Public health policy and gay bathhouses

Prevention of HIV in the MSM Population: A Cultural-Historical Comparison of Sweden and the Netherlands

The aim of this article is to compare the cultural-historical events and decisions regarding how to deal with the higher risks of HIV in MSM, and more specifically, gay populations in Sweden and the Netherlands. A narrative literature was used, based on 46 scientific articles and 20 additional semi-scientific resources. The themes of the arrival of HIV and AIDS, blood donations, offender/victim, the balance of risks with respect to the statistical probabilities and the human factor, and finally, prevention were discussed. It is concluded that certain context-specific historical events (the Dutch Bloody Sunday and the Swedish gay sauna ban) and culturally determined processes (trust in others in the Netherlands, and disapproval of casual sex in Sweden) have led to some important differences in how HIV and AIDS and the higher risks for gay men and MSM have been dealt with. In the Netherlands, there is a stronger protective attitude when it comes to the freedom and autonomy of MSM both when it comes to decisions about sexual behavior and to sharing any positive HIV status. In Sweden, on the other hand, there is a stronger tendency to enforce informing others of their HIV status. In both countries, despite efforts to prevent this, HIV has increased stigma for gay men and other MSM.

Implementing Geospatial Science and Technology to Get to Zero New HIV Infections

PURPOSE OF REVIEW

Tremendous advancements have been made in HIV treatment and prevention during the last 40 years that zero new HIV cases has become an attainable goal declared by international agencies. However, new cases of HIV infection persist.

RECENT FINDINGS

The emerging field of geospatial science is positioned to play key role in the reduction of continued HIV incidence through technology-driven interventions and innovative research that gives insights into at-risk populations. As these methods become more utilized, findings consistently show the important role of location and environment plays in HIV incidence and treatment adherence. This includes distance to HIV provider, locations of where HIV transmissions occurs compared to where people with HIV reside, and how geospatial technology has been leveraged to identify unique insights among varying groups of those at increased risk for HIV, among others. Given these insights, leveraging geospatial technology would play a prominent role in achieving zero new cases of HIV infections.

Rethinking Risk, Culture, and Intervention in Collective Sex Environments

This article provides a narrative overview of research on HIV/STI risk and collective sexual behavior based on an inclusive analysis of research on environments where people gather for sexual activity-sex clubs, swingers' clubs, bathhouses, parks, private sex parties, etc. The aim is to analyze how collective sex has been approached across disciplines to promote conversation across paradigms and suggest new lines of inquiry. Attention to context-such as the location of sex-was a necessary redress to universalizing models of sexual risk-taking behavior, leading to insights rooted in the particularities of each environment and its users. However, the identification of ever more precise risk groups or environmental idiosyncrasies eventually becomes theoretically restrictive, leading to an overestimation of the uniqueness of sexual enclaves, and of the difference between any given enclave and the broader social milieu. Using a theoretical framework of transgression to interpret the interdisciplinary literature, similarities in the spatial and social organization of collective sex environments are identified. Insights generated from this complementary perspective are then applied to understandings of collective sex: first, the example of male-female (MF) "swingers" is used to illustrate the need to establish, rather than assume, the distinctiveness of each non-normative sexual enclave, and to broaden the conceptualization of context; second, questions are raised about the practicality of interventions in collective sex environments. Finally, new lines of intellectual inquiry are suggested to shed light not just on collective sex but on sociosexual issues more generally, such as increasing protective sexual health behavior or negotiating consent in sexual encounters.

