Event-Level Associations Among Drinking Motives, Alcohol Consumption, and Condomless Anal Sex in a Sample of Young Men Who Have Sex With Men

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

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

Differentiating the role of alcohol in young men's use of substances with sex: A qualitative study

BACKGROUND

Alcohol consumption is common among young men and occurs in many contexts. The sexualized substance use literature has generated some insight into the role of alcohol alongside other substances in the context of sex, though there remain opportunities for targeted and context-sensitive studies to examine the sexual practices and outcomes associated with alcohol, specifically.

METHODS

This interpretive description study explores how experiences and contexts of alcohol use feature in the sexual lives of young men who use substances with sex. Data collection involved in-depth interviews conducted between 2018 and 2021 in Vancouver, Canada, with N = 76 young men (ages 18-30; mean = 23.9 years) who use substances with sex, including men with diverse sexual identities. Data were analyzed in an iterative manner through a social constructivist lens and an interpretive description framework, leveraging constant comparison techniques.

FINDINGS

This analysis yielded three interconnected themes: (1) using alcohol for sexual(ity) freedoms; (2) backgrounding alcohol within a sexualized polysubstance milieu; and (3) navigating the risks and consequences of using alcohol with sex. Alcohol use was found to reduce inhibitions and support experimentation, including by facilitating the transgression of conservative or restrictive social and sexual norms. Alcohol was seldom explicitly classified as a sexualized substance, though it was evidently a widespread and normative social practice. This practice was associated with important risk and consequences, including with respect to consent, pregnancy and sexually transmitted and bloodborne infection risk, and sexual dysfunction.

CONCLUSIONS

Findings from this study position alcohol as a backgrounded yet significantly influential substance that young men use with sex. The sexualized use of substances must be understood, and responded to, in a manner that is grounded in harm reduction and that considers the full spectrum of substances-inclusive of but not limited to alcohol-and associated benefits and risks that feature in young men's sexual lives. Specifically, sexual health and primary care providers working with young men should invite and open up meaningful conversation about how they may be using substances (including alcohol) with sex, while offering de-stigmatizing, sex-positive, and affirming education and supports to promote safer sex and substance use.

Characterizing Racial Differences of Mental Health Burdens, Psychosocial Determinants, and Impacts on HIV Prevention Outcomes Among Young Men Who have Sex With Men: a Community-based Study in Two U.S. Cities

Few studies examine racial differences (e.g., Black vs. White) regarding the psychosocial pathways linking mental health burdens and various HIV-related outcomes among young men who have sex with men (MSM) in the U.S. We conducted a community-based study to examine the racial differences of mental health burdens (e.g., depression, anxiety, stress), the psychosocial determinants (e.g., HIV stigma, homonegativity, resilience, social support, loneliness, housing/food security) and impact on HIV-related outcomes (e.g., event-level alcohol/drug use before sex, condomless insertive/receptive anal sex, recent HIV testing, and PrEP awareness/willingness/use) among young Black MSM (YBMSM; n = 209) and young White MSM (YWMSM; n = 109) from two cities (Nashville, TN and Buffalo, NY) in the United States. Overall, we found YBMSM were more likely (p < 0.05) to experience anxiety and depression compared to YWMSM. Among YBMSM, we found structural inequities (housing instability, food insecurity, internalized homonegativity) were positively associated with anxiety/depression/stress (p < 0.001); we also found anxiety/depression was associated with increased alcohol/drug use before sex, and stress was associated with reduced recent HIV testing and pre-exposure prophylaxis awareness/willingness/use. Among YWMSM, we found psychological buffers (perceived social support, resilience) were associated with reduced anxiety/depression/stress (p < 0.001); anxiety was associated with increased condomless insertive/receptive anal sex and recent HIV testing among this subgroup. YBMSM and YWMSM differed in psychosocial determinants and HIV-related consequences regarding their mental health. Our findings provide important implications for developing culturally and contextually tailored interventions to address mental health burdens and HIV prevention outcomes among young MSM at highest risk for HIV acquisition.

