Police Harassment and Psychiatric, Sexual, and Substance Use Risk Among Black Sexual Minority Men and Black Transgender Women in the HIV Prevention Trials 061 Cohort

BACKGROUND

Black sexual minority men and Black transgender women (BSMM/BTW) experience disproportionate levels of HIV/STI-related risk factors as well as police harassment (PH). PH is linked to psychiatric risk and could play a role in substance use, sexual risk behavior, and HIV/STI risk.

METHODS

We used data from the HIV Prevention Trials Network 061(HPTN 061) study to examine associations between PH and HIV/STI-related outcomes. Using PH exposure measured at baseline and 6-month study visits, we examined an ordinal exposure (PH reported at both visits, PH reported at either visit, versus PH reported at neither baseline nor 6 months) and a binary exposure of persistent PH reported at both visits (yes versus no). We estimate risk ratios (RR) for associations between PH and depression, use of alcohol and methamphetamine, multiple partnerships, condomless sex, and syphilis.

RESULTS

Persistent PH (binary) was associated with a 20% or greater increase in the risk of depression (RR, 1.26 (1.07, 1.47)) and multiple partnerships (RR, 1.20 (1.05, 1.39)). There was evidence that ordinal PH was associated with elevated risk of alcohol use (RR, 1.17 (1.00, 1.36)); the point estimate for the association between persistent PH and alcohol use was similar but the imprecision was greater (RR, 1.16 (0.95, 1.42)).

CONCLUSION

PH may influence not only mental health but also behavioral risks that contribute to HIV/STI among BSMM/BTW, highlighting the potential wide-ranging and downstream effects of PH on health. Further research is required to confirm associations and elucidate pathways through which PH may influence HIV/STI among BSMM/BTW.

Impact of Decarceration Plus Alcohol, Substance Use, and Mental Health Screening on Life Expectancies of Black Sexual Minority Men and Black Transgender Women Living With HIV in the United States: A Simulation Study Based on HPTN 061

BACKGROUND

Given the disproportionate rates of incarceration and lower life expectancy (LE) among Black sexual minority men (BSMM) and Black transgender women (BTW) with HIV, we modeled the impact of decarceration and screening for psychiatric conditions and substance use on LE of US BSMM/BTW with HIV.

METHODS

We augmented a microsimulation model previously validated to predict LE and leading causes of death in the US with estimates from the HPTN 061 cohort and the Veteran's Aging Cohort Studies. We estimated independent associations among psychiatric and substance use disorders, to simulate the influence of treatment of one condition on improvement on others. We used this augmented simulation to estimate LE for BSMM/BTW with HIV with a history of incarceration under alternative policies of decarceration (ie, reducing the fraction exposed to incarceration), screening for psychiatric conditions and substance use, or both.

RESULTS

Baseline LE was 61.3 years. Reducing incarceration by 25%, 33%, 50%, and 100% increased LE by 0.29, 0.31, 0.53, and 1.08 years, respectively, versus no reductions in incarceration. When reducing incarceration by 33% and implementing screening for alcohol, tobacco, substance use, and depression, in which a positive screen triggers diagnostic assessment for all psychiatric and substance use conditions and linkage to treatment, LE increased by 1.52 years compared with no screening or decarceration.

DISCUSSION

LE among BSMM/BTW with HIV is short compared with other people with HIV. Reducing incarceration and improving screening and treatment of psychiatric conditions and substance use could substantially increase LE in this population.

Age Differences in the Associations Between Incarceration and Subsequent Substance Use, Sexual Risk-Taking, and Incident STI Among Black Sexual Minority Men and Black Transgender Women in the HIV Prevention Trials 061 Cohort

Incarceration can lead to different risk behaviors often due to increased distress and disruption of social networks. It is not well known, however, how these associations may differ by age. In this study, we measure age differences in longitudinal associations between incarceration and substance use, sex risk, and sexually transmitted infection (STI) among Black sexual minority men and Black transgender women (BSMM/BTW). We recruited BSMM/BTW from 2009 to 2011 that were part of the HIV Prevention Trials Network 061 study. We compared those less than 30 years old (n = 375) to those 30 years old or greater (n = 794) examining substance use, sex risk, and STI infection stratified by age. Logistic regression with inverse probability weighting was used for the statistical analysis. Approximately 59% of the sample reported incarceration history. In adjusted analysis, incarceration was more strongly associated with alcohol use and stimulant use among older individuals as was sexual risk behaviors including buying and selling sex. Concurrent partnerships were associated with the younger age groups. STI incidence was associated with younger individuals while associations with HIV infection were similar for the two age groups. Understanding differences in substance use and STI risk among age cohorts is imperative to the design and implementation of re-entry programs. Younger BSMM/BTW participating in re-entry support programs may benefit in particular from HIV/STI prevention and care efforts, while post-release substance abuse treatment and harm reduction programs should target older individuals with continued substance abuse.

