Explaining disparities in HIV infection among black and white men who have sex with men: a meta-analysis of HIV risk behaviors

History of arrest and associated factors among men who have sex with men

Incarceration has been proposed to be a driving factor in the disproportionate impact of HIV in African-American communities. However, few data have been reported on disparities in criminal justice involvement by race among men who have sex with men (MSM). To describe history of arrest and associated factors among, we used data from CDC's National HIV Behavioral Surveillance system. Respondents were recruited by time-space sampling in venues frequented by MSM in 15 US cities from 2003 to 2005. Data on recent arrest (in the 12 months before the interview), risk behaviors, and demographic information were collected by face-to-face interview for MSM who did not report being HIV-positive. Six hundred seventy-nine (6.8%) of 10,030 respondents reported recent arrest. Compared with white MSM, black MSM were more likely to report recent arrest history (odds ratio (OR), 1.6; 95% confidence interval (CI), 1.3-2.1). Men who were less gay-identified (bisexual [OR, 1.5; 95% CI, 1.1-1.9] or heterosexual [OR, 2.0; 95% CI, 1.2-3.5]) were more likely to report recent arrest than homosexually identified men. In addition, men who reported arrest history were more likely to have used non-injection (OR, 3.0; 95% CI, 2.4-3.6) and injection (OR, 4.7; 95%, 3.3-6.7) drugs, exchanged sex (OR, 2.7; 95% CI, 2.1-3.4), and had a female partner (OR, 1.5; 95% CI, 1.2-2.0) in the 12 months before interview. Recent arrest was associated with insertive unprotected anal intercourse in the 12 months before interview (OR, 1.4; 95% CI, 1.2-1.7). Racial differences in arrest seen in the general US population are also present among MSM, and history of arrest was associated with high-risk sex. Future research and interventions should focus on clarifying the relationship between criminal justice involvement and sexual risk among MSM, particularly black MSM.

Age of MSM sexual debut and risk factors: results from a multisite study of racial/ethnic minority YMSM living with HIV

The average reported age of sexual debut for youth in the United States is 14.4 years, with approximately 7% reporting their sexual debut prior to age 13. While the research literature on sexual debut for youth addresses gender and ethnic differences (with males and African-American youth experiencing earlier sexual debut), there is limited data regarding factors associated with sexual debut for young men who have sex with men (YMSM). Early sexual debut poses potential health risks, such as contracting HIV with an increased risk of unprotected intercourse. Given current high HIV infection rates for racial/ethnic minority YMSM, learning more about their sexual debuts and associated risk factors of this population is of great importance. This study investigated risk behaviors and emotional distress, and their association with MSM sexual debut for a multisite cohort of racial/ethnic minority YMSM living with HIV. We hypothesized that a MSM sexual debut younger than age 16 would be associated with engagement in more high-risk sexual behaviors (unprotected sex and exchange sex), substance use, and emotional distress than a MSM sexual debut at age 16 or older. Results indicated that participants having a MSM sexual debut before the age of 16 reported more exchange sex; drug use (specifically marijuana); emotional/psychological problems related to substance use; and a history of suicide attempts, compared to participants with later MSM sexual debuts. Comprehensive interventions that are racially/ethnically sensitive, inquire about initial sexual experiences, and focus on sexual health and healthy relationships are needed to improve health outcomes for this population.

Sexual partner characteristics, serodiscordant/serostatus unknown unprotected anal intercourse and disclosure among human immunodeficiency virus-infected and uninfected black men who have sex with men in New York City

OBJECTIVES

Black men who have sex with men (MSM) are disproportionately infected with human immunodeficiency virus (HIV) in the United States. This study describes sexual partner characteristics and disclosure of HIV serostatus and evaluates factors associated with sexual risk behaviors during last sex among black MSM.

DESIGN AND METHODS

Between 2008 and 2009, 328 black MSM who reported recent unprotected anal intercourse were enrolled in an HIV behavioral intervention study in New York City. Factors associated with serodiscordant/serostatus unknown UAI (defined as having UAI with a partner of different or unknown HIV serostatus) with a male partner during last sex were assessed using logistic regression.

RESULTS

A total of 205 HIV-infected and 123 uninfected men were enrolled in this study. Almost all men (91.6%) reported having a black male partner during last sex. About half (47.3%) of men used alcohol and 38.7% used other substances before or during last sex. About two-thirds (68.8%) of participants disclosed their HIV status to their last sex partner, while 57.2% of partners disclosed. In multivariate analysis, meeting a partner on the internet or chat line was associated with serodiscordant/serostatus unknown UAI during last sex among HIV-infected men. The only factor associated with serodiscordant/serostatus unknown UAI during last sex among HIV-uninfected men was the partner being a non-main partner.

CONCLUSIONS

A significant proportion of black MSM in this study did not disclose their HIV status. Our data highlight the need for more data on dyadic variables and sexual risk behaviors among black MSM, as well as interventions to encourage communication between partners.

Understanding disparities in HIV infection between black and white MSM in the United States

OBJECTIVE

We evaluated several hypotheses for disparities in HIV infection between black and white MSM in the United States, including incarceration, partner HIV status, circumcision, sexual networks, and duration of infectiousness.

DESIGN

The 2008 National HIV Behavioral Surveillance System (NHBS), a cross-sectional survey conducted in 21 US cities.

METHODS

MSM were interviewed and tested for HIV infection. For MSM not previously diagnosed with HIV infection, we used logistic regression to test associations between newly diagnosed HIV infection and incarceration history, partner HIV status, circumcision status, and sexual networks (older partners, concurrency, and partner risk behaviors). For HIV-infected MSM, we assessed factors related to duration of infectiousness.