Latent Class Analysis of Polysubstance Use and Sexual Risk Behaviors among Men Who Have Sex with Men Attending Sexual Health Clinics in Mexico City

Men who have sex with men (MSM) are more likely to use drugs and other substances compared to their heterosexual peers. No studies have evaluated patterns of substance use among MSM adults in Mexico. We used latent class analysis (LCA) to identify MSM subgroups with specific substance use patterns and their associations with sexual behaviors. Methods: Data from 1850 adult MSM were collected at HIV clinics in Mexico City between September 2018 and December 2019. The structural equation modeling approach was used to estimate a LC model to identify patterns of substance use by self-report of substance use (i.e., cigarette smoking, alcohol, and drugs). To evaluate LC membership, we included HIV status, condomless anal sex (CAS), and serosorting, while controlling for demographic variables. Results: 30.3% were under the age of 22. Alcohol use in last 30 days (76.2%), binge drinking (29.2%), marijuana (29.4%), sex-drugs (23.9%), stimulants (13.7%), and depressants (6.3%). MSM reported engaging in CAS (55.9%) and serosorting (13.5%) behaviors, and 40% reported being HIV positive. LCA indicated three general categories of MSM substance users: Class 1 (49.0%), Class 2 (29.8%), and Class 3 (20.4%). Members of Class 3 were younger: 23–28 age years (aOR = 1.86) and 29–33 age years (aOR = 1.86), more educated: completed graduate studies (aOR = 1.60), had a high probability of polysubstance use and were more likely to engage in CAS and serosorting. Conclusions: Attempts to detect alcohol and problematic use of substances are needed for MSM followed by culturally competent approaches that address alcohol and drug use disorders.

Longitudinal Event-Level Sexual Risk and Substance Use among Gay, Bisexual, and Other Men Who Have Sex with Men

(1) Background: Condomless anal sex and substance use are associated with STI risk among gay, bisexual, and other men who have sex with men (gbMSM). Our first study objective was to describe event-level sexual risk and substance use trends among gbMSM. Our second study objective was to describe substances associated with event-level sexual risk. (2) Methods: Data come from the Momentum Health Study in Vancouver, British Columbia and participants were recruited from 2012-2015, with follow-up until 2018. Stratified by self-reported HIV status, we used generalized estimating equations to assess trends of sexual event-level substance use and assessed interactions between substance use and time period on event-level higher risk sex defined as condomless anal sex with an HIV serodifferent or unknown status partner. (3) Results: Event-level higher risk anal sex increased across the study period among HIV-negative/unknown (baseline prevalence: 13% vs. study end prevalence: 29%) and HIV-positive gbMSM (baseline prevalence: 16% vs. study end prevalence: 38%). Among HIV-negative/unknown gbMSM, event-level erectile drug use increased, while alcohol use decreased over the study period. Overall, interactions between substance use and time on higher risk anal sex were not statistically significant, regardless of serostatus. However, we found a number of time-specific significant interactions for erectile drugs, poppers, Gamma-hydroxybutyrate (GHB), crystal methamphetamine and ecstasy/MDMA use among HIV-negative/unknown gbMSM. (4) Conclusion: Significant differences in substance use trends and associated risks exist and are varied among gbMSM by serostatus. These findings provide a more comprehensive understanding of the effects of event-level substance use on sexual risk through longitudinal follow-up of nearly six years.

Using the Experience Sampling Method to Study Sexual Risk Behavior among Men Who Have Sex With Men (MSM)

Toward the goal of advancing understanding of rates of HIV transmission among men who have sex with men (MSM) populations, this article provides preliminary data on the use of the experience sampling method (ESM) in a sample of 165 MSM. Participants completed 6 weeks of experience sampling in two 3-week measurement bursts with a 3-week rest interval. Criterion validity of the random and retrospective daily assessments was supported by expected within-person correlations between sexual risk behavior and sexual arousal. Participants reported some sexual activity with a male partner on 18.62% of the days, condomless anal sex (CAS) on 6.52% of days, and not using condoms on 66.56% of days they had anal sex. Over half of the variability in CAS was at the within-person level, which suggests the significance of time varying contextual factors. Finally, CAS reports were relatively stable across the study, suggesting a lack of reactivity to the self-monitoring.