Associations between police harassment and distrust in and reduced access to healthcare among Black sexual minority men: A longitudinal analysis of HPTN 061

OBJECTIVE

Evaluate associations between racialized and homophobia-based police harassment (RHBPH) and healthcare distrust and utilization among Black Sexual Minority Men (BSMM).

METHODS

We utilized data from a longitudinal cohort study from HIV Prevention Trials Network (HPTN) 061 with baseline, six and 12 month follow-up assessments. Using multivariable analysis, we evaluated associations between RHBPH and healthcare distrust and utilization reported at the 6 and 12 month visits.

RESULTS

Of 1553 BSMM present at baseline, 1160 were available at six-month follow-up. In multivariable analysis, increasing frequency of RHBPH was associated with increasing levels of distrust in healthcare providers (aOR 1.31, 95% CI: 1.00, 1.74) and missing 50% or more of healthcare visits at six-month follow-up (aOR 1.93, 95% CI: 1.09, 3.43).

CONCLUSIONS

Recent experiences of RHBPH are associated with reduced trust in and access to healthcare among BSMM, with more frequent RHBPH associated with greater vulnerability.

Multilevel Stigma and Its Associations with Medical Care Ratings Among Men Who Have Sex With Men in HPTN 078

INTRODUCTION

Our research assessed associations between stigma-related variables and medical care ratings among clients with HIV in HIV Prevention Trials Network (HPTN) 078 who were men who have sex with men (MSM).

METHODS

Logistic regression explored care ratings, stigma, socio-demographics (N = 637). Qualitative thematic coding and themes explored stigmatizing experiences in different settings (N = 111).

RESULTS

Whites were twice as likely as African-Americans to report high care ratings (P < .05). Clients who reported familial exclusion due to having sex with men were 40% less likely to report high medical care ratings (P < .05). Clients who agreed healthcare providers think people with HIV "sleep around" were half as likely to report high care ratings (P < .08). Stigmatization included "treating me like they'll catch HIV from my hand," and care avoidance so others didn't "know I was having sex with men".

CONCLUSIONS

Providers can promote African American MSM client retention with more affirming healthcare provision, namely minimizing assumptions and addressing identities and client needs beyond just HIV care.

The associations of incarceration and depression with healthcare experiences and utilization among Black men who have sex with men in HPTN 061

Associations of incarceration with healthcare access and utilization among Black sexual minority men (BSMM) and differences in association among those with and without pre-incarceration symptoms of depression were measured. Secondary analysis using survey data from the longitudinal cohort HIV Prevention Trials Network 061 study was conducted among 1553 BSMM from six major U.S. cities from 2009 to 2011. We used modified log-binomial regression with robust standard errors to estimate associations of incarceration (reported at 6 month follow-up) on next six-month healthcare utilization and access (reported at the 12 month follow-up). We tested the significance of baseline depressive symptoms by incarceration interaction and reported differences in associations when observed. Participants with a history of incarceration were more likely to have depressive symptoms at baseline compared to those without. Recent incarceration was associated with almost twice the risk of mistrust in healthcare providers and emergency room utilization. Among men reporting depressive symptoms, a history of incarceration was associated with almost tripled risk of reporting providers do not communicate understandably. Among those with depression, one in five reported a missed visit regardless of incarceration status.

Incarceration and Sexual Risk Behavior and Incident Sexually Transmitted Infection/HIV in HIV Prevention Trials Network 061: Differences by Study City and Among Black Sexual Minority Men Who Have Sex With Men, Black Sexual Minority Men Who Have Sex With Men and Women, and Black Transgender Women

BACKGROUND

Black sexual minority men (BSMM) and Black transgender women face a disproportionate risk of incarceration and sexually transmitted infection (STI)/HIV, yet research on the longitudinal association between incarceration and STI/HIV risk in these groups is limited.

METHODS

We used data from the HIV Prevention Trials Network (HPTN) 061 study conducted among BSMM and Black transgender women in Atlanta, Boston, Los Angeles, New York City, San Francisco, and Washington, DC, restricting analyses to those who returned for the 6-month follow-up visit when recent incarceration was measured (n = 1169). Using inverse probability of treatment weighting, we measured associations between incarceration and next 6-month multiple partnerships; selling or buying sex; condomless anal intercourse; and incident chlamydia, gonorrhea, syphilis, and HIV. We explored differences by study city, and among BSMM who had sex with men only, BSMM who had sex with men and women, and Black transgender women.