Sex Behaviors as Social Cues Motivating Social Venue Patronage Among Young Black Men Who Have Sex with Men

HIV prevention programs often focus on the physical social venues where men who have sex with men (MSM) frequent as sites where sex behaviors are assumed to be practiced and risk is conferred. But, how exactly these behaviors influence venue patronage is not well understood. In this study, we present a two-mode network analysis that determines the extent that three types of sex behaviors-condomless sex, sex-drug use, and group sex-influence the patronage of different types of social venues among a population sample of young Black MSM (YBMSM) (N = 623). A network analytic technique called exponential random graph modeling was used in a proof of concept analysis to verify how each sex behavior increases the likelihood of a venue patronage tie when estimated as either: (1) an attribute of an individual only and/or (2) a shared attribute between an individual and his peers. Findings reveal that sex behaviors, when modeled only as attributes possessed by focal individuals, were no more or less likely to affect choices to visit social venues. However, when the sex behaviors of peers were also taken into consideration, we learn that individuals were statistically more likely in all three behavioral conditions to go places that attracted other MSM who practiced the same behaviors. This demonstrates that social venues can function as intermediary contexts in which relationships can form between individuals that have greater risk potential given the venues attraction to people who share the same risk tendencies. As such, structuring interventions around these settings can be an effective way to capture the attention of YBMSM and engage them in HIV prevention.

High risks of HIV transmission for men who have sex with men--a comparison of risk factors of HIV infection among MSM associated with recruitment channels in 15 cities of China

Objective

While the HIV epidemic varies greatly by region and population group throughout China, the HIV incidence among men who have sex with men (MSM) continues to rise at an alarmingly fast pace. We seek to analyze the risk factors associated with HIV infection among MSM recruited from different channels in large urban centers across China, in an attempt to shed light on the design of future targeted intervention strategies.

Methods

A total of 33,684 MSM from 14 cities and one province were recruited from July to December 2011. Demographic (e.g. age, marital status, education) and behavioral (e.g. condom use, HIV testing history) data were collected using information collection cards. Blood samples were also collected to test for HIV and Syphilis.

Results

Participants were recruited from five different channels, and all demonstrated distinct characteristics. The overall rate of positive HIV screening was 6.27% and the rate of syphilis infection was 6.50%. Participants recruited from bathhouses had the highest HIV (11.80%) and syphilis infection rates (11.20%). Participants who were infected with syphilis had the highest HIV-positive screening rate (13.75%; 95% CI OR, 2.33-3.06). living in the southwest region of the country (11.64%; OR=2.76, 95%CI OR 2.19-3.47), Being >20 years of age (P<0.001), living in the southwest region of the country (OR=2.76, 95%CI 2.19-3.47), not having sex with female over the previous 3 months (OR=1.27, 95%CI 1.09-1.48), no condom use during the last anal intercourse (OR=1.54, 95%CI 1.39-1.70) and other factors were all associated with a higher probability of having an HIV-positive test result.

Conclusion

Depending on the way they are recruited, more targeted interventions are required to prevent the spread of HIV/AIDS among MSM with different characteristics and behaviors. Results from this study could provide evidence for researchers to conduct further studies and policy-makers to establish more effective and strategic interventions for MSM in China.

Health promotion within a sex on premises venue: notes from the field

Despite their historical controversy as perceived public health risks, sex on premises venues (SOPV) such as saunas and sex clubs can afford structured opportunities for on-site sexual health interventions within a supportive, regulated and confidential environment. Building upon previous interventions to deliver on-site clinical and health promotion programmes, an education and referral outreach service was established at one particular SOPV within the inner Brisbane city area. This report outlines the experiences of that on-site education/referral outreach over a five-year period. The service did afford opportunities for a minority of patrons to discuss concerns, resolve misunderstandings, obtain advice and referral, and would suggest that a health promotion presence within such a venue is a useful mechanism for engaging with highly sexually active men.

Gay saunas and the risks of HIV and syphilis transmissions in China--results of a meta-analysis

Introduction

Previous studies suggest the risk of human immunodeficiency virus (HIV) transmission among men who have sex with men (MSM) is associated with characteristics of venues. However, very few studies have systematically compared HIV/sexually transmitted disease (STD) prevalence among MSM according to key venue type for sourcing sex partners.

Aims

The aim of this study was to investigate the associations between HIV/syphilis prevalence and the types of venues, namely saunas, parks, gay bars, and the Internet, which are mostly used for sourcing male sex partners by MSM in China.

Methods

Meta‐analyses using fixed‐effect and random‐effect methods were conducted. Secondary data were obtained from 10 concurrent surveys conducted in 10 cities basing on a common protocol. Pairwise comparisons (e.g., “saunas” vs. “parks”) were made.

Main Outcomes Measures

Odds ratios (OR) for HIV/syphilis infection in relations to venue type for partner sourcing.

Results

The distribution of the most commonly used source to recruit male sex partner was 59.32% (Internet), 18.47% (gay bars), 14.18% (gay saunas), and 8.02% (parks). The median prevalence of HIV/syphilis was 10.49% and 19.38% (gay saunas), 2.12% and 16.25% (parks), 6.06% and 15.45% (Internet), and 4.41% and 11.90% (gay bars). We found significant between‐group differences when comparing “sauna” against “Internet” (HIV: OR = 2.27, 95% confidence interval [CI] = 1.65–3.12; syphilis: OR = 1.61, 95% CI = 1.07–2.41), “sauna” against “bars” (HIV: OR = 1.65, 95% CI = 1.14–2.39; syphilis: OR = 1.35, 95% CI = 1.02–1.78), and “parks” against “Internet” (syphilis: OR = 1.55, 95% CI = 1.12–2.15) as the main source to recruit male sex partners. Other pairwise comparisons were not statistically significant.

Conclusions

The results of this study suggest that those sourcing partners mainly from gay saunas have higher prevalence of HIV/syphilis when compared with those doing so via the Internet or gay bars. Venue based (sauna‐based) interventions using socio‐ecological approaches are greatly warranted in order to reduce HIV and syphilis prevalence among MSM in China. Lau JTF, Zhao J‐K, Wu X‐B, Gu J, and Hao C. Gay saunas and the risks of HIV and syphilis transmissions in China—results of a meta‐analysis. J Sex Med 2013;10:642–652.

Overcoming biological, behavioral, and structural vulnerabilities: new directions in research to decrease HIV transmission in men who have sex with men

Men who have sex with men (MSM), including transgender women, comprise a heterogeneous group of individuals whose sexual behaviors and gender identities may vary widely between cultures and among individuals. Their sources of increased vulnerability to HIV are diverse, including the increased efficiency of HIV transmission via unprotected anal intercourse, sexual role versatility, asymptomatic sexually transmitted infections, and behavioral factors that may be associated with condomless sex with multiple partners. Societal stigmatization of homosexual behavior and gender nonconformity may result in internalized negative feelings that lead to depression, other affective disorders, and substance use, which in turn are associated with increased risk-taking behaviors. Social stigma and punitive civil environments may lead to delays in seeking HIV and sexually transmitted disease screening, and later initiation of antiretroviral therapy. The iPrEX study demonstrated that chemoprophylaxis can decrease HIV acquisition in MSM, and the HIV prevention trials network 052 study established the biological plausibility that earlier initiation of highly active antiretroviral therapy can decrease HIV transmission to uninfected partners. Despite these advances, MSM remain among the most significantly HIV-affected population in resource-rich and limited settings. New studies will integrate enhanced understanding of the biology of enhanced rectal transmission of HIV and the focused use of antiretrovirals for prevention with culturally tailored approaches that address the potentiating social and behavioral factors associated with enhanced HIV spread among MSM.

Gay bathhouse HIV prevention: the use of staff monitoring of patron sexual behavior

Many HIV prevention interventions have been launched in gay bathhouses and sex clubs since the onset of the AIDS epidemic, such as condom distribution and HIV testing. Perhaps none of these are as intrusive to the venue's environment as what is called "monitoring," which involves staff, during every shift, repeatedly walking throughout the public areas of a bathhouse to check on patrons' sexual behavior. Yet, monitoring has received little evaluation. Between 2002 and 2004, we conducted qualitative interviews with venue managers, staff and patrons in New York City, Los Angeles, and the San Francisco Bay Area. An analysis found that monitoring was influenced by the kinds of space available for sex, suggesting three approaches to monitoring: 1) monitoring all sex in clubs that only had public areas where men had sex ; 2) monitoring some sex in clubs with private rooms for sex; and 3) no monitoring of sex, regardless of the kinds of space for sex. This paper explores each approach as described by club managers, staff, and patrons to understand the potential effectiveness of monitoring as an HIV prevention intervention.

Use of incentives to encourage sexually transmissible infection testing amongst sex-on-premises venue patrons

BACKGROUND

Incentives have been explored as a strategy for increasing access to sexually transmissible infection (STI) testing. This project sought to trial the offer of free entry to sex-on-premises venues (SOPVs) for venue patrons as an incentive to access sexual health checks.

METHOD

SOPV patrons were offered free entry into venues if they took advantage of sexual health testing at a range of clinics. Patrons were given testing cards from the SOPV that could be exchanged at the time of the clinical consultation for a free entry pass to the SOPV of their choice. Cards collected at clinics and SOPVs were collated.

RESULTS

In total, 244 cards were distributed to patrons from four venues over a 6-month period. Ten persons accessed one of the six clinical sites, one person attending twice. Of these persons, five attended two general practices and the remaining five accessed public sexual health clinics. Of these 10 persons, three used their free entry passes to attend an SOPV. Two persons accessed these clinical sites for the first time, one of whom tested reactive for an STI. Another regular attendee also tested reactive.

CONCLUSION

Despite the low uptake, the free entry promotion was inexpensive and could, given sufficient time, be considered an effective incentive. Nonetheless, this study may have contributed to at least two new persons undertaking testing, one of whom was diagnosed with an STI.

Offending the other: Deconstructing narratives of deviance and pathology

Narratives of homophobia and the repathologization of gay men now emerge and coalesce in often unconsidered ways. Within this paper, we present a deconstructive analysis of a recent paper published within the British Journal of Social Psychology (Crossley, 2004) and highlight how a narrative of repathology emerges through the selective appropriation of particular textual sources. By employing pathological constructions of sexual conduct between men; focusing upon singular homogenized constructions of gay men and simplistic constructions of health promotion and through a process of reconstructing HIV as a gay plague and it is possible to embroider a moral tale which constitutes a further deviant 'othering' of gay men. We contend that by employing (functional) discourses of 'unconscious motivation', together with a constellation of disclaimers, caveats and tokenistic pluralization, it becomes possible for psychologists to engage in homophobic knowledge production whilst maintaining an identity as a (dis)interested professional. Our analysis raises issues pertinent to all social psychologists engaged in 'suspicious' research on 'the other'. To this end, we expand our critique by employing ideas from Ricoeur's hermeneutic phenomenology to provide more general discussion of ethical and constructive ways of engaging in textual analyses of persons outside one's own tradition.

HIV prevention in gay bathhouses and sex clubs across the United States

Gay bathhouses (including sex clubs) contributed to HIV prevention from the early days of the AIDS epidemic, but the extent to which prevention interventions are implemented in bathhouses is unknown. Using telephone survey methodology, bathhouse managers provided data about HIV prevention in their bathhouses. All the bathhouses provided free condoms, and nearly all displayed educational posters in public areas and had informational pamphlets available for patrons. A few of the bathhouses offered outreach services and counseling services. Almost all promoted testing for HIV/sexually transmitted infection (which included providing information about where to get tested), and 75.5% had HIV testing programs in their venues. Most of the HIV testing programs were started during the past 5 years, initiated by the bathhouse management or a community agency, and operated by community-based agencies. About one third of the programs offered rapid HIV testing. The results of the telephone survey revealed that all the bathhouses engaged in prevention and many offered a wide range of prevention services, suggesting that managers have embraced the issue of HIV and collaborated in bringing prevention to high-risk men. The absence of studies evaluating these prevention efforts remains a concern and an obstacle for efficient use of the prevention resources.

Australian men's sexual practices in saunas, sex clubs and other male sex on premises venues

BACKGROUND

Sex on premises venues (SOPVs) where men have sex with men have been implicated in the spread of sexually transmissible infections, but few studies have described men's sexual encounters in SOPVs, particularly the degree to which men from different backgrounds engage in risky sexual practices.

METHODS

Interviewer administered surveys were conducted with 186 Australian men who have sex with men (MSM) within 48 h of visiting an SOPV. They reported their sexual practices, the characteristics of their partners and other circumstances surrounding their sexual encounters.

RESULTS

All analyses were based on the number of sexual encounters (n = 430). Oral sex was the most common practice, occurring in 74.9% of encounters, followed by massage, frottage or kissing (53.7%), solo or mutual masturbation (36.3%), and anal sex (32.1%). Multivariate analyses revealed age as a significant factor for having protected anal sex (P = 0.001), insertive anal sex (P = 0.004) and receptive anal sex (P < 0.001). These practices were more frequent in encounters among younger men, while masturbation (P = 0.03) was more frequent among older men. When men's sexual partners were affected by alcohol, encounters were less likely to involve unprotected anal intercourse (P = 0.006) and more likely to involve massage, frottage or kissing (P = 0.009). Men disclosed their HIV status in only 7.7% of encounters.

CONCLUSIONS

With the likelihood of risky sexual practices varying according to background, results from this study should be used to guide interventions aiming to promote safer sex in SOPVs.

Condom availability inTaiwanese gay bathhouses: the right things in the wrong places

Gay bathhouses were identified as public venues where men having sex with men are more likely to engage in risky sexual behaviors. This study applied Binson and Woods's (Journal of Homosexuality, 44, 2003) theoretical framework of risk environment/bathhouse setting to (a) describe four domains of bathhouse environments, (b) investigate condom availability in bathhouses, and (c) identify barriers of condom distribution. An ethnographic study was conducted at eight gay bathhouses in Taiwan, including environmental observations, interviews of 16 staff members, and self-administered questionnaires of 409 bathhouse patrons. Condoms were provided upon request in eight bathhouses. Environmental observations showed a poor match between the places where condoms were distributed and where men had sex. Cost and police harassment were two barriers of condom distribution in bathhouses. Our findings highlight the importance of the extension of condom distribution at places where men have sex in gay bathhouses.

HIV risk factors reported by two samples of male bathhouse attendees in Los Angeles, California, 2001-2002

BACKGROUND

We aimed to describe the use of voluntary HIV counseling and testing services, risk behaviors, and risk factors for unprotected anal sex (UAS) among men who have sex with men (MSM) who attended a bathhouse in Los Angeles during 2001-2002.

METHODS

Using 2 cross-sectional study samples, we compared (in order below) 458 of 640 MSM who used voluntary HIV counseling and testing in the bathhouse with 398 MSM surveyed upon exit. Within each group, logistic regression identified factors associated with UAS at their most recent bathhouse visit.

RESULTS

Of 640 MSM, 71 (11%) tested HIV-positive for the first time. Of the 50 HIV-positive MSM who completed a survey, 50% tested because of the convenient services. Similar proportions of MSM in both survey samples reported UAS (7%-8%) during their recent bathhouse visit. Risk factors associated with UAS in both survey samples were UAS with men outside the bathhouse and greater numbers of partners within the bathhouse.

CONCLUSIONS

Comprehensive prevention services provided within bathhouses may reduce undiagnosed HIV infections among MSM, and targeting HIV prevention at the bathhouse may reduce risks with partners both inside and outside the bathhouse.

Probability Sample Estimates of Bathhouse Sexual Risk Behavior

OBJECTIVE

Previous research links high rates of unprotected anal intercourse (UAI) with men who go to bathhouses; however, the literature provides no prevalence estimates. An exit survey of a probability sample was conducted to describe the prevalence of risk activity at the bathhouse.

METHODS

Data are from a 2-stage probability sample of men exiting a gay bathhouse (n = 400).

RESULTS

During their visit, 91.5% of men had oral sex and 44.2% had anal sex (11.1% reported UAI and 5.5% reported unprotected receptive anal intercourse). In the prior 3 months, 85% reported having anal sex, which was more likely to be unprotected when it occurred in a private home or hotel as opposed to a public setting (P < 0.001). Moreover, having UAI at home was a significant correlate of risk during the bathhouse visit (P < 0.001).

CONCLUSIONS

Most men at the bathhouse engaged in oral sex rather than anal sex, and most anal sex included use of condoms. Furthermore, men were more likely to have UAI in a private home than in any public setting. The bathhouse seems to have facilitated condom use when anal sex occurred on-site.

Prevalence of Human Immunodeficiency Virus and Sexually Transmitted Infections and Risky Sexual Behaviors Among Men Visiting Gay Bathhouses in Taiwan

OBJECTIVES

This study aimed to investigate the prevalence of human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) and predictors of risky sexual behaviors among men visiting gay bathhouses.

STUDY DESIGN

A cross-sectional study was conducted at 8 gay bathhouses in Taiwan. Bathhouse attendees were invited to complete a questionnaire and to be screened for HIV/STIs.

RESULTS

Of 451 men recruited for the study, 339 (75%) completed the questionnaire and were screened for HIV/STIs. The study indicated that seroprevalence rates of anti-HIV-1 antibody, specific Treponema pallidum antibodies detected by hemagglutination assay, surface antigen of hepatitis B virus, IgG antibodies for hepatitis A virus, antibody for hepatitis C virus, and indirect hemagglutination antibody for Entamoeba histolytica (serum titer > or =1:128) were 8%, 18%, 16%, 38%, 3%, and 6%, respectively. Prevalence rates for chlamydial and gonococcal infections reflected by nucleic acid amplification tests in urine samples were 7% and 4%, respectively. Irregular use of condoms during oral sex, condom inaccessibility at bathhouses, unprotected sex at public venues, no prior HIV test, and 5 or more visits to bathhouses every month were independently associated with unprotected anal intercourse.

CONCLUSION

Men attending gay bathhouses report engaging in unsafe sex practices and are at substantial risk of acquisition of HIV/STIs. These findings highlight the need for more comprehensive prevention efforts at gay bathhouses.

Building an HIV/STI prevention program in a gay bathhouse: a case study

Gay bathhouses have long been subject to community and public health pressures owing to the perceived link between the behaviors associated with these settings and various sexually transmitted infections. The straightforward solution of closing gay bathhouses has not worked for long when it has been tried. The more complex approach of working with management to develop holistic prevention programs can be problematic also, because developing successful HIV/STD prevention programs requires the collaboration of multiple stake-holders. Furthermore, to overcome the stigma associated with disease, the population, and bathhouse environments places significant, and sometimes awkward, demands on those who undertake such prevention programs. Nevertheless, a number of U.S. cities now have had years of experience with such efforts. This article provides an example of a collaboration of multiple stakeholders to develop a holistic prevention program. We examine our own process of building a collaborative team of bathhouse managers, health department officials, and academics to provide HIV/STD prevention programs in a bathhouse. We describe the process of developing the collaboration and offer recommendations for establishing mutually beneficial relationships among stakeholders.

Men who have sex with men (MSM) in public sex environments (Pses): a systematic review of quantitative literature

We systematically review quantitative research relating to the sexual behaviours of MSM in PSEs. We examine the methodological rigour of these studies to determine an appropriate framework for future PSE-based research and quantify sexual behavioural trends therein. Medline, BIDS, Web of Science and recent HIV/AIDS conferences were searched according to a systematic inclusion criteria. Nine papers were included for review. Recruitment of participants' outwith PSE settings, and low response rates (6%) of participants contacted in situ, question the validity and generalizability of current evidence. Most PSE users were gay or bisexually identified and half of men in the gay community reported recent PSE use. Around 10% of men reported casual status-unknown/serodiscordant unprotected anal intercourse (UAI) within PSEs. HIV testing rates amongst PSE users were similar to the wider gay community, though the proportion of men who tested positive was twice as high. Rates of casual UAI suggest that PSEs represent important sites for HIV prevention. However, since extant evidence is scant and methodologically flawed, further research is urgent. Such work must recruit participants in situ, and obtain satisfactory response rates, to be generalizable to the wider population of men who cruise.