMSM community venues, and frequent social media use were associated with awareness. Among participants who were aware but had not used GetCheckedOnline, knowing GetCheckedOnline users, using social media, not knowing where else to test, and not wanting to see a doctor were associated with intention to use GetCheckedOnline.

Conclusion

Early promotion of GetCheckedOnline resulted in greater awareness among those connected to GBMSM.

Very High HIV Incidence and Associated Risk Factors in a Longitudinal Cohort Study of Diverse Adolescent and Young Adult Men Who Have Sex with Men and Transgender Women

To report HIV incidence and associated factors among young men who have sex with men (YMSM) and transgender women (TW). Data were collected February 2015 to July 2018 in the RADAR longitudinal cohort study of YMSM/TW aged 16-29 years (N = 1093). Data included tests for HIV and rectal STIs and self-reported sexual behaviors and networks characteristics. HIV incidence rates were 2.91 per 100 person years (44 seroconversions among 1513 person years). Incidence was significantly higher in Black participants than white (IRR 8.81; 95% CI 2.72-45.26) and Latinx (IRR 3.15; 1.49-7.28) participants, but no significant differences by gender identity were found. Testing positive for rectal STIs (HR 2.50; 95% CI 1.27-4.92) and sex with a partner from a high HIV incidence community area (HR 2.46; 95% CI 1.19-5.07) were associated with higher incidence. HIV incidence was very high and Black YMSM/TW experienced higher HIV incidence attributable to partner race and geographic residence. Rectal STIs were associated with increased HIV incidence.