RESULTS

Approximately 14% reported past 6-month incarceration. Incarceration was associated with next 6-month selling sex (adjusted risk ratio [ARR], 1.80; 95% confidence interval [CI], 1.12-2.87) in the overall sample and multiple partnerships among BSMM who had sex with men and women (ARR, 1.34; 95% CI, 1.10-1.63) and transgender women (ARR, 1.77; 95% CI, 1.22-2.57). There is evidence suggesting that incarceration may predict gonorrhea (ARR, 2.35; 95% CI, 0.95-5.77), with particularly strong associations observed in Los Angeles (ARR, 6.48; 95% CI, 1.48-28.38).

CONCLUSIONS

Incarceration may increase STI/HIV risk among BSMM and Black transgender women. Additional mixed-methods research is needed to validate associations and understand pathways.

Pre-Exposure Prophylaxis (PrEP) Awareness Among Black Men Who Have Sex with Men with a History of Criminal Justice Involvement in Six U.S. Cities: Findings from the HPTN 061 Study

Transition from detention to the community for Black men who have sex with men with criminal justice involvement (BMSM-CJI) represents a particularly vulnerable period for HIV acquisition and transmission. We examined levels of HIV PrEP awareness among BMSM-CJI. PrEP awareness among BMSM-CJI was low (7.9%) with evidence of lower awareness levels among those with STI. There was evidence that HIV testing history was associated with higher PrEP awareness. Study findings highlight needs for further assessment of PrEP knowledge among BMSM-CJI. The strong association between HIV testing and PrEP awareness underscores an opportunity to integrate PrEP education within HIV/STI testing services.

Characterisation of social support following incarceration among black sexual minority men and transgender women in the HPTN 061 cohort study

OBJECTIVE

To examine longitudinal associations between recent incarceration and subsequent social support among black sexual minority men and transgender women, and whether associations differed between those who did and did not have support prior to incarceration.

DESIGN

A secondary analysis in 2020 of data from the HIV Prevention Trials Network 061, a cohort study of black sexual minority men and transgender women recruited in 2009-2010 and followed for 12 months.

SETTING

Six US cities (Atlanta, Boston, Los Angeles, New York City, San Francisco and Washington DC).

PARTICIPANTS

Individuals ≥18 years of age who identified as black, reported being male or assigned male at birth, reported ≥1 unprotected anal intercourse event with a male partner in the past 6 months, and reported on incarceration at the 6-month follow-up visit.

EXPOSURE

Having spent ≥1 night in jail/prison in the past 6 months reported at the 6-month follow-up visit.

OUTCOME

Social support measured using a six-item scale assessing frequency of emotional/informational, affectionate and tangible support (range 6-30); and dichotomous indicators of low support for each item (ie, receiving that form of support none/little of the time).

RESULTS

Among participants who returned for the 6-month visit (N=1169), 14% had experienced incarceration in the past 6 months. Mean support score was 20.9; 18.9 among those with recent incarceration versus 21.2 among those without. Recent incarceration predicted lower support (adjusted β -2.40, 95% CI -3.94 to -0.85). Those recently incarcerated had increased risk of lacking emotional/informational (eg, no one to talk to adjusted risk ratio (aRR) 1.55, 95% CI 1.13 to 2.13) and affectionate (aRR 1.51, 95% CI 1.11 to 2.04) but not tangible support. Effects appeared somewhat stronger among those who had support at baseline.

CONCLUSIONS

Incarceration may reduce support on re-entry among black sexual minority men and transgender women, populations unequally targeted for incarceration and at risk for low support.

Lifetime Burden of Incarceration and Violence, Internalized Homophobia, and HIV/STI Risk Among Black Men Who Have Sex with Men in the HPTN 061 Study

Black men who have sex with men (BMSM) have disproportionate HIV/STI acquisition risk. Incarceration may increase exposure to violence and exacerbate psychosocial vulnerabilities, including internalized homophobia, which are associated with HIV/STI acquisition risk. Using data from HIV Prevention Trials Network 061 (N = 1553), we estimated adjusted prevalence ratios (APR) and 95% confidence intervals (CIs) for associations between lifetime burden of incarceration and HIV/STI risk outcomes. We measured associations between incarceration and HIV/STI risk outcomes with hypothesized mediators of recent violence victimization and internalized homophobia. Compared to those never incarcerated, those with 3-9 or ≥ 10 incarcerations had approximately 10% higher prevalence of multiple partnerships. Incarceration burden was associated with selling sex (1-2 incarcerations: APR: 1.52, 95% CI 1.14-2.03; 3-9: APR: 1.77, 95% CI 1.35-2.33; ≥ 10: APR: 1.85, 95% CI 1.37-2.51) and buying sex (≥ 10 incarcerations APR: 1.80, 95% CI 1.18-2.75). Compared to never incarcerated, 1-2 incarcerations appeared to be associated with current chlamydia (APR: 1.47, 95% CI 0.98-2.20) and 3-9 incarcerations appeared to be associated with current syphilis (APR: 1.46, 95% CI 0.92-2.30). Incarceration was independently associated with violence, which in turn was a correlate of transactional sex. Longitudinal research is warranted to clarify the role of incarceration in violence and HIV/STI risk in this population.

