Incidence and risk factors for human immunodeficiency virus seroconversion in a cohort of Sydney homosexual men

Danger and Context: Unsafe Anal Sexual Practice among Homosexual and Bisexual Men in the AIDS Crisis

Exploring the social dimension of sexuality is crucial to prevention strategies for AIDS. New developments in social theories of sexuality can inform empirical research. A survey of 535 gay and bisexual men in New South Wales and the Australian Capital Territory was designed in the light of practice-based analyses of gender and sexuality. Anal intercourse without condoms ranks high in physical and emotional significance though it is known to be relatively unsafe with regard to transmission of the human immunodeficiency virus. This practice shows few statistical connections to variables describing social structure, but is linked to variables describing gay social milieu attachment, patterns of sexuality, and awareness of the situation created by the AIDS crisis. Potentially dangerous anal practice is more common within established relationships and especially common with men who describe themselves as 'monogamous'. This creates dilemmas for prevention strategy. Connections between social variables and the frequency of unprotected anal intercourse point to the importance of informed social support for safer sex. Prevention strategy needs to emphasise collective action, not just personal change.

Amphetamine-type stimulants and HIV infection among men who have sex with men: implications on HIV research and prevention from a systematic review and meta-analysis

Introduction

HIV infections and the use of amphetamine-type stimulants (ATS) among men who have sex with men (MSM) have been increasing internationally, but the role of ATS use as a co-factor for HIV infection remains unclear. We aimed to summarize the association between ATS use and HIV infection among MSM.

Methods

We conducted a systematic search of MEDLINE, EMBASE, GLOBAL HEALTH and PsycINFO for relevant English, peer-reviewed articles of quantitative studies published between 1980 and 25 April 2013. Pooled estimates of the association – prevalence rate ratios (PRR, cross-sectional studies), odds ratio (OR, case-control studies) and hazard ratio (HR, longitudinal studies), with 95% Confidence Intervals (CI) – were calculated using random-effects models stratified by study design and ATS group (meth/amphetamines vs. ecstasy). We assessed the existence of publication bias in funnel plots and checked for sources of heterogeneity using meta-regression and subgroup analysis.

Results

We identified 6710 article titles, screened 1716 abstracts and reviewed 267 full text articles. A total of 35 publications were eligible for data abstraction and meta-analysis, resulting in 56 records of ATS use. Most studies (31/35) were conducted in high-income countries. Published studies used different research designs, samples and measures of ATS use. The pooled association between meth/amphetamine use and HIV infection was statistically significant in all three designs (PRR=1.86; 95% CI: 1.57–2.17; OR=2.73; 95% CI: 2.16–3.46 and HR=3.43; 95% CI: 2.98–3.95, respectively, for cross-sectional, case-control and longitudinal studies). Ecstasy use was not associated with HIV infection in cross-sectional studies (PRR=1.15; 95% CI: 0.88–1.49; OR=3.04; 95% CI: 1.29–7.18 and HR=2.48; 95% CI: 1.42–4.35, respectively, for cross-sectional, case-control and longitudinal studies). Results in cross-sectional studies were highly heterogeneous due to issues with ATS measurement and different sampling frames.

Conclusions

While meth/amphetamine use was significantly associated with HIV infection among MSM in high-income countries in all study designs, evidence of the role of ecstasy in HIV infection was lacking in cross-sectional studies. Cross-sectional study design, measurement approaches and source populations may also be important modifiers of the strength and the direction of associations. Event-specific measure of individual drug is required to establish temporal relationship between ATS use and HIV infection. HIV prevention programmes targeting MSM should consider including interventions designed to address meth/amphetamine use.

HIV Risk Perception, Sexual Behavior, and HIV Prevalence among Men-Who-Have-Sex-with-Men at a Community-Based Voluntary Counseling and Testing Center in Kuala Lumpur, Malaysia

We describe the HIV risk perception, sexual behavior, and HIV prevalence among 423 men-who-have-sex-with-men (MSM) clients who received voluntary counseling and testing (VCT) services at a community-based center in Kuala Lumpur, Malaysia. The mean age was 29 years old. One hundred one (23.9%) clients rated themselves as low risk, 118 (27.9%) as medium risk, 36 (8.5%) as high risk, and 168 (39.7%) were unsure of their risk. Twenty-four (9.4%) clients tested HIV positive (4 (4%) low risk, 9 (7.6%) medium risk, 11 (30.6%) high risk, and 13 (7.7%) unsure risk). We found a positive correlation between risk perception and HIV infection in this study. Clients with high HIV risk perception have 17x the odds of testing HIV positive compared to low risk clients. High HIV risk perception was significantly associated with multiple sex partners, multiple types of sex partners, alcohol use before intercourse, unprotected sex beyond 6 months, and inconsistent condom use during anal sex compared to low risk clients. There were no statistically significant differences between medium risk and unsure risk clients compared to low risk clients. Strategies should be targeted towards change in sexual practices among those who are perceived to be at high risk.

High and persistent HIV seroincidence in men who have sex with men across 47 U.S. cities

OBJECTIVE

To provide HIV seroincidence data among men who have sex with men (MSM) in the United States and to identify predictive factors for seroconversion.

METHODS

From 1998-2002, 4684 high-risk MSM, age 18-60 years, participated in a randomized, placebo-controlled HIV vaccine efficacy trial at 56 U.S. clinical trial sites. Demographics, behavioral data, and HIV status were assessed at baseline and 6 month intervals. Since no overall vaccine efficacy was detected, data were combined from both trial arms to calculate HIV incidence based on person-years (py) of follow-up. Predictors of seroconversion, adjusted hazards ratio (aHR), were evaluated using a Cox proportional hazard model with time-varying covariates.

RESULTS

Overall, HIV incidence was 2.7/100 py and was relatively uniform across study sites and study years. HIV incidence was highest among young men and men reporting unprotected sex, recreational drug use, and a history of a sexually transmitted infection. Independent predictors of HIV seroconversion included: age 18-30 years (aHR = 2.4; 95% CI 1.4,4.0), having >10 partners (aHR = 2.4; 95% CI 1.7,3.3), having a known HIV-positive male sex partner (aHR = 1.6; 95% CI 1.2, 2.0), unprotected anal intercourse with HIV positive/unknown male partners (aHR = 1.7; 95% CI 1.3, 2.3), and amphetamine (aHR = 1.6; 95% CI 1.1, 2.1) and popper (aHR = 1.7; 95% CI 1.3, 2.2) use.

CONCLUSIONS

HIV seroincidence was high among MSM despite repeated HIV counseling and reported declines in sexual risk behaviors. Continuing development of new HIV prevention strategies and intensification of existing efforts will be necessary to reduce the rate of new HIV infections, especially among young men.

Contingency management to reduce methamphetamine use and sexual risk among men who have sex with men: a randomized controlled trial

BACKGROUND

Methamphetamine use is associated with HIV acquisition and transmission among men who have sex with men (MSM). Contingency management (CM), providing positive reinforcement for drug abstinence and withholding reinforcement when abstinence is not demonstrated, may facilitate reduced methamphetamine use and sexual risk. We compared CM as a stand-alone intervention to a minimal intervention control to assess the feasibility of conducting a larger, more definitive trial of CM; to define the frequency of behavioral outcomes to power such a trial; and, to compute preliminary estimates of CM's effectiveness.

METHODS

We randomly assigned 127 MSM from Seattle, WA who use methamphetamine to receive a 12-week CM intervention (n = 70) or referral to community resources (n = 57).

RESULTS

Retention at 24 weeks was 84%. Comparing consecutive study visits, non-concordant UAI declined significantly in both study arms. During the intervention, CM and control participants were comparably likely to provide urine samples containing methamphetamine (adjusted relative risk [aRR] = 1.09; 95%CI: 0.71, 1.56) and to report non-concordant UAI (aRR = 0.80; 95%CI: 0.47, 1.35). However, during post-intervention follow-up, CM participants were somewhat more likely to provide urine samples containing methamphetamine than control participants (aRR = 1.21; 95%CI: 0.95, 1.54, P = 0.11). Compared to control participants, CM participants were significantly more likely to report weekly or more frequent methamphetamine use and use of more than eight quarters of methamphetamine during the intervention and post-intervention periods.

CONCLUSIONS

While it is possible to enroll and retain MSM who use methamphetamine in a trial of CM conducted outside drug treatment, our data suggest that CM is not likely to have a large, sustained effect on methamphetamine use.

Amphetamine-group substances and HIV

Amphetamine-group substances are used worldwide and are more prevalent than either cocaine or opioids. We reviewed published reports about amphetamine-group substances and did a meta-analysis of randomised controlled trials of behavioural interventions for their use. Most research was done in developed countries. Many, but not all, studies show an association between amphetamine-group substance use and risk of HIV infection. Much use of amphetamine-group substances is non-injection and is associated with increased HIV risk, particularly in men who have sex with men. The structural, social, interpersonal, and personal factors that link to amphetamine-group substance use and HIV risk are poorly understood. 13 studies, with a cumulative sample size of 1997 individuals, qualified for the meta-analysis. Overall, high-intensity behavioural interventions were moderately effective in reducing use of amphetamine-group substances (effect size 0.28, 95% CI 0.13-0.44). We did not find conclusive evidence that behavioural interventions as a group are more effective than are passive or minium treatment for reduction of amphetamine-group substance use or sexual risk behaviours. The search for effective, scalable, and sustainable interventions for amphetamine-group substance use, including pharmacotherapies, should be supported and encouraged.

Methamphetamine use, dependence and treatment access in rural and regional North Coast of New South Wales, Australia

INTRODUCTION AND AIMS

To identify the sociodemographic, health, drug use patterns, treatment coverage and barriers to treatment among regular methamphetamine users in rural and regional North Coast of New South Wales.

DESIGN AND METHODS

A structured questionnaire was used to measure sociodemographic factors, health and well-being, drug use patterns, methamphetamine dependence, engagement in methamphetamine treatment and barriers to treatment. Participants were 140 regular methamphetamine users. Dependent and non-dependent participants were compared to identify factors associated with dependence.

RESULTS

Participants were predominantly in their thirties, male and had low levels of education, high levels of unemployment and polydrug use. Participants who were dependent on methamphetamine (59%) were more likely to report impaired mental health and to have been diagnosed with depression, anxiety and drug-induced psychosis. One quarter of dependent methamphetamine users had received treatment in the last year and half had ever received treatment. The main barriers to receiving treatment were a lack of perceived need or motivation to seek treatment and concerns about confidentiality.

DISCUSSION AND CONCLUSIONS

Methamphetamine users living on the North Coast of New South Wales require treatment options tailored to address a complex array of physical and psychological problems. The findings highlight the need for psychiatric support and improved coordination between mental health and drug and alcohol services in rural and regional areas.

Prediction of HIV acquisition among men who have sex with men

OBJECTIVE

To develop and validate an easy-to-use prediction model for HIV acquisition among men who have sex with men (MSM).

METHODS

We developed prediction models using medical records data from an STD clinic (2001-2008) and validated these models using data from the control arm of Project Explore, an HIV prevention trial (1999-2003).

RESULTS

Of 1903 MSM who tested for HIV more than once in the development sample, 101 acquired HIV over 6.7 years of follow-up. Annual HIV incidence was 2.57% (95% confidence interval [CI]: 2.09%, 3.12%). During 4 years of follow-up of 2081 Project Explore control arm participants, 144 acquired HIV for an incidence of 2.32% (95% CI: 1.96%, 2.73%). A prediction model that included variables indicating use of methamphetamine or inhaled nitrites in the prior 6 months, unprotected anal intercourse with a partner of positive or unknown HIV status in the prior year, > or =10 male sex partners in the prior year, and current diagnosis or history of bacterial sexually transmitted infection was well calibrated overall (expected-observed ratio = 1.01; 95% CI: 0.97, 1.05) and had modest discriminatory accuracy at 1 year (area under the receiver-operator characteristic curve = 0.67; 95% CI: 0.60, 0.75) and at 4 years (area under the receiver-operator characteristic curve = 0.66; 95% CI: 0.61, 0.71). Over 4 years, cumulative incidence ranged from 3.9% to 14.3% for groups of men defined by the prediction model.

CONCLUSIONS

A new risk score was predictive of HIV acquisition and could assist providers in counseling MSM and in targeting intensified prevention to MSM at greatest risk for HIV infection. Its accuracy requires further evaluation.

Determinants of recent HIV infection among Seattle-area men who have sex with men

OBJECTIVES

We sought to identify HIV-infection risk factors related to partner selection and sexual behaviors with those partners among men who have sex with men (MSM) in King County, Washington.

METHODS

Participants were recruited from HIV testing sites in the Seattle area. Recent HIV infection status was determined by the Serologic Testing Algorithm for Recent HIV Seroconversion (STARHS) or a self-reported previous HIV-negative test. Data on behaviors with 3 male partners were collected via computer-based self-interviews. Generalized estimating equation models identified partnership factors associated with recent infection.

RESULTS

We analyzed data from 32 HIV-positive MSM (58 partners) and 110 HIV-negative MSM (213 partners). In multivariate analysis, recent HIV infection was associated with meeting partners at bathhouses or sex clubs, bars or dance clubs, or online; methamphetamine use during unprotected anal intercourse; and unprotected anal intercourse, except with HIV-negative primary partners.

CONCLUSIONS

There is a need to improve efforts to promote condom use with casual partners, regardless of their partner's HIV status. New strategies to control methamphetamine use in MSM and to reduce risk behaviors related to meeting partners at high-risk venues are needed.

Associations between substance use, erectile dysfunction medication and recent HIV infection among men who have sex with men

We conducted a case-control study to compare illicit substance and erectile dysfunction medication (EDM) use between recently HIV-infected and uninfected men who have sex with men (MSM). Eighty-six recently (previous 12 months) HIV-infected MSM (cases) and 59 MSM who recently tested HIV-negative (controls) completed computer-assisted self-interviews. There were no statistical differences in demographics or number of sexual partners by HIV status. Cases were more likely than controls to report methamphetamine or nitrite use, but not EDM, gamma hydroxybutyrate, 3,4 methylenedioxymethamphetamine, cocaine, or marijuana use, in the previous 12 months and with their last three sexual partners in multivariate logistic regression models. Use of nitrites and amphetamine may increase HIV risk among MSM.

Trends in HIV prevalence among homosexual and bisexual men in eastern Australian states

OBJECTIVES

In Australia, HIV notification rates in homosexual men, previously much higher in New South Wales, have become similar across the eastern states. We examined whether trends in HIV prevalence in community-based samples of homosexual men were consistent with the trends in HIV notifications.

METHODS

We examined data on self-reported HIV status from annual cross-sectional, self-completed anonymous surveys of homosexual men conducted between 1998 and 2006 in Sydney, Melbourne and Brisbane. Men were recruited at gay community venues, clinics and large gay community events. We calculated age-specific and age-standardised HIV prevalence rates. Comparisons of HIV prevalence between the three cities and across time were carried out using age-specific rates, and using logistic regression, controlling for age.

RESULTS

Men recruited from clinics had a much higher prevalence of HIV (P < 0.001) and were excluded from further analyses. Among the 50 239 completed questionnaires obtained at non-clinic sites, there was a marked decline in aged-standardised HIV prevalence in Sydney (from 14.2 to 8.98%, P < 0.001), a small decline in Brisbane (from 8.51 to 6.94%, P = 0.012) and no change in Melbourne (from 8.35 to 8.06%, P = 0.848). There were significant declines in men aged less than 50 years in Sydney, and in men aged less than 30 years in Brisbane. In Melbourne there was no significant trend in HIV at any age.

CONCLUSION

HIV prevalence among young homosexual men has declined in Sydney, and these data suggest that HIV incidence among homosexual men is now similar in the eastern state capitals of Australia.

Characteristics and harms associated with injecting versus smoking methamphetamine among methamphetamine treatment entrants

INTRODUCTION AND AIMS

To compare the characteristics and harms associated with injecting and smoking methamphetamine among methamphetamine treatment entrants.

METHOD AND DESIGN

A structured face-to-face interview was used to assess demographics, drug use patterns and harms [physical and mental health, psychological distress, psychotic symptoms, crime and human immunodeficiency virus (HIV) risk behaviour] among 400 methamphetamine treatment entrants in Sydney and Brisbane, Australia. Participants who had injected but not smoked methamphetamine in the month before treatment (n = 195, injectors) were compared to participants who had either: (a) injected and smoked (n = 90, injectors who smoke), or (b) smoked but not injected (n = 73, smokers), during this time.

RESULTS

In comparison with injectors, smokers were primarily non-injecting drug users, who were younger, more likely to be female and use ecstasy rather than heroin. After adjusting for these differences smokers were less dependent on methamphetamine than injectors, but they took the drug as often and had similarly high levels of psychological distress, poor physical and mental health, psychotic symptoms, sexual risk behaviour and criminal involvement. Injectors who smoked had a similar demographic and clinical profile to injectors, including comparable levels of needle sharing, but they used methamphetamine more often and had greater criminal involvement.

CONCLUSION

Within this treatment sample, smoking methamphetamine occurred among both long-standing injecting drug users and a comparatively younger group of non-injecting drug users. It was associated with less severe methamphetamine dependence than injecting, but more intense use patterns and similar levels of other harms.

Major physical and psychological harms of methamphetamine use

ISSUES

The major physical and psychological health effects of methamphetamine use, and the factors associated with such harms.

APPROACH

Comprehensive review.

KEY FINDINGS

Physical harms reviewed included toxicity and mortality, cardiovascular/cerebrovascular pathology, dependence and blood-borne virus transmission. Psychological harms include methamphetamine psychosis, depression, suicide, anxiety and violent behaviours.

IMPLICATIONS

While high-profile health consequences, such as psychosis, are given prominence in the public debate, the negative sequelae extend far beyond this. This is a drug class that causes serious heart disease, has serious dependence liability and high rates of suicidal behaviours.

CONCLUSION

The current public image of methamphetamine does not portray adequately the extensive, and in many cases insidious, harms caused.

A discursive approach to disinhibition theory: the normalization of unsafe sex among gay men

HIV research and prevention commonly cite disinhibition theory as an explanation for HIV infection among gay men. Analyzing qualitative interview data in which men talk about recreational substance use and their safer sex practices, we interrogate the concept of disinhibition theory from a discursive perspective. From this perspective, we treat talk not as a route or resource to something presumed to lie beyond the talk, but as a form of action designed for its interactional context. We demonstrate how the men normalize unsafe sex through constructions of disinhibition as common and widespread. In doing so, the men manage accountability for their own experiences with foregoing condom use while using substances. Our analysis demonstrates the men's displayed concerns to avoid individualized explanations for having engaged in unprotected sex. This may explain why some gay men may resist HIV prevention campaigns, based on these very individualized explanations.

Trends in HIV incidence in homosexual men in developed countries

Objectives: To describe trends in HIV notifications and in other measures of HIV incidence in homosexual men in developed countries. Methods: A literature search was conducted using PubMed. In addition to the peer-reviewed literature, data on HIV surveillance trends were sought by searching websites of surveillance authorities in developed countries. Results: The availability of long-term HIV surveillance data varied considerably. However, in almost all jurisdictions in which such data were available, notifications of new HIV diagnoses among homosexual men have increased, mostly since the late 1990s. The magnitude of this increase varied, but was more than 50% in many countries. There were much fewer data available on trends in direct measures of HIV incidence in homosexual men, and increases in HIV testing rates may have contributed to the increases in HIV diagnoses in many countries. However, since the late 1990s, several clinic- and community-based cohort studies in Europe and North America reported increasing incidence. Conclusion: There were increases in HIV notifications in homosexual men in almost all developed countries, starting in the late 1990s and continuing to 2006. Although increases in HIV testing probably contributed to the increases in some settings, limited cohort data do support the existence of a true increase in HIV incidence in European and North American countries. Improved monitoring of HIV incidence in homosexual men at the population level is required to allow more timely assessment of the drivers underlying such trends.

Amphetamine use and sexual risk among men who have sex with men: results from the National HIV Behavioral Surveillance study--New York City

A 2004-2005 survey among 503 men who have sex with men who attend public venues in New York City was used to examine the relationship of amphetamine use with sexual risk behaviors. Among the men recruited, 51.1% were under 30 years of age, 27.4% were Latino, and 23.3% were African American. Most identified as either gay (78.9%) or bisexual (18.1%). A standardized questionnaire collected data on demographics, sexual risk behaviors, drug and alcohol use, history of HIV testing, and occurrences of sexually transmitted infections. Amphetamine use in the past year was reported by 13.8%. Of those, 71.0% used amphetamines with sex. Amphetamine use was associated with unprotected receptive anal intercourse with non-main partners. In event-specific analysis, amphetamine use was higher with unprotected encounters compared with protected encounters. This study confirms the association between amphetamine use and sexual risk furthers our understanding of risky circumstances and lays the groundwork for the design of interventions.

Unprotected anal intercourse and substance use among men who have sex with men with recent HIV infection

OBJECTIVES

To examine within-subjects and combined between- and within-subjects associations between substance use and unprotected anal intercourse (UAI) among men who have sex with men (MSM) with recent HIV infection.

METHODS

One hundred ninety-four MSM who were recently infected with HIV completed a computer-assisted questionnaire regarding sexual behaviors and substance use with their last 3 partners. Associations between UAI and substance use were assessed using conditional logistic regression (CLR) to assess associations among the 116 MSM reporting UAI with some but not all partners and generalized linear mixed effects models (GLMMs) to examine a combination of within- and between-subjects associations in the entire sample (N = 194).

RESULTS

In multivariate CLR models and GLMMs, UAI was associated with the use of methamphetamine (odds ratio [OR] = 4.9 and OR = 3.5, respectively), marijuana (OR = 4.0 and OR = 2.2, respectively) and erectile dysfunction medications (EDMs) when used with a main partner (OR = 13.8 and OR = 10.1, respectively).

CONCLUSIONS

Results indicate that a direct association may exist between specific substances and UAI and provide evidence that the use of methamphetamine and EDMs may contribute to HIV transmission.

Risk factors for HIV seroconversion in homosexual men in Australia

BACKGROUND

Rates of newly acquired HIV infection are increasing in Australia, and sexual contact between men accounts for 85% of cases.

OBJECTIVE

To investigate behavioural risk factors for HIV seroconversion among gay and bisexual men from Sydney and Melbourne, Australia.

METHODS

103 men with newly acquired HIV infection were recruited from clinics in Sydney and Melbourne and behavioural risk factor questionnaires were administered between January 2003 and October 2004. Results were compared with a cross sectional and a cohort study performed by our group that enrolled similar populations of men.

RESULTS

The majority of seroconverters (73%) reported more than five sexual partners in the last six months. Ninety-five men (92%) were able to identify a high-risk event (HRE) that they thought had led to their HIV seroconversion. Most (70%) reported receptive unprotected anal intercourse (UAI), insertive UAI, or both at their HRE. Sixteen men (16%) reported no UAI in the preceding six months including the HRE. Men were more likely to report receptive UAI at their HRE when they perceived a partner to be HIV-negative as compared with when they perceived a partner to be HIV-positive (P = 0.05). Injection drug use was reported by 22% of the men in the previous six months, and 62% reported intoxication with alcohol (> or =5 drinks) or mood altering recreational drug use at the HRE.

CONCLUSIONS

Gay and bisexual men who have recently seroconverted are highly sexually active and report high rates of unprotected anal intercourse and recreational drug use at the HRE.

Greater risk for HIV infection of black men who have sex with men: a critical literature review

HIV rates are disproportionately higher for Black men who have sex with men (MSM) than for other MSM. We reviewed the literature to examine 12 hypotheses that might explain this disparity. We found that high rates of HIV infection for Black MSM were partly attributable to a high prevalence of sexually transmitted diseases that facilitate HIV transmission and to undetected or late diagnosis of HIV infection; they were not attributable to a higher frequency of risky sexual behavior, nongay identity, or sexual nondisclosure, or to reported use of alcohol or illicit substances. Evidence was insufficient to evaluate the remaining hypotheses.Future studies must address these hypotheses to provide additional explanations for the greater prevalence of HIV infection among Black MSM.

Unsafe sexual behavior and correlates of risk in a probability sample of men who have sex with men in the era of highly active antiretroviral therapy

OBJECTIVE

To assess the levels and correlates of potential exposure to and transmission of HIV in a contemporary, community-based probability sample of men who have sex with men (MSM).

METHODS

In 2003, 311 sexually active MSM participated in a random-digit dial telephone survey in Seattle neighborhoods with a high prevalence of MSM. The primary outcomes were potential exposure to and transmission of HIV, defined as unprotected anal intercourse with a man of opposite or unknown HIV status in the preceding 12 months.

RESULTS

Fourteen percent of respondents reported being HIV-positive, 77% reported being HIV-negative, and 8% had not been tested. Of 241 HIV-negative MSM, 25 (10%; 95% confidence interval [CI], 7-15%) were potentially exposed to HIV; among 45 HIV-positive MSM, 14 (31%; 95% CI, 20-46%) were potential HIV-transmitters. Among HIV-negative men, the strongest bivariate correlates of potential exposure to HIV were recent bacterial sexually transmitted disease (odds ratio [OR], 5.8), number of recent male sexual partners (OR, 1.01 per partner), recent sex at a bathhouse (OR, 9.1), and recent use of sildenafil (OR, 4.4), amyl nitrite (OR, 6.2), and methamphetamine (OR, 8.0). Among HIV-infected men, the strongest correlates of potential HIV transmission were recent use of amyl nitrite (OR, 3.1), number of recent male sex partners (OR, 1.07 per partner), and having a male spouse or domestic partner (OR, 0.3).

CONCLUSIONS

Most MSM knew their HIV status and adopted safer sexual behaviors to reduce their risk of HIV acquisition or transmission. However, 10% of HIV-negative MSM and 31% of HIV-positive MSM recently engaged in behaviors that placed them at high risk for acquiring or transmitting HIV.

Alcohol and sexual HIV risk behavior among problem drinking men who have sex with men: An event level analysis of timeline followback data

While heavy drinking among men who have sex with men (MSM) has been shown to be associated with an increase in sexual risk taking, a temporal relationship between drinking and an increase in subsequent HIV risk behaviors among adult samples has been less obvious. This study used an event level analysis to examine this relationship among HIV negative problem drinking MSM. Within subjects analyses show a higher probability of unprotected anal intercourse after drinking. Post-hoc analyses of within subjects data indicate that drinking increases risk taking when engaging in receptive anal intercourse but not for insertive anal intercourse. Findings from this study support evidence that drinking is a factor that increases risk taking among HIV negative problem drinking MSM, particularly for receptive anal intercourse.

Risk factors for HIV infection among men who have sex with men

OBJECTIVES

Risk factors for HIV acquisition were examined in a recent cohort of men who have sex with men (MSM).

DESIGN

A longitudinal analysis of 4295 HIV-negative MSM enrolled in a randomized behavioral intervention trial conducted in six US cities.

METHODS

MSM were enrolled and assessed for HIV infection and risk behaviors semi-annually, up to 48 months.

RESULTS

In multivariate analysis, men reporting four or more male sex partners, unprotected receptive anal intercourse with any HIV serostatus partners and unprotected insertive anal intercourse with HIV-positive partners were at increased risk of HIV infection, as were those reporting amphetamine or heavy alcohol use and alcohol or drug use before sex. Some depression symptoms and occurrence of gonorrhea also were independently associated with HIV infection. The attributable fractions of high number of male partners, use of alcohol or drugs before sex, and unprotected receptive anal intercourse with unknown status partners and the same with presumed negative partners accounted for 32.3, 29.0, 28.4 and 21.6% of infections, respectively.

CONCLUSIONS

The challenge is to develop strategies to identify men in need. Interventions are needed to help men reduce their number of sexual partners, occurrences of unprotected anal intercourse, alcohol or drug use before sex and address other mental health issues.

Club drugs as causal risk factors for HIV acquisition among men who have sex with men: a review

We reviewed medical and psychology databases for articles published between January 1980 and August 2005 demonstrating associations between HIV/Sexually Transmitted Infection risk and club drug use. Seventy-four articles were reviewed, of which 30 provided adjusted risk ratios for associations between HIV/sexually transmitted infection risk and club drug use among men who have sex with men. Definitions and lists of club drugs were broad and inconsistent. We constructed a conceptual framework of biologically plausible pathways for causation. Using Hill's criteria to examine club drugs as causal risk factors for HIV, we found the most evidence for methamphetamine and volatile nitrites; however, more studies are needed.

Associations of race/ethnicity with HIV prevalence and HIV-related behaviors among young men who have sex with men in 7 urban centers in the United States

Using data from a multisite venue-based survey of male subjects aged 15 to 22 years, we examined racial/ethnic differences in demographics, partner type, partner type-specific condom use, drug use, and HIV prevalence in 3316 US black, multiethnic black, Latino, and white men who have sex with men (MSM). We further estimated associations of these factors with HIV infection and their influence on racial/ethnic disparities in HIV prevalence. HIV prevalences were 16% for both black and multiethnic black participants, 6.9% for Latinos, and 3.3% for whites. Paradoxically, potentially risky sex and drug-using behaviors were generally reported most frequently by whites and least frequently by blacks. In a multiple logistic regression analysis, positive associations with HIV included older age, being out of school or work, sex while on crack cocaine, and anal sex with another male regardless of reported condom use level. Differences in these factors did not explain the racial/ethnic disparities in HIV prevalence, with both groups of blacks experiencing more than 9 times and Latinos experiencing approximately twice the fully adjusted odds of infection compared with whites. Understanding racial/ethnic disparities in HIV risk requires information beyond the traditional risk behavior and partnership type distinctions. Prevention programs should address risks in steady partnerships, target young men before sexual initiation with male partners, and tailor interventions to men of color and of lower socioeconomic status.

Regional patterns and correlates of substance use among young men who have sex with men in 7 US urban areas

OBJECTIVES

We sought to characterize substance use patterns in young men who have sex with men (MSM) in 7 US urban areas and sociodemographic characteristics and history associated with such use.

METHODS

We examined data collected from 1994 through 1998 in a venue-based, cross-sectional survey.

RESULTS

Among the 3492 participants, 66% reported use of illicit drugs; 28%, use of 3 or more drugs; 29%, frequent drug use (once a week or more); and 4%, injection drug use. These practices were more common among participants who were White, self-identified as bisexual or heterosexual, had run away, or had experienced forced sex.

CONCLUSIONS

Effective drug prevention and treatment programs addressing local drug-use patterns and associated factors are urgently needed for young MSM, a population with a high rate of illicit drug use.

HIV transmission among gay men through oral sex and other uncommon routes: case series of HIV seroconverters, Sydney

Seventy-five homosexual men with recently acquired HIV were interviewed about their risk behaviour. Fifty-nine reported unprotected anal intercourse, and one shared injecting equipment, with a partner not known to be HIV negative. Of the remaining 15, 11 reported protected anal intercourse. In five of the 15 we judged oral sex to be the most likely source of infection, including three men who had a genital piercing. The possible transmission risk from genital piercing should be investigated.

Determinants of human immunodeficiency virus (HIV) prevalence in homosexual and bisexual men screened for admission to a cohort study of HIV negatives in Belo Horizonte, Brazil: Project Horizonte

Project Horizonte, an open cohort of homosexual and bisexual human immunodeficiency virus (HIV-1) negative men, is a component of the AIDS Vaccine Program, in Belo Horizonte, Minas Gerais, Brazil. The objective of this study was to compare volunteers testing HIV positive at cohort entry with a sample of those who tested HIV negative in order to identify risk factors for prevalent HIV infection, in a population being screened for enrollment at Project Horizonte. A nested case-control study was conducted. HIV positive volunteers at entry (cases) were matched by age and admission date to three HIV negative controls each. Selected variables used for the current analysis included demographic factors, sexual behavior and other risk factors for HIV infection. During the study period (1994-2001), among the 621 volunteers screened, 61 tested positive for HIV. Cases were matched to 183 HIV negative control subjects. After adjustments, the main risk factors associated with HIV infection were unprotected sex with an occasional partners, OR = 3.7 (CI 95% 1.3-10.6), receptive anal intercourse with an occasional partner, OR = 2.8 (95% CI 0.9-8.9) and belonging to the negro racial group, OR = 3.4 (CI 95% 1.1-11.9). These variables were associated with an increase in the risk of HIV infection among men who have sex with men at the screening for admission to an open HIV negative cohort.

Risk factors associated with HIV infection among young gay and bisexual men in Canada

OBJECTIVE

To assess risk factors associated with HIV prevalence and incidence among gay and bisexual men in two prospective Canadian cohorts.

METHODS

The Vanguard Project and the Omega Cohort are prospective cohort studies of gay and bisexual men ongoing in Vancouver and Montreal, respectively. For this analysis, baseline sociodemographic characteristics, sexual behavior, and substance use data from these two cohorts were combined. Assessment of risk factors for HIV seroprevalence and seroconversion were carried out using univariate and multivariate analysis.

RESULTS

This analysis was based on 1373 gay and bisexual men aged 16 to 30 years. Men who were HIV-seropositive at baseline (n = 48) were more likely to report living in unstable housing, to have had less than a high school education, and to have been unemployed than those who were HIV-negative (n = 1325). HIV-positive men were also more likely to report having engaged in sexual risk behavior, including having had consensual sex at a younger age, having had at least 6 partners during the previous year, ever having been involved in the sex trade, and having engaged in unprotected receptive anal intercourse. With respect to substance use, HIV-positive men were more likely to report the use of crack, cocaine, heroin, and marijuana and to use injection drugs. Similarly, men who seroconverted during the course of the studies (n = 26) were more likely to report having less than a high school education and having lived in unstable housing at baseline. Compared with HIV-negative men, men who seroconverted were more likely to report ever having been involved in the sex trade and engaging in unprotected receptive anal intercourse. Reports of cocaine use and injection drug use were also significantly higher for men who seroconverted compared with HIV-negative men.

CONCLUSIONS

Our data indicate that HIV-positive gay and bisexual men are more likely to be living in unstable conditions and to report more risky sexual and substance use behaviors than HIV-negative men.

The repertoire of human efforts to avoid sexually transmissible diseases: past and present. Part 1: Strategies used before or instead of sex

BACKGROUND/OBJECTIVE

Despite the focus by public health programmes on condoms, chastity, or monogamy, people use a much wider variety of strategies to minimise their personal risk of sexually transmissible disease (STD). The objective of this study was to compile a comprehensive list of personal and societal STD avoidance strategies.

METHODS

Data from clinical and research observations, computer searches, and historical texts were pooled.

RESULTS

In addition to discriminating between potential sexual partners, a variety of behaviours before or instead of sex were identified that have been perceived to alter STD risk. Traditional STD avoidance strategies were often poorly documented and difficult to disentangle from other drives such as the maintenance of social order, paternity guarantee, and eugenics. They also varied in popularity in time and place. Some examples were displacement activities such as masturbation or exercise, circumcision, infibulation, shaving, vaccination, or requiring partners to be tested for infection. Social and moral forces typically discourage non-marital sex, and this affects most people most of the time but few people all of the time.

CONCLUSION

The full spectrum of STD avoidance strategies warrants further study because some are ubiquitous across cultures and because they have the potential to complement or undermine safer sex programmes. Because of their greater acceptability, some less efficacious strategies may have greater public health importance than less popular but more efficacious strategies such as condoms.

Socio-demographic and spatial aspects of male mortality from HIV-AIDS related diseases in New South Wales, Australia, 1990-1994

During 1990-1994, a very high proportion of males aged under 40 who died from HIV-AIDs related diseases in New South Wales were never married. However, a significant minority of men aged 40-64 who died had been married at some stage in their lives and in the cities of Newcastle, Wollongong and in higher income areas of Sydney this proportion approached 40%. AIDS related mortality was over-represented in professional, managerial, paraprofessional and service occupations even though educational levels were higher in these groups and, thus, presumably knowledge about risk behaviour and preventative behaviour. AIDS related mortality was also elevated among men with no stated occupation. Thus, with males, AIDS was in part a disease of affluence, even though the highest proportions of those dying resided in lower income areas, where marginalised persons may also be at risk. The proportion of deaths to men over age 40 was markedly higher than that in Australia in the 1980s. Elevated mortality with the New Zealand and the Americas birthplace groups may reflect overseas travel and exposure to risk in overseas countries, of persons domiciled in Australia. There was a very strong spatial pattern of AIDS-related mortality in the inner and eastern suburbs in Sydney and there is limited evidence of persons having migrated back to places of origin to be cared for by families. The impact on total mortality under age 65 in these localised areas was considerable. Prevention strategies should include the sensitive targeting of bisexual men, men generally having sex with men and those who are both gay and members of the drug sub-culture.

A theoretical model of the evolution of virulence in sexually transmitted HIV/AIDS

INTRODUCTION

The evolution of virulence in host-parasite relationships has been the subject of several publications. In the case of HIV virulence, some authors suggest that the evolution of HIV virulence correlates with the rate of acquisition of new sexual partners. In contrast some other authors argue that the level of HIV virulence is independent of the sexual activity of the host population.

METHODS

Provide a mathematical model for the study of the potential influence of human sexual behaviour on the evolution of virulence of HIV is provided.

RESULTS

The results indicated that, when the probability of acquisition of infection is a function both of the sexual activity and of the virulence level of HIV strains, the evolution of HIV virulence correlates positively with the rate of acquisition of new sexual partners.

CONCLUSION

It is concluded that in the case of a host population with a low (high) rate of exchange of sexual partners the evolution of HIV virulence is such that the less (more) virulent strain prevails.

Stimulant abuse treatment as HIV prevention

Individuals who use illicit stimulants, primarily cocaine and methamphetamine, engage in substantial amounts of HIV-related sexual risk behaviors when under the influence. This paper presents the idea that reductions in stimulant use consequent to drug treatment makes stimulant drug treatment an important HIV prevention tool for this high-risk population. Data are presented to describe many of the HIV-related sexual risks reported by out-of-treatment methamphetamine users and by cocaine and methamphetamine abusers at treatment entry and six months post treatment entry. Overall, our findings demonstrate that following initiation of a treatment episode, stimulant abusers demonstrate significant and relevant reductions in HIV-related sexual behaviors, primarily by reducing the number of sexual partners. Reasons for why stimulant treatment corresponds to HIV transmission risk reductions and suggestions for implementing prevention messages in treatment settings are offered.

Alcohol and drug use patterns have declined between generations of younger gay-bisexual men in San Francisco

OBJECTIVES

To describe changes in alcohol and drug use between two independent samples of gay-bisexual men aged 25-29.

METHODS

Comparisons between the 1984 San Francisco Men's Health Survey (SFMHS) and the 1992 San Francisco Young Men's Health Survey (SFYMHS).

RESULTS

Heaviest levels of alcohol use decreased between the 1984 and 1992 samples as did most types of drug use, with the exception of an increase in the use of MDA.

CONCLUSIONS

Important declines in heavy alcohol use and overall drug use occurred among young gay men between 1984 and 1992. However, levels of substance use still remain high and may constitute a continued threat to the health of gay-bisexual men.

Histories of substance use and risk behavior: precursors to HIV seroconversion in homosexual men

OBJECTIVES

This study compared history of substance use and episodic use in terms of HIV seroconversion.

METHODS

A sample of 337 baseline HIV-negative gay men was followed for 6 years. Bivariate and survival analyses were used to compare 39 converters with nonconverters on substance use behaviors.

RESULTS

Seroconverters were consistently more likely to report use of marijuana, nitrite inhalants, amphetamines, and cocaine than nonconverters. Consistent use of nitrite inhalants and amphetamines increases the relative risk of seroconversion, while episodic use does not. Both patterns of cocaine use increase seroconversion risk.

CONCLUSIONS

There are three potential mechanisms for an increased risk of conversion due to consistent substance use.

Incidence of HIV infection in a cohort of homosexually active men

The purpose of this study was to estimate the incidence of human immunodeficiency virus (HIV) in a cohort of homosexually active men in Sydney. In 1984-85 the Sydney AIDS Prospective Study enrolled homosexually active men, who were followed by six-monthly visits, although regular contact with most participants ceased in the early 1990s. In 1993-94 a major effort was made to establish the HIV status of all participants who had attended more than once. Of the 1075 men enrolled, 528 (49 per cent) were negative at enrollment and had at least one further documented HIV test. The annual incidence rate of HIV infection was highest in the early years of the study, 1984 (9.6 per cent) and 1986 (5.0 per cent), and remained low from 1987 (1.9 per cent) to 1994 (0.0 per cent). The incidence of HIV infection was higher among men aged under 34 years at enrollment and men who reported more than four sexual partners in the six months before enrollment, but these associations disappeared by 1987. The decrease in HIV incidence is consistent with findings from other cohorts followed for this length of time.

A national surveillance system for newly acquired HIV infection in Australia. National HIV Surveillance Committee

OBJECTIVES

The purpose of this study was to describe the establishment of a national surveillance system for newly acquired human immunodeficiency virus (HIV) infection and present the first 3 years' results.

METHODS

All new cases of diagnosed HIV infection were reported to the national HIV surveillance center through state and territory health authorities. Information sought on each case included evidence of whether the infection had been newly acquired, defined by the diagnosis of HIV seroconversion illness or by the report of a negative or indeterminate HIV antibody test result occurring within the 12 months prior to diagnosis of infection.

RESULTS

Of 3602 reported cases of HIV infection in adults and adolescents newly diagnosed in Australia between 1991 and 1993, 11.4% were identified as newly acquired. The majority (85%) of cases of newly diagnosed HIV infection occurred among men who reported homosexual contact, and 15% of these cases were identified as newly acquired. Average age at diagnosis was 31 years for cases of newly acquired infection and 34 years for other cases.

CONCLUSIONS

Surveillance for newly acquired HIV infection has been established at a national level in Australia and provides valuable information for planning primary HIV prevention programs.

Knowledge and practice of sexual safety in Melbourne gay men in the nineties

Despite the impact of education programs, the ability of gay men to sustain sexual safety still comes under public scrutiny. A self-administered questionnaire was distributed in 1990 to a convenience sample of 284 gay-identified Melbourne men recruited from gay groups, health clinics, gay pubs and nightclubs, sex-on-premises venues, and the social networks of these men. The questionnaire measured the perceived safety of various sexual practices and the practice of unprotected anal intercourse over the previous three months. These results were compared with results from other Australian studies. Whereas nearly all the men were sexually active, only a small proportion considered activities such as oral sex without ejaculation and anal sex with condoms to be 'totally safe'. The majority considered these activities to be 'more safe than unsafe', suggesting a risk-reduction rather than a 'no-risk' approach to sex. Comparisons with other Australian studies suggest that gay men are becoming more confident in the safety of sexual activities labelled as 'safe' by the AIDS Council. There was no elevated practice of unprotected anal sex at 'sex-on-premises' venues. Most men who had anal sex used condoms all of the time, whether sexual partnerships were 'once only' or were 'ongoing', suggesting that 'condoms always' is still a viable option in various partnerships. There was some evidence that a minority of men abandoned condoms in ongoing partnerships. If specific education campaigns are developed to promote 'negotiated safety' in partnerships, then such campaigns should not contradict the 'condoms always' strategy.

Correlates of sexual risk-taking among gay male substance abusers

This paper examines sexual risk-taking within a sample of sexually active gay and bisexual men entering substance abuse treatment (n = 383), and identifies correlates of unprotected anal sex within this group. Sexual risk-taking was high, with 55% of these men engaging in anal intercourse without a condom within a 90-day period. Correlates of unprotected anal sex varied somewhat when looking at unprotected anal sex with a primary partner only and with non-primary partners; substance use variables (number of drugs used, use of inhalant nitrites or stimulant drugs with sex, length of time since use of alcohol/drugs, loss of control problems associated with alcohol/drug use) appear to play more of a role in unprotected anal sex with non-primary partners. Overall, logistic regression analyses indicated that sexual risk was greater for those who were more sexually active, enjoyed unprotected anal sex with withdrawal prior to ejaculation, did not approve of sex outside of a love relationship, and identified themselves as more risky. In addition, those who reported more social problems due to substance use had fewer expectations that substance use increased risk, had been HIV-tested, and used reappraisal/problem-solving coping strategies showed greater risk with a primary partner only. Sexual risk with non-primary partners was greater for those who used more drugs, reported more difficulty avoiding high-risk sex when aroused and were HIV+. The paper discusses the implications of these findings for the design of sexual risk-reduction interventions.

Estimation of time since infection using longitudinal disease-marker data

We propose a method to estimate the usually unknown time since infection for individuals infected with human immunodeficiency virus type 1 (HIV-1). If we assume the time since infection has an exponential prior distribution, then under the model the conditional distribution of time since infection, given the CD4 level at the time of the first positive HIV-1 antibody test, is a truncated normal density. We applied the method to prevalent cohort data both from intravenous drug users and from homosexual/bisexual men. For the intravenous drug users the estimated mean time since infection was 15.0 months from infection at a presumed mean CD4 level of 1060 cells/ml to first positive antibody test at a CD4 level of 597 cells/ml, which was the average CD4 at enrollment for infected subjects. For the homosexual/bisexual men the estimated mean time since infection was 16.7 months from infection at a presumed mean CD4 level of 699 cells/ml to first positive antibody test at an average CD4 level of 577 cells/ml. We performed a validation study using initially seronegative subjects in these cohorts who seroconverted to HIV-1-positive antibody status during the follow-up period. For the intravenous drug users, data were too few to provide definitive verification of the method. In the cohort of homosexual/bisexual men, however, there was a total of 70 seroconverters with relevant data. Among them, the median absolute difference between the midpoint of the known seroconversion interval and the estimated mean infection date was 4.6 months, conditional on CD4-lymphocyte measurements taken approximately 18 months subsequent to infection. Conditional on CD4 approximately 30 months after infection, this median difference increased modestly to 8.2 months. Our analysis suggested that the underlying mathematical model tends to overestimate short times since infection and underestimate long times since infection. We consider potential corrective modifications to the model.

Falling incidence of HIV infection in a cohort of clinic attenders

It is widely accepted that changes in sexual behaviour in the mid-1980s drastically reduced the spread of human immunodeficiency virus (HIV) through male homosexual contact in Western countries, but documentation of changes in infection rates has been based on observation of subjects enrolled in cohort studies, who may be highly selected and motivated. In this study, the incidence of HIV seroconversion was investigated among people attending a major site of HIV testing, counselling and patient care in Sydney. Over the period March 1985 to June 1990, 2,301 people were tested for HIV antibody on more than one occasion, following a negative result at the first test. On the basis of subsequent tests, 107 were found to have seroconverted during the study period, including 91 men who reported homosexual or bisexual contact as their only exposure to HIV. Overall, the incidence rate of HIV infection among men reporting homosexual or bisexual contact was 404 per 100 person-years of follow-up. Under various methods of calculation, the incidence was estimated to have declined between 1985 and 1989-1990. However, there was continuing HIV seroconversion in 1989-1990 and no indication of declining incidence in younger men. The fall in HIV incidence documented in this study supports the role of HIV prevention programs aimed at homosexual and bisexual men.

The acquired immunodeficiency syndrome in Australia: incidence 1982-1991

OBJECTIVE

To describe the incidence of the acquired immunodeficiency syndrome (AIDS) in Australia between 1982 and 1991.

DESIGN

State and Territory Health Departments notified new diagnoses of AIDS to the National AIDS Registry. Information reported for each case included sex, date of birth, date of AIDS diagnosis, presumed mode of exposure to the human immunodeficiency virus (HIV), and illness(es) on which the diagnosis of AIDS was based.

RESULTS

To the end of March 1992, 3,160 cases of AIDS were reported as having been diagnosed between 1982 and the end of 1991. The cumulative incidence per head of population was about twice as high in New South Wales as in Australia as a whole. Over 97% of cases were in men, of whom 91% were adults or adolescents reporting homosexual contact. In women, 40% of cases were acquired through receipt of blood, blood products or tissue. The annual incidence of AIDS rose sharply until about 1988, but the annual rates of increase slowed in subsequent years. This trend was also apparent in cases acquired through sexual contact between men. In other exposure groups, numbers of cases were much smaller and trends less apparent. However, there was no indication of a similar levelling in AIDS incidence, except among blood transfusion recipients, in whom incidence may be declining.

CONCLUSION

Transmission of HIV among people with AIDS in Australia has been overwhelmingly attributed to sexual contact between men. The annual incidence of cases attributed to sexual contact between men appears to be stabilising.

AIDS and promiscuity: muddles in the models of HIV prevention

AIDS has been blamed on promiscuity and the promiscuous, and a major goal of many HIV-prevention programs has been to induce people to reduce the number of their sexual partners. Despite the salience of this concept in the AIDS discourse of scientists, policymakers, the media, religious leaders, and the gay community, critical analysis of the role of promiscuity in this epidemic has been lacking. Following a review of promiscuity in various genres of AIDS discourse, this article discusses promiscuity in American society and in HIV-prevention campaigns. The relative risks associated with monogamy, abstinence and promiscuity are examined, and the author concludes that the partner-reduction strategy, instead of contributing to a reduction in HIV transmission has been an impediment to AIDS prevention efforts, exacerbating the problem by undermining the sex-positive approaches to risk reduction that have proven effective. Responsibility for this misguided strategy is attributed to a moralistic approach to AIDS and to the misapplication of epidemiological concepts and inappropriate social science models to the task of promoting healthy forms of sexuality.