Sexual health, HIV, and sexually transmitted infections among gay, bisexual, and other men who have sex with men in the United States

HIV Prevention and Care Among Black Cisgender Sexual Minority Men and Transgender Women: Protocol for an HIV Status-Neutral Cohort Study Using an Observational-Implementation Hybrid Approach

BACKGROUND

Black cisgender gay, bisexual, and other sexual minority men (SMM) and transgender women (TW) continue to be heavily affected by HIV. Further research is needed to better understand HIV prevention and care outcomes in this population. In particular, there is a need for research examining the impact of substance use and sleep health on HIV prevention and treatment outcomes among Black SMM and TW.

OBJECTIVE

This paper outlines the study methods being used in the recently launched follow-up study to the Neighborhoods and Networks (N2) study, which we refer to as N2 Part 2 (N2P2). N2P2 aims to address this gap in the literature, build off the findings of the original N2 study, and identify socioenvironmental determinants of health, including whether neighborhood and network factors mediate and moderate these relationships.

METHODS

Building on the N2 cohort study in Chicago from 2018 to 2022, N2P2 used a prospective longitudinal cohort design and an observational-implementation hybrid approach. With sustained high levels of community engagement, we aim to recruit a new sample of 600 Black SMM and TW participants residing in the Chicago metropolitan statistical area. Participants are asked to participate in 3 study visits across an 18-month study period (1 visit every 9 months). Four different forms of data are collected per wave: (1) an in-person survey, (2) biological specimen collection, (3) a daily remote ecological momentary assessment for 14 days after each study visit, and (4) data from electronic health records. These forms of data collection continue to assess neighborhood and network factors and specifically explore substance use, sleep, immune function, obesity, and the implementation of potential interventions that address relevant constructs (eg, alcohol use and pre-exposure prophylaxis adherence).

RESULTS

The N2P2 study was funded in August 2021 by the National Institute of Drug Abuse (R01DA054553 and R21DA053156) and National Heart, Lung, and Blood Institute (R01HL160325). This study was launched in November 2022. Recruitment and enrollment for the first wave of data collection are currently ongoing.

CONCLUSIONS

The N2P2 study is applying innovative methods to comprehensively explore the impacts of substance use and sleep health on HIV-related outcomes among an HIV status-neutral cohort of Black SMM and TW in Chicago. This study is applying an observational-implementation hybrid design to help us achieve findings that support rapid translation, a critical priority among populations such as Black SMM and TW that experience long-standing inequities with regard to HIV and other health-related outcomes. N2P2 will directly build off the findings that have resulted from the original N2 study among Black SMM and TW in Chicago. These findings provide a better understanding of multilevel (eg, individual, network, and neighborhood) factors that contribute to HIV-related outcomes and viral suppression among Black SMM and TW.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48548.

High Prevalence of Anal Sexually Transmitted Infections among Men Who Have Sex with Men and Transgender Women Attending a Clinic for Prevention of Anal Cancer in Salvador, Brazil

Men who have sex with men (MSM) and transgender women (TGW) are highly vulnerable to anal sexually transmitted infections (STIs). Objectives-to evaluate the prevalence of anal STIs among MSM and TGW attending a referral clinic for anal cancer prevention. Methods-MSM and TGW attending a medical visit for high-resolution anoscopy in Salvador, Brazil, from February 2021 to June 2022 were screened for HPV, gonorrhea, and chlamydial infection by PCR of anal swab and by serum VDRL titration for syphilis screening. They also responded to a questionnaire on sociodemographic characteristics and sexual behavior. Results-we evaluated 141 participants: 117 (82.9%) MSM, 9 (6.4%) bisexual men (BSM), and 15 (10.6%) TGW. Most (111/141, 78.7%) were older than 30 years, 89 (63.1%) had over 12 years of education, and 124 (87.9%) had a family income of up to five minimum wages. At least one STI was detected in 112 (79.4%) of the participants (86.7% among TGW). HIV infection was detected in 102 (72.3%) participants; HIV frequency was higher in BSM (7/9, 88.9%) and in MSM (89/116, 76.1%) than in TGW (5/15, 33.3%). A lower income (p = 0.004) was predictive of anal STIs, while syphilis was significantly more frequent among participants with HIV (29.1% vs. 5,3%, for HIV positive and negative, respectively, p = 0.002). Presenting at least one active STI was also associated with having had group sex in the last year (p = 0.03) and with use of sexualized drugs (p = 0.02). Conclusions-MSM and TGW present a high vulnerability to anal STIs. Number of sexual partners, use of sexualized drugs, and lower income are predictive of a higher risk of acquiring an STI in such populations.

Informing efforts beyond tailored promotional campaigns by understanding contextual factors shaping vaccine hesitancy among equity-deserving populations in Canada: an exploratory qualitative study

BACKGROUND

Vaccine hesitancy exists on a continuum ranging between complete adherence and complete refusal due to doubts or concerns within a heterogeneous group of individuals. Despite widespread acknowledgement of the contextual factors influencing attitudes and beliefs shaping COVID-19 vaccine hesitancy, qualitative research with equity-deserving groups, accounting for unique lived experiences, remains a gap in the literature. We aim to identify and begin to understand and document the unique contextual factors shaping hesitancy by equity-deserving groups as it relates to relationships with government and health authorities.

METHODS

Participants were recruited and interviewed between Aug-Dec 2021. Semi-structured interviews using a convergent interviewing technique were conducted with individuals from the general population, as well as individuals who identify as First Nations, Métis, or Inuit, members of the LGBT2SQ + community, low-income Canadians, Black Canadians, and newcomers. Interviews were audio recorded and transcribed by a team of researchers. Memos were written following interviews and used to complement the thematic analysis of the interview data. Themes are presented in the results section.

RESULTS

The rationale for hesitancy among equity-deserving groups is consistent with literature documenting hesitancy in the general population. Contextual factors surrounding equity-deserving groups' attitudes and beliefs, however, are unique and relate to a history of oppression, discrimination, and genocide. We identified factors unique to subgroups; for example, religious or fatalistic beliefs among participant who identify as FNMI, fear associated with lack of testing and speed of vaccines' production among participants who identify as FNMI, Black, and LGBT2SQ + , distrust of the healthcare system for LGBT2SQ + and Black Canadians, and distrust of the government and opposition to vaccine mandates for participating who identify as LGBT2SQ + , low-income, FNMI, or Black Canadian. Newcomers stood out as very trusting of the government and accepting of COVID-19 vaccination.

CONCLUSIONS

While our data on vaccine hesitancy largely mirror concerns reported in the vast body of literature citing rationale for COVID-19 hesitancy in high-income countries, the contextual factors identified in our work point to the need for wider systemic change. Our results may be used to support efforts, beyond tailored promotion campaigns, to support the confident acceptance of vaccines for COVID-19 and the acceptance of novel vaccines as future infectious diseases emerge.

Elevated inflammatory fecal immune factors in men who have sex with men with HIV associate with microbiome composition and gut barrier function

Introduction

People living with HIV infection (PLWH) exhibit elevated levels of gastrointestinal inflammation. Potential causes of this inflammation include HIV infection and associated immune dysfunction, sexual behaviors among men who have sex with men (MSM) and gut microbiome composition.

Methods

To better understand the etiology of gastrointestinal inflammation we examined levels of 28 fecal soluble immune factors (sIFs) and the fecal microbiome in well-defined cohorts of HIV seronegative MSM (MSM-SN), MSM with untreated HIV infection (MSM-HIV) and MSM with HIV on anti-retroviral treatment (MSMART). Additionally, fecal solutes from these participants were used to stimulate T-84 colonic epithelial cells to assess barrier function.

Results

Both MSM cohorts with HIV had elevated levels of fecal calprotectin, a clinically relevant marker of GI inflammation, and nine inflammatory fecal sIFs (GM-CSF, ICAM-1, IL-1β, IL-12/23, IL-15, IL-16, TNF-β, VCAM-1, and VEGF). Interestingly, four sIFs (GM-CSF, ICAM-1, IL-7 and IL-12/23) were significantly elevated in MSM-SN compared to seronegative male non-MSM. Conversely, IL-22 and IL-13, cytokines beneficial to gut health, were decreased in all MSM with HIV and MSM-SN respectively. Importantly, all of these sIFs significantly correlated with calprotectin, suggesting they play a role in GI inflammation. Principal coordinate analysis revealed clustering of fecal sIFs by MSM status and significant associations with microbiome composition. Additionally, fecal solutes from participants in the MSM-HIV cohort significantly decreased colonic transcellular fluid transport in vitro, compared to non-MSM-SN, and this decrease associated with overall sIF composition and increased concentrations of eight inflammatory sIFs in participants with HIV. Lastly, elevated levels of plasma, sCD14 and sCD163, directly correlated with decreased transcellular transport and microbiome composition respectively, indicating that sIFs and the gut microbiome are associated with, and potentially contribute to, bacterial translocation.