Longitudinal Associations between Police Harassment and Experiences of Violence among Black Men Who Have Sex with Men in Six US Cities: the HPTN 061 Study

Interactions with the police may result in police brutality, particularly for people of color. Black men who have sex with men (BMSM) face disproportionate risk of police contact and may experience elevated violence risk. We measured longitudinal associations between discriminatory police harassment (DPH) and subsequent risk of a range of interpersonal violence experiences, including intimate partner violence (IPV). In this study, we estimated associations between DPH motivated by racism, homophobia, or both, and subsequent violent experiences (being physically harassed, hit, threatened with weapons, and intimate partner violence) among BMSM. Bivariate and multivariable regression analyses were used to control for demographic and behavioral factors. Among 1160 BMSM included at 12-month follow-up, experiencing DPH motivated by racism and homophobia was associated with over four times the odds of being threatened with violence (AOR 4.85, 95% CI 3.20, 7.33), four times the odds of or experiencing violence defined as being punched, kicked, or beaten, or having an object thrown at them (AOR 4.51, 95% CI 2.82, 7.19), and nearly three times the odds of physical partner abuse (AOR 3.49, 95% CI 1.69, 7.19). Findings suggest that for BMSM, DPH is associated with the threat and experience of violence, with a dose-response relationship between DPH motivated by one or more causes. Given that BMSM are a population particularly vulnerable to both police harassment related to race and sexual orientation and violence coupled with stigma, additional research evaluating mechanisms linking these associations is needed in order to develop additional supportive interventions.

Estimating the Roles of Racism and Homophobia in HIV Testing Among Black Sexual Minority Men and Transgender Women With a History of Incarceration in the HPTN 061 Cohort

Black sexual minority men (BSMM) and Black transgender women (BTW) have disproportionately high HIV prevalence, making HIV testing critical for treatment and prevention. Racism and homophobia may be barriers to testing among BSMM/BTW, particularly in the context of previous incarceration. We analyzed a subsample (n = 655) of HIV-negative, previously incarcerated BSMM/BTW in the HIV Prevention Trials Network 061 study, generating prevalence ratios and interaction terms testing associations between experienced racism and homophobia with past-year HIV testing. Both racism (aPR = 0.83, 95% CI [0.70, 0.98]) and homophobia (aPR: 0.68, 95% CI [0.48, 0.98]) were associated with lower testing, although their interaction was associated with unexpectedly higher testing (Interaction aPR = 1.77, 95% CI [1.25, 2.49]). Among BSMM/BTW with a history of incarceration, racism and homophobia are barriers to HIV testing. Positive interactions between racism and homophobia could be explained by numerous factors (e.g., resilience, coping) and warrants further study.

Police harassment and psychosocial vulnerability, distress, and depressive symptoms among black men who have sex with men in the U.S.: Longitudinal analysis of HPTN 061

The mental health impact of exposure to police harassment is understudied, particularly among Black men who have sex with men (BMSM), a group at elevated risk of exposure to such discrimination. This study aimed to identify the associations among BMSM between recent police harassment and psychosocial vulnerability, psychological distress, and depression measured six months later. Data come from the HIV Prevention Trials Network (HPTN) 061 Study, a cohort study of BMSM recruited in 6 U.S. cities (Atlanta, GA, Boston, MA, Los Angeles, CA, New York, NY, San Francisco, CA, and Washington DC). Participants completed baseline, 6-month follow-up, and 12-month follow-up interviews. A convenience sample of 1553 BMSM was recruited between July 2009 and October 2010 of whom 1155 returned for a follow-up interview 12 months later. Accounting for previous police interaction, poverty, psychopathology, drug use, and alcohol use, we estimated associations between recent police harassment reported at the 6 month follow-up interview and 12 month outcomes including psychosocial vulnerability (elevated racial/sexual identity incongruence), psychological distress (being distressed by experiences of racism and/or homophobia), and depression. About 60% of men reported experiencing police harassment between the baseline and 6-month interview due to their race and/or sexuality. Adjusted analyses suggested police harassment was independently associated with a 10.81 (95% CI: 7.97, 13.66) point increase and 8.68 (95% CI: 6.06, 11.30) point increase in distress due to experienced racism and distress due to experienced homophobia scores, respectively. Police harassment perceived to be dually motivated predicted disproportionate levels of distress. Police harassment is prevalent and associated with negative influences on psychosocial vulnerability and psychological distress among BMSM. Reducing exposure to police harassment may improve the psychosocial health of BMSM.

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We examine the impact of police harassment on Black men who have sex with men.

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Data from the HPTN 061 Study show that police harassment is highly prevalent.

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Police harassment is associated with psychosocial vulnerability.

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Police harassment is associated with psychological distress.

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Harassment motivated by racism and homophobia is associated with added distress.

Disclosure of HIV Status and HIV Sexual Transmission Behaviors among HIV-Positive Black Men Who Have Sex with Men in the BROTHERS (HPTN 061) Study

We assessed whether disclosure of HIV status is significantly associated with reported HIV sexual risk behaviors among HIV positive Black/African American men who have sex with men (MSM) (Black MSM) in six cities in the USA. Participants from the BROTHERS (HIV Prevention Trials Network [HPTN 061]) study focused on assessing the feasibility and acceptability of a multifaceted HIV prevention intervention to reduce HIV infections among Black MSM enrolled between July 2009 and October 2010. All participants completed a behavioral assessment using an audio computer-assisted self-interview that included questions about HIV status disclosure, HIV sexual risk behaviors, and other behaviors. Biological samples were also collected. This analysis focused on baseline data of HIV-positive Black MSM in the HPTN 061 study. Of the 143 HIV-positive Black MSM (majority ≥ 35 years of age) included in this analysis, 58% reported disclosing their HIV status to their last male anal sex partner. Forty-three percent and 42% reported condomless insertive and receptive anal intercourse respectively with their last male partner; whereas, 17% and 18% of the sample engaged in condomless insertive and receptive anal intercourse with a serodiscordant/unknown status partner, respectively. In multivariable logistic regression models, there was no statistically significant association between HIV status disclosure and condomless insertive anal intercourse (aOR = 0.35, 95% CI 0.11, 1.08; p = 0.30), condomless receptive anal intercourse (aOR = 2.48, 95% CI 0.94, 6.52; p = 0.20), or condomless receptive anal intercourse with a serodiscordant/unknown status partner (aOR = 0.55, 95% CI 0.20, 1.49; p = 0.45). However, HIV status disclosure was significantly associated with lower odds of reporting condomless insertive anal intercourse with a serodiscordant/unknown status partner (aOR = 0.19, 95% CI 0.06, 0.68; p ≤ 0.01). Among this multi-city sample of HIV-positive Black MSM, disclosure of HIV status was common and associated with lower HIV sexual risk behaviors. These findings should motivate and guide research to develop prevention messages to increase HIV status disclosures.

Pre-exposure prophylaxis initiation and adherence among Black men who have sex with men (MSM) in three US cities: results from the HPTN 073 study

INTRODUCTION

Randomized clinical trials have demonstrated the efficacy of antiretroviral pre-exposure prophylaxis (PrEP) in preventing HIV acquisition among men who have sex with men (MSM). However, limited research has examined initiation and adherence to PrEP among Black MSM (BMSM) in the United States (US) who are disproportionately represented among newly HIV infected and late to care individuals. This research reports on the HIV Prevention Trials Network 073 (HPTN 073) study aimed to examine PrEP initiation, utilization and adherence among Black MSM utilizing the theoretically principled, culturally informed and client-centered care coordination (C4) model.

METHODS

The HPTN 073 study enrolled and followed 226 HIV-uninfected Black MSM in three US cities (Los Angeles, CA; Washington DC; and Chapel Hill, NC) from February 2013 through September 2015. Study participants were offered once daily oral emtricitabine/tenofovir (FTC/TDF) PrEP combined with C4 and followed up for 52 weeks. Participants received HIV testing, risk reduction education and clinical monitoring.