RESULTS

Among 5183 MSM not previously diagnosed with HIV infection, incarceration history, circumcision status, and sexual networks were not independently associated with HIV infection. Having HIV-infected partners [adjusted odds ratio (AOR) = 1.9, 95% confidence interval (CI) = 1.2–3.0] or partners of unknown status (AOR = 1.4, CI = 1.1–1.7) were associated with HIV infection. Of these two factors, only one was more common among black MSM – having partners of unknown HIV status. Among previously diagnosed HIV-positive MSM, black MSM were less likely to be on antiretroviral therapy (ART).

CONCLUSION

Less knowledge of partner HIV status and lower ART use among black MSM may partially explain differences in HIV infection between black and white MSM. Efforts to encourage discussions about HIV status between MSM and their partners and decrease barriers to ART provision among black MSM may decrease transmission.

Linkage and retention in HIV care among men who have sex with men in the United States

Men who have sex with men (MSM) continue to be disproportionately affected by human immunodeficiency virus (HIV) infection. While the MSM population does better than other HIV infection risk groups with regard to linkage to and retention in care, little is known about engagement in care outcomes for important subpopulations of MSM. There is also a dearth of research on engagement in care strategies specific to the MSM population. Key MSM subpopulations in the United States on which to focus future research efforts include racial/ethnic minority, young, and substance-using MSM. Health care systems navigation may offer a promising engagement in care strategy for MSM and should be further evaluated. As is the case for HIV-infected populations in general, future research should also focus on identifying the best metrics for measuring engagement in care.

A plausible causal model of HAART-efficacy beliefs, HIV/AIDS complacency, and HIV-acquisition risk behavior among young men who have sex with men

Despite considerable research, the causal relationship remains unclear between HIV/AIDS complacency, measured as reduced HIV/AIDS concern because of highly active antiretroviral therapy (HAART), and HIV risk behavior. Understanding the directionality and underpinnings of this relationship is critical for programs that target HIV/AIDS complacency as a means to reduce HIV incidence among men who have sex with men (MSM). This report uses structural equation modeling to evaluate a theory-based, HIV/AIDS complacency model on 1,593 MSM who participated in a venue-based, cross-sectional survey in six U.S. cities, 1998-2000. Demonstrating adequate fit and stability across geographic samples, the model explained 15.0% of the variance in HIV-acquisition behavior among young MSM. Analyses that evaluated alternative models and models stratified by perceived risk for HIV infection suggest that HIV/AIDS complacency increases acquisition behavior by mediating the effects of two underlying HAART-efficacy beliefs. New research is needed to assess model effects on current acquisition risk behavior, and thus help inform prevention programs designed to reduce HIV/AIDS complacency and HIV incidence among young MSM.

A way forward: the National HIV/AIDS Strategy and reducing HIV incidence in the United States

In July 2010, the Obama Administration released a National HIV/AIDS Strategy for the United States to refocus national attention on responding to the domestic HIV epidemic. The goals of the strategy are to reduce HIV incidence; to increase access to care and optimize health outcomes among people living with HIV; and to reduce HIV-related disparities. The strategy identifies a small number of action steps that will align efforts across federal, state, local, and tribal levels of government, and maximally impact the domestic HIV epidemic. In this article, we outline key programmatic and research issues that must be addressed to accomplish the prevention goals of the National HIV/AIDS Strategy.

Lower HIV prevalence among Asian/Pacific Islander men who have sex with men: a critical review for possible reasons

We conducted a critical literature review for possible reasons that may explain the lower HIV prevalence observed among API MSM compared to MSM of other races/ethnicities. Trends emerging from the literature suggest that traditional individual-level factors-unprotected anal intercourse, substance use, STD prevalence, rates and frequency of HIV testing, and utilization of HIV prevention services-do not appear to be related to the lower HIV prevalence among API MSM. Some evidence suggests that socio-cultural and structural factors might be the more critical forces in determining racial/ethnic disparities of HIV among MSM. For API MSM, these factors include structures of sexual networks, access to and reception of medical care and treatment among HIV-positive MSM, and influences of different levels and types of acculturation. Moreover, emerging risk reduction strategies, such as seroadaptive behaviors, could play a role. Future research should address these factors in intervention design. In addition, better theories of resilience and measurement of strengths and protective factors are needed to enhance the efficacy of HIV interventions.

Number of casual male sexual partners and associated factors among men who have sex with men: results from the National HIV Behavioral Surveillance system

BACKGROUND

In 2006, the majority of new HIV infections were in MSM. We sought to describe numbers of casual sex partners among US MSM.

METHODS

Data are from the first MSM cycle of the National HIV Behavioral Surveillance system, conducted from 2003 to 2005. Relationships between number of casual male sex partners within the previous year and demographic information, self-reported HIV status, and risk behaviors were determined through regression models.

RESULTS

Among 11,191 sexually active MSM, 76% reported a casual male partner. The median casual partner number was three. Lower number of casual partners was associated with black race, Hispanic ethnicity, and having a main sex partner in the previous year. Factors associated with a higher number included gay identity, exchange sex, both injection and non-injection drug use. Being HIV-positive was associated with more partners among non-blacks only. Age differences in partner number were seen only among chat room users.

CONCLUSIONS

MSM who were black, Hispanic or had a main sex partner reported fewer casual sex partners. Our results suggest specific populations of MSM who may benefit most from interventions to reduce casual partner numbers.