Conclusion

Taken together, these data demonstrate that inflammatory sIFs are elevated in MSM, regardless of HIV infection status, and are associated with the gut microbiome and intestinal barrier function.

Comparison between HIV self-testing and facility-based HIV testing approach on HIV early detection among men who have sex with men: A cross-sectional study

Background

To assess whether HIV self-testing (HIVST) has a better performance in identifying HIV-infected cases than the facility-based HIV testing (HIVFBT) approach.

Methods

A cross-sectional study was conducted among men who have sex with men (MSM) by using an online questionnaire (including information on sociodemographic, sexual biography, and HIV testing history) and blood samples (for limiting antigen avidity enzyme immunoassay, gene subtype testing, and taking confirmed HIV test). MSM who were firstly identified as HIV positive through HIVST and HIVFBT were compared. Chi-square or Fisher’s exact test was used to explore any association between both groups and their subgroups.

Results

In total, 124 MSM HIV cases were identified from 2017 to 2021 in Zhuhai, China, including 60 identified through HIVST and 64 through HIVFBT. Participants in the HIVST group were younger (≤30 years, 76.7% vs. 46.9%), were better educated (>high school, 61.7% vs. 39.1%), and had higher viral load (≥1,000 copies/ml, 71.7% vs. 50.0%) than MSM cases identified through HIVFBT. The proportion of early HIV infection in the HIVST group was higher than in the HIVFBT group, identified using four recent infection testing algorithms (RITAs) (RITA 1, 46.7% vs. 25.0%; RITA 2, 43.3% vs. 20.3%; RITA 3, 30.0% vs. 14.1%; RITA 4, 26.7% vs. 10.9%; all p < 0.05).

Conclusions

The study showed that HIVST has better HIV early detection among MSM and that recent HIV infection cases mainly occur in younger and better-educated MSM. Compared with HIVFBT, HIVST is more accessible to the most at-risk population on time and tends to identify the case early. Further implementation studies are needed to fill the knowledge gap on this medical service model among MSM and other target populations.

The Impact of Lifestyle on Prostate Cancer: A Road to the Discovery of New Biomarkers

Prostate cancer (PCa) is one of the most common cancers among men, and its incidence has been rising through the years. Several risk factors have been associated with this disease and unhealthy lifestyles and inflammation were appointed as major contributors for PCa development, progression, and severity. Despite the advantages associated with the currently used diagnostic tools [prostate-specific antigen(PSA) serum levels and digital rectal examination (DRE)], the development of effective approaches for PCa diagnosis is still necessary. Finding lifestyle-associated proteins that may predict the development of PCa seems to be a promising strategy to improve PCa diagnosis. In this context, several biomarkers have been identified, including circulating biomarkers (CRP, insulin, C-peptide, TNFα-R2, adiponectin, IL-6, total PSA, free PSA, and p2PSA), urine biomarkers (PCA3, guanidine, phenylacetylglycine, and glycine), proteins expressed in exosomes (afamin, vitamin D-binding protein, and filamin A), and miRNAs expressed in prostate tissue (miRNA-21, miRNA-101, and miRNA-182). In conclusion, exploring the impact of lifestyle and inflammation on PCa development and progression may open doors to the identification of new biomarkers. The discovery of new PCa diagnostic biomarkers should contribute to reduce overdiagnosis and overtreatment.

Awareness and Use of Post-exposure Prophylaxis for HIV Prevention Among Men Who Have Sex With Men: A Systematic Review and Meta-Analysis

Background: The use of post-exposure prophylaxis (PEP) is effective in reducing HIV risk, but it is underused by men who have sex with men (MSM) due to certain psychological and sociostructural factors. This article assessed the awareness and use of PEP among MSM in an effort to increase the visibility and uptake of PEP among at-risk populations.

Methods: We conducted a systematic literature search of the PubMed, Web of Science, PsycINFO, and Google Scholar electronic databases. Studies were screened for inclusion, and relevant data were abstracted, assessed for bias, and synthesized. Pooled effect estimates were calculated using random effects meta-analysis, meta-regression and subgroup analysis, and a qualitative review and risk of bias assessment were performed (PROSPERO, CRD42019123815).

Results: Twenty eligible studies involving 12,579 MSM were included in the meta-analysis. The pooled estimate of the proportions of MSM who were aware of PEP was modest at 59.9% (95% CI: 50.5~68.7) and that of MSM who previously used PEP was very low at 4.9% (95% CI: 2.4~9.8). PEP awareness showed no clear change over time, while PEP use significantly changed over time. Multiple factors affected awareness, including educational attainment, race/ethnicity, levels of HIV stigma, access to condoms, and so on. Many factors could potentially impede or facilitate the use of PEP, such as income, lack of PEP information, and partnership.

Conclusion: We observed that PEP is an underused HIV prevention strategy among MSM and that once MSM become aware of PEP, the majority are willing to use it if they are supported appropriately in terms of a range of individual, social, and structural barriers.

Systematic Review Registration: http://www.cdr.york.ac.uk/prospero, PROSPERO [CRD42019123815].

Community-Based Prevalence Estimates of Chlamydia trachomatis and Neisseria gonorrhoeae Infections Among Gay, Bisexual, and Other Men Who Have Sex With Men in Montréal, Canada

BACKGROUND

Reported cases of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections are increasing among Canadian men. Estimates of community-based CT/NG prevalence are lacking among gay, bisexual, and other men who have sex with men (GBM).

METHODS

Respondent driven sampling was used to recruit GBM in Montréal, Canada between February 2017 and June 2018. Specimens provided from urogenital, rectal, and pharyngeal sites were analyzed using nucleic acid amplification test to detect CT/NG. Prevalence estimates of CT/NG, overall and by anatomical site were calculated. All estimates are respondent-driven sampling-adjusted.

RESULTS

Among 1177 GBM, the prevalence of rectal, urogenital, pharyngeal and overall were respectively 2.4%, 0.4%, 0.4%, and 2.8% for CT infections, and 3.1%, 0.4%, 3.5%, and 5.6% for NG infections. If testing had been limited to the urogenital site, 80% and 94% of CT and NG infections, respectively, would have been missed.

CONCLUSIONS

This community-based study among GBM shows that the CT prevalence was about half of that observed for NG. A large part of CT/NG infections involves only the extragenital sites, highlighting the need for systematic multisite screening regardless of symptoms. In the mist of the COVID-19 pandemic and the limited CT/NG screening capacity due to test kits shortage, it might be considered to prioritize rectal and pharyngeal CT/NG testing over urogenital testing in asymptomatic GBM.

Effects of the Affordable Care Act Dependent Coverage Mandate on Health Insurance Coverage for Individuals in Same-Sex Couples

A large body of research documents that the 2010 dependent coverage mandate of the U.S. Affordable Care Act was responsible for significantly increasing health insurance coverage among young adults. No prior research has examined whether sexual minority young adults also benefitted from the dependent coverage mandate despite previous studies showing lower health insurance coverage among sexual minorities. Our estimates from the American Community Survey, using difference-in-differences and event study models, show that men in same-sex couples aged 21-25 experienced a significantly greater increase in the likelihood of having any health insurance after 2010 than older, 27- to 31-year-old men in same-sex couples. This increase is concentrated among employer-sponsored insurance, and it is robust to permutations of periods and age groups. Effects for women in same-sex couples and men in different-sex couples are smaller than the associated effects for men in same-sex couples. These findings confirm the broad effects of expanded dependent coverage and suggest that eliminating the federal dependent mandate could reduce health insurance coverage among young adult sexual minorities in same-sex couples.