A Pilot Randomized Trial of Intervention Components Addressing Drug Use in Couples HIV Testing and Counseling (CHTC) with Male Couples

Men who have sex with men (MSM) experience high rates of substance use and HIV infection. Main partners are the source of many (35-68%) of these new HIV infections. This study developed and examined the efficacy of two adjunct components to couples HIV testing and counseling (CHTC)-communication training (CT) videos and a substance use module (SUM)-to reduce drug use and sexual HIV transmission risk in MSM couples. Participants included 70 male couples randomized into one of four conditions: CHTC, CHTC + CT videos, CHTC + SUM, and CHTC + CT videos + SUM. Participants completed a survey pre-intervention and 1-, 3-, and 6-months later. Completion of the SUM in the absence of CT videos was associated with significant immediate decreases in drug use and related problems; however, at 3- and 6-month follow ups, the SUM was only associated with reductions in drug use and related problems among men who also viewed the CT videos. There were no between-condition differences in sexual behavior. CHTC may serve as a vehicle for the delivery of brief substance use intervention for MSM couples.ClinicalTrails.gov NCT # 03125915.

Relationship functioning and substance use in same-sex male couples

BACKGROUND

Research suggests that substance use among partnered sexual minority men will be inversely associated with the quality of dyadic functioning. We tested whether dimensions of relationship functioning implied within Couples Interdependence Theory (e.g., rewards, costs, barriers, alternatives, investment, and comparison to an ideal) predicted drug use and problematic alcohol use consistent with this hypothesis.

METHODS

This study utilized baseline data from a sample of 70 couples recruited in the New York City area. All participants were cis-gender male and 18 or older. In each couple, at least one partner reported recent drug use, at least one was aged 18 to 29, and at least one was HIV negative. Participants provided demographic information; completed measures of relationship functioning and problematic alcohol use; and reported recent (past 30 day) drug use.

RESULTS

Actor-partner interdependence models were calculated. The use of miscellaneous recreational drugs (excluding marijuana) was positively associated with participants' perception of rewards, costs, and barriers to leaving and negatively associated with comparisons to an ideal, alternatives, and investment. In addition, partner perceptions of rewards were positively associated with this outcome. AUDIT scores were negatively associated with comparison to an ideal; and positively associated with partner perceptions of alternatives. Relationship functioning was unrelated to marijuana use.

CONCLUSIONS

These findings provide support for the hypothesis that relationship functioning and substance use are related. Couples Interdependence Theory implies such an assumption and it underlies many couples-based approaches to drug use intervention. These findings point to the potential utility of integrating relationship skill building into substance use interventions for partnered sexual minority men.

Safer sex intentions modify the relationship between substance use and sexual risk behavior among black South African men who have sex with men

Due to the global burden of HIV, a better understanding of the relationship between substance use and HIV risk behavior is a public health priority, particularly among populations with high rates of HIV infection. The current study explored the moderating effects of psychosocial factors on the relationship between substance use and sexual risk behavior. Among 480 black South African men who have sex with men recruited using respondent-driven sampling, a cross-sectional survey was conducted that included questions about their last sexual event that involved anal sex. Substance use was not associated with unprotected anal intercourse (UAI) ( P = 0.97). The effect of substance use on UAI was modified by safer sex intentions ( P = 0.001). Among those with higher safer sex intentions, substance use was positively associated with UAI (aOR = 5.8, 95%CI = 1.6–21.3, P < 0.01). This study found that among men who have sex with men with high intentions to engage in safer sex, substance use was associated with increased risky sexual behavior.