RESULTS

Of the 226 men enrolled, 178 participants initiated PrEP (79%), and of these 64% demonstrated PrEP utilization at week 26 (mid-point of the study) based on pharmacokinetic testing. Condomless anal sex with an HIV-infected or unknown status casual male partner was statistically significantly associated with a greater likelihood of PrEP initiation (adjusted odds ratio (OR) 4.4, 95% confidence interval (CI) 1.7, 11.7). Greater age (≥25 vs. <25, OR 2.95, 95% CI 1.37 -6.37), perception of having enough money (OR 3.6, 95% CI 1.7 to 7.7) and knowledge of male partner taking PrEP before sex (OR 2.22, 95% CI 1.03 to 4.79) were statistically significantly associated with increased likelihood of PrEP adherence at week 26. Annualized HIV incidence was 2.9 (95% CI 1.2 to 7.9) among those who initiated PrEP, compared to 7.7 (95% CI 2.5 to 24.1) among those who did not initiate PrEP (p = 0.18).

CONCLUSIONS

Results suggest a high level of PrEP initiation among at-risk Black MSM, a group historically characterized as hard to reach. The data support the importance of addressing contextual factors that affect PrEP initiation and adherence, and of additional research on the ultimate benefit of PrEP in HIV prevention among Black MSM.

The Association Between Condomless Anal Sex and Social Support Among Black Men Who Have Sex With Men (MSM) in Six U.S. Cities: A Study Using Data from the HIV Prevention Trials Network BROTHERS Study (HPTN 061)

We assessed how egocentric (i.e., self-generated descriptions of a person's social contacts) network structure and composition corresponded with reported instances of condomless receptive and insertive anal intercourse with men who were reportedly HIV-infected or of unknown HIV serostatus in a sample of black men who have sex with men (MSM) in six U.S. cities. Ratings showing a higher percentage of network members who provided social participation and medical support were positively associated with reporting condomless sex. There were also significant positive associations between stimulant use and condomless insertive and receptive anal sex. Future research should examine the social processes that underlie these associations and explore ways that social support can affect HIV prevention efforts for black MSM.

Sex Trade and Health Care Utilization Among People Living with HIV/AIDS

People living with HIV/AIDS (PLWH) are more likely to have a history of trading sex, but little research has examined whether trading sex is associated with lower health care utilization amongst PLWH. This study assesses this association with PLWH (N = 583) recruited and surveyed from seven community sites in six US cities participating in a multi-site community-based HIV test and treat initiative. Participants were 90.6% Black or Latino, 30.4% homeless, and 9.0% (1 in 11) sold sex (past 90 days). Most reported receiving HIV clinical care (63.9%, past 6 months) and HIV case management (68.9%, past year), but 35.7% reported a missed health care appointment (past 3 months). In adjusted regression models, trading sex was associated with a missed health care appointment (OR = 2.44) and receiving psychological assistance (OR = 2.31), past 90 days, but not receipt of HIV care or supportive HIV services. Trading sex may compromise consistent health care utilization among PLWH.

A Longitudinal Analysis of Treatment Optimism and HIV Acquisition and Transmission Risk Behaviors Among Black Men Who Have Sex with Men in HPTN 061

Little is known about HIV treatment optimism and risk behaviors among Black men who have sex with men (BMSM). Using longitudinal data from BMSM in the HPTN 061 study, we examined participants' self-reported comfort with having condomless sex due to optimistic beliefs regarding HIV treatment. We assessed correlates of treatment optimism and its association with subsequent risk behaviors for HIV acquisition or transmission using multivariable logistic regression with generalized estimating equations. Independent correlates of treatment optimism included age ≥35 years, annual household income <$20,000, depressive symptoms, high HIV conspiracy beliefs, problematic alcohol use, and previous HIV diagnosis. Treatment optimism was independently associated with subsequent condomless anal sex with a male partner of serodiscordant/unknown HIV status among HIV-infected men, but this association was not statistically significant among HIV-uninfected men. HIV providers should engage men in counseling conversations to assess and minimize willingness to have condomless sex that is rooted in optimistic treatment beliefs without knowledge of viral suppression.

Relation of Childhood Sexual Abuse, Intimate Partner Violence, and Depression to Risk Factors for HIV Among Black Men Who Have Sex With Men in 6 US Cities

OBJECTIVES

We assessed the relation of childhood sexual abuse (CSA), intimate partner violence (IPV), and depression to HIV sexual risk behaviors among Black men who have sex with men (MSM).

METHODS

Participants were 1522 Black MSM recruited from 6 US cities between July 2009 and December 2011. Univariate and multivariable logistic regression models were used.

RESULTS

Participants reported sex before age 12 years with someone at least 5 years older (31.1%), unwanted sex when aged 12 to 16 years (30%), IPV (51.8%), and depression (43.8%). Experiencing CSA when aged 12 to 16 years was inversely associated with any receptive condomless anal sex with a male partner (adjusted odds ratio [AOR] = 0.50; 95% confidence interval [CI] = 0.29, 0.86). Pressured or forced sex was positively associated with any receptive anal sex (AOR = 2.24; 95% CI = 1.57, 3.20). Experiencing CSA when younger than 12 years, physical abuse, emotional abuse, having been stalked, and pressured or forced sex were positively associated with having more than 3 male partners in the past 6 months. Among HIV-positive MSM (n = 337), CSA between ages 12 and 16 years was positively associated with having more than 3 male partners in the past 6 months.