How Stigma Toward Anal Sexuality Promotes Concealment and Impedes Health-Seeking Behavior in the U.S. Among Cisgender Men Who Have Sex with Men

Gay, bisexual, and other men who have sex with men (MSM) experience alarming HIV disparities alongside sub-optimal engagement in HIV interventions. Among MSM, stigma toward anal sexuality could interfere with engagement in HIV prevention, yet few studies have examined MSM perspectives on anal sex stigma or its health-related sequelae. Guided by theory, we aimed to characterize anal sex stigma, related sexual concerns, and barriers to health seeking, like concealment. We elicited community input by purposively interviewing 10 experts in MSM health and then 25 racially, ethnically, and geographically diverse cisgender MSM. Participants reported experienced, internalized, and anticipated forms of anal sex stigma that inhibited health seeking. Experienced stigma, including direct and observed experiences as well as the absence of sex education and information, contributed to internalized stigma and anticipation of future devaluation. This process produced psychological discomfort and concealment of health-related aspects of anal sexuality, even from potentially supportive sexual partners, social contacts, and health workers. Participants characterized stigma and discomfort with disclosure as normative, pervasive, and detrimental influences on health-seeking behavior both during sex and within healthcare interactions. Omission of information appears to be a particularly salient determinant of sexual behavior, inhibiting prevention of harm, like pain, and leading to adverse health outcomes. The development of measures of anal sex stigma and related sexual concerns, and testing their impact on comfort with disclosure, sexual practices, and engagement in health services could identify modifiable social pathways that contribute to health disparities among MSM, like those seen in the HIV epidemic.

Development and Psychometric Evaluation of the PrEP Sexual Expectancies (PSEXS) Scale

The goal of this study was to develop and evaluate psychometric properties of the PrEP Sexual Expectancies Scale (PSEXS). The PSEXS represents a range of expectations for how PrEP use will affect one's sexual experience. The scale was developed to understand perceived reinforcements of PrEP use among men who have sex with men (MSM), including sexual risk-taking. The study builds upon Expectancy Theory to develop a measure of sex-related PrEP expectancies with a representative sample of 1155 MSM participants from Ukraine and 408 MSM participants from the U.S. Expectancy items represented two domains: increased sexual risk-taking and enhancement of sexual experience. Confirmatory analyses showed that a two-factor model provided a good fit to the data. The PSEXS scale had a high internal reliability in both samples (Ukraine α = 0.88, U.S. α = 0.83), and the identified factor structure explains a large amount of variance in both samples. Recent studies suggest that expectations of intimacy and better sexual experience can be a significant deciding factor for PrEP uptake. The PSEXS provides researchers with a useful measure for examining MSM's expectancy beliefs about the impact of PrEP use on their sexual life.

Sexual Minority People's Perspectives of Sexual Health Care: Understanding Minority Stress in Sexual Health Settings

Sexual minority individuals (e.g., lesbian, gay, bisexual people) face sexual health inequalities related to their experiences with providers in sexual health care settings, yet few prior studies have focused on these experiences. In the current study, we analyzed qualitative interviews with a diverse sample of 58 sexual minority individuals from three age cohorts in the United States to explore sexual minority people's perspectives of sexual health care. Thematic content analysis revealed four key themes: erasure, enacted stigma, felt stigma, and affirmative care. Subgroup differences in themes across gender, sexual identity, race/ethnicity, and age cohort were also assessed. Women and genderqueer participants reported erasure in the context of identity dismissal in family planning conversations, and men reported felt stigma in the context of hyperawareness of sexual minority identity. Some sexual minority people of color also reported intersectional felt stigma as a result of multiple marginalized identities. Additionally, fewer men reported erasure compared to women or genderqueer people and fewer gay and lesbian participants reported erasure than bisexual or queer people. Implications of these findings include the need for more sexual minority health care initiatives and training and the development of affirmative care practices for sexual minority populations, including those with multiple marginalized identities.

Toward Sexual Health Equity for Gay, Bisexual, and Transgender Youth: An Intergenerational, Collaborative, Multisector Partnerships Approach to Structural Change

Background. Gay, bisexual, and transgender youth (GBTY) experience sexual health inequities and contend with intersectional oppression. The Michigan Forward in Enhancing Research and Community Equity (MFierce) Coalition formed as an intergenerational, collaborative, multisector partnership with a focus on implementing community-identified policy, systems, and environmental (PSE) change strategies to address inequities and injustices. Aims. We describe MFierce coalition development and structural change activities organized within Collaborating for Equity and Justice (CEJ) principles and provide empirical data supporting the utility of such principles. Method. We prioritized leadership by GBTY and created personal and professional capacity-building activities to support GBTY in being change agents. Our work was grounded in community-engaged scholarship and used a shared-power community development process. Our PSE change intervention, the Health Access Initiative (HAI), was a structural change program for health facilities aimed at improving the quality of and access to sexual health care for GBTY. Results. We evaluated coalition functioning and activities through multimethod assessments and evaluated PSE changes through HAI participant surveys. Data demonstrated positive and steady coalition dynamics, multiple benefits of participation for GBTY, and strategies for collaborative multigenerational community work. HAI outcome data revealed significant increases in PSE changes. Discussion. Centering life experiences of GBTY in collaborative partnerships and building opportunities for professional and personal development can support sustainable community change. We offer recommendations for developing future intergenerational, collaborative, multisector partnerships that prioritize youth leadership. Conclusion. Collaborative methods and careful consideration of adult-youth dynamics can inform future transformative efforts focused on health equity and justice for GBTY.

Internalizing Symptoms and Externalizing Behaviors in Latinx Adolescents with Same Sex Behaviors in Miami

Sexual minorities report poorer mental health relative to heterosexual counterparts, but this is underexplored in Latinx youth. This study compares internalizing symptoms and externalizing behaviors in Latinx adolescents with Same Sex Behaviors (LASSB) to their Latinx adolescent peers who did not report same sex behaviors (non-LASSB). It also explores the moderating role of biculturalism on the relationship between internalizing symptoms and externalizing behaviors, and same-sex behaviors. Individual-level baseline data (Total N=1,634; LASSB n=195) from five trials of a preventive intervention for Latinx adolescents were synthesized. Normal and clinical levels of internalizing symptoms and externalizing behaviors were determined, and logistic regression models were conducted to determine the odds of LASSB reporting these behaviors relative to non-LASSB. Additional adjusted models tested for the moderating effect of biculturalism. LASSB reported significantly higher odds of normal levels of all externalizing behaviors and clinical levels of anxious/depressed compared to non-LASSB. Biculturalism significantly moderated the association between same-sex behavior and clinical levels of internalizing behaviors; however, in subgroup analyses among LASSB, biculturalism did not significantly predict any of these behaviors. Latinx adolescents exhibited mental health disparities by same-sex behavior. Biculturalism may be an important indicator for describing these disparities in LASSB and should be further explored.

"Talking About it Publicly Made Me Feel Both Curious and Embarrassed": Acceptability, Feasibility, and Appropriateness of a Stigma-Mitigation Training to Increase Health Worker Comfort Discussing Anal Sexuality in HIV Services

Health workers report challenges to broaching sexual behavior with gay and bisexual men (MSM). We conducted a stigma-mitigation training to increase provider-initiated conversation about anal sexuality among Chinese health workers. The two-day workshop, titled Smarter Sex is the New Safer Sex: Anal Pleasure and Health, coupled information about anal physiology and sexual response with gradual exposure to trainees' emotional and cognitive responses. We analyzed surveys and one-time interviews. Acceptability (satisfaction with training activities and recommended practices), feasibility (compatibility with participants' current practices), and appropriateness (perceived fit with participants' work mission and goals) were high, reaching 84-95% of the scale range, though with variable ratings for trainee comfort during participation. Qualitative data confirm health workers' motivation to discuss anal sexuality and the value of learning about anal physiology and sexual response, but revealed continued uncertainty about how to broach and navigate discussion with clients. Refinement of the training to align with health worker recommendations and to augment communication options and skills is warranted, as is involvement of MSM clientele themselves.

The Health Challenges of Emerging Adult Gay Men: Effecting Change in Health Care

This article focuses on the health and health care challenges experienced by young and emerging adult gay men. Evidence is provided on the extent to which young and emerging adult gay men are disproportionally burdened by multidimensional health disparities, barriers to health care access, and inadequate provider-patient interactions. Recommendations are provided for health care providers and public health officials working with populations of emerging adult gay men that might have the greatest overall impact on improving this population's well-being and access to competent health care by increasing providers' awareness of the unique needs of young and emerging adult gay men.

Gender Identity and Sexual Orientation in Chinese Men Who Have Sex with Men: A Latent Class Analysis

Men who have sex with men (MSM) are a diverse population yet are often treated as a monolithic risk group. In China, MSM have long been characterized as a "bridge population" of closeted men who are married to (or will marry) women due to sociocultural expectations. Latent class models can inform a more nuanced yet empirical characterization of this population. In total, 1424 eligible respondents recruited online provided self-reported behavioral data. Nine items related to constructs including sexual behaviors, sexual orientation, and gender identity informed the latent class model. Logistic regression was used to measure associations between latent class membership and HIV-related sexual and health-seeking behaviors. Model fit indicated a population structure made up of four classes that we characterized as "Gender nonconforming" (4.3%), "Closeted-unmarried" (29.9%), "Closeted-married" (24.6%), and "Out" (41.2%). Members of the "gender nonconforming" class were more likely to report HIV-related risk behaviors, and "Closeted-unmarried" class members were less likely to report health-seeking behaviors, both relative to "Out" members. The largest latent class was made up of members of the "Out" class, an enlightening revision of a population traditionally viewed as largely closeted men. Two types of "closeted" classes emerged, distinguished by divergent tendencies regarding marriage and health seeking. Findings suggest that current understandings of Chinese MSM are simplistic (regarding closeted behaviors) and too narrow (in its definition of MSM as cisgender men). A more nuanced understanding of MSM subgroups and their heterogeneous risk behaviors will be critical for provision of more meaningful prevention services.

Does Stigma Toward Anal Sexuality Impede HIV Prevention Among Men Who Have Sex With Men in the United States? A Structural Equation Modeling Assessment

INTRODUCTION

Men who have sex with men (MSM) are suboptimally engaged in efficacious HIV interventions, due in part to stigma.

AIM

We sought to validate the Anal Health Stigma Model, developed based on theory and prior qualitative data, by testing the magnitude of associations between measures of anal sex stigma and engagement in HIV prevention practices, while adjusting for covariates.

METHODS

We conducted a cross-sectional online survey of 1,263 cisgender MSM living in the United States and analyzed data with structural equation modeling. We tested a direct path from Anal Sex Stigma to Engagement in HIV Prevention alongside 2 indirect paths, 1 through Anal Sex Concerns and another through Comfort Discussing Anal Sexuality with Health Workers. The model adjusted for Social Support, Everyday Discrimination, and Sociodemographics.

MAIN OUTCOME MEASURE

Engagement in HIV Prevention comprised an ad hoc measure of (i) lifetime exposure to a behavioral intervention, (ii) current adherence to biomedical intervention, and (iii) consistent use of a prevention strategy during recent penile-anal intercourse.

RESULTS

In the final model, anal sex stigma was associated with less engagement (β = -0.22, P < .001), mediated by participants' comfort talking about anal sex practices with health workers (β = -0.52; β = 0.44; both P < .001), adjusting for covariates (R² = 67%; χ²/df = 2.98, root mean square error of approximation = 0.040, comparative fit index = 0.99 and Tucker-Lewis index = 0.99). Sex-related concerns partially mediated the association between stigma and comfort (β = 0.55; β = 0.14, both P < .001). Modification indices also supported total effects of social support on increased comfort discussing anal sex (β = 0.35, P < .001) and, to a lesser degree, on decreased sex-related concerns (β = -0.10; P < .001).

CLINICAL IMPLICATIONS

Higher stigma toward anal sexuality is associated with less engagement in HIV prevention, largely due to discomfort discussing anal sex practices with health workers.

STRENGTH & LIMITATIONS

Adjustment for mediation in a cross-sectional design cannot establish temporal causality. Self-report is vulnerable to social desirability and recall bias. Online samples may not represent cisgender MSM in general. However, findings place HIV- and health-related behaviors within a social and relational context and may suggest points for intervention in health-care settings.

CONCLUSION

Providers' willingness to engage in discussion about anal sexuality, for example, by responding to questions related to sexual well-being, may function as social support and thereby bolster comfort and improve engagement in HIV prevention. Kutner BA, Simoni JM, King KM, et al. Does Stigma Toward Anal Sexuality Impede HIV Prevention Among Men Who Have Sex With Men in the United States? A Structural Equation Modeling Assessment. J Sex Med 2020;17:477-490.

Condom-Associated Erectile Function, But Not Other Domains of Sexual Functioning, Predicts Condomless Insertive Anal Sex Among Young Men Who Have Sex with Men

Condoms effectively prevent against HIV, especially when used in conjunction with biomedical strategies such as PrEP and viral suppression. However, consistent use of condoms in the real world has been a continual health promotion challenge, even among populations at highest risk, such as young men who have sex with men (YMSM). Inconsistent condom use may be related to poor sexual functioning, but limited research exists. The analytic sample comprised 688 racially diverse YMSM aged 16-29 (M = 22.9 years) living in Chicago, IL (19.2% living with HIV). Using multivariable logistic regression, we examined longitudinal associations between condom-associated sexual functioning (erectile function, orgasm satisfaction, global satisfaction, and anal discomfort) and condomless insertive anal sex (CIAS) and condomless receptive anal sex (CRAS) 6 months later. CIAS at Time 2 was associated with condom-associated erectile function at the bivariate and multivariable levels, even after controlling for CIAS at Time 1 (p < .05). Condom-associated erectile function, orgasm satisfaction, and global satisfaction predicted Time 2 CRAS in bivariate models, but none remained significant in the multivariable models. Age, having had a serious partner in the past 6 months, and HIV/PrEP status at Time 2 were significant predictors of CIAS/CRAS in some but not all models. Future interventions to improve consistent condom use should specifically highlight information and skills on how to use condoms within real-world contexts rather than from a clinical perspective. Our results also support the importance of biomedical strategies for those who have continued problems with sexual functioning when using condoms.

PrEP and sexual well-being: a qualitative study on PrEP, sexuality of MSM, and patient-provider relationships

Most new diagnoses of HIV in the United States are among men who have sex with men (MSM). Pre-exposure prophylaxis (PrEP) is a medication that mitigates risk of HIV acquisition and requires regular STI testing and prescription refills with PrEP providers. Because PrEP care monitors sexual behavior, there is a need to understand how PrEP providers approach sexual health care for MSM patients. In this study, semi-structured qualitative interviews were conducted with 20 MSM in Atlanta, Georgia with current or past prescriptions for PrEP. Data were analyzed with thematic analysis using four major steps: (1) code and codebook development, (2) assigning codes to segments of interviews, (3) code-based and comparative analysis methods, and (4) developing thematic findings. Findings from interviews about changes in sexuality while using PrEP include decreased anxiety surrounding sex, increased feelings of control over personal health, and experiencing less stigma towards sexual partners with HIV. Participants indicated needs for tailored health advice based on individual sexual preferences, sexual health care free from stereotypical assumptions, and improved access to PrEP providers identifying as gay men or who practice in LGBT-friendly settings. Study findings support a call for a gain-frame approach to sexual health in PrEP care for MSM.

Prevalence of gonorrhea and chlamydia in a community clinic for men who have sex with men in Lisbon, Portugal

Men who have sex with men (MSM) are at greater risk for sexually transmitted infections (STIs). Data on MSM chlamydia and gonorrhea prevalence estimates and associated risk factors are scarce. To our knowledge, this is the first study to describe the prevalence and the determinants of both chlamydia and gonorrhea infections in MSM in Portugal. We conducted a cross-sectional study using data from 1832 visits to CheckpointLX, a community-based center for screening blood-borne viruses and other STIs in MSM. Overall prevalence of chlamydia or gonorrhea in our sample was 16.05%, with 14.23% coinfection and 40.73% asymptomatic presentation among those testing positive. Anorectal infection was most common for chlamydia (67.26%), followed by urethral (24.78%) and oral (19.47%) infection. Oral infection was most common for gonorrhea (55.63%), followed by anal (51.25%) and urethral (17.50%) infection. In multivariate analyses, young age (U = 94684, p = 0.014), being foreign-born (χ² = 11.724, p = 0.003), reporting STI symptoms (χ² = 5.316, p = 0.021), inhaled drug use (χ² = 4.278, p = 0.039) and having a higher number of concurrent (χ² = 18.769, p < 0.001) or total (χ² = 5.988, p = 0.050) sexual partners were each associated with higher rates of chlamydia or gonorrhea infection. Young and migrant MSM are a vulnerable population to STIs, as are those who use inhaled drugs and those with a higher number of concurrent or total sexual partners. Although Portugal has no guidelines on chlamydia and gonorrhea screening, our results point toward a need for greater awareness about the importance of high-frequency screening for those at increased risk (i.e., every three to six months).

Stigma on the Streets, Dissatisfaction in the Sheets: Is Minority Stress Associated with Decreased Sexual Functioning Among Young Men Who Have Sex with Men?

INTRODUCTION

Sexual function and satisfaction are understudied aspects of adolescent and young adult sexual wellbeing, and even less is known about sexual minority youth who are vulnerable to unique lesbian, gay, bisexual, and transgender (LGBT)-related stigma.

AIM

We aimed to describe sexual functioning (sexual interest, erectile function, orgasm satisfaction, global satisfaction with one's sex life, and anal discomfort) and examine its associations with demographics, sexual and relationship behavior, and minority stressors (internalized stigma, victimization, microaggressions, and perceived LGBT acceptance within residential neighborhood) among a cohort of young men who have sex with men (YMSM) aged 16-29.

METHODS

Data for this cross-sectional analysis came from an ongoing longitudinal study of HIV and substance use among YMSM (analytic N = 678). We conducted univariate and bivariate analyses and multivariable linear regression, controlling for age, race/ethnicity, and sexual orientation as well as sexual and relationship characteristics that were significant at the bivariate level.

MAIN OUTCOME MEASURE

We assessed sexual functioning in the previous 30 days using the Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction Measures Brief Profile for Males.

RESULTS

YMSM in our sample reported high levels of sexual functioning that were significantly greater than an adult clinical reference population. However, 13.9% of the sample reported having any difficulty with erections, 6.9% reported having less than "good" satisfaction with orgasms, 20.0% reported being "somewhat" or less satisfied with their sex lives, and 9.1% reported experiencing problems during receptive anal sex at least "sometimes." Most associations between minority stressors and sexual functioning domains that were significant at the bivariate level attenuated to non-significance in multivariable analyses. Internalized stigma remained negatively associated with global satisfaction, whereas perceived neighborhood acceptance remained positively associated with orgasm satisfaction. Being sexually active was significantly associated with increased sexual interest and orgasm satisfaction. Having had a recent serious partner was significantly associated with sexual interest and global satisfaction. Negative effects were found for having had casual partners and being HIV positive.

CLINICAL IMPLICATIONS

Although most YMSM have high sexual functioning, a minority report problems and dissatisfaction that may warrant intervention.

STRENGTHS & LIMITATIONS

Our study was limited by its cross-sectional design, measurement limitations, and generalizability to other populations, but it is one of the first to examine sexual functioning among YMSM, using a large, diverse community sample.

CONCLUSION

Public health research and practice must continue to combat LGBT stigma and include sexual functioning as integral to healthy sexuality. Li DH, Remble TA, Macapagal K, et al. Stigma on the Streets, Dissatisfaction in the Sheets: Is Minority Stress Associated with Decreased Sexual Functioning Among Young Men Who Have Sex with Men? J Sex Med 2019;16:267-277.

Genetic Counselors' and Genetic Counseling Students' Implicit and Explicit Attitudes toward Homosexuality

Members of the lesbian, gay, and bisexual (LGB) community experience significant health disparities. Widespread preferences for heterosexual over homosexual people among healthcare providers are believed to contribute to this inequity, making recognition (and ultimately reduction) of healthcare providers' sexual prejudices of import. The present study sought to characterize North American genetic counselors' and genetic counseling students' implicit and explicit attitudes toward homosexuality. During January 2017, 575 participants completed a Web-based survey and Sexuality Implicit Association Test (SIAT). A majority of participants (60.2%) harbored implicit preferences for heterosexual over homosexual people. Mean implicit attitude score (0.24) indicated a slight automatic preference for heterosexual over homosexual people, while mean explicit attitude score (0.033) indicated no preference for either group. Although participants' implicit and explicit attitudes were positively correlated (p < 0.001), there was greater implicit bias for heterosexual over homosexual people than suggested by explicit attitude scores (p < 0.001). Implicit attitudes differed across self-reported sexual orientation (p < 0.001), but not across gender, race, or genetic counseling specialty. Education has been demonstrated to be moderately effective at reducing sexual prejudices, and almost all participants (95.8%) indicated that they would support the implementation of genetic counseling curricula addressing lesbian, gay, bisexual, and transgender (LGBT) issues. The study's combined findings suggest that North American genetic counselors and genetic counseling students support, and may benefit from, the implementation of genetic counseling curricula addressing LGBT issues.

Incidence of HCV infection amongst HIV positive men who had sex with men and prevalence data from patients followed at the Infectious Diseases Clinic of Modena, Italy

BACKGROUND

Men who had sex with men (MSM) living with HIV are at higher risk of developing sexual transmitted diseases. This study reports two years incidence rate and prevalence of HCV in a cohort of HIV positive MSM.

METHODS

MSM HIV-positive outpatients negative to HCV-Ab at first observation entered a Kaplan-Meier model in order to assess the HCV infection incidence rate. Prevalence analysis was performed with MSM HIV-positive that were on follow-up at 2016. An MSM population HIV-negative served as control.

RESULTS

421 patients entered the incidence analysis. The incidence rate of HCV infection among MSM-HIV people was 0.44 per 100 patients-years (19 events). 40 out of 442 (9%) patients were HCV-positive (prevalence analysis); they were mostly genotype 1a and 3 with APRI score <0.7 (87.5%). Univariate analysis between MSM HIV-positive patients and MSM HIV-negative showed significant differences in the prevalence rate (9.0% vs 0.6%, P < 0.001) and median age (39 vs 47, P < 0.001).

CONCLUSION

Incidence and prevalence rate of HCV amongst MSM HIV-positive patients is higher than in other settings. Annual HCV-Ab screening for MSM HIV-positive patients should be enforced and early treatment of HCV recommended.

Circumstances Surrounding High-risk Sexual Experiences Among Primary Care Patients Living With and Without HIV

INTRODUCTION

Rates of sexually transmitted infection (STI) are rising in the USA, yet STI risk remains under-addressed by providers, even in HIV care, and with high-risk patients. We interviewed primary care patients living with and without HIV regarding circumstances surrounding sexual risk behavior to identify opportunities for providers to address and reduce STI risk.

METHODS

We conducted semi-structured 1:1 interviews with patients living with and without HIV reporting ≥ 1 sex partner and varying STI exposure risk in the past 12 months from four geographically diverse US HIV and primary care clinics. We audio-recorded, transcribed, and coded interviews by circumstance type, using double-coding to ensure inter-coder reliability. We used Fisher's exact and T tests to determine associations with demographic/risk factors.

RESULTS

Patients (n = 91) identified a mean of 3 of 11 circumstances. These included substance use (54%), desire for physical/emotional intimacy (48%), lack of HIV/STI status disclosure (44%), psychological drivers (i.e., coping, depression; 38%), personal dislike of condoms (22%), partner condom dislike/refusal (19%), receiving payment for sex (13%), and condom unavailability (9%). Higher proportions of those who were high STI-exposure risk patients, defined as those with ≥ 2 sex partners in the past 3 months reporting never or sometimes using condoms, reported disliking condoms (p = .006); higher proportions of the high-risk and moderate-risk (≥ 2 partners and condom use "most of the time") groups reported substance use as a circumstance (p = .04).

CONCLUSION

Circumstances surrounding perceived STI exposure risk were diverse, often overlapping, and dependent on internal, environmental, and partner-related factors and inadequate communication. Meaningful care-based interventions regarding HIV/STI transmission behavior must address the diversity and interplay of these factors.

Development and Content Validation of a Patient-Reported Sexual Risk Measure for Use in Primary Care

BACKGROUND

Patient-provider sexual risk behavior discussions occur infrequently but may be facilitated by high-quality sexual risk screening tools.

OBJECTIVE

To develop the Sexual Risk Behavior Inventory (SRBI), a brief computer-administered patient-reported measure.

DESIGN

Qualitative item development/quantitative instrument validation.

PARTICIPANTS

We developed SRBI items based on patient interviews (n = 128) at four geographically diverse US primary care clinics. Patients were diverse in gender identity, sex, sexual orientation, age, race/ethnicity, and HIV status. We compared sexual risk behavior identified by the SRBI and the Risk Assessment Battery (RAB) among patients (n = 422).

APPROACH

We constructed an item pool based on validated measures of sexual risk, developed an in-depth interview guide based on pool content, and used interviews to elicit new sexual risk concepts. We coded concepts, matched them to item pool content, and developed new content where needed. A provider team evaluated item clinical relevance. We conducted cognitive interviews to assess item comprehensibility. We administered the SRBI and the RAB to patients.

KEY RESULTS

Common, clinically relevant concepts in the SRBI included number of sex partners; partner HIV status; partner use of antiretroviral medication (ART)/pre-exposure prophylaxis (PrEP); and recent sex without barrier protection, direction of anal sex, and concern regarding HIV/STI exposure. While 90% reported inconsistent condom use on the RAB, same-day SRBI administration revealed that for over one third, all their partners were on ART/PrEP.

CONCLUSION

The SRBI is a brief, skip-patterned, clinically relevant measure that ascertains sexual risk behavior across sex, sexual orientation, gender identity, partner HIV serostatus, and partner treatment status, furnishing providers with context to determine gradations of risk for HIV/STI.

Rural Primary Care Providers' Experiences and Knowledge Regarding LGBTQ Health in a Midwestern State

PURPOSE

Health disparities among LGBTQ people have been documented across various settings and recent research has indicated that many disparities are heightened in the context of rurality. Among these disparities is the decreased rate of primary care utilization by rural LGBTQ individuals. Understanding and addressing provider knowledge and attitudes related to LGBTQ health provides a relevant avenue for addressing underutilization.

METHODS

The study presented was a mail-out survey regarding rural primary care providers' knowledge and experiences regarding LGBTQ health. Publicly available records were compiled to recruit a total sample of 113 primary care providers, at a response rate of 19.8%.

FINDINGS

A majority of respondents reported experience providing care to LGBTQ patients, while only slightly over half had received LGBTQ health education. Data analyses revealed significant associations between reported experiences and patient characteristics including religion, religiousness, age, length of time practicing in current provider role, and gender identity. Provider knowledge of LGBTQ health varied greatly across the items assessed. Provider profession (physician, nurse practitioner, physician assistant) and length of current county residence were significantly predictive of LGBTQ knowledge scores.

CONCLUSION

Results provide insight into rural health care for LGBTQ people. Preeminent findings were: (1) an existing need for LGBTQ health education, (2) variation in knowledge across content areas, and (3) association between knowledge, profession, and length of current county residence. Promotion of rural LGBTQ health may benefit by addressing identified gaps in current care.

Old Pathogen, New Challenges: A Narrative Review of the Multilevel Drivers of Syphilis Increasing in American Men Who Have Sex With Men

Since the turn of the current century, syphilis incidence and prevalence have been increasing more rapidly among men who have sex with men (MSM) than any other US subpopulation, exceeding their previously high rates in the 1970s and 1980s, before the AIDS epidemic. The reasons for these trends are multifactorial and complex, involving individual behavioral, sociocultural, structural, and biological factors, which will be reviewed in this article. Men who have sex with men tend to have more sexual partners than heterosexuals, and engage in practices (e.g., anal sex) that are highly efficient for syphilis transmission and nondetection of primary chancres. In the era of highly active antiretroviral therapy rendering adherent patients noninfectious and the use of preexposure prophylaxis, there is substantially less concern about HIV transmission and acquisition among MSM, resulting in higher levels of condomless sex. The increased concentration of syphilis among black MSM is partially related to assortative mixing, that is, black MSM being more likely to have other black sex partners, as well as decreased access to preventive services and treatment due to economic marginalization, Societal rejection and discrimination may also potentiate factors that may increase sexual risks resulting in syphilis, for example, depression and substance use. The anticipation of experiencing homophobic discrimination in health care settings may lead many sexually active MSM to delay needed screening and treatment, thus being infectious to partners for longer periods than other populations. To effectively control the syphilis epidemic among MSM, scaling up a combination of programs, ranging from enhanced community education to training clinicians and health care systems to provide culturally competent care, will be necessary.

Post-exposure Prophylaxis Awareness, Knowledge, Access and Use Among Three Populations in New York City, 2016-17

Post-exposure prophylaxis (PEP) is a cost-effective, but underused HIV prevention strategy. PEP awareness, knowledge, access, and usage was assessed among young men of color who have sex with men (YMSMOC; n = 177), transgender women (TW; n = 182), and cisgender women of color (CWOC; n = 170) in New York City. 59% were aware of PEP: 80% among YMSMOC, 63% among TW and 34% among CWOC (p < 0.001). 13% had ever used PEP. PEP awareness was higher among YMSMOC with a recent HIV test and lower among those with ≥ 4 partners. PEP awareness was lower among TW who anticipated stigma and reported barriers to taking PEP, and higher among TW who exchanged sex for resources. Among CWOC, more barriers to taking PEP reduced the odds of PEP awareness. PEP education and outreach needs to be deliberate about population-specific campaigns, with a need to focus on reducing PEP stigma and other barriers which impede PEP access.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

Associations Between Major Depressive Episode, Methamphetamine Use Disorder Severity, and Engagement in Sexual Risk-Taking Among Methamphetamine-Using Men Who Have Sex with Men

Depression and methamphetamine use have been associated with increased sexual risk-taking among men who have sex with men (MSM). This study estimated associations between current major depressive episode and/or methamphetamine use disorder and engagement in condomless anal intercourse (CAI). From March 2014 thru January 2016, 286 methamphetamine-using MSM were enrolled into a RCT to reduce methamphetamine use and sexual risk-taking. Analyses revealed that current major depressive episode was associated with a 92% increase in the rate of engagement in CAI with casual male partners (IRR 1.92; 95% CI 1.12-3.31) and a 76% increase in the rate of engagement in CAI with anonymous male partners (IRR 1.76; 95% CI 1.00-3.09). Additionally, for each unit increase in diagnostic methamphetamine use disorder severity, rates of engagement in CAI with anonymous male partners increased by 44% (IRR 1.44; 95% CI 1.11-1.87) and rates of engagement in CAI with exchange male partners increased by 140% (IRR 2.40; 95% CI 1.39-4.13). Neither diagnosis was associated with CAI with main male partners. Depression and methamphetamine use influence sexual risk-taking in unique ways, and interventions working with MSM should assess participants for both depression and methamphetamine use, and may tailor intervention content based on diagnostic outcomes.

How well are U.S. primary care providers assessing whether their male patients have male sex partners?

Identifying patients at-risk for HIV infection, such as men who have sex with men (MSM), is an important step in providing HIV testing and prevention interventions. It is unknown how primary care providers (PCPs) assess MSM status and related HIV-risk factors. We analyzed data from a panel-derived web-based survey for healthcare providers conducted in 2014 to describe how PCPs in the U.S. determined their patients' MSM status. We calculated adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) to describe PCP characteristics associated with systematically determining MSM status (i.e., PCP used "a patient-completed questionnaire" or "routine verbal review of sex history"). Among the 1008 PCPs, 56% determined MSM status by routine verbal review of sexual history; 41% by patient disclosure; 39% by questions driven by symptoms/history; 23% by using a patient-completed questionnaire, and 9% didn't determine MSM status. PCPs who systematically determined MSM status (n=665; 66%) were more likely to be female (aPR=1.16, CI=1.06-1.26), to be affiliated with a teaching hospital (aPR=1.15, CI=1.06-1.25), to routinely screen all patients aged 13-64 for HIV (aPR=1.29, CI=1.18-1.41), and to estimate that 6% or more of their male patients are MSM (aPR=1.14, CI=1.01-1.30). The majority of PCPs assessed MSM status and HIV risk factors through routine verbal reviews of sexual history. Implementing a systematic approach to identify MSM status and assess risk may allow PCPs to identify more patients needing frequent HIV testing and other preventive services, while mitigating socio-cultural barriers to obtaining such information.

Differences in Risky Sexual Behavior According to Sexual Orientation in Korean Adolescents

Adolescents in sexual minority groups are known to be at risk of contracting sexually transmitted diseases through risky sexual behavior. However, few studies have examined associations between sexual orientation and risky sexual behavior and sexually transmitted diseases in Korean adolescents. Therefore, this cross-sectional study used raw data from the Tenth Korea Youth Risk Behavior Web-Based Survey to explore these relationships. Logistic regression analyses were performed to examine the associations between risky sexual behavior and sexual orientation in adolescents. The participants were 6,884 adolescents who provided data regarding demographic characteristics, sexual orientation, and risky sexual behavior. The proportions of homosexual and bisexual subjects who used condoms, engaged in sexual intercourse after drinking alcohol, and experienced sexually transmitted diseases were higher relative to those of heterosexual subjects. Associations between homosexuality and bisexuality and sexually transmitted diseases and engagement in sexual intercourse after drinking remained after multivariate adjustment. Interventions to prevent risky sexual behavior should target sexual orientation, to improve sexual health and prevent sexually transmitted disease in homosexual and bisexual adolescents.

Unsafe Sexual Behavior Among Gay/Bisexual Men in the Era of Combination Antiretroviral Therapy (cART)

The aim of this study was to determine the association between psychosocial determinants of unprotected receptive anal intercourse (URAI) and unprotected insertive anal intercourse (UIAI). Data from 417 HIV positive men who have sex with men (MSM) in the Multicenter AIDS Cohort Study from April 1999 to March 2012 were analyzed and adjusted odds were calculated. It was found that 66% (n = 277) and 72% (n = 299) reported any UIAI or URAI over follow-up, respectively. Cumulative cART-years (median = 5.30 years) was associated with 33 and 47% increases in UIAI and URAI, respectively. Not having reduced concern about HIV transmission (UIAI: OR 0.37, p-value = 0.0004; URAI: OR 0.57, p-value = 0.04), increased safe sex fatigue (UIAI: OR 2.32, 95% p-value = 0.0002; URAI: OR 1.94, p-value = 0.003), and sexual sensation seeking (UIAI: OR 1.76, p-value = 0.002; URAI: OR 1.56, p-value = 0.02) were associated with UIAI and URAI. Serosorting was associated with UIAI (OR 6.11, p-value < 0.0001) and URAI (OR 6.80, p-value < 0.0001). Findings suggest that negative attitudes about HIV transmission are sustained among older men who have sex with men.

Young Men's Disclosure of Same Sex Behaviors to Healthcare Providers and the Impact on Health: Results from a US National Sample of Young Men Who Have Sex with Men

Many men who have sex with men (MSM) do not disclose their same sex behaviors to healthcare providers (HCPs). We used a series of logistic regression models to explore a conceptual framework that first identified predictors of disclosure to HCPs among young MSM (YMSM), and subsequently examined young men's disclosure of male-male sexual behaviors to HCPs as a mediator between sociodemographic and behavioral factors and three distinct health outcomes [HIV testing, sexually transmitted infection (STI) testing, and human papillomavirus (HPV) vaccination]. We determined the predictors of disclosure to HCPs among YMSM and examined the relationship between disclosure and the receipt of appropriate healthcare services. Data were collected online through a US national sample of 1750 YMSM (ages 18-29 years) using a social and sexual networking website for MSM. Sexual history, STI/HIV screening history, sexual health, and patient-provider communication were analyzed in the logistic regression models. Participants were predominantly white (75.2%) and gay/homosexual (76.7%) with at least some college education (82.7%). Young men's disclosure of male-male sexual behaviors to HCPs was associated with the receipt of all healthcare outcomes in our model. Disclosure was a stronger mediator in HPV vaccination than in HIV and STI testing. Disclosure to non-HCP friends and family, HCP visit in the past year, and previous STI diagnosis were the strongest predictors of disclosure. Young men's disclosure of male-male sexual behaviors to HCPs is integral to the receipt of appropriate healthcare services among YMSM. HPV vaccination is more dependent on provider-level interaction with patients than HIV/STI testing.

Sexual Networks, Dyadic Characteristics, and HIV Acquisition and Transmission Behaviors Among Black Men Who Have Sex With Men in 6 US Cities

The role of sexual networks in the epidemiology of human immunodeficiency virus (HIV) among black men who have sex with men (MSM) is poorly understood. Using data from 1,306 black MSM in the BROTHERS Study (2009-2010) in the United States, we examined the relationships between multiple sexual dyadic characteristics and serodiscordant/serostatus-unknown condomless sex (SDCS). HIV-infected participants had higher odds of SDCS when having sex at least weekly (odds ratio (OR) = 2.41, 95% confidence interval (CI): 1.37, 4.23) or monthly (OR = 1.94, 95% CI: 1.17, 3.24) versus once to a few times a year. HIV-uninfected participants had higher odds of SDCS with partners met offline at sex-focused venues (OR = 1.79, 95% CI: 1.15, 2.78) versus partners met online. In addition, having sex upon first meeting was associated with higher odds of SDCS (OR = 1.49, 95% CI: 1.21, 1.83) than was not having sex on first meeting, while living/continued communication with sexual partner(s) was associated with lower odds of SDCS (weekly: OR = 0.64, 95% CI: 0.47, 0.85; monthly: OR = 0.60, 95% CI: 0.44, 0.81; yearly: OR = 0.58, 95% CI: 0.39, 0.85) versus discontinued communication. Persons with primary/steady nonprimary partners versus commercial partners had lower odds of SDCS regardless of HIV serostatus. This suggests the need for culturally relevant HIV prevention efforts for black MSM that facilitate communication with sexual partners especially about risk reduction strategies, including preexposure prophylaxis.

A Multi-Group Latent Class Analysis of Chronic Medical Conditions Among Men Who Have Sex with Men

Until recently, research on the health of gay and other men who have sex with men (MSM) has focused on risk for and the health consequences of HIV and other sexually transmitted infections. A multigroup latent class analysis examined a range of lifetime chronic medical conditions (CMCs) among MSM. Covariates included sociodemographics, substance use, psychological distress, and HIV serostatus. A two-class model best fit the medical condition data: a low probabilities class for most CMCs and a moderate to high probabilities (MHP) class. HIV serostatus was associated with increased within-class probabilities for some CMCs, particularly gastrointestinal and skin disorders. Only increasing age and use of erectile dysfunction drugs were directly associated with increased odds of being in the MHP class whereas methamphetamine use, identifying as gay, and lower alcohol use were indirectly associated. Implications of the findings for future research and the health care needs of MSM are discussed.

Sexual health information disparities between heterosexual and LGBTQ+ young adults: Implications for sexual health

Most studies on young adults' sources of sexual health information and confidence in sexual health practices have focused primarily on heterosexual university students. This study sought to bridge this gap in the literature by exploring where emerging adults, including LGBTQ+ individuals and those who do not pursue postsecondary education, obtain their sexuality information and how this relates to sexual self-efficacy. A total of 386 adults between the ages of 18 and 25 were divided into higher education (n=306) versus high school (n=80) groups and heterosexual (n=215) versus LGBTQ+ (n=171) emerging adults. Participants completed measures of sexual health information sources, as well as self-efficacy with regard to sexual health practices. Heterosexual participants obtained significantly more information from school/university courses and less from educational websites/news outlets than LGBTQ+ participants. Heterosexual participants were significantly more confident in their sexual health practices than LGBTQ+ participants. Different sources of information helped predict sexual self-efficacy across these four groups. Acquiring more information from significant others was the only significant predictor of sexual self-efficacy for all four groups. This study suggests that sexual health information should be discussed within a more relational or interpersonal framework, and that LGBTQ+ issues should be further incorporated and integrated in sex education curricula. Implications for healthcare providers, public health policy, sex educators, clinicians and future research are discussed.

Prevalence of Sexually Transmitted Viral and Bacterial Infections in HIV-Positive and HIV-Negative Men Who Have Sex with Men in Toronto

Background

Hepatitis B (HBV), hepatitis C (HCV) and other sexually transmitted infections (STIs) have been associated with HIV transmission risk and disease progression among gay men and other men who have sex with men (MSM), but the frequency and distribution of STIs in this community in Canada has not been extensively studied.

Methods

We recruited MSM living with and without HIV from a large primary care clinic in Toronto. Participants completed a detailed socio-behavioural questionnaire using ACASI and provided blood for syphilis, HIV, HBV and HCV, herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2), and human cytomegalovirus (CMV) serology, urine for chlamydia and gonorrhea, and a self-collected anal swab for human papillomavirus (HPV) molecular diagnostics. Prevalences were expressed as a proportion and compared using chi-square.

Results

442 MSM were recruited, 294 living with HIV and 148 without. Active syphilis (11.0% vs. 3.4%), ever HBV (49.4% vs. 19.1%), HCV (10.4% vs. 3.4%), HSV-2 (55.9% vs. 38.2%), CMV (98.3% vs. 80.3%) and high-risk (HR) anal HPV (67.6% vs. 51.7%) infections were significantly more common in men living with HIV. Chlamydia and gonorrhea were infrequent in both groups. Regardless of HIV infection status, age and number of lifetime male sexual partners were associated with HBV infection and lifetime injection drug use with HCV infection.

Conclusions

Syphilis and viral infections, including HBV, HCV, HSV-2, CMV, and HR-HPV, were common in this clinic-based population of MSM in Toronto and more frequent among MSM living with HIV. This argues for the implementation of routine screening, vaccine-based prevention, and education programs in this high-risk population.

Exploring sexual health among young Black men who have sex with men in New York City

Young Black men who have sex with men (YBMSM) account for approximately 10% of the total HIV infection in the United States but represent <1% of the population. Few interventions exist that address their unique needs, and those that do adopt a narrow, risk-based framework for prevention. Qualitative data from the Brothers Connect Study were analyzed to explore how a Sexual Health Model (SHM) developed by Robinson et al. (The sexual health model: application of a sexological approach to HIV prevention. Health Educ Res 2002; 17:43-57) could be used as a framework for HIV prevention in YBMSM. Content analysis identified five key themes within SHM: (i) race/ethnicity, including the cultural diversity and unique challenges of YBMSM; (ii) disclosure, as the ongoing process of self-identification rather than a single instance of 'coming out'; (iii) sex, in terms of practices, behaviors and health; (iv) daily challenges, microaggressions and acute instances of discrimination; and (v) the self, resilience and identity. Technology represents a new component for the SHM that may be relevant to YBMSM. YBMSM are in need of comprehensive sexual health programs that go beyond typical HIV frameworks. A tailored SHM could be used for identifying and addressing the specific sexual health needs of YBMSM in research and intervention.

Hypothetical Rectal Microbicide Acceptability and Factors Influencing It among Men Who Have Sex with Men in Tianjin, China

Objectives

To measure potential acceptability of rectal microbicides and to explore factors likely to affect their acceptability among men who have sex with men (MSM).

Methods

Cross-sectional and retrospective surveys were conducted in this study. A questionnaire and a scale were used to measure the acceptability score for physical and functional characteristics of hypothetical rectal microbicides. We also evaluated the involvement of other factors such as sexual behaviors, social context, etc.

Results

MSMs we interviewed showed a high acceptability to rectal microbicides, indicated by the mean acceptability score of 2.92 (SD, 0.54, scale of 1–4). The results also suggested that microbicides were preferred in a cream form that can moisten and lubricate the rectum, prevent HIV infection and go unnoticed by their partners. Multivariate analysis showed that the microbicides acceptability varied significantly by education level (β = 0.135; P = 0.028), having casual partners (β = 0.174; P = 0.007), frequency of lubricant use (β = 0.134; P = 0.031), history of HIV test (β = 0.129; P = 0.036), willingness to use lubricant (β = 0.126; P = 0.045), locus of control by partners regarding STI infection (β = 0.168; P = 0.009).

Conclusions

A positive response to rectal microbicides among MSMs was found in our study, suggesting that rectal microbicides might have a potential market in MSMs and they might play an important role in HIV/STIs prevention as a supplement. Further studies may be considered to combine the acceptability study with clinical research together to understand the true feelings of MSMs when they use the products.

A Pilot Trial of a Sexual Health Counseling Intervention for HIV-Positive Gay and Bisexual Men Who Report Anal Sex without Condoms

Background

Even in the presence of promising biomedical treatment as prevention, HIV incidence among men who have sex with men has not always decreased. Counseling interventions, therefore, continue to play an important role in reducing HIV sexual transmission behaviors among gay and bisexual men and other men who have sex with men. The present study evaluated effects of a small-group counseling intervention on psychosocial outcomes and HIV sexual risk behavior.

Method

HIV-positive (HIV+) peer counselors administered seven 2-hour counseling sessions to groups of 5 to 8 HIV+ gay and bisexual men. The intervention employed information provision, motivational interviewing, and behavioral skills building to reduce sexual transmission risk behaviors.

Results

There was a significant reduction in condomless anal sex (CAS) with HIV-negative and unknown HIV-status partners, from 50.0% at baseline to 28.9% of the sample at 3-month follow-up. Findings were robust even when controlling for whether the participant had an undetectable viral load at baseline. Significant reductions were also found in the two secondary psychosocial outcomes, loneliness and sexual compulsivity.

Conclusions

The findings provide preliminary evidence that this intervention may offer an efficient way of concurrently reducing CAS and mental health problems, such as sexual compulsivity and loneliness, for HIV+ gay and bisexual men.

Trial Registration

ClinicalTrials.gov NCT02546271

Sexual Behaviors of U.S. Men by Self-Identified Sexual Orientation: Results From the 2012 National Survey of Sexual Health and Behavior

INTRODUCTION

Although a large body of previous research has examined sexual behavior and its relation to risk in men of diverse sexual identities, most studies have relied on convenience sampling. As such, the vast majority of research on the sexual behaviors of gay and bisexual men, in particular, might not be generalizable to the general population of these men in the United States. This is of particular concern because many studies are based on samples of men recruited from relatively "high-risk" venues and environments.

AIMS

To provide nationally representative baseline rates for sexual behavior in heterosexual, gay, and bisexual men in the United States and compare findings on sexual behaviors, relationships, and other variables across subgroups.

METHODS

Data were obtained from the 2012 National Survey of Sexual Health and Behavior, which involved the administration of an online questionnaire to a nationally representative probability sample of women and men at least 18 years old in the United States, with oversampling of self-identified gay and bisexual men and women. Results from the male participants are included in this article.

MAIN OUTCOME MEASURES

Measurements include demographic characteristics, particularly sexual identity, and their relations to diverse sexual behaviors, including masturbation, mutual masturbation, oral sex, vaginal sex, and anal sex. Behaviors with male and female partners were examined.

RESULTS

Men of all self-identified sexual identities reported engaging in a range of sexual behaviors (solo and partnered). As in previous studies, sexual identity was not always congruent for gender of lifetime and recent sexual partners.

CONCLUSION

Patterns of sexual behaviors and relationships vary among heterosexual, gay, and bisexual men. Several demographic characteristics, including age, were related to men's sexual behaviors. The results from this probability study highlight the diversity in men's sexual behaviors across sexual identities, and these data allow generalizability to the broader population of gay and bisexual men, in particular, in the United States, which is a major advancement in research focused on individuals in a sexual minority.

Hypersexual, Sexually Compulsive, or Just Highly Sexually Active? Investigating Three Distinct Groups of Gay and Bisexual Men and Their Profiles of HIV-Related Sexual Risk

Emerging research supports the notion that sexual compulsivity (SC) and hypersexual disorder (HD) among gay and bisexual men (GBM) might be conceptualized as comprising three groups-Neither SC nor HD; SC only, and Both SC and HD-that capture distinct levels of severity across the SC/HD continuum. We examined data from 370 highly sexually active GBM to assess how the three groups compare across a range of risk factors for HIV infection. Comparisons focused on psychosexual measures-temptation for condomless anal sex (CAS), self-efficacy for avoiding CAS, sexual excitation and inhibition-as well as reports of actual sexual behavior. Nearly half (48.9 %) of this highly sexually active sample was classified as Neither SC nor HD, 30 % as SC Only, and 21.1 % as Both SC and HD. While we found no significant differences between the three groups on reported number of male partners, anal sex acts, or anal sex acts with serodiscordant partners, the Both SC and HD group reported higher numbers of CAS acts and CAS acts with serodiscordant partners and also had a higher proportion of their anal sex acts without condoms compared to the SC Only group. Our findings support the validity of a three-group classification system of SC/HD severity in differentiating psychosexual and HIV-related sexual risk behavior outcomes in a sample of GBM who report similarly high levels of sexual activity. Notwithstanding the need for sex positive HIV prevention programs, interventions that attempt to help Both SC and HD men deal with distress and address their psychosexual needs specifically may derive HIV prevention benefits.