High HIV prevalence and diagnosis rates in New York City black men

We sought to identify population and subpopulation disparities in rates of HIV diagnosis and prevalence among black males 13 years and older in New York City. We used population-based data from the New York City HIV/AIDS surveillance registry and US Census 2000 to calculate HIV prevalence in 2006 and HIV diagnosis rates in 2007. Black males were the largest demographic group of new HIV diagnoses (n = 1,161, 33%) and persons living with HIV/AIDS in New York City (n = 24,294, 29%) and had the highest diagnosis rates (1.7 per 1,000 population) and prevalence (3.7%). Prevalence and diagnosis rates among black males were higher in higher-poverty neighborhoods than in lower-poverty neighborhoods (p < 0.01). However, very high prevalence (19.3%) was found among black males in three adjacent Manhattan neighborhoods with relatively low poverty rates, and where overall diagnosis rates among black males (7.4 per 1,000) and proportions attributable to men who have sex with men (60.0%) were high. HIV-related disparities exist not only between black males and other groups but also within black males. Success addressing the citywide HIV epidemic will be linked to success in the various portions of this highly affected, heterogeneous population.

Socioeconomic position and HIV risk-relevant behavior among lower-income heterosexuals in San Francisco

We assess whether there is evidence of an association between socioeconomic position (SEP) and HIV risk-relevant behavior among lower income heterosexual men and women in San Francisco. Respondents residing in low income areas with high heterosexual AIDS case burden in San Francisco were recruited through long-chain referral in 2006–2007. Risk measures included unprotected vaginal intercourse, concurrency and exchange sex. SEP was defined as household annual income, per capita income, and employment. Analyses utilized mixed and fixed effects models. A total of 164 men and 286 women were included in the study. SEP was only significant in the case of exchange sex among men: men reporting annual income greater than $30,000 had significantly lower odds of exchange sex relative to other men. Evaluating the connection between economic status and HIV requires additional studies covering diverse populations. Future studies should focus on community economic context as well as individual SEP.

HealthMpowerment.org: development of a theory-based HIV/STI website for young black MSM

Black men who have sex with men (BMSM) are disproportionately affected by the HIV epidemic, yet few prevention interventions have been developed specifically for them. Recent studies suggest that the Internet is a promising intervention delivery avenue. We describe results from our formative work in developing a theory-based online HIV/STI prevention intervention for young BMSM including focus groups, semistructured interviews, and usability testing. The Intervention, HealthMpowerment.org , was created based on the Institute of Medicine's integrated model of behavior change with extensive input from young BMSM. Key interactive Web site features include live chats, quizzes, personalized health and "hook-up/sex" journals, and decision support tools for assessing risk behaviors. Creating an interactive HIV/sexually transmitted infection web site for BMSM was a complex process requiring many adjustments based on iterative feedback throughout all development stages. Preliminary satisfaction, content acceptability, and usability findings support the use of the Internet to deliver risk reduction messages to young BMSM.

Levels and Predictors of Sexual HIV Risk in Social Networks of Men who Have Sex with Men in the Midwest

Past studies have primarily focused on individual-level factors influencing the HIV risk practices of gay or bisexual men. The role of one's social network has been less explored. This study identified 75 indexes in venues frequented by men who have sex with men and then recruited all willing persons named as members of each index's egocentric social network. Two hundred fifty-five unique network members completed assessments of risk-related characteristics and also sociometric measures that were used to identify the influence leader of each network. White and African American networks were composed primarily of men of the same race. Over 70% of men reported recent casual sexual partners. About one fourth of men engaged in unprotected anal intercourse (UAI) with a casual partner or with multiple partners in the past 3 months. The social network to which a man belonged, weaker risk reduction intentions, and greater substance use independently predicted a range of high-risk sexual behaviors. There were modest but significant correlations between the risk-related characteristics of network members and network leaders. Social network-level approaches are feasible for reaching hidden subgroups of MSM at high risk for contracting HIV.

Persistence of racial differences in attitudes toward homosexuality in the United States

BACKGROUND

Stigma may mediate some of the observed disparity in HIV infection rates between black and white men who have sex with men (MSM).

METHODS

We used data from the General Social Survey to describe race-specific trends in the US population's attitude toward homosexuality, reporting of male same-sex sexual behavior, and behaviors that might mediate the relationship between stigma and HIV transmission among MSM.

RESULTS

The proportion of blacks who indicated that homosexuality was "always wrong" was 72.3% in 2008, largely unchanged since the 1970s. In contrast, among white respondents, this figure declined from 70.8% in 1973 to 51.6% in 2008 with most change occurring since the early 1990s. Participants who knew a gay person were less likely to have negative attitudes toward homosexuality (relative risk, 0.60; 95% confidence interval, 0.52 to 0.69). Among MSM, twice as many black MSM reported that homosexuality is "always wrong" compared with white MSM (57.1% versus 26.8%, P = 0.003). MSM with unfavorable attitudes toward homosexuality were less likely to report ever testing for HIV compared with MSM with more favorable attitudes (relative risk, 0.50; 95% confidence interval, 0.31 to 0.78).

CONCLUSIONS

US attitudes toward homosexuality are characterized by persistent racial differences, which may help explain disparities in HIV infection rates between black and white MSM.

HIV risk among young African American men who have sex with men: a case-control study in Mississippi

OBJECTIVES

We conducted a case-control study in the Jackson, Mississippi, area to identify factors associated with HIV infection among young African American men who have sex with men (MSM).

METHODS

During February to April 2008, we used surveillance records to identify young (16-25 years old) African American MSM diagnosed with HIV between 2006 and 2008 (case participants) and recruited young African American MSM who did not have HIV (controls). Logistic regression analysis was used to assess factors associated with HIV infection.

RESULTS

In a multivariable analysis of 25 case participants and 85 controls, having older male partners (adjusted odds ratio [OR] = 5.5; 95% confidence interval [CI] = 1.8, 17.3), engaging in unprotected anal intercourse with casual male partners (adjusted OR = 6.3; 95% CI = 1.8, 22.3), and being likely to give in to a partner who wanted to have unprotected sex (adjusted OR = 5.0; 95% CI = 1.2, 20.6) were associated with HIV infection.

