Correlates of sexual risk behaviors among HIV-positive men who have sex with men

Reasons for Migration and Their Associations with HIV Risk and Prevention Among Cisgender Sexual Minority Men: A Latent Class Analysis

The immigrant population in the United States (U.S.) is rapidly growing; yet there is limited knowledge about how reasons for migrating to the U.S. are associated with HIV prevention behaviors. Using data from the American Men's Internet Survey (2018-2020), we performed a Latent Class Analysis (LCA) to identify patterns in reasons for migration among cisgender gay, bisexual, and other sexual minority men (SMM) who born outside the U.S. We used multivariable logistic regression controlling for demographic characteristics to assess class associations with the following in the past 12 months: condomless anal sex (CAS), illicit drug use, marijuana use, HIV testing, and PrEP use. LCA identified six distinct patterns in reasons for migration among the sample (n = 1,657): (1) Family and friends (14%); (2) Financial (17%); (3) Personal freedom related to being gay (10%); (4) Pursuit of opportunities while living openly as SMM (12%); (5) Educational purposes (18%); (6) Not my decision (29%). While HIV testing (range = 57.6-65.4%) and PrEP use (range = 15.6-21.4%) did not vary by class (p > .05 for all), CAS and illicit drug use were significantly different (p < .05). SMM who migrated to pursue opportunities while living openly and whose reasons were not their decision had greater odds of CAS than SMM who migrated for educational purposes (aOR:1.72, 95% confidence interval [95%CI]:1.15-2.59; 1.57, 1.13-2.19, respectively). Reasons for migration among SMM were associated with behaviors that can increase HIV risk, but not testing or PrEP. Push and pull factors related to migration should be considered when developing behavioral HIV interventions for immigrant SMM.

Social Media Communication and Network Correlates of HIV Infection and Transmission Risks Among Black Sexual Minority Men: Cross-sectional Digital Epidemiology Study

BACKGROUND

In the United States, HIV disproportionately affects Black cisgender sexual minority men (BSMM). Although epidemiological and behavioral surveillance are integral to identifying BSMM at risk of HIV infection and transmission, overreliance on self-reported data, inability to observe social contexts, and neglect of populations with limited engagement in health care systems limits their effectiveness. Digital epidemiological approaches drawing on social media data offer an opportunity to overcome these limitations by passively observing in organic settings activities, beliefs, behaviors, and moods that indicate health risks but are otherwise challenging to capture.

OBJECTIVE

The primary aim of this study was to determine whether features of Facebook communication and networks were associated with biological, behavioral, and psychological indicators of HIV infection and transmission risk.

METHODS

Facebook and survey data were collected from BSMM aged 18 to 35 years living in Chicago (N=310). Participants' Facebook posts were characterized using 4 culturally tailored topic dictionaries related to aspects of HIV protection and risk among BSMM (sexual health; substance use; sex behavior; and ballroom culture, a salient subculture in lesbian, gay, bisexual, transgender, and queer communities of color). Social network methods were used to capture structural features of BSMM's Facebook friendships (centrality, brokerage, and local clustering) and Facebook group affiliations. Multivariable regressions revealed relationships between these Facebook features and 5 ground truth indicators of HIV infection and transmission risk (sexually transmitted infection incidence, condomless sex, sex drug use, biomedical prevention, and depression).

RESULTS

Although analysis of participants' Facebook posts revealed that HIV-related topics occupied a small portion of the total messages posted by each participant, significant associations were found between the following HIV risk indicators and Facebook features: Condomless sex, including communication about sexual health (odds ratio [OR] 1.58, 95% CI 1.09-2.29), ballroom culture (OR 0.76, 95% CI 0.63-0.93), and friendship centrality (OR 0.69, 95% CI 0.52-0.92); Sex drug use, including communication about substance use (OR 1.81, 95% CI 1.17-2.79) and friendship centrality (OR 0.73, 95% CI 0.55-0.96) and brokerage (OR 0.71, 95% CI 0.51-0.99); Biomedical prevention, including communication about ballroom culture (OR 0.06, 95% CI 0.01-0.71); and Depression, including communication about sexual health (β=-0.72, 95% CI -1.42 to -0.02), ballroom culture (β=.80, 95% CI 0.27-1.34), friendship centrality (β=-0.90, 95% CI -1.60 to -0.21), and Facebook group affiliations (β=.84, 95% CI 0.25-1.43). Facebook features provided no significant explanatory value for sexually transmitted infection incidence.

CONCLUSIONS

Finding innovative strategies to detect BSMM at risk of contracting or transmitting HIV is critical to eliminating HIV disparities in this community. The findings suggest that social media data enable passive observance of social and communicative contexts that would otherwise go undetected using traditional HIV surveillance methods. As such, social media data are promising complements to more traditional data sources.

Emotional Outcomes of Casual Sexual Relationships and Experiences: A Systematic Review

Casual sexual relationships and experiences (CSREs) are common and emotionally significant occurrences. Given the uncommitted, often emotionally complicated nature of CSREs, researchers have asked whether these experiences may have positive and/or negative emotional consequences. We reviewed 71 quantitative articles examining emotional outcomes of CSREs, including subjective emotional reactions (e.g., excitement, regret) and emotional health (e.g., depression, self-esteem). Overall, people evaluated their CSREs more positively than negatively. In contrast, CSREs were associated with short-term declines in emotional health in most studies examining changes in emotional health within a year of CSRE involvement. Emotional outcomes of CSREs differed across people and situations. Women and individuals with less permissive attitudes toward CSREs experienced worse emotional outcomes of CSREs. Alcohol use prior to CSREs, not being sexually satisfied, and not knowing a partner well were also associated with worse emotional outcomes. These findings suggest directions for prevention/intervention related to CSREs. For example, skill-building related to sexual decision-making may help individuals decide whether, and under what circumstances, CSREs are likely to result in positive or negative emotional outcomes. In addition, the limitations of extant research suggest directions for future inquiry (e.g., examining whether verbal and nonverbal consent practices predict emotional outcomes of CSREs).

A three-arm randomised controlled trial to evaluate the efficacy of a positive psychology and social networking intervention in promoting mental health among HIV-infected men who have sex with men in China

AIMS

There is a lack of mental health promotion and treatment services targeting HIV-positive men who have sex with men (HIVMSM) in China. The aim of this study was to evaluate the mental health promotion efficacy of an online intervention that combined Three Good Things (TGT) with electronic social networking (TGT-SN) and an intervention that used TGT only (TGT-only), compared with a control group.

METHODS

We conducted a randomised controlled trial among HIVMSM in Chengdu, China. The participants were randomly assigned to the TGT-SN, TGT-only, and control groups. The participants in the TGT-SN group were divided into five social network groups and asked to post brief messages to the group about three good things that they had experienced and for which they felt grateful. The participants in the TGT-only group were only required to write down their three good things daily without sharing them with others. The control group received information about mental health promotion once a week for a month. The primary outcome was probable depression. Secondary outcomes were anxiety, positive and negative affect, gratitude, happiness and social support. These outcomes were assessed at baseline, 1, 3, 6 and 12 months after the intervention. Repeated-measures analyses were conducted using generalised estimation equations. The study was registered with the Chinese Clinical Trial Registry (ChiCTR-TRC-13003252).

RESULTS

Between June 2013 and May 2015, 404 participants were enrolled and randomly assigned to either the TGT-SN (n = 129), TGT-only (n = 139) or control group (n = 136). The main effects of TGT-SN (adjusted odds ratio (aOR) = 0.75, 95% CI 0.52-1.09; p = 0.131) and TGT-only (aOR = 0.83, 95% CI 0.57-1.21; p = 0.332) in reducing depression were statistically non-significant. The participants of the TGT-SN group showed significantly lower anxiety symptoms (aOR = 0.62, 95% CI 0.43-0.89; p = 0.009) and negative affect (β = -1.62, 95% CI 2.98 to -0.26; p = 0.019) over time compared with those of the control group. No significant main effect was found for any secondary outcomes for the TGT-only group.

CONCLUSIONS

The novel intervention combining the TGT exercise with electronic social networking was found effective in reducing anxiety and negative affect among HIVMSM.

Disability-adjusted life years and mortality rate attributed to unsafe sex and drug use for AIDS in the Middle East and North Africa countries

BACKGROUND

The Middle East and North Africa, is one of few regions where the number of new human immunodeficiency virus infections is increasing. The present study aimed to estimate the attributable burden of unsafe sex and drug use in Acquired immunodeficiency syndrome in the Middle East and North Africa countries.

METHODS

We used the Global Burden of Disease data 2017 to estimate the attributable mortality and disability-adjusted life-years to unsafe sex and drug use in Acquired immunodeficiency syndrome in the Middle East and North Africa countries (21 countries) from 1990 to 2017 by region, sex and age. The percent change was calculated at three time points by country and sex.

RESULTS

The rate of Disability-adjusted life years/100,000 attributed to drug use for Acquired immunodeficiency syndrome increased 1.10 (95% CI: 0.75-1.71) to 13.39 (95% CI: 9.98-18.17) in women of Middle East and North Africa countries from 1990 to 2017, and there is an increasing trend in Disability-adjusted life years attributable to drug use for Acquired immunodeficiency syndrome in men. The rate of Disability-adjusted life years/100,000 attributed to unsafe sex for Acquired immunodeficiency syndrome increased in women of Middle East and North Africa countries, 5.15 (95% CI: 3.34-8.07) to 53.44 (95% CI: 38.79-75.89); and 10.06 (95% CI: 6.61-16.18) to 46.16 (95% CI: 31.30-72.66) in men. Age-standardized mortality rate attributed to drug use and unsafe sex for Acquired immunodeficiency syndrome increased from 1990 to 2017 in both sex in Middle East and North Africa countries.

CONCLUSION

The rate of Disability-adjusted life years /100,000 and age-standardized mortality rate attributed to unsafe sex and drug use increased in Middle East and North Africa from 1990 to 2017. While most of such countries have traditional cultures with religious believes, such increase need to be addressed in more depth by all policy makers.

Neighborhood Crime and Sexual Transmission Risk Behavior among Black Men Living with HIV

Here, we examined the association of exposure to neighborhood crime with sexual risk-taking behavior among Black men living with HIV. HIV-positive Black men on antiretroviral therapy in California completed an audio computer-assisted self-interview. Crime risk per census block group was derived from the Federal Bureau of Investigation's Uniform Crime Report. Among 193 men, the mean (SD) number of sexual partners among those who were sexually active was 2.7 (3.3). 49% reported condomless sex, and 23% reported sex with an HIV-negative or unknown-serostatus partner. In multivariate analysis, illicit drug use ([IRR=1.86; 95%CI: 1.20-2.89] p=.006), depressive symptoms ([IRR=1.59; 95%CI: 1.03-2.44] p=.03), an undetectable viral load ([IRR=1.91; 95%CI: 1.22-3.00] p=.005), and neighborhood total crime risk ([IRR=1.02; 95%CI: 1.01-1.04] p=.007) remained significant. Among Black men living with HIV, exposure to neighborhood crime is associated with having multiple sexual partners whose HIV status was negative or unknown.

Latent Classes of Sexual Positioning Practices and Sexual Risk Among Men Who Have Sex with Men in Paris, France

HIV/STI risk varies by sexual positioning practices; however, limited data have characterized the behavioral profiles of men who have sex with men (MSM) in France. This study used latent class analysis (LCA) to explore sexual risk profiles among MSM in Paris, France. LCA was used to classify sexual positioning and serosorting profiles among MSM in Paris (n = 496). Age, HIV status, relationship status, substance use, group sex, and PrEP history were used in a multinomial regression model predicting class membership. Three latent classes were identified: majority top/serosorters, versatile/low partners, and majority bottom/some serosorters. Majority top/serosorters had the highest probability of condomless serosorting; majority bottom/some serosorters had the highest mean number of partners (~ 12 partners) for condomless receptive anal intercourse. HIV-positive MSM were more likely to be classified as majority bottom/some serosorters than versatile/low partners (AOR 7.61; 95% CI 2.28, 25.3). Findings support the need for tailored and targeted interventions for highest-risk individuals.

Exploring and Adapting a Conceptual Model of Sexual Positioning Practices and Sexual Risk Among HIV-Negative Black Men Who Have Sex With Men

Estimates show a 50% lifetime human immunodeficiency virus (HIV) risk among Black men who have sex with men (BMSM) in the United States(U.S.). Studying the dynamics of sexual positioning practices among BMSM could provide insights into the disparities observed among U.S. groups of men who have sex with men (MSM). This study explored sexual positioning dynamics among HIV-negative BMSM and how they aligned with a theoretical model of sexual positioning and HIV/sexually transmitted infection (STI) risk among MSM. In-depth qualitative interviews were conducted with 29 HIV-negative BMSM between ages 25 and 35 in Los Angeles. Comments related to sexual behaviors were reviewed for relevance regarding oral or anal sexual positioning practices. Data presented represent the range of themes related to decision making regarding sexual positioning. Personal preference, partner attraction, HIV avoidance, and feeling obligated to practice partner preferences influenced sexual positioning. Drug use also affected decision making and was sometimes preferred in order to practice receptive anal intercourse. These variables build on the conceptual model of sexual positioning practices and sexual risk, and add understanding to the relationship between preferences, practices, and risk management. Future research on risk among HIV-negative BMSM should quantify the relative impact of personal preferences, partner attraction, partner type, compromise, and substance use on sexual positioning practices and risk.

The relationship of discrimination related to sexual orientation and HIV-relevant risk behaviors among men who have sex with men

Men who have sex with men (MSM) are at high risk for contraction and transmission of Human Immunodeficiency Virus (HIV). Increased risk of infection has been linked to high risk behaviors, such as alcohol and drug use, as well as engaging in unsafe sexual behaviors. Experiences of discrimination related to sexual orientation often experienced in this population predict risky behavior outcomes, but little research has examined the mechanisms implicated in this model. The current study examined the effect of anxiety and depressive symptoms in the relationship between discrimination related to sexual orientation and high-risk behaviors of alcohol use, drug use, using sex to cope with negative emotions, frequency of sex without a condom, and frequency of sex with an HIV+ or unknown status partner. Three hundred and eighty-nine MSM were recruited to participate in a survey based study. Results indicated anxiety was maintained a significant indirect effect between discrimination related to sexual orientation and coping behaviors (using sex to cope, alcohol, substance use), but showed no significant indirect associations with risky sexual behavior. Overall, the current study provides novel empirical evidence that discrimination related to sexual orientation is associated with increased anxiety, which in turn, is associated with certain HIV risk behaviors. Importantly, it is possible that alcohol use, drug use, and using sex to cope with negative emotions may be precursors to more risky sexual behavior, such as engaging in anal sex without a condom or having sex with an HIV+ or unknown status partner. Clinically, reducing symptoms of anxiety in the context of discrimination related to sexual orientation may help reduce HIV risk behavior among MSM.

Relationships Between Illness Perception and Post-traumatic Growth Among Newly Diagnosed HIV-Positive Men Who have Sex with Men in China

Newly diagnosed HIV-positive men who have sex with men (NHMSM) are at high risk of mental health problems but may also develop post-traumatic growth (PTG). According to the Common Sense Model, illness perception (including both cognitive representation and emotional representation) affects coping and health-related outcomes. A cross-sectional survey was conducted to examine the associations between illness perception and PTG among 225 NHMSM in Chengdu, China. Linear regression analyses indicated that the constructs of emotional representation subscale (β = -0.49) and five cognitive representation subscales (timeline, consequence, identity, attribution to god's punishment/will, and attribution to chance/luck) (β = -0.13 to -0.37) were negative correlates of PTG, while four other constructs of cognitive representation (coherence, treatment control, personal control, and attribution to carelessness) were positive correlates (β = 0.15 to 0.51). No moderating effects were observed. The associations between five cognitive representation subscales and PTG were fully-mediated via emotional representation. The results indicate that interventions promoting PTG among NHMSM are warranted and should alter illness perception, emotional representation in particular. Future studies should clarify relationships between cognitive representation and emotional representation, and extend similar research to other health-related outcomes and HIV-positive populations.

Sexual Risk Behaviors of Patients with HIV/AIDS over the Course of Antiretroviral Treatment in Northern Vietnam

Antiretroviral therapy (ART) improves the health and well-being of people living with the human immunodeficiency virus (HIV, PLWH), and reduces their risk of transmitting the virus to sexual partners. However, patterns of sexual risk behavior among HIV-positive patients taking ART in Vietnam remain largely unknown. In this study, we sought to examine sexual risk behaviors and their associated factors among HIV-positive patients receiving ART in northern Vietnam. The socio-demographic characteristics, ART use, health status, and sexual behaviors of 1133 patients taking ART in the Hanoi and Nam Dinh provinces were explored through face-to-face interviews. There were 63.5% of patients who had one sex partner, while 3.6% and 5.6% of patients had sexual intercourse with casual partners or sex workers, respectively, in the previous 12 months. Most participants tended to use condoms more often with commercial sex partners (90.2%) and intimate partners (79.7%), and less often with casual partners (60.9%). Higher age (odds ratio, OR = 1.0; 95% CIs = 1.0, 1.1) or suffering pain/discomfort (OR = 1.7; 95% CIs = 1.2, 2.4) were factors more likely to be associated with multiple sex partners. Patients who were self-employed were more likely to have sexual intercourse with casual partners/sex workers (OR = 2.1; 95% CIs = 1.1, 4.0). Meanwhile, a higher score on the EuroQol visual analog scale (EQ-VAS), an unknown HIV stage, and a longer duration of ART were adversely associated with not using condoms with casual partners/sex workers. Patients with longer durations of ART had a lower likelihood of not using a condom with casual partners/sex workers (OR = 0.5; 95% CIs = 0.3, 0.8). Our study underscored a relatively high rate of unsafe sexual behaviors among HIV-positive patients. Continuing to improve the physical and psychological well-being of HIV-positive patients in Vietnam is important in reducing the spread of HIV via risky sexual behaviors. In addition, safe-sex education should be provided to older people, and to those who are self-employed.

Substance Use and Cognitive Function as Drivers of Condomless Anal Sex Among HIV-Positive Gay, Bisexual, and Other Men Who Have Sex with Men Aged 50 and Older: The Gold Studies

PURPOSE

Substance use has been linked to the sexual transmission of HIV among gay, bisexual, and other men who have sex with men (MSM) across the lifespan. Among older, HIV-positive, MSM populations, cognitive dysfunction associated with age and HIV disease progression also may play a role in sexual risk-taking. People aged 50 years and older represent a growing proportion of the overall HIV-positive population. This study aimed to explore relationships between substance use and cognitive function, and their impact on condomless anal sex (CAS) among HIV-positive gay, bisexual, and other MSM aged 50 years and older.

METHODS

Data from a cross-sectional study of HIV-positive MSM, aged 50 and older (N = 169) were gathered using a computer-assisted survey, researcher-administered behavioral and neurocognitive measures.

RESULTS

More than 50% of the men used substances and had one or more cognitive impairments. However, only 25% were at higher risk for dementia (i.e., two or more cognitive impairments). Multivariable modeling indicated that use of alcohol to intoxication and date of HIV diagnosis were the strongest predictors of CAS in both a model that included dementia risk and a model that included impaired executive function risk. Current illicit substance use was a significant predictor of CAS only in the model that included dementia risk. Those with better cognitive and executive function had higher odds of CAS. However, only executive function was a significant cognitive predictor of CAS.

CONCLUSION

Further research is needed to clarify the impact of cognitive function and substance use on sexual risk behaviors as these HIV-positive men achieve normal life expectancies, while continuing to use substances and engage in CAS. Furthermore, addiction treatment remains a critical need for this group even as they transition into later adulthood.

Alcohol and substance use diagnoses among HIV-positive patients receiving care in NYC clinic settings

BACKGROUND

Substance use among HIV-positive persons exacerbates health problems. This study sought to estimate the prevalence of alcohol and drug-use diagnoses and examined hypothesized predictors associated with alcohol and drug-use diagnoses among HIV-positive patients in New York City (NYC).

METHODS

This cohort study reviewed electronic medical records (EMRs) of 4965 HIV-positive patients based on diagnostic codes. These patients attended a comprehensive care clinic in NYC in 2012. Multinomial logistic regression was used to predict the odds of classification into substance use diagnosis grouping.

RESULTS

Of the full sample, only 12.7% of patients had an alcohol use diagnosis documented in their EMR compared with more than one-quarter (26.4%) of patients having a recorded drug use diagnosis (p<0.001). Compared with the No Alcohol or Drugs group, the regression model showed that older age and having a recent inpatient hospital stay independently predicted being in the Alcohol Only group; years living with HIV, having an unsuppressed viral load, and having a recent inpatient hospital stay were associated with higher odds of being in the Drugs Only and Alcohol and Drugs groups; and being women and men who have sex with men (MSM) were associated with decreased odds of being in the Drugs Only and Alcohol and Drugs groups.

CONCLUSIONS

Substance use diagnosis was associated with viremia and low CD4 counts and hospital stays. This implies that providers should screen for substance use in HIV-positive patients with poor health. Further examination of the extent of such comorbidity is instrumental for intervention efforts.

Sexual Risk-Taking in HIV-Negative Gay and Bisexual Men Increases with Depression: Results from a U.S. National Study

The link between depression and sexual risk-taking has received mixed findings in the literature. The current study analyzed the links between depression and recent condomless anal sex (CAS) with casual partners among 1033 HIV-negative, non-PrEP-using, gay and bisexual men. When CAS was dichotomized as either none or some, depression was not associated with the odds of CAS (with receptive and insertive combined) or insertive CAS only, but was positively associated with the odds of receptive CAS. When CAS was tallied as a count variable of events, depression was positively associated with total CAS, receptive CAS, and insertive CAS. With the addition of a quadratic term for depression, a positive quadratic effect was only found for total CAS and receptive CAS, but not for insertive CAS. These findings highlight the utility of using count data for CAS events and treating CAS separately with regard to receptive and insertive positioning when considering the role of depression among gay and bisexual men.

Association Between Depression and Condom Use Differs by Sexual Behavior Group in Patients with HIV

Identifying a relationship between depression and sexual risk behavior in HIV-infected patients could establish a mechanism to enhance prevention efforts. We conducted a cross-sectional analysis using data from the University of Pennsylvania Center for AIDS Research and used ordinal logistic regression to measure the association between depression and non-condom use. 716 men who have sex with men (MSM), 262 heterosexual men and 277 heterosexual women were included. The association between depression and non-condom use was strongest in heterosexual men with and without HIV-infected regular partners (OR 8.53, 95% CI 1.18-61.89 and OR 2.30, 95% CI 0.99-5.36 respectively), but absent in heterosexual women regardless of partner. Although the OR was low in MSM overall, an association was detected in MSM without HIV-infected regular partners (OR 2.44, 95% CI 1.39-4.31). In conclusion, we demonstrated an association between depression and non-condom use driven by heterosexual men and MSM without HIV-infected regular partners. Sexual risk should be addressed when intervening on depressive symptoms in these subgroups.

Psychometric evaluation of the Condom Barriers and Motivations Scale (CBMS)

The Condom Barriers and Motivations Scale (CBMS) was developed to measure four distinct categories of barriers and motives to condom use, including: risk reduction motivations, pleasure reduction barriers, intimacy interference barriers, and partner pressure barriers. The CBMS is a 16-item scale with four items that correspond to each of these subscales. The CBMS was tested in two samples of gay and bisexual men. Results support the reliability and validity of the scale and its structure. Results also indicate that CBMS subscales are distinct from general measures of sexual wellbeing, personality factors, or relationship quality (i.e., discriminant validity) and are associated with self-reported condom use with different partner types (i.e., construct validity). The CBMS can be helpful in better understanding the dynamics of condom use in the context of pre-exposure prophylaxis decision-making, and can shed light on innovative approaches to enhance condom use as part of comprehensive HIV prevention and sexual health goals.

Sexual Positioning Among Men Who Have Sex With Men: A Narrative Review

Sexual positioning practices among men who have sex with men (MSM) have not received a thorough discussion in the MSM and HIV literature, given that risks for acquiring or transmitting HIV and STIs via condomless anal sex vary according to sexual positioning. MSM bear a disproportionate burden of HIV compared to the general population in the United States; surveillance efforts suggest that HIV and STIs are increasing among domestic and international populations of MSM. We conducted a narrative review, using a targeted literature search strategy, as an initial effort to explore processes through which sexual positioning practices may contribute to HIV/STI transmission. Peer-reviewed articles were eligible for inclusion if they contained a measure of sexual positioning identity and/or behavior (i.e., "top", "bottom," etc.) or sexual positioning behavior (receptive anal intercourse or insertive anal intercourse), or assessed the relationship between sexual positioning identity with HIV risk, anal sex practice, masculinity, power, partner type, or HIV status. A total of 23 articles met our inclusion criteria. This review highlights dynamic psychosocial processes likely underlying sexual decision making related to sexual positioning identity and practices among MSM and MSM who have sex with women (MSMW), and ways these contexts may influence HIV/STI risk. Despite limited focus in the extant literature, this review notes the important role the contextual factors (masculinity stereotypes, power, partner type, and HIV status) likely to play in influencing sexual positioning identity and practices. Through this review we offer an initial synthesis of the literature describing sexual positioning identities and practices and conceptual model to provide insight into important areas of study through future research.

The Relationship Between Methamphetamine Use, Sexual Sensation Seeking and Condomless Anal Intercourse Among Men Who Have Sex With Men in Vietnam: Results of a Community-Based, Cross-Sectional Study

This study assessed the relationship between methamphetamine use and condomless anal intercourse (CAI) among men who have sex with men (MSM) in Hanoi and Ho Chi Minh City, Vietnam. Of 622 MSM participants, 75.7% reported any CAI in the last three months, 23.2% reported engaging in sex work in the last three months, 21.1% reported group sex in the last twelve months (21.1%) and 14.3% had used methamphetamine for sex in the last three months. CAI was associated with living in Ho Chi Minh City vs. Hanoi, being versatile during anal sex, a greater degree of sexual sensation-seeking, and more strongly agreeing that withdrawal before ejaculation is effective in preventing HIV. Effect-modification analysis showed that recent sex-related methamphetamine use was related to a higher probability of CAI for men with low sexual sensationseeking scores. Methamphetamine assessment and/or interventions should be incorporated into HIV prevention and research with Vietnam's MSM population.

Associations between depressive syndromes and HIV risk behaviors among San Francisco men who have sex with men

HIV prevention plans for men who have sex with men (MSM) are often multifaceted. They involve reduction of sexual risk behaviors, such as condomless intercourse, but also often include pharmaceutical approaches, such as early treatment of HIV-infected individuals with antiretroviral therapy (ART). Effectiveness is possibly threatened by individual-level factors, such as depression. In this study of 322 San Francisco MSM (240 HIV-uninfected individuals and 82 HIV-infected individuals, according to self-report), we examine associations between depressive syndromes and HIV risk behaviors (sexual risk behaviors and ART non-adherence). Our study failed to find evidence that depressive syndromes lead to increases in ART non-adherence (risk difference, RD: 27.9; 95% confidence interval, CI: -3.5, 59.3). However, the study does suggest an association between depressive syndromes and concurrence of non-adherence and potentially HIV-discordant condomless receptive anal intercourse (RD: 36.0; 95% CI: 5.2, 66.8). Among HIV-uninfected MSM, our study suggests negative associations between depressive syndromes and sexual risk behaviors. We recommend screening and treatment of depression among HIV-infected MSM.

Prevalence of and factors associated with unprotected anal intercourse with regular and nonregular male sexual partners among newly diagnosed HIV-positive men who have sex with men in China

OBJECTIVES

This study investigated the prevalence of, and multi-dimensional factors associated with, unprotected anal intercourse (UAI) with regular male sexual partners ('regular partners') and nonregular male sexual partners ('nonregular partners') among newly diagnosed HIV-positive men who have sex with men (MSM) in Chengdu, China.

METHODS

A total of 225 newly diagnosed HIV-positive MSM were interviewed using a combined interviewer-computer-assisted method in Chengdu, China.

RESULTS

The prevalence of UAI with regular and nonregular partners since diagnosis was 27.7% and 33.8% among participants reporting having sex with regular and nonregular partners (n = 159 and 133), respectively. Adjusted analysis showed that: (1) cognitive variables based on the Health Belief Model (perceived susceptibility to HIV transmission and perceived severity of the consequences of HIV transmission, perceived barriers and perceived self-efficacy related to consistent condom use), (2) emotion-related variables (worry about transmitting HIV to others), (3) psychological factors (post-traumatic growth) and (4) socio-structural factors (perceived partners' responsibility for condom use) were significantly associated with UAI with regular and/or nonregular partners.

CONCLUSIONS

Interventions are warranted, and should be designed with consideration of multi-dimensional factors and be partner type-specific.

Relation between HIV status, risky sexual behavior, and mental health in an MSM sample from three Chilean cities

OBJECTIVE

To explore the association among HIV status; negative psychological symptoms (anxiety, depression, and hostility); and risky sexual behaviors (multiple sexual partners and unprotected sexual intercourse) in a Chilean sample of men who have sex with men (MSM).

METHODS

This study had a cross-sectional design and a sample of 325 MSM whose ages ranged from 18 to 64 years (mean: 30.8; standard deviation: 9.8). Association tests (chi-squared) and group mean comparisons (Student's t-tests and F-tests) were performed.

RESULTS

No statistically significant differences were found for condom use or for the number of sexual partners between HIV-positive men and those who are not infected. In both groups, about 50% reported sexual encounters without condom use in the past six months. There were statistically significant differences in symptoms associated with depression between the two groups.

CONCLUSIONS

These results reveal the need to strengthen messages about the importance of condom use, as the only way to prevent HIV, and as a means of preventing HIV infection and reinfection, in national prevention and self-care programs for sexually active subjects. More studies are needed in Latin America to advance HIV prevention efforts for the MSM population. The data generated by this study can be used to inform the development of HIV prevention programming strategies and interventions targeting the MSM population in Latin America.

Roles of Self-Stigma, Social Support, and Positive and Negative Affects as Determinants of Depressive Symptoms Among HIV Infected Men who have Sex with Men in China

Poor mental health was prevalent among HIV positive men who have sex with men (HIVMSM), and a tremendous burden extents on their families and society. The present study investigated the prevalence of depression and its relationship with social support, HIV self-stigma, positive affect and negative affect among 321 HIVMSM in Chengdu, China. The study was conducted during July 2013 through October 2013. Findings showed that 55.8 % of the participants had mild to severe depression. The results of structural equation modeling showed that social support and positive affect were negatively associated with depression, while HIV self-stigma and negative affect were positively associated with depression. Social support, positive affect, and negative affect mediated the association between HIV self-stigma and depression. The hypothesized model had a satisfactory fit. Interventions improving mental health among this population are warranted.

Incidence of syphilis seroconversion among HIV-infected persons in Asia: results from the TREAT Asia HIV Observational Database

INTRODUCTION

Outbreaks of syphilis have been described among HIV-infected men who have sex with men (MSM) in Western communities, whereas reports in Asian countries are limited. We aimed to characterize the incidence and temporal trends of syphilis among HIV-infected MSM compared with HIV-infected non-MSM in Asian countries.

METHODS

Patients enrolled in the TREAT Asia HIV Observational Database cohort and with a negative non-treponemal test since enrolment were analyzed. Incidence of syphilis seroconversion, defined as a positive non-treponemal test after previously testing negative, was evaluated among patients at sites performing non-treponemal tests at least annually. Factors associated with syphilis seroconversion were investigated at sites doing non-treponemal testing in all new patients and subsequently testing routinely or when patients were suspected of having syphilis.

RESULTS

We included 1010 patients from five sites that performed non-treponemal tests in all new patients; those included had negative non-treponemal test results during enrolment and subsequent follow-ups. Among them, 657 patients were from three sites conducting regular non-treponemal testing. The incidence of syphilis seroconversion was 5.38/100 person-years (PY). Incidence was higher in MSM than non-MSM (7.64/100 PY vs. 2.44/100 PY, p<0.001). Among MSM, the incidence rate ratio (IRR) for every additional year from 2009 was 1.19 (p=0.051). MSM status (IRR 3.48, 95% confidence interval (CI) 1.88-6.47), past syphilis diagnosis (IRR 5.15, 95% CI 3.69-7.17) and younger age (IRR 0.84 for every additional 10 years, 95% CI 0.706-0.997) were significantly associated with syphilis seroconversion.

CONCLUSIONS

We observed a higher incidence of syphilis seroconversion among HIV-infected MSM and a trend to increasing annual incidence. Regular screening for syphilis and targeted interventions to limit transmission are needed in this population.

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

Prevalence and associated factors of depressive and anxiety symptoms among HIV-infected men who have sex with men in China

HIV-positive men who have sex with men (HIVMSM) face severe stigma and high levels of stressors, and have high prevalence of mental health problems (e.g., depression and anxiety). Very few studies explored the role of positive psychological factors on mental health problems among HIVMSM. The present study investigated the prevalence of two mental health problems (anxiety and depression), and their associated protective (gratitude) and risk (enacted HIV-related stigma, and perceived stress) factors among HIVMSM in China. A cross-sectional survey was conducted among 321 HIVMSM in Chengdu, China, by using a structured questionnaire. Over half (55.8%) of the participants showed probable mild to severe depression (as assessed by the Center of Epidemiologic Studies Depression scale); 53.3% showed probable anxiety (as assessed by the General Anxiety Disorder scale). Adjusted logistic regression models revealed that gratitude (adjusted odds ratio (ORa = 0.90, 95% confidence intervals (95% CI) = 0.86-0.94) was found to be protective, whilst perceived stress (ORa = 1.17, 95% CI = 1.12-1.22) and enacted stigma (ORa = 7.72, 95% CI = 2.27-26.25) were risk factors of depression. Gratitude (ORa = 0.95, 95% CI = 0.91-0.99) was also found to be protective whilst perceived stress (ORa = 1.19, 95% CI = 1.14-1.24) was a risk factor of anxiety. Gratitude did not moderate the associations found between related factors and poor mental health. It is warranted to promote mental health among HIVMSM, as depression/anxiety was highly prevalent. Such interventions should consider enhancement of gratitude, reduction of stress, and removal of enacted stigma as potential strategies, as such factors were significantly associated with depression/anxiety among HIVMSM.

Description and Demonstration of Cognitive Behavioral Therapy to Enhance Antiretroviral Therapy Adherence and Treat Depression in HIV-Infected Adults

There are an estimated 1.1 million individuals living with HIV/AIDS in the United States. In addition to the various medical comorbidities of HIV infection, depression is one of the most frequently co-occurring psychiatric conditions among HIV-infected individuals. Furthermore, depression has been found to be associated with nonadherence to antiretroviral therapy (ART), as well as HIV disease progression. Cognitive behavioral therapy (CBT) has repeatedly been found to effectively treat depression in adult populations, and CBT for adherence and depression (CBT-AD) is an effective treatment for improving depressive symptoms and medication adherence in the context of various chronic health conditions, including diabetes and HIV-infection. This paper provides a description of the CBT-AD approach to treat depression and ART adherence in HIV-infected adults, which we have developed and tested in our clinic, and for which detailed therapist and client guides exist. To augment the description of treatment, the present article provides video component demonstrations of several core modules that highlight important aspects of this treatment, including Life-Steps for medication adherence, orientation to CBT-AD and psychoeducation, and suggestions for adaptation of core CBT modules for HIV-infected adults. Discussion of video demonstrations highlights differences in patient presentations and course of treatment between HIV-infected adults receiving CBT-AD and HIV-uninfected adults receiving traditional CBT for depression. This description and the accompanying demonstrations are intended as a practical guide to assist therapists wishing to conduct such a treatment in the outpatient setting.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

HIV sexual transmission risks in the context of clinical care: a prospective study of behavioural correlates of HIV suppression in a community sample, Atlanta, GA, USA

Introduction

Antiretroviral therapy (ART) improves the health of people living with HIV and has the potential to reduce HIV infectiousness, thereby preventing HIV transmission. However, the success of ART for HIV prevention hinges on sustained ART adherence and avoiding sexually transmitted infections (STI).

Objectives

To determine the sexual behaviours and HIV transmission risks of individuals with suppressed and unsuppressed HIV replication (i.e., viral load).

Methods

Assessed HIV sexual transmission risks among individuals with clinically determined suppressed and unsuppressed HIV. Participants were 760 men and 280 women living with HIV in Atlanta, GA, USA, who completed behavioural assessments, 28-daily prospective sexual behaviour diaries, one-month prospective unannounced pill counts for ART adherence, urine screening for illicit drug use and medical record chart abstraction for HIV viral load.

Results

Individuals with unsuppressed HIV demonstrated a constellation of behavioural risks for transmitting HIV to uninfected sex partners that included symptoms of STI and substance use. In addition, 15% of participants with suppressed HIV had recent STI symptoms/diagnoses, indicating significant risks for sexual infectiousness despite their HIV suppression in blood plasma. Overall, 38% of participants were at risk for elevated sexual infectiousness and just as many engaged in unprotected sexual intercourse with non-HIV-infected partners.

Conclusions

Implementation strategies for using HIV treatments as HIV prevention requires enhanced behavioural interventions that extend beyond ART to address substance use and sexual health that will otherwise undermine the potential preventive impact of early ART.

Comparing Psychosocial Correlates of Condomless Anal Sex in HIV-Diagnosed and HIV-Nondiagnosed Men Who Have Sex with Men: A Series of Meta-Analyses of Studies from 1993-2013

PURPOSE

Men who have sex with men (MSM) continue to be overrepresented in rates of incidence and prevalence of human immunodeficiency virus (HIV). Both HIV-diagnosed (HIV-D) and HIV-nondiagnosed (HIV-N) MSM report a variety of reasons for intentional and unintentional nonuse of condoms. Elucidating and comparing reasons for continued engagement in condomless anal sex specific to both HIV-D and HIV-N MSM likely is important to identifying effective prevention.

METHODS

This study employed meta-analytic methods to evaluate and compare correlates to condomless anal sex in both HIV-D and HIV-N MSM from primary studies from 1993 to February 2013.

RESULTS

Of the 19 individual correlates assessed within the subgroup of HIV-D MSM, variables that achieved significant effect were alcohol, mind-altering substance use, sexual-enhancement medication, intentional condom nonuse, self-efficacy, attitudes toward condom use, social support, gay identity, compulsivity, trading sex, and number of sex partners. Those that were statistically non-significant were intention to use a condom, perceived risk, perceived norms, perceived responsibility, HIV medical management, treatment optimism, mental health, and setting. Of the 12 correlates assessed within the subgroup of HIV-N MSM, variables that achieved significant effect were alcohol, mind-altering substance use, intentional condom nonuse, attitudes toward condom use, perceived risk, and setting. Those observed as statistically non-significant were perceived norms, social support, gay identity, mental health, trading sex, and number of sex partners.

CONCLUSION

Study results have clinical implications that may guide future prevention research and practice by highlighting risk variables shared between HIV-N and HIV-D MSM, as well as variables observed to be unique to each group that may warrant more tailored intervention. Further investigation is recommended to elucidate the relationships among these variables such that optimal intervention can be determined.

The Relationship Between Online Social Network Use, Sexual Risk Behaviors, and HIV Sero-Status Among a Sample of Predominately African American and Latino Men Who have Sex with Men (MSM) Social Media Users

Social networking technologies have emerged as potential platforms to reach HIV(+) MSM in HIV interventions. This study sought to compare use of online social networking sites (SNSs) and sexual risk behaviors between HIV(+) and HIV(-) individuals among a sample of predominately African American and Latino SNS-using MSM. A total of 112 MSM Facebook users were recruited online and offline and completed an online survey. We performed regression models to assess the association between HIV status, SNS use, and sexual risk behaviors. After adjusting for age, race, and employment status, being HIV positive was significantly associated with a greater number of sexual partners (ARR = 2.84, p = 0.0017) and lower comfort levels of discussing HIV/STI status on SNSs (AOR: 0.23, p = 0.011). Findings suggest that HIV status is associated with sexual risk behaviors and SNS use among SNS-using MSM. We discuss the implications for online HIV prevention.

Longitudinal Trends in Sexual Behaviors with Advancing Age and Menopause Among Women With and Without HIV-1 Infection

We assessed changes in self-reported sexual activity (SA) over 13 years among HIV-infected and uninfected women. The impact of aging and menopause on SA and unprotected anal or vaginal intercourse (UAVI) was examined among women in the Women's Interagency HIV Study (WIHS), stratifying by HIV status and detectable viral load among HIV-infected women. Generalized mixed linear models were fitted for each outcome, adjusted for relevant covariates. HIV-uninfected women evidenced higher levels of SA and UAVI than HIV-infected. The odds of SA declined by 62-64 % per decade of age. The odds of SA in a 6-month interval for women aged 40-57 declined by 18-22 % post-menopause (controlling for age). Among HIV+/detectable women only, the odds of any UAVI decreased by 17 % per decade of age; the odds of UAVI were unchanged pre-menopause, and then decreased by 28 % post-menopause. Elucidating the factors accounting for ongoing unprotected sex among older women should inform interventions.

Prevalence and associated factors of unprotected anal intercourse with regular male sex partners among HIV negative men who have sex with men in China: a cross-sectional survey

The HIV prevalence and incidence among men who have sex with men (MSM) in China are high. Unprotected anal intercourse (UAI) with a regular male sex partner (RP), a significant predictor of HIV sero-conversion, was high yet under-emphasized among MSM having RP (MSMRP). The present cross-sectional survey interviewed 307 HIV negative MSMRP recruited through convenient sampling from multiple sources, including venue-based outreaching, online recruitment, and referrals made by peers, in Beijing and Chengdu, China. Among MSMRP, the prevalence of UAI with RP in the last three months was 52.4%. The results of the multivariate analysis showed that trust and intimacy within the relationship with RP and presence of clinical depression symptoms were positively associated with UAI with RP in the last three months. Other associated scalar factors derived from the Theory of Planned Behavior were related to perceptions on condom use, including positive attitudes toward condom use (a negative association), subjective norm of the perception that MSM do not usually use condoms during anal intercourse with RP (a positive association), perceived behavioral control over condom use with RP (a negative association), and behavioral intention to use condoms with RP in the coming three months (a negative association). It is seen that MSMRP were at high risk of HIV/STD transmission. The associated factors hence involved those related to perceptions about condom use, mental health, and interpersonal relationship. Future interventions should take these multi-dimensional factors into account. In particular, future research to test the efficacy of couple-based interventions that include mental health elements needs to be conducted, as trust and intimacy within the relationship were associated with UAI among MSMRP, and mental health problems may exist for both the MSMRP and their RP.

Motivational interviewing targeting risky sex in HIV-positive young Thai men who have sex with men

Motivational interviewing (MI) has been shown to reduce sexual risks among HIV-positive men who have sex with men (HMSM) in the US. We conducted a randomized trial of Healthy Choices, a 4-session MI intervention, targeting sexual risks among 110 HIV-positive youth ages 16-25 years in Thailand. Risk assessments were conducted at baseline, 1 month, and 6 months post-intervention. This report presents the analysis of 74 HMSM in the study. There were 37 HMSM in the Intervention group and 37 in the control group. The proportions of participants having anal sex and having sex with either HIV-uninfected or unknown partners in past 30 days were significantly lower in Intervention group than in Control group at 6 months post-intervention (38 vs. 65 %, p = .04; and 27 vs. 62 %, p < .01, respectively). There were no significant differences in general mental health scores and HIV stigma scores between the two groups at any study visit. Thirty-five (95 %) HMSM in the Intervention group vs. 31 (84 %) in control group attended ≥ 3 sessions. Loss to follow-up was 8 and 30 %, respectively (p = .04). Healthy Choices for young Thai HMSM was associated with sexual risk reduction. Improvements in mental health were noted in Intervention group. Healthy Choices is a promising behavioral intervention and should be further developed to serve the needs of young HMSM in resource-limited countries.

Loneliness, HIV-related stigma, and condom use among a predominantly rural sample of HIV-positive men who have sex with men (MSM)

Most previous studies of the sexual behaviors of men who have sex with men (MSM) living with HIV are based on samples recruited within relatively urban and suburban areas of the United States. Using an internet-based questionnaire, we assessed HIV-related stigma, loneliness, and event-level sexual behaviors in a sample of HIV positive MSM (n = 100) residing within a largely rural area in the Midwestern United States. HIV-related stigma was correlated with loneliness (r = 0.619, p < 0.01). Loneliness was negatively associated with condom usage with the most recent partner of unknown status (p < 0.05). Namely, a 1-unit increase in the UCLA loneliness score was met with a 10% decrease in odds of condom usage. Further studies are warranted that explore loneliness, within the context of HIV-related stigma, among HIV-positive MSM residing in rural areas. More refined data will inform clinical and social service practice, as they provide much-needed information on sexual health outcomes and experiences of an often underserved and under studied population.

Where does treatment optimism fit in? Examining factors associated with consistent condom use among people receiving antiretroviral treatment in Rio de Janeiro, Brazil

In the era of highly active antiretrovirals, people living with HIV (PLWH) have resumed sexual activity in the context of longer and healthier lives, and thus the chances of transmitting the HIV virus, as well as the potential to be re-infected also increase. HIV treatment optimism has been found to be associated with sexual risk behaviors among PLWH in different settings. A cross sectional survey was conducted to examine the relationship between treatment optimism, safer sex burnout and consistent condom use as well as variables associated with treatment optimism in a sample of PLWH on antiretrovirals (ARVs) in Rio de Janeiro, Brazil (n = 604). Seventy-two percent of participants always used a condom in the last 6 months. Homosexual, bisexual, transexual persons were less likely to use condoms consistently than heterosexuals (AOR .58 CI .42-.78). Those who were treatment optimistic (AOR .46 CI .25-.88) were more likely not use a condom consistently in the past 6 months, as were participants who reported safer sex burnout (AOR .58 CI .36-.90). Sexual orientation, safer sex burnout, and lower education levels were significantly associated with higher treatment optimism in multivariate analysis. Study findings highlight the need to address psychosocial factors such as treatment optimism and safer sex burnout associated with lower consistent condom use among PLWH in Rio de Janeiro, Brazil.

Understanding structural barriers to accessing HIV testing and prevention services among black men who have sex with men (BMSM) in the United States

Structural-level factors have contributed to the substantial disproportionate rates of HIV among Black men who have sex with men (BMSM) in the United States. Despite insufficient HIV testing patterns, however, there is a void in research investigating the relationship between structural factors and access to HIV testing and prevention services among BMSM. Building on previous scholarly work and incorporating a dynamic social systems conceptual framework, we conducted a comprehensive review of the literature on structural barriers to HIV testing and prevention services among BMSM across four domains: healthcare, stigma and discrimination, incarceration, and poverty. We found that BMSM experience inadequate access to culturally competent services, stigma and discrimination that impede access to services, a deficiency of services in correctional institutions, and limited services in areas where BMSM live. Structural interventions that eliminate barriers to HIV testing and prevention services and provide BMSM with core skills to navigate complex systems are needed.

Sexual transmission of giardiasis: a neglected route of spread?

Sexually transmitted infections (STIs) are often discussed in the context of syphilis, gonorrhea, herpes, chlamydiasis and AIDS. However, since the past 30 years of the last century, epidemiology and natural history studies have led to improved understanding of giardiasis as a STI, as a result of oral-anal sexual contact. Studies suggest that Giardia is an increasingly recognized infection that may be underdiagnosed under the STI context. Health care providers should maintain a high index of suspicion for Giardia, obtain suitable diagnostic tests to identify and screen those at high risk for this infection, institute appropriate therapy, counsel patients regarding treatment compliance, follow-up, encourage partner notification and teach strategies for preventing the transmission of this disease, including the discussion of the risk of enteric infections after oral-anal sexual contact. We summarize some data concerning the research and clinical literature on Giardia infection as a STI and identify the specific recommendations for control of giardiasis as STI that available evidence indicates can reduce its transmission.

Personality as a predictor of unprotected sexual behavior among people living with HIV/AIDS: a systematic review

The present investigation involved a systematic literature review to (1) identify associations between personality constructs and unprotected sex among people living with HIV/AIDS (PLWH); (2) assess patterns of direct versus indirect personality-risky sex associations; and (3) explore possible differences in personality-risky sex associations among PLWH versus non-infected populations. Among the 26 studies yielded through the systematic search, sensation seeking and sexual compulsivity were the constructs most frequently examined, with fewer studies investigating traditional personality typologies. Personality constructs that were more conceptually proximal to the sexual act, such as sexual compulsivity and sex-related sub-components of sensation seeking, showed relatively direct associations with unprotected sex, whereas more conceptually distal constructs such as generalized impulsivity demonstrated only weak or indirect associations. Associations were also frequently mediated by other risk factors, including perceived responsibility and substance use. These findings have implications for the development of interventions to reduce high risk sexual behavior among PLWH.

Social network composition and sexual risk-taking among gay and bisexual men in Atlanta, GA

Social network composition is known to effect patterns of reported sexual risk-taking among men who have sex with men (MSM); however, consensus as to the directionality and size of these effects is lacking. We examined the relationships between novel aspects of social network composition and sexual risk-taking using a cross-sectional survey of 870 MSM. Social network composition was found to have mixed effects on reported sexual risk-taking: reporting proportionally more lesbian, gay, or bisexual (LGB)-identified friends and reporting friends who were on average significantly older than the respondent were both associated with reporting increased sexual risk, while reporting proportionally more LGB-identified friends in relationships and reporting a social network proportionally more aware of the respondent's homosexuality/bisexuality were both associated with reporting decreased sexual risk. The support structures created by differing social network compositions-and particularly the presence of LGB couples-may be a potential area for targeting sexual risk-reduction interventions for MSM.

Prospective predictors of unprotected anal intercourse among HIV-seropositive men who have sex with men initiating antiretroviral therapy

Contemporary HIV prevention efforts are increasingly focused on those already living with HIV/AIDS (i.e., "prevention with positives"). Key to these initiatives is research identifying the most risky behavioral targets. Using a longitudinal design, we examined socio-demographic and psychosocial factors that prospectively predicted unprotected anal intercourse (UAI) in a sample of 134 HIV-seropositive men who have sex with men (MSM) initiating, changing, or re-starting an antiretroviral therapy regimen as part of a behavioral intervention study. Computer-based questionnaires were given at baseline and 6 months. In a sequential logistic regression, baseline measures of UAI (step 1), socio-demographic factors such as Latino ethnicity (step 2), and psychosocial factors such as crystal methamphetamine use, greater life stress, and lower trait anxiety (step 3) were predictors of UAI at 6 months. Problem drinking was not a significant predictor. Prevention efforts among MSM living with HIV/AIDS might focus on multiple psychosocial targets, like decreasing their crystal methamphetamine use and teaching coping skills to deal with life stress.

Social responsibility, substance use, and sexual risk behavior in men who have sex with men

Considerable public health literature focuses on relationships between problematic human characteristics (e.g., psychopathology) and unhealthy behaviors. A recent movement termed positive psychology emphasizes the advantages of assessing relationships between human strengths (e.g., altruism) and beneficial health behaviors. The present study assessed social responsibility, an orientation to help or protect others even when there is nothing to be gained as an individual, and its relationship to HIV-relevant behaviors. In our sample of 350 men who have sex with men (MSM), social responsibility was negatively correlated with substance use and HIV risk behaviors. Men who had been tested for HIV and knew their HIV status-a behavior that helps men protect their partners but does not protect themselves from the virus-also scored higher in social responsibility. Interventions designed to reduce HIV risk behavior in MSM may benefit from efforts to promote human strengths.

Risk behaviors among HIV-positive gay and bisexual men at party-oriented vacations

OBJECTIVE

This study examined substance use (intended and actual), unprotected sex, and HIV disclosure practices (disclosure and questioning) among HIV-positive men who have sex with men (MSM) at two party-oriented vacations, where substance use and sexual risk may be heightened.

METHOD

A random sample of 489 MSM attending one of two party-oriented vacations participated in PartyIntents, a short-term longitudinal survey. Nearly half (47%) completed a follow-up assessment at the event or online for up to 2 weeks after the event. We examined rates of baseline intentions to use substances, actual substance use, and unprotected intercourse among HIV-positive men in attendance.Rates among HIV-negative men were estimated for comparison. Multiple logistic regression was used to assess the impact of illegal drug use and HIV status on unprotected anal intercourse (UAI).

RESULTS

HIV-positive attendees (17%) were significantly more likely than HIV-negative attendees to use nitrite inhalants (or "poppers") (24.3% vs. 10.7%). HIV-positive attendees were also significantly more likely to have insertive UAI (64.3% vs. 34.1%) and receptive UAI (68.8% vs. 22.2%). Multivariate models showed associations between HIV status and illegal drug use with UAI (for HIV status, odds ratio [OR] = 4.5, p = .001; for any illegal drug use, OR = 16.4, p < .001). There was no evidence that the influence of drug use moderated risk by HIV status. Rates of HIV disclosure and questioning did not differ by HIV status.

CONCLUSIONS

HIV-positive men attending these events engaged in higher rates of illegal drug use and sexual risk than HIV-negative men. Prevention campaigns targeting MSM at high-risk events should include messages geared toward HIV-positive men.

Mental Health Functioning Among Men who Use the Internet Specifically to Find Partners for Unprotected Sex

Previous studies have shown a link between mental health functioning and involvement in HIV risk practices. The present research examines how well one specific group of men who have sex with other men (MSM) fare in terms of their mental health functioning, and then focuses on how mental health functioning relates to HIV risk practices in this population. The study was based on a national random sample of 332 MSM who use the Internet to seek men with whom they can engage in unprotected sex. Data collection was conducted via telephone interviews between January 2008 and May 2009. Depression is more common among men in this population than in the adult male population-at-large. All other measures of mental health functioning that were examined (self-esteem, impulsivity, current life satisfaction, optimism about the future) indicated low rates of mental health problem. Contrary to expectations, in nearly all instances, mental health functioning was not related to HIV risk practices. More work needs to be done to understand the causes of depression among these men, and to assess how, if at all, depression relates to risk practices in this population. These findings suggest that factors other than mental health problems must be considered if one wishes to understand HIV risk taking in this population.

Measurement model exploring a syndemic in emerging adult gay and bisexual men

The current study was designed to develop a better understanding of the nature of the relationships between mental health burden, drug use, and unprotected sexual behavior within a sample of emerging adult gay and bisexual men, ages 18-19 (N = 598) and to test a theory of syndemics using structural equation modeling. Participants were actively recruited from community-based settings and the Internet for participation in a seven-wave cohort study. Data for participant characteristics and mental health were collected via computer-assisted survey, while drug use and unprotected sex behaviors for the month prior to assessment were collected via a calendar-based technique. Using the baseline data, we developed and tested structural equation models for mental health burden, drug use, and unprotected sex and also tested a second-order model for a single syndemic. First-order measurement models for each of the three epidemics were successfully identified using observed data. Tests of a second-order model seeking to explain the three epidemics as a single syndemic fit poorly. However, a second-order construct comprised of mental health burden and drug use fit the data well and was highly associated with the first-order construct of unprotected sex. The findings advance a theory of syndemics and suggest that in order to be maximally effective both HIV prevention and HIV care must be delivered holistically such that sexual risk behaviors are addressed in relation to, and in sync with, the drug use and mental health of the individual.

HIV-infected men who have sex with men who engage in very high levels of transmission risk behaviors: establishing a context for novel prevention interventions

Men who have sex with men (MSM) comprise the largest risk group of individuals living with HIV in the USA and have the highest rates of new infections. A minority of HIV-infected MSM engage in unprotected anal intercourse after learning about their infection, potentially transmitting the virus to others. The current study sought to generate self-generated descriptive themes, from a group of HIV-infected MSM who reported high rates of sexual transmission risk behavior that may be relevant for understanding sexual risk in this group. Five descriptive themes emerged during content analysis: (a) serostatus attribution, (b) assumption of sexual partner's responsibility for safer sex, (c) sexual sensation seeking, (d) ongoing substance use, and (e) dissatisfaction with current relationships. Traditional HIV transmission risk reduction interventions that have been known to have only modest effects should be augmented by developing HIV prevention strategies for this subgroup of MSM to address these salient themes.

Community-based HIV prevention interventions that combat anti-gay stigma for men who have sex with men and for transgender women

Men who have sex with men (MSM) have been disproportionately affected by HIV since the onset of the epidemic. Public health discourse about prevention has traditionally focused on individual risk behavior and less on the socio-structural factors that place MSM at increased risk of infection. Anti-gay bias and stigma are key structural drivers of HIV and must therefore be treated as a public health threat. Community-based prevention intervention programs that affirm the healthy formation of gay and transgender identities are strongly needed. Gay affirming school-based interventions and resiliency-focused social marketing campaigns have shown positive impact on health outcomes and should be implemented on a broader scale to challenge anti-gay stigma.

Coping with HIV stigma: do proactive coping and spiritual peace buffer the effect of stigma on depression?

Although HIV stigma is a significant predictor of depression, little is known about which factors might most effectively buffer, or attenuate, this effect. We examined whether two coping-related factors-proactive coping and spiritual peace-modified the effect of HIV stigma on likelihood of depression among a sample of 465 people living with HIV/AIDS (PLWHA). In a cross-sectional analysis, we conducted hierarchical logistic regressions to examine the effect of HIV stigma, proactive coping, spiritual peace, and their interactions on likelihood of significant depressive symptoms. Spiritual peace moderated the effect of HIV stigma on depression at high-but not low-levels of HIV stigma. No such effect was observed for proactive coping. Findings suggest that spiritual peace may help counteract the negative effect of HIV stigma on depression. Intervention components that enhance spiritual peace, therefore, may potentially be effective strategies for helping PLWHA cope with HIV stigma.