CONCLUSIONS

Rates of CSA, IPV, and depression were high, but associations with HIV sexual risk outcomes were modest.

Seroadaptation in a sample of very poor Los Angeles area men who have sex with men

Data from 635 very poor men who have sex with men (MSM) were used to identify seroadaptation with 1,102 male partners reported between 2005 and 2007 in Los Angeles as part of the Sexual Acquisition and Transmission of HIV Cooperative Agreement Program. The mean age of the sample was 41.7 years; 53 % had experienced homelessness in the past year. Condoms were reported in 51 % of sexual events involving anal intercourse. HIV seroconcordance was reported in 41 % of sexual partnerships among HIV-positive participants. HIV-positive men were more likely to have oral-only or unprotected receptive anal intercourse and less likely to have unprotected insertive anal intercourse with HIV-negative or unknown partners compared to HIV-positive partners. Even in the face of poverty, HIV-positive MSM report mitigating risks of HIV-transmission though seroadaptation in the context of modest rates of condom use.

Bridging sexual boundaries: men who have sex with men and women in a street-based sample in Los Angeles

The purpose of the study was to determine the potential contribution of bisexual men to the spread of HIV in Los Angeles. We compare the characteristics and behaviors of men who have sex with men and women (MSMW) to men who have sex with only women (MSW) and men who have sex with only men (MSM) in Los Angeles. Men (N = 1,125) who participated in one of the two waves of data collection from 2005 to 2007 at the Los Angeles site for NIDA's Sexual Acquisition and Transmission of HIV-Cooperative Agreement Program were recruited using Respondent Driven Sampling. Participants completed Audio Computer Assisted Self Interviews and received oral HIV rapid testing with confirmatory blood test by Western Blot and provided urine specimens for detection of recent powder cocaine, crack cocaine, methamphetamine, or heroin use. MSM, MSW, or MSMW were defined by the gender of whom they reported sex with in the past 6 months. Chi-square tests and ANOVAs were used to test independence between these groups and demographic characteristics, substance use, and sexual behaviors. We fit generalized linear random intercept models to predict sexual risk behaviors at the partner level. Men were mostly of low income, unemployed, and minority, with many being homeless; 66% had been to jail or prison, 29% had ever injected drugs, and 25% had used methamphetamine in the past 30 days. The sample had high HIV prevalence: 12% of MSMW, 65% of MSM, and 4% of MSW. MSMW were behaviorally between MSW and MSM, except that more MSMW practiced sex for trade (both receiving and giving), and more MSMW had partners who are drug users than MSW. Generalized linear random intercept models included a partner-level predictor with four partner groups: MSM, MSMW-male partners, MSMW-female partners, and MSW. The following were significantly associated with unprotected anal intercourse (UAI): MSW (AOR 0.15, 95% CI 0.08, 0.27), MSMW-female partners (AOR 0.4, 95% CI 0.27, 0.61), HIV-positive partners (AOR 2.03, 95% CI 1.31, 3.13), and being homeless (AOR 1.37, 95% CI 1.01, 1.86). The factors associated with giving money or drugs for sex were MSMW-female partners (AOR 1.70, 95% CI 1.09, 2.65), unknown HIV status partners (AOR 1.72, 95% CI 1.29, 2.30), being older (AOR 1.02, 95% CI 1.00, 1.04), history of incarceration (AOR 1.64, 95% CI 1.17, 2.29), and being homeless (AOR 1.73, 95% CI 1.27, 2.36). The following were associated with receiving money or drugs for sex: MSW (AOR 0.53, 95% CI 0.32, 0.89), African American (AOR 2.42, 95% CI 1.56, 3.76), Hispanic (AOR 1.85, 95% CI 1.12, 3.05), history of incarceration (AOR 1.44, 95% CI 1.04, 2.01), history of injecting drugs (AOR 1.57, 95% CI 1.13, 2.19), and had been recently homeless (AOR 2.14, 95% CI 1.57, 2.94). While overall HIV-positive MSM had more UAI with partners of any HIV status than MSMW with either partner gender, among HIV-positive MSMW, more had UAI with HIV-negative and HIV status unknown female partners than male partners. Findings highlight the interconnectedness of sexual and drug networks in this sample of men-as most have partners who use drugs and they use drugs themselves. We find a concentration of risk that occurs particularly among impoverished minorities-where many men use drugs, trade sex, and have sex with either gender. Findings also suggest an embedded core group of drug-using MSMW who may not so much contribute to spreading the HIV epidemic to the general population, but driven by their pressing need for drugs and money, concentrate the epidemic among men and women like themselves who have few resources.

Homonegativity, substance use, sexual risk behaviors, and HIV status in poor and ethnic men who have sex with men in Los Angeles

This study evaluates associations between internalized homonegativity and demographic factors, drug use behaviors, sexual risk behaviors, and HIV status among men who have sex with men (MSM) and with men and women (MSM/W). Participants were recruited in Los Angeles County using respondent-driven sampling (RDS) and completed the Internalized Homonegativity Inventory (IHNI) and questionnaires on demographic and behavioral factors. Biological samples were tested for HIV and for recent cocaine, methamphetamine, and heroin use. The 722 MSM and MSM/W participants were predominantly African American (44%) and Hispanic (28%), unemployed (82%), homeless (50%), and HIV positive (48%) who used drugs in the past 6 months (79.5%). Total and Personal Homonegativity, Gay Affirmation, and Morality of Homosexuality IHNI scores were significantly higher for African American men than for other ethnicities, for MSM/W than for MSM, for recent cocaine users than for recent methamphetamine users, and for HIV-seronegative men than for HIV-seropositive men. Linear regression showed the Gay Affirmation scale significantly and inversely correlated with the number of sexual partners when controlling for effects of ethnicity/race and sexual identification, particularly for men who self-identified as straight. Highest IHNI scores were observed in a small group of MSM/W (n = 62) who never tested for HIV. Of these, 26% tested HIV positive. Findings describe ways in which internalized homophobia is a barrier to HIV testing and associated HIV infection and signal distinctions among participants in this sample that can inform targeted HIV prevention efforts aimed at increasing HIV testing.

Factors associated with HIV viral load in a respondent driven sample in Los Angeles

This study used a modified version of the Behavioral Model for Vulnerable Populations to examine the predisposing, enabling, and need factors associated with detectable viral load (VL). HIV status was measured using saliva and confirmed by blood. Of 797 persons enrolled, 193 were HIV positive and provided VL counts. A hierarchical multivariate logistic regression approach demonstrated that the predisposing factors of homelessness and recent substance abuse, particularly methamphetamine abuse, had a negative association with VL. The negative association of homelessness on VL was weakened with the introduction of enabling and need utilization factors. Mediation analysis indicated homelessness and HIV medication taking significantly associated with methamphetamine use as a predictor of detectable viral load. Guided policy to address substance abuse among those who are HIV positive is needed to improve biological outcomes.

Behavioral treatment approaches for methamphetamine dependence and HIV-related sexual risk behaviors among urban gay and bisexual men

BACKGROUND

Methamphetamine-dependent gay and bisexual men (GBM) are at high risk for HIV transmission, largely due to drug-associated sexual risk behaviors. This project evaluated the efficacy of four behavioral drug abuse treatments for reducing methamphetamine use and sexual risk behaviors among this population.

METHODS

In this randomized controlled trial, 162 methamphetamine-dependent (SCID-verified) GBM in Los Angeles County were randomly assigned to one of four treatment conditions for 16 weeks: standard cognitive behavioral therapy (CBT, n=40), contingency management (CM, n=42), combined cognitive behavioral therapy and contingency management (CBT+CM, n=40), and a culturally tailored cognitive behavioral therapy (GCBT, n=40). Stimulant use was assessed thrice-weekly during treatment using urine drug screens (48 measures). Sexual risk behaviors were monitored monthly (four measures). Follow-up assessments were conducted at 6 (80.0%) and 12 months (79.9%).

RESULTS

Statistically significant differences in retention (F(3,158)=3.78, p<.02), in longest period of consecutive urine samples negative for methamphetamine metabolites (F(3,158)=11.80, p<.001), and in the Treatment Effectiveness Score were observed by condition during treatment (F(3,158)=7.35, p<.001) with post hoc analyses showing the CM and CBT+CM conditions to perform better than standard CBT. GEE modeling results showed GCBT significantly reduced unprotected receptive anal intercourse (URAI) during the first 4 weeks of treatment (X2=6.75, p<.01). During treatment between-group differences disappeared at follow-up with overall reductions in outcomes sustained to 1-year.

CONCLUSIONS

Among high-risk methamphetamine-dependent GBM, drug abuse treatments produced significant reductions in methamphetamine use and sexual risk behaviors. Drug abuse treatments merit consideration as a primary HIV prevention strategy for this population.