CONCLUSIONS

Given the high prevalence of risk behaviors among the young African American MSM in our study, HIV prevention efforts must begin before or during early adolescence and need to focus on improving negotiation and communication regarding sex.

Elevated HIV prevalence despite lower rates of sexual risk behaviors among black men in the District of Columbia who have sex with men

The District of Columbia (DC) has among the highest HIV/AIDS rates in the United States, with 3.2% of the population and 7.1% of black men living with HIV/AIDS. The purpose of this study was to examine HIV risk behaviors in a community-based sample of men who have sex with men (MSM) in DC. Data were from the National HIV Behavioral Surveillance system. MSM who were 18 years were recruited via venue-based sampling between July 2008 and December 2008. Behavioral surveys and rapid oral HIV screening with OraQuick ADVANCE ½ (OraSure Technologies, Inc., Bethlehem, PA) with Western blot confirmation on positives were collected. Factors associated with HIV positivity and unprotected anal intercourse were identified. Of 500 MSM, 35.6% were black. Of all men, 14.1% were confirmed HIV positive; 41.8% of these were newly identified HIV positive. Black men (26.0%) were more likely to be HIV positive than white (7.9%) or Latino/Asian/other (6.5%) men (p<0.001). Black men had fewer male sex partners than non-black, fewer had ever engaged in intentional unprotected anal sex, and more used condoms at last anal sex. Black men were less likely to have health insurance, have been tested for HIV, and disclose MSM status to health care providers. Despite significantly higher HIV/AIDS rates, black MSM in DC reported fewer sexual risks than non-black. These findings suggest that among black MSM, the primary risk of HIV infection results from nontraditional sexual risk factors, and may include barriers to disclosing MSM status and HIV testing. There remains a critical need for more information regarding reasons for elevated HIV among black MSM in order to inform prevention programming.

The role of peer support on condom use among Black and Latino MSM in three urban areas

This article examines the sociodemographic/behavioral variables associated with low peer support of condom use and the relation between low peer support of condom use and unprotected anal sex for Black and Latino MSM in cities heavily impacted by the HIV/AIDS epidemic. Our findings indicate that perceived low peer support of condom use is associated with increased odds of recent unprotected anal intercourse (UAI) among Black and Latino MSM, regardless of male partner type. Although many participants reported having high peer support of condom use, this analysis highlights a considerable subgroup of Black and Latino MSM, 21% and 30%, respectively, who report low peer support of condoms. Given the prevalence of low peer support of condom use and its association with UAI in these highly impacted MSM populations, we recommend future intervention work that draws upon Black and Latino MSM's peer and social network members to reduce HIV risk behaviors.

Stigma and sexual health risk in HIV-positive African American young men who have sex with men

Understanding the multiple forms of stigma experienced by young HIV-positive African American men who have sex with men and how they relate to sexual risk behaviors is essential to design effective HIV prevention programs. This study of 40 African American young MSM found that 90% of those surveyed experienced sexual minority stigma, 88% experienced HIV stigma, and 78% experienced dual stigma. Sexual minority stigma was characterized by experiences of social avoidance, and HIV stigma, by shame. Individuals with high HIV stigma were significantly more likely to engage in unprotected sex while high or intoxicated. Associations between stigma and sexual practices were examined; youth endorsing higher levels of sexual minority stigma engaged in less insertive anal intercourse. Individuals endorsing more HIV stigma reported more receptive anal intercourse. These findings support the development of stigma-informed secondary prevention interventions for African American HIV-positive young MSM.

Walking the line: stimulant use during sex and HIV risk behavior among Black urban MSM

BACKGROUND

Although the association of stimulant use to sexual risk taking and HIV transmission has been well documented among white gay men, stimulant use during sex continues to be under-explored among Black men who have sex with men (MSM).

METHODS

Black MSM (n=197) recruited via modified respondent-driven sampling between January and July 2008 completed an interviewer-administered quantitative assessment and optional HIV counseling and testing. Bivariate logistic regression procedures were employed to examine the association of demographics, sexual risk, and other psychosocial factors with stimulant use (at least monthly during sex in the past 12 months). Variable elimination using the backward selection process was used to fit two separate final multivariable logistic regression models examining stimulant use as the outcome and HIV sexual risk in the past 12 months by gender as the primary predictor: (1) Model 1: HIV sexual risk behavior with a casual male sex partner as a primary, forced predictor; (2) Model 2: HIV sexual risk behavior with a female sex partner as primary, forced predictor.

RESULTS

One-third (34%) of Black MSM reported using stimulants monthly or more frequently during sex in the past 12 months. The following factors were independently associated with stimulant use during sex: (1) Model 1: unprotected anal sex with a casual male sex partner in the past 12 months (AOR=2.61; 95% CI=1.06-6.42; p=0.01), older age (AOR=1.09; 95% CI=1.05-1.15; p<0.001), erectile dysfunction (ED) medication use monthly or more during sex in the past 12 months (AOR=7.81; 95% CI=1.46-41.68; p=0.02), problematic alcohol use (AOR=3.31; 95% CI=1.312-8.38; p=0.005), and higher HIV treatment optimism (AOR=0.86; 95% CI=0.76-0.97; p=0.01). (2) Model 2: unprotected vaginal or anal sex with a female partner in the past 12 months (AOR=3.54; 95% CI=1.66-7.56; p=0.001), older age (AOR=1.10; 95% CI=1.05-1.14; p<0.001), ED use monthly or more during sex in the past 12 months (AOR=3.70; 95% CI=1.13-12.13; p=0.03), clinically significant depressive symptoms (CES-D) at the time of study enrollment (AOR=3.11; 95% CI=1.45-6.66; p=0.004), and supportive condom use norms (AOR=0.69; 95% CI=0.49-0.97; p=0.03).

CONCLUSION

Frequent stimulant use is an important factor in HIV and STD sexual risk among Black MSM, particularly for older men and those with co-occurring psychosocial morbidities. HIV and STD prevention interventions in this population may benefit from addressing the precipitants of stimulant use and sexual risk taking.

Adaptation of a Couple-Based HIV Intervention for Methamphetamine-Involved African American Men who have Sex with Men

In the U.S., incidence of HIV infection among men who have sex with men (MSM) has steadily increased since the 1990s. This points to a need for innovation to address both emerging trends as well as longer-standing disparities in HIV risk and transmission among MSM, such as the elevated rates of HIV/STIs among African American MSM and methamphetamine users. While couple-based sexual risk reduction interventions are a promising avenue to reduce HIV/STI transmission, prior research has been almost exclusively with heterosexual couples. We sought to adapt an existing, evidence-based intervention—originally developed and tested with heterosexual couples—for a new target population consisting of African American MSM in a longer-term same-sex relationship where at least one partner uses methamphetamine. The adaptation process primarily drew from data obtained from a series of focus groups with 8 couples from the target population. Attention is given to the methods used to overcome challenges faced in this adaptation process: limited time, a lead investigator who is phenotypically different from the target population, a dearth of descriptive information on the experiences and worldviews among the target population, and a concomitant lack of topical experts. We also describe a visualization tool used to ensure that the adaptation process promotes and maintains adherence to the theory that guides the intervention and behavior change. The process culminated with an intervention adapted for the new target population as well as preliminary indications that a couple-based sexual-risk reduction intervention for African American, methamphetamine-involved male couples is feasible and attractive.

HIV treatment optimism and unsafe anal intercourse among HIV-positive men who have sex with men: findings from the positive connections study

This study was designed to examine the impact of HIV treatment optimism on sexual risk among a racially diverse sample of HIV-positive MSM. Survey data were collected from 346 racially diverse HIV-positive MSM.

INCLUSION CRITERIA

18 years of age, male, at least one incident of unprotected anal intercourse (UAI) in the last year, currently on treatment. Other variables included demographics, sexual risk, depression, internalized homonegativity, HIV treatment history, alcohol/drug use and beliefs about HIV treatments (Susceptibility to transmit HIV, Severity of HIV infection and Condom Motivation). Those with lower income were more likely to report that HIV was less transmissible. A self-reported decrease in condom motivation was associated with being White, well-educated and increased alcohol/drug use. A decrease in Severity of HIV was associated with better mental health, being non-White and undetectable viral load. Sexual risk appears related to beliefs about how treatment affects the transmissibility of HIV. Race, socioeconomic status, alcohol/drug use, mental health and viral load were also associated with treatment beliefs.

Characteristics associated with retention among African American and Latino adolescent HIV-positive men: results from the outreach, care, and prevention to engage HIV-seropositive young MSM of color special project of national significance initiative

BACKGROUND

Surveillance points to an urgent public health need for HIV prevention, access, and retention among young men of color who have sex with men (YMSM). The purpose of this multisite study was to evaluate the association between organizational- and individual-level characteristics and retention in HIV care among HIV-positive YMSM of color.

METHODS

Data were collected quarterly via face-to-face interviews and chart abstraction between June 2006 and September 2008. Participants were aged 16-24 years, enrolled at 1 of 8 participating youth-specific demonstration sites, and engaged or reengaged in HIV care within the last 30 days. Generalized estimating equations were used to examine factors associated with missing research and care visits. Stata v.9.0se was used for analysis.

RESULTS

Of 224 participants, the majority were African American (72.7%), 19-22 years old (66.5%), had graduated high school or equivalent (71.8%), identified as gay or homosexual (80.8%), and disclosed having had sex with a man before HIV diagnosis (98.2%). Over the first 2(1/4) years of the study, only 11.4% of visits were missed without explanation or patient contact. Characteristics associated with retention included being <21 years old, a history of depression, receipt of program services, and feeling respected at clinic; those associated with poorer retention included having a CD4 count <200 at baseline and being Latino.

CONCLUSIONS

Special Projects of National Significance programs were able to achieve a high level of retention over time, and individual and program characteristics were associated with retention. Latino YMSM, those not receiving services, and those not perceiving respect at the clinic were at increased risk of falling out of care. Retention is essential to providing HIV+ adolescents with treatment, including reducing antiretroviral resistance development. Innovative programs that address the needs of the YMSM of color population may result in improved retention.

Sexual partner selection and HIV risk reduction among Black and White men who have sex with men

OBJECTIVES

We examined differences in sexual partner selection between Black and White men who have sex with men (MSM) to better understand how HIV status of participants' sexual partners and related psychosocial measures influence risk taking among these men.

METHODS

We collected cross-sectional surveys from self-reported HIV-negative Black MSM and White MSM attending a gay pride festival in Atlanta, Georgia.

RESULTS

HIV-negative White MSM were more likely than were HIV-negative Black MSM to report having unprotected anal intercourse with HIV-negative men, and HIV-negative Black MSM were more likely than were HIV-negative White MSM to report having unprotected anal intercourse with HIV status unknown partners. Furthermore, White MSM were more likely to endorse serosorting (limiting unprotected partners to those who have the same HIV status) beliefs and favorable HIV disclosure beliefs than were Black MSM.

CONCLUSIONS

White MSM appear to use sexual partner-related risk reduction strategies to reduce the likelihood of HIV infection more than do Black MSM. Partner selection strategies have serious limitations; however, they may explain in part the disproportionate number of HIV infections among Black MSM.

Sexual partnering and HIV risk among black men who have sex with men: New York City

Black men who have sex with men (MSM) are disproportionately affected with HIV in the US. Limited event-specific data have been reported in Black MSM to help understand factors associated with increased risk of infection. Cross-sectional National HIV Behavioral Surveillance Study data from 503 MSM who reported > or =1 male sexual partner in the past year in New York City (NYC) were analyzed. Case-crossover analysis compared last protected and last unprotected anal intercourse (UAI). A total of 503 MSM were enrolled. Among 349 tested for HIV, 18% were positive. Black MSM (N = 117) were more likely to test HIV positive and not know their HIV-positive status than other racial/ethnic groups. Case-crossover analysis of 208 MSM found that men were more likely to engage in protected anal intercourse with a first time partner and with a partner of unknown HIV status. Although Black MSM were more likely to have Black male partners, they were not more likely to have UAI with those partners or to have a partner aged >40 years. In conclusion, HIV prevalence was high among Black MSM in NYC, as was lack of awareness of HIV-positive status. Having a sexual partner of same race/ethnicity or older age was not associated with having UAI among Black MSM.

New syphilis cases and concurrent STI screening in a southeastern U.S. HIV clinic: a call to action

Syphilis outbreaks in the United States have been reported since 2000 with highest rates in the South and many cases among HIV-infected individuals. We evaluated incident syphilis cases and concurrent gonorrhea and chlamydia screening at a southern HIV clinic. A retrospective cohort study included HIV-infected patients with at least one reactive plasma reagin (test for serum reagin antibodies to cardiolipin-cholesterol-lecithin antigen) and primary care visit from July 2004 to June 2007. Primary, secondary, and early latent syphilis cases were identified as incident syphilis and evaluation for gonorrhea and chlamydia within 1 month were described. Logistic regression was performed to determine factors associated with incident syphilis. Among 1544 patients, 40 incident syphilis cases were identified (5 primary, 29 secondary, and 6 early latent). The majority of patients were not virologically suppressed and only 25% had gonorrhea and chlamydia testing. In adjusted analyses, younger age (0.57 per 10 years, 95% confidence interval [CI] 0.41-0.80) and minority race (2.26, 95% CI 1.12-4.59) were associated with incident syphilis. Among 40 incident syphilis cases, only 1 in 4 were further tested for gonorrhea and chlamydia. These low rates are concerning as concurrent sexually transmitted infections (STIs) increase risk for HIV transmission. HIV care provider education with emphasis on STI testing in the setting of incident syphilis is key in prevention.

Risk behaviours in HIV-positive men who have sex with men participating in an intervention in a primary care setting

Men who have sex with men receiving HIV care reported their sexual behaviours and their intentions, classified according to the Transtheoretical Model of Change, to modify the following behaviours: (1) condom use by partner type and activity type; (2) reduction of partner number; and (3) disclosure of HIV serostatus to partners. Most participants were white (68.8%) or black (29.5%) and were more likely to report unprotected sex with HIV-positive than with serodiscordant partners for most activities. Whites reported more partners than black patients (mean 4.1 versus 2; P < 0.0001) and black participants reported fewer HIV-negative (P = 0.0084) and -unknown status partners (P = 0.00095) than whites. Cocaine/crack use was associated with more sexual partners (P = 0.001) and more frequent unprotected sex with HIV-negative or -unknown status partners (P = 0.036). Readiness to change risk behaviour varied by partner status and type of sexual activity. Understanding patients' risks and their readiness to change behaviours may help providers to promote sexual health.

Race-based sexual stereotyping and sexual partnering among men who use the internet to identify other men for bareback sex

This qualitative study used sexual scripting theory to explore sexual stereotyping and sexual partnering practices among a racially diverse sample of men who use the Internet to engage in "bareback" sex with other men. The sample included 81 (73%) HIV-negative and 30 (27%) HIV-positive men who were recruited on Web sites where men seek other men to have bareback sex. Participants completed a semi-structured interview that included topics on their racial identification, their sexual experiences tied to race, and their experiences having sex with men of different racial groups. The findings suggested that a variety of race-based sexual stereotypes were used by participants. Sexual stereotyping appeared to directly and indirectly affect the sexual partnering decisions of participants. Sexual scripts may reinforce and facilitate race-based sexual stereotyping, and this behavior may structure sexual networks.

Racial mixing and HIV risk among men who have sex with men

We conducted a cross-sectional survey of MSM using a time-location-sampling design in San Francisco during 2007-2008. The investigation focused on the selection of sexual partners, partner preferences, perceptions of HIV risk, and social mixing with respect to race/ethnicity. The sample of 1,142 MSM was 56% White, 22% Latino, 14% Asian, and 9% Black and reported on 3,532 sexual partnerships. Black MSM had a significant, three-fold higher level of same race sexual partnering than would be expected by chance alone (i.e., in the absence of selective forces with respect to race among partners). Black MSM were reported as the least preferred as sexual partners, believed at higher risk for HIV, counted less often among friends, were considered hardest to meet, and perceived as less welcome at the common venues that cater to gay men in San Francisco by other MSM. Our findings support the hypothesis that the sexual networks of Black MSM, constrained by the preferences and attitudes of non-Blacks and the social environment, are pushed to be more highly interconnected than other groups with the potential consequence of more rapid spread of HIV and a higher sustained prevalence of infection. The racial disparity in HIV observed for more than a decade will not disappear until the challenges posed by a legacy of racism towards Blacks in the US are addressed.

Understanding differences in HIV sexual transmission among Latino and black men who have sex with men: The Brothers y Hermanos Study

HIV sexual transmission risk behaviors were examined among 1,065 Latino and 1,140 black men who have sex with men (MSM). Participants completed a computer-administered questionnaire and were tested for HIV infection. Of men who reported that their last HIV test was negative or that they had never been tested or did not get the result of their last test, 17% of black and 5% of Latino MSM tested HIV-positive in our study. In both ethnic groups, the three-month prevalence of unprotected anal intercourse (UAI) with HIV-negative or unknown serostatus partners was twice as high among men unaware of their HIV infection than men who knew they were HIV seropositive at the time of enrollment. UAI exclusively with HIV-positive partners was more prevalent among HIV-positive/aware than HIV-positive/unaware men. The findings advance understanding of the high incidence of HIV infection among black MSM in the U.S.

Sexual mixing patterns and partner characteristics of black MSM in Massachusetts at increased risk for HIV infection and transmission

Black men who have sex with men (MSM) are at increased risk for HIV infection in the United States compared to other MSM. The aim of this study was to investigate Black MSM's sexual mixing patterns and partner characteristics in relation to sexual risk taking, as a possible explanation for this observed increase in HIV incidence. Between January and July 2008, 197 Black MSM were recruited via modified respondent-driven sampling and completed optional pretest and post-test HIV serological testing, counseling, and a demographic, behavioral, and psychosocial assessment battery. Bivariate and multivariable logistic regression procedures were used to examine predictors of risky sex across partner types. Overall, 18% of the sample was HIV-infected; 50% reported unprotected intercourse with men, 30% with women, and 5% with transgender partners. Fifty-three percent identified as bisexual or straight, although all reported oral or anal sex with another man in the prior 12 months. Significant predictors of engaging in at least one episode of: (1) serodiscordant unprotected anal sex (UAS) with a male partner in the past 12 months: individuals at risk for social isolation (AOR = 4.23; p = 0.03), those with unstable housing (AOR = 4.19; p = 0.03), and those who used poppers at least weekly during sex (AOR = 5.90; p = 0.05); (2) UAS and/or unprotected vaginal intercourse with a female partner in the past 12 months: those with unstable housing (AOR = 4.85; p = 0.04), those who used cocaine at least weekly during sex (AOR = 16.78; p = 0.006), being HIV-infected (AOR = 0.07; p = 0.02), and feeling social norms favor condom use (AOR = 0.60; p = 0.05); (3) UAS with the participants' most recent nonmain male sex partner: use of alcohol and drugs during last sex by participant (AOR = 4.04; p = 0.01), having sex with a Hispanic/Latino male (AOR = 2.71; p = 0.04) or a Black male (AOR = 0.50; p = 0.05) compared to a White male, and lower education (AOR = 1.31; p = 0.02). Findings suggest that sexual risk behaviors of Black MSM differ across partner type and by the characteristics of their sexual networks and that this subpopulation of MSM are at high risk for HIV acquisition and transmission. Effective prevention strategies need to address the distinct sexual and behavioral risk patterns presented by different sexual partnerships reported by Black MSM.

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.

HIV sexual risk behavior by men who use the Internet to seek sex with men: results of the Men's INTernet Sex Study-II (MINTS-II)

This study sought to identify the magnitude of HIV risk in a diverse sample of Men who use the Internet to seek Sex with Men (MISM), and test if specific subpopulations are at sufficiently increased risk to warrant tailored interventions. A sample of 2,716 American MISM, stratified by race/ethnicity, completed an Internet survey of online and offline sex seeking behavior during the last 3 months. Across most demographics, a minority of MISM reported unprotected anal intercourse with male partners (UAIMP). Across all demographics, risk of UAIMP substantially increased with partners met online. Other predictors of increased online partner risk include being 30-39 years old, having children, not living in the Northeast, and low income. HIV-positive men and African Americans reported increased online and offline partner risk. To address higher risk of UAIMP, online HIV interventions should prioritize the needs of MISM, especially HIV-positive men, with content focused on online-mediated liaisons.

Efficacy of an HIV/STI prevention intervention for black men who have sex with men: findings from the Many Men, Many Voices (3MV) project

Black men who have sex with men (MSM) in the United States experience disproportionately high rates of HIV and other sexually transmitted infections (STIs); however, the number of evidence-based interventions for Black MSM is limited. This study evaluated the efficacy of Many Men, Many Voices (3MV), a small-group HIV/STI prevention intervention developed by Black MSM-serving community-based organizations and a university-based HIV/STI prevention and training program. The study sample included 338 Black MSM of HIV-negative or unknown HIV serostatus residing in New York city. Participants were randomly assigned to the 3MV intervention condition (n = 164) or wait-list comparison condition (n = 174). Relative to comparison participants, 3MV participants reported significantly greater reductions in any unprotected anal intercourse with casual male partners; a trend for consistent condom use during receptive anal intercourse with casual male partners; and significantly greater reductions in the number of male sex partners and greater increases in HIV testing. This study is the first randomized trial to demonstrate the efficacy of an HIV/STI prevention intervention for Black MSM.

