Lifetime Prevalence and Sociodemographic Correlates of Multifactorial Discrimination Among Middle-Aged and Older Adult Men Who Have Sex with Men

This study describes multifactorial discrimination (discrimination attributed to multiple social identities) among middle-aged and older adult MSM. MSM aged 40+ years (N = 1,193) enrolled in the Multicenter AIDS Cohort Study completed behavioral surveys ascertaining experiences of discrimination and their social identity attributions. Non-proportional odds regressions assessed multifactorial discrimination by age, race/ethnicity, HIV status, and covariates. Twenty-seven percent of participants reported multifactorial discrimination. Adjusted models indicated that middle-aged men were more likely to report multifactorial discrimination compared to older adult men. Racial/ethnic minorities were more likely to report multifactorial discrimination compared to non-Hispanic white participants. These same patterns emerged among the sub-sample of participants living with HIV. To our knowledge, this is the first assessment of multifactorial discrimination in middle-aged and older MSM. Our findings support the deleterious association between multiple-marginalization and multifactorial discrimination. Multilevel interventions targeting interconnected experiences of stigma may improve the health of MSM in transition to older age.

Black Men Who Have Sex with Men and Lifetime HIV Testing: Characterizing the Reasons and Consequences of Having Never Tested for HIV

HIV testing remains a critical point of entry to HIV treatment services and now biomedical prevention as well. Yet despite the high HIV prevalence among Black men who have sex with men (MSM), insufficient attention has been given to factors associated with those Black MSM in the United States who have never received an HIV test in their lifetime. Promoting Our Worth, Equality, & Resilience (POWER) is a cross-sectional observational study that recruited Black MSM at Black Pride events across six cities in the United States from 2014 to 2017. Participants completed an anonymous questionnaire and were offered free, confidential HIV testing. Of the 4174 Black MSM without a prior HIV diagnosis, 404 (9.68%) had never tested for HIV (mean age = 31.03 years). Lower education and greater internalized homophobia were associated with never having tested for HIV. Higher age (AOR = 1.05, 95%, 1.02-1.07) and assumption of HIV-positivity (AOR = 3.24, 95% CI 1.53-6.84) were both associated with increased odds of an HIV-positive test result (n = 119; 36%). To compare, HIV prevalence among Black MSM who had received at least one HIV test before study participation was 23%. While a minority of Black MSM had never received an HIV test, this group had a significantly higher likelihood of HIV infection. Alternative HIV testing strategies are needed to facilitate HIV testing initiation among Black MSM for whom conventional HIV testing modalities are insufficient.

Multifactorial discrimination, discrimination salience, and prevalent experiences of internalized homophobia in middle-aged and older MSM

Objectives: We sought to test whether discrimination salience and multifactorial discrimination were associated with prevalent experiences of internalized homophobia among middle-aged and older men who have sex with men (MSM).Methods: We analyzed data from 498 middle-aged and older MSM from the Multicenter AIDS Cohort Study (MACS) who reported any lifetime discrimination experience. We estimated the prevalence ratio of current internalized homophobia using multivariable Poisson regressions, accounting for discrimination salience, multifactorial discrimination, and covariates. We then assessed whether multifactorial discrimination moderated the association between discrimination salience and internalized homophobia.Results: Over half (56.4%) of our sample reported any current experience of internalized homophobia. More than two-thirds reported multifactorial discrimination (68.2%) and more than one-third (36.7%) reported moderate-to-high discrimination salience. Increases in discrimination salience (PR = 1.11; 95% CI: 1.03-1.20) were associated with any current internalized homophobia among middle-aged and older MSM. Multifactorial discrimination was not statistically associated with internalized homophobia and did not moderate the association between discrimination salience and internalized homophobia.Conclusions: Our study underscores internalized homophobia as a persisting concern among MSM in midlife and older adulthood. Our findings suggest that salience, as a characteristic of discrimination experiences, may have a greater impact on internalized homophobia compared with exposure. Future research efforts should assess facets of discrimination salience, such as severity, frequency, and chronicity, to better understand how discrimination shapes psychosocial well-being across the life course. Mental health advocates at policy, organizational, and community levels should aim to reduce intersectional stigma and address individual experiences of internalized homophobia.