Determining the Roles that Club Drugs, Marijuana, and Heavy Drinking Play in PrEP Medication Adherence Among Gay and Bisexual Men: Implications for Treatment and Research

Researchers have established that substance use interferes with anti-retroviral medication adherence among gay and bisexual men (GBM) living with HIV. There is limited parallel examination of pre-exposure prophylaxis (PrEP) adherence among HIV-negative GBM. We conducted retrospective 30-day timeline follow-back interviews and prospective semi-weekly diary data for 10 weeks with 104 PrEP-using GBM, half of whom engaged in club drug use (ketamine, ecstasy, GHB, cocaine, or methamphetamine)-generating 9532 days of data. Participants reported their day-by-day PrEP, club drug, marijuana, and heavy alcohol use (5 + drinks in one sitting). On average, club drug users were no more likely to miss a dose of PrEP than non-club drug users (M = 1.6 doses, SD = 3.0, past 30 days). However, we found that club drug use (at the event level) increased the odds of missing a dose on the same day by 55% and the next day (e.g., a "carryover effect") by 60%. Further, missing a dose on one day increased the odds of missing a dose the following day by eightfold. We did not identify an event-level effect of marijuana use or heavy drinking on PrEP adherence. Our data suggest club drug users could have greater protective effects from daily oral or long-acting injectable PrEP compared to a time-driven PrEP regimen because of the concurrence of club drug use and PrEP non-adherence.

Rationale and Design of a Remote Web-Based Daily Diary Study Examining Sexual Minority Stress, Relationship Factors, and Alcohol Use in Same-Sex Female Couples Across the United States: Study Protocol of Project Relate

Background

The Healthy People 2020 initiative aims to reduce health disparities, including alcohol use, among sexual minority women (SMW; eg, lesbian, bisexual, queer, and pansexual). Compared with heterosexual women, SMW engage in more hazardous drinking and report more alcohol-related problems. Sexual minority stress (ie, the unique experiences associated with stigmatization and marginalization) has been associated with alcohol use among SMW. Among heterosexuals, relationship factors (eg, partner violence and drinking apart vs together) have also been associated with alcohol use. Negative affect has also been identified as a contributor to alcohol use. To date, most studies examining alcohol use among SMW have used cross-sectional or longitudinal designs.

Objective

Project Relate was designed to increase our understanding of alcohol use among young SMW who are at risk for alcohol problems. The primary objectives of this study are to identify daily factors, as well as potential person-level risk and protective factors, which may contribute to alcohol use in SMW. Secondary objectives include examining other physical and mental concerns in this sample (eg, other substance use, eating, physical activity, and stress).

Methods

Both partners of a female same-sex couple (aged 18-35 years; n=150 couples) are being enrolled in the study following preliminary screening by a market research firm that specializes in recruiting sexual minority individuals. Web-based surveys are being used to collect information about the primary constructs of interest (daily experiences of alcohol use, sexual minority stress, relationship interactions, and mood) as well as secondary measures of other physical and mental health constructs. Data are collected entirely remotely from women across the United States. Each member of eligible couples completes a baseline survey and then 14 days of daily surveys each morning. Data will be analyzed using multilevel structural equation modeling.

Results

To date, 208 women (ie, 104 couples) were successfully screened and enrolled into the study. In total, 164 women have completed the 14-day daily protocol. Compliance with completing the daily diaries has been excellent, with participants on average completing 92% of the daily diaries. Data collection will be completed in fall 2018, with results published as early as 2019 or 2020.

Conclusions

Project Relate is designed to increase our understanding of between- and within-person processes underlying hazardous drinking in understudied, at-risk SMW. The study includes a remote daily diary methodology to provide insight into variables that may be associated with daily hazardous alcohol use. Before the development of programs that address hazardous alcohol use among young SMW, there is a need for better understanding of individual and dyadic variables that contribute to risk in this population. The unique challenges of recruiting and enrolling SMW from across the United States in a daily diary study are discussed.

International Registered Report Identifier (IRRID)

DERR1-10.2196/11718

Motivations for alcohol use to intoxication among young adult gay, bisexual, and other MSM in New York City: The P18 Cohort Study

INTRODUCTION

Motivations for alcohol use to intoxication vary among young adults depending on social setting and other contextual factors. However, there is limited research exploring the role of different drinking motivations among young men who have sex with men (YMSM).

METHODS

Data from a racially/ethnically and socioeconomically diverse sample of YMSM (n = 426) were used to examine associations between recent (last 30 days) alcohol use to intoxication and scores on three distinct drinking motivation subscales: convivial, intimate, and negative coping drinking. Multinomial logistic regression models were constructed to examine associations between drinking motivations and days of alcohol use to intoxication, controlling for sociodemographic characteristics.

RESULTS

YMSM who scored higher on all three drinking motivation subscales were more likely to engage in recent alcohol use to intoxication compared to those who reported no alcohol use to intoxication. In multivariable models, Black and Hispanic YMSM had lower odds of intoxication compared to White YMSM, and those reporting lower perceived familial SES had lower odds compared to higher SES. In a final model including all three motivations, only convivial drinking was significantly associated with days of intoxication (1-2 days: AOR = 1.22; 3+ days: AOR = 1.45).

CONCLUSIONS

This study identifies distinct associations between different motivations for drinking and alcohol use to intoxication in a sample of YMSM. These findings highlight a need to incorporate an understanding of motivations for alcohol use to intoxication into research and clinical practice with YMSM, as different reasons for drinking carry respective potential health risks.

Day-Level Associations Between Substance Use and HIV Risk Behavior Among a Diverse Sample of Transgender Women

Purpose: Transgender women in the United States face elevated rates of HIV and of substance use. Studies measuring overall or aggregate levels of substance use have linked use to increased HIV transmission risk behavior (TRB). Although intensive longitudinal studies in other populations have found day-level links between substance use and TRB, no study has yet explored such links among transgender women. This study aimed to fill this gap in the literature. Methods: Utilizing survey and 60-day timeline follow-back interview data from a sample of 214 transgender women in New York City, we tested whether day-level heavy drinking, marijuana use, and/or nonprescription stimulant use were associated with odds of engaging in any sex (vs. no sexual activity) or engaging in TRB (vs. sex without TRB), adjusting for overall levels of use. Results: Multilevel models showed that each of the three substance types was associated with greater odds of engaging in sex on a given day-and more strongly so for heavy drinking among those with higher rates of heavy drinking, and for stimulant use among those with lower rates of stimulant use. Only marijuana use was associated with greater odds of TRB on a given day, but only among those with higher rates of use. Conclusion: These findings substantiate day-level links between substance use and engaging in sexual activity among transgender women, and importantly, between marijuana use and greater likelihood of TRB on a day when sexual activity occurs. This highlights the importance of addressing substance use for sexual health among transgender women especially focusing on marijuana use.

Motivational interviewing with couples: A theoretical framework for clinical practice illustrated in substance use and HIV prevention intervention with gay male couples

Epidemiological data indicate the need to address substance use and sexual HIV transmission risk among gay and bisexual men in relationships. While brief Motivational Interviewing (MI) delivered to the individual has shown efficacy in reducing sexual HIV risk with casual partners and substance use, the application of MI with couples has received less attention. Most studies of MI with couples have conceptualized the "spouse" or partner as an adjunct participant in the treatment of an identified client. We propose a theoretical framework for conducting MI with a couple, which approaches the couple as the identified client, and may be adopted when either one or both partners engage in the target behavior. We then discuss similarities between MI-processes conceptualized with our proposed framework and those that are salient in existing couples therapies. We utilize case examples from brief MI sessions targeting substance use and sexual HIV risk in gay male couples to illustrate three phenomena unique to the implementation of MI with couples: 1) interpersonal ambivalence; 2) the role of dyadic functioning in tolerating and resolving interpersonal ambivalence; and 3) joint goal formation as a prerequisite to the planning phase of MI. Connecting these phenomena with the transformation of motivation and accommodation processes outlined in Couples Interdependence Theory, this paper suggests that brief MI may be a promising modality for substance use and HIV risk reduction interventions with couples generally and gay couples specifically.

The role of chronotype, circadian misalignment, and tiredness in the substance use behaviors of gay and bisexual men

Although the potential of alcohol and drugs to detrimentally affect sleep has been established, the potential of tiredness to in turn influence substance use has received less attention. We contend that tiredness increases risk for substance use because tiredness impairs self-regulation and heightens the utility of substances to combat tiredness, albeit temporarily-and that these links are especially important because decision-making regarding use often occurs late at night when people are tired. Accordingly, we investigated chronotype, circadian misalignment, and perceived tiredness as risk factors in substance use among gay and bisexual men (GBM). We analyzed two online survey datasets-one of 3,696 GBM and one of 1,113 GBM-asking participants about their time for most frequently using alcohol or club/party drugs, their chronotype, whether they use substances to stay awake, and use severity. Alcohol use and club/party drug use most often occurred from 9pm onwards (for 51.3% and 75.1% of men, respectively), especially among younger men and evening types. Further, many men with a morning chronotype reported most often using alcohol (33.2%) and drugs (64.7%) from 9pm onwards, implicating circadian misalignment. Additionally, feeling tired was a motivator of alcohol use and drug use (for 53.1% and 26.9% of men, respectively), especially among younger men. Finally, those endorsing this motivation had greater use severity. These findings highlight the importance of chronotype, circadian misalignment, and tiredness in substance use, especially among younger men. We therefore recommend including substance use among the behaviors adversely affected by tiredness from circadian misalignment and inadequate/overdue sleep.

Age of Onset of Alcohol Consumption and Subsequent Negative Health Outcomes in Gay and Bisexual Men Who Have Sex With Men

The correlation between current alcohol use and sexual risk behaviors among men who have sex with men (MSM) is well documented, but little is known about age of drinking onset and current risks among this population. Data from a 2008 Internet survey of 8,452 MSM in the United States were used to assess factors associated with age of onset of alcohol use. In a multivariable model, drinking onset before age 15 was significantly associated with a higher number of lifetime male anal sex partners and being behaviorally bisexual in the past 12 months. Men who reported depressive symptoms in the past two weeks or who screened positive for alcohol abuse in the past 60 days were more likely to have early age of drinking onset. Findings suggest the need for targeting younger adolescents for alcohol screening, particularly sexual minority youth, to prevent risk behaviors in adulthood.

Condom and Substance Use at Last Sex: Differences between MSMO and MSWO High School Youth

HIV disproportionately impacts youth, particularly young men who have sex with men (YMSM), a population that includes subgroups of young men who have sex with men only (YMSMO) and young men who have sex with men and women (YMSMW). In 2015, among male youth, 92% of new HIV diagnoses were among YMSM. The reasons why YMSM are disproportionately at risk for HIV acquisition, however, remain incompletely explored. We performed event-level analyses to compare how the frequency of condom use, drug and/or alcohol use at last sex differed among YMSMO and YMSWO (young men who have sex with women only) over a ten-year period from 2005–2015 within the Youth Risk Behavior Survey (YRBS). YMSMO were less likely to use condoms at last sex compared to YMSWO. However, no substance use differences at last sexual encounter were detected. From 2005–2015, reported condom use at last sex significantly declined for both YMSMO and YMSWO, though the decline for YMSMO was more notable. While there were no significant differences in alcohol and substance use at last sex over the same ten-year period for YMSMO, YMSWO experienced a slight but significant decrease in reported alcohol and substance use. These event-level analyses provide evidence that YMSMO, similar to adult MSMO, may engage in riskier sexual behaviors compared to YMSWO, findings which may partially explain the increased burden of HIV in this population. Future work should investigate how different patterns of event-level HIV risk behaviors vary over time among YMSMO, YMSWO, and YMSMW, and are tied to HIV incidence among these groups.