Meta-analytical studies on the epidemiology, prevention, and treatment of human immunodeficiency virus infection

Since the beginning of the epidemic, extensive research has been conducted in the field of HIV infection. Original research and subsequent meta-analyses have contributed to a better understanding of the disease. Epidemiologic research has shown, for example, that male circumcision reduces the risk of female-to-male transmission. Nevertheless, the question whether circumcision confers protection against HIV transmission in MSM remains open. Studies have shown a positive correlation between HIV and HSV-2 infection. However, a recent RCT found that suppressive antiherpes therapy did not affect rates of HIV acquisition. Meta-analytical studies have advanced the knowledge on the global prevalence of infection among MSM, and disparities among black and white MSM. They have also solidified the evidence that the prophylactic use of ARVs reduces the risk of MTCT. It has also been shown that prolonged ruptured of membranes increases the rates of vertical transmission, and that breastfeeding is associated with postnatal transmission. In addition, prognostic markers of disease progression have been identified. The introduction of ART has resulted in substantial improvements in morbidity and mortality for HIV-seropositive individuals. Several studies have defined recommended and alternative regimens. In a recent meta-analysis it was shown that in treatment naïve patients, NNRTI-based or boosted-PI-based regimens are superior to triple NRTI or unboosted PI-based regimens in terms of virologic suppression. Recent evidence has demonstrated that ART can be successfully used in Africa with better outcomes in those receiving free treatment. Regarding resistance testing in treatment-experienced patients with virologic failure, GRT offers a benefit of small magnitude and there is insufficient evidence to support the use of PRT, in contrast to current guidelines. Meta-analyses have also shown that interventions to improve adherence can be successfully implemented. Finally, the efficacy of the influenza and hepatitis vaccine in the setting of HIV infection has been analyzed. As our knowledge advances, further questions will inevitably arise and will need to be addressed in well-conducted trials.

HIV prevention for black men who have sex with men in the United States

The HIV/AIDS epidemic has exacted a devastating toll upon Black men who have sex with men (MSM) in the United States, and there is a tremendous need to escalate HIV-prevention efforts for this population. The social context in which Black MSM experience the impact of racism and heterosexism strongly affects their risk for HIV infection; thus, HIV-prevention research focused on Black MSM should focus on contextual and structural factors. There is a pronounced lack of community-level HIV-intervention research for Black MSM, but effective preliminary strategies involve adapting existing effective models and tailoring them to the needs of Black MSM. Future research should develop new, innovative approaches, especially structural interventions, that are specifically targeted toward HIV prevention among Black MSM.

Learning from successful interventions: A culturally congruent HIV risk-reduction intervention for African American men who have sex with men and women

Few HIV prevention interventions have been developed for African American men who have sex with men or who have sex with both men and women. Many interventions neglect the historical, structural or institutional, and sociocultural factors that hinder or support risk reduction in this high-risk group. We examined ways to incorporate these factors into Men of African American Legacy Empowering Self, a culturally congruent HIV intervention targeting African American men who have sex with men and women. We also studied how to apply key elements from successful interventions to future efforts. These elements include having gender specificity, a target population, a theoretical foundation, cultural and historical congruence, skill-building components, and well-defined goals.

Public health responses to the HIV epidemic among black men who have sex with men: A qualitative study of US health departments and communities

In the United States, Black men who have sex with men (MSM) are disproportionately affected by HIV/AIDS. Thus, there is a need to understand the challenges facing health departments and community-based organizations responding to the HIV epidemic among this population. We interviewed 71 AIDS program directors, health department staff, and leaders of community-based organizations in 9 states and the District of Columbia. Participants identified psychosocial factors, a lack of capacity-building efforts, and stigma as barriers to HIV prevention responses targeting Black MSM. Participants identified culturally competent staff and culturally sensitive interventions as facilitating prevention responses. To ensure that HIV/AIDS interventions targeting Black MSM are effective, it is imperative to solicit the perceptions of frontline workers in health departments and community-based organizations.

Epidemiology of STD disparities in African American communities

This article reviews the epidemiology of sexually transmitted disease (STD) disparities for African American communities in the United States. Data are reviewed from a variety of sources such as national case reporting and population-based studies. Data clearly show a disproportionately higher burden of STDs in African American communities compared with white communities. Although disparities exist for both viral and bacterial STDs, disparities are greatest for bacterial STDs such as gonorrhea, chlamydia, and syphilis. Gonorrhea rates among African Americans are highest for adolescents and young adults, and disparities are greatest for adolescent men. Although disparities for men who have sex with men (MSM) are not as great as for heterosexual populations, STD rates for both white and African American MSM populations are high, so efforts to address disparities must also include African American MSM. Individual risk behavior and sociodemographic characteristics of African Americans do not seem to account fully for increased STD rates for African Americans. Population-level determinants such as sexual networks seem to play an important role in STD disparities. An understanding of the epidemiology of STD disparities is critical for identifying appropriate strategies and tailoring strategies for African American communities. Active efforts are needed to reduce not only the physical consequences of STDs, such as infertility, ectopic pregnancy, chronic pelvic pain, newborn disease, and increased risk of HIV infection, but also the social consequences of STDs such as economic burden, shame, and stigma.

Research needed to more effectively combat HIV among African-American men who have sex with men

It is estimated that nearly half of all African-American men who have sex with men (AAMSM) living in major U.S. cities are already infected with HIV. Without a substantial and committed investment in research in HIV prevention among AAMSM and subsequent evidence-based policies and community programs, it is unlikely that we will ever be able to curtail the HIV epidemic among African Americans in general, regardless of gender, age or sexual orientation. In this paper, we briefly review what is known and what research questions remain in order to curtail the epidemic among AAMSM. Finally, we provide recommendations for future research that include the: 1) development of a national cohort of young AAMSM to prospectively study biological, behavioral, social and contextual factors that place AAMSM at risk for infection with HIV and other STDs; 2) adapting existing interventions in HIV prevention to the unique characteristics of AAMSM and evaluating their effectiveness; 3) evaluating factors such as intracommunity and familial discrimination against AAMSM that may lead to lack of disclosure; and 4) enhancing our understanding of how cultural and social factors can be used in a positive and self-affirming way to strengthen HIV prevention and care for AAMSM.