Characterizing Experiences of Conversion Therapy Among Middle-Aged and Older Men Who Have Sex with Men from the Multicenter AIDS Cohort Study (MACS)

Conversion therapies are practices that attempt to change an individuals' same-sex attractions through psychotherapeutic and aversive therapeutic techniques. Conversion therapies were developed based on homophobic beliefs that same-sex attractions are a mental illness. We sought to describe the prevalence and characteristics of conversion therapy experienced among middle-aged and older men who have sex with men in the United States. Given associations of homophobic stigma and HIV risk, we hypothesized that HIV-positive men would report higher odds of conversion therapy compared to HIV-negative men. We analyzed data from 1,237 middle-aged and older MSM enrolled in the Multicenter AIDS Cohort Study. Among participants, 17.7% reported lifetime conversion therapy, of which the average start of therapy age was 22.67 (sd = 10.56) years, 25.8% reported therapy durations of 6+ months, 37.7% reported session frequencies 1+ session per week, and 35.9% indicated that undergoing therapy was either a little or not at all their decision. We observed no statistically significant association between reporting lifetime conversion therapy and HIV status. Future efforts should continue to assess the magnitude of harm conversion therapies impose on MSM's health across the life course as well as test potential, indirect associations that may link these practices to HIV.

Assessing HIV Stigma on Prevention Strategies for Black Men Who Have Sex with Men in the United States

The deleterious effects of HIV stigma on HIV+ Black MSM care continuum outcomes have been well-documented. How HIV stigma shapes HIV prevention for HIV- persons in this community is poorly understood. We sought to test the relationship of HIV stigma with HIV- Black MSM on HIV testing, pre-exposure prophylaxis (PrEP) awareness, and PrEP use. We recruited 772 participants at Black Pride events across five US cities in 2016. Multivariable logistic regression models assessed the association of external HIV stigma on prevention outcomes adjusting for sociodemographic variables. Stigma was positively associated with PrEP awareness (AOR = 1.34; 95% CI = 1.09, 1.66; p value = 0.005), and not associated with PrEP use or HIV testing in our sample. These findings highlight the complex nature of HIV stigma among BMSM and include results for PrEP, which can affect uptake other prevention methods. We support anti-HIV stigma efforts and advise further exploration on HIV stigma among BMSM and prevention outcomes.

Elevated HIV Prevalence and Correlates of PrEP Use Among a Community Sample of Black Men Who Have Sex With Men

BACKGROUND

The HIV epidemic among black men who have sex with men (BMSM) demands urgent public health attention. Pre-exposure prophylaxis (PrEP) is a highly efficacious option for preventing HIV, but characteristics of PrEP use among community samples of BMSM are not well-understood.

METHODS

A serial cross-sectional survey assessment (N = 4184 BMSM reporting HIV-negative/unsure status) and HIV testing were conducted at Black Gay Pride events in 6 US cities in 2014, 2015, 2016, and 2017.

RESULTS

HIV prevalence was higher among BMSM self-reporting current PrEP use (1 of 3 participants) than BMSM not self-reporting current PrEP use (1 of 5 participants) [32.3%, N = 103/319 vs. 20.0%, N = 639/3,193, adjusted odds ratio (aOR) = 1.68, 95% confidence interval (CI): 1.31 to 2.15]. BMSM reporting current PrEP use (N = 380) were more likely to report having a greater number of male sex partners (aOR = 1.02, 95% CI: 1.01 to 1.03), a sexually transmitted infection diagnosis (aOR = 2.44, 95% CI: 1.88 to 3.16), and stimulant drug use (aOR = 2.05, 95% CI, 1.21 to 3.47) when compared with BMSM not reporting current PrEP use (N = 3804). PrEP use increased from 4.7% (2014) to 15.5% (2017) (aOR = 1.19, 95% CI: 1.13 to 1.25). Among PrEP users, inability to afford health care coverage was associated with testing HIV-positive (aOR = 2.10, 95% CI: 1.24 to 3.56).

CONCLUSIONS

The high prevalence of HIV infection among BMSM reporting PrEP use is concerning. It does not, however, challenge the efficacy of PrEP itself but rather the uptake of the surrounding preventative package including behavioral risk reduction support, sexually transmitted infection treatment, and medication adherence counseling. Further research to understand barriers to fully effective PrEP is needed to guide operational and behavioral interventions that close the gap on incident infection.

A Multi-US City Assessment of Awareness and Uptake of Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Black Men and Transgender Women Who Have Sex with Men

The HIV epidemic among Black men and transgender women who have sex with men (BMTW) demands an urgent public health response. HIV point prevalence among this population ranges from 25 to 43%-a rate far exceeding any other group. Pre-exposure prophylaxis (PrEP) for HIV prevention is a very promising prevention tool; however, its full potential to slow the epidemic has yet to be realized. For the current study, random time-location sampling at Black Gay Pride Events was used to collect data from N = 1274 BMTW, from five US cities, reporting HIV-negative/unknown status. In-field HIV testing was also provided to participants. Participants were assessed on awareness and use of PrEP, health care factors, HIV testing history, psychosocial variables, and sex behaviors. About one third of participants were aware of PrEP (39%), and a small percentage of participants were users of PrEP (4.6%). In multivariable analyses, being in a relationship, testing for HIV in the past 6 months, and others being aware of one's sexuality were positively associated with PrEP awareness. Higher levels of internalized homophobia and greater numbers of female sex partners were positively associated with PrEP use, while education and condom use were negatively associated. Based on study findings, messaging and uptake of PrEP needs greater expansion and requires novel approaches for scale-up. Improving linkage to HIV testing services is likely critical for engaging BMTW with PrEP. The potential for PrEP to slow the HIV epidemic is high; however, we must strengthen efforts to ensure universal availability and uptake.

High HIV incidence among young black men who have sex with men: constructing a retrospective cohort from a community health programme

OBJECTIVES

We sought to calculate HIV incidence in a retrospective cohort of young (13-29 years old) black men who have sex with men (YBMSM) accessing repeated HIV-antibody testing in a mid-size city in the USA.

METHODS

We aggregated site-specific HIV-antibody testing results from the project's inception among YBMSM who received an initial negative result and accessed at least one additional HIV-antibody test. From these data, we assessed number of seroconversions and person-years and calculated HIV incidence using a mid-P exact test to estimate 95% CIs.

RESULTS

Five seroconversions were documented over 42.3 person-years (the mean age at first onsite test: 19.7 years), resulting in an HIV incidence rate of 11.8% (95% CI 4.3% to 26.2%). The mean age at seroconversion was 20.4 (±3.0) years.

CONCLUSIONS

Even in mid-size cities with low HIV prevalence rates in the general population, HIV incidence among YBMSM may be high. Community-based HIV-antibody testing organisations serving YBMSM should be encouraged and trained to track repeated HIV testing and calculate HIV incidence rates. Increased resources should be deployed to develop and encourage regular HIV testing in community health sites serving YBMSM.

Anti-retroviral Therapy Based HIV Prevention Among a Sample of Men Who Have Sex with Men in Cape Town, South Africa: Use of Post-exposure Prophylaxis and Knowledge on Pre-exposure Prophylaxis

Men who have Sex with Men (MSM) have been affected disproportionately by the global HIV pandemic. Rates of consistent condom-use are low and there is a need for further biomedical prevention interventions to prevent new HIV infections. Post exposure prophylaxis (PEP) can reduce the risk of HIV, but uptake among MSM is low. Pre-exposure prophylaxis (PrEP), an innovative anti-retroviral-based HIV prevention tool might be an appropriate intervention for MSM who have recently accessed PEP that involves HIV negative individuals taking daily tenofovir+emtricitabine for HIV prevention. 44 MSM, attending a primary health-care level MSM-focused sexual health clinic in Cape Town, South Africa, who had initiated PEP were enrolled in this study. Participants were followed up after 2, 4 and 12 weeks. Self-administered electronic surveys were completed at the initial, 4 and 12 week visit. Barriers and facilitators to accessing PEP and remaining adherent were examined, as was knowledge about PrEP. Thirty-two participants (80 %) were <40 years of age (range 20-65 years). 35 % of the participants reported their reason for requiring PEP as condomless receptive anal intercourse. A further 20 % required PEP following condomless penetrative anal intercourse; 27.5 % required PEP due to a broken condom during receptive anal sex and 2 participants during insertive anal sex. Three participants did not complete 28 days of PEP or were lost to follow up. Over half (58.5 %) of the participants reported being completely adherent to their regime; under a third (31.7 %) reported missing one PEP dose; and 9.8 % reported missing more than one dose. 36/40 (90 %) had heard of PrEP and 30/40 (75 %) indicated that they would use PrEP if it were accessible to them. That we enrolled 44 MSM who accessed PEP from a Department of Health affiliated clinic over 12 months, speaks to the low uptake by MSM of PEP services in South Africa. Adherence was high and demonstrates that adherence support is feasible from a state health clinic. Reported risk behaviors in some high-risk participants did not change over time, demonstrating the need for additional longer-term HIV preventions such as PrEP. PEP users could conceivably be transitioned from PEP to PrEP.

Associations between LGBTQ-affirmative school climate and adolescent drinking behaviors

BACKGROUND

We investigated whether adolescents drank alcohol less frequently if they lived in jurisdictions with school climates that were more affirmative of lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals.

METHODS

Data from the 2010 School Health Profile survey, which measured LGBTQ school climate (e.g., percentage of schools with safe spaces and gay-straight alliances), were linked with pooled data from the 2005 and 2007 Youth Risk Behavior Survey, which measured sexual orientation identity, demographics, and alcohol use (number of drinking days, drinking days at school, and heavy episodic drinking days) in 8 jurisdictions. Two-level Poisson models tested the associations between school climate and alcohol use for each sexual-orientation subgroup.

RESULTS

Living in jurisdictions with more (versus less) affirmative LGBTQ school climates was significantly associated with: fewer heavy episodic drinking days for gay/lesbian (incidence-rate ratio [IRR]=0.70; 95% confidence interval [CI]: 0.56, 0.87; p=0.001) and heterosexual (IRR=0.80; 95% CI: 0.76, 0.83; p<0.001) adolescents; and fewer drinking days at school for adolescents unsure of their sexual orientation (IRR=0.57; 95% CI: 0.35, 0.93; p=0.024).

CONCLUSIONS

Fostering LGBTQ-affirmative school climates may reduce certain drinking behaviors for gay/lesbian adolescents, heterosexual adolescents, and adolescents unsure of their sexual orientation.

Sexual-Orientation Differences in Positive Youth Development: The Mediational Role of Bullying Victimization

OBJECTIVES

To examine sexual-orientation differences in positive youth development, and how bullying victimization mediated these differences in a sample of adolescents.

METHODS

In 2007 to 2008, positive youth development was measured in 1870 adolescents from US schools and after-school programs in 45 states by using the validated Five Cs model of competence, confidence, connection, character, and caring/compassion. Sexual-minority youths (6.8%) reported having same- or both-gender sexual attractions. Nonattracted youths (4.2%) reported having no sexual attractions.

RESULTS

Compared with sexual-minority youths, heterosexual and nonattracted youths had lower odds of being a victim of bullying. Heterosexual and nonattracted youths also had higher average scores in competence, confidence, and connection, but these associations between sexual orientation and positive youth development scores were partly attributable to lack of bullying victimization.

CONCLUSIONS

Designing, implementing, and evaluating interventions that reduce bullying can give sexual-minority youths access to several building blocks of health and well-being.

Running Backwards: Consequences of Current HIV Incidence Rates for the Next Generation of Black MSM in the United States

Black men who have sex with men (MSM) in the United States are disproportionately impacted by HIV. To better understand this public health problem, we reviewed the literature to calculate an estimate of HIV incidence among Black MSM. We used this rate to model HIV prevalence over time within a simulated cohort, which we subsequently compared to prevalence from community-based samples. We searched all databases accessible through PubMed, and Conference on Retroviruses and Opportunistic Infections abstracts for HIV incidence estimates among Black MSM. Summary HIV incidence rates and 95 % confidence intervals (CIs) were calculated using random effects models. Using the average incidence rate, we modeled HIV prevalence within a simulated cohort of Black MSM (who were all HIV-negative at the start) from ages 18 through 40. Based on five incidence rates totaling 2898 Black MSM, the weighted mean incidence was 4.16 % per year (95 % CI 2.76-5.56). Using this annual incidence rate, our model predicted that 39.94 % of Black MSM within the simulated cohort would be HIV-positive by age 30, and 60.73 % by 40. Projections were similar to HIV prevalence found in community-based samples of Black MSM. High HIV prevalence will persist across the life-course among Black MSM, unless effective prevention and treatment efforts are increased to substantially reduce HIV transmission among this underserved and marginalized population.

Differences in alcohol use and alcohol-related problems between transgender- and nontransgender-identified young adults

BACKGROUND

Little is known about differences in alcohol use and alcohol-related problems between transgender- and nontransgender-identified populations. Using data from a large-scale health survey, we compare the drinking patterns and prevalence of alcohol-related problems of transgender-identified individuals to nontransgender-identified males and females. For transgender-identified people, we examine how various forms of victimization relate to heavy episodic drinking (HED).

METHODS

Cross-sectional surveys were completed by 75,192 students aged 18-29 years attending 120 post-secondary educational institutions in the United States from 2011 to 2013. Self-reported measures included alcohol use, alcohol-related problems, victimization, and sociodemographics, including 3 gender-identity groups: transgender-identified individuals; nontransgender-identified males; and nontransgender-identified females.

RESULTS

Compared to transgender-identified individuals, nontransgender-identified males were more likely to report HED in the past 2 weeks (relative risk=1.42; p=0.006); however, nontransgender-identified males and females reported HED on fewer days than transgender-identified people (incidence-rate ratios [IRRs] ranged from 0.28 to 0.43; p-values<0.001). Compared to transgender-identified people, nontransgender-identified males and females had lower odds of past-year alcohol-related sexual assault and suicidal ideation (odds ratios ranged from 0.24 to 0.45; p-values<0.05). Among transgender-identified people, individuals who were sexually assaulted (IRR=3.21, p=0.011) or verbally threatened (IRR=2.42, p=0.021) in the past year had greater HED days than those who did not experience those forms of victimization.

CONCLUSIONS

Compared to transgender-identified people, nontransgender-identified males and females: have fewer HED occasions (despite nontransgender-identified males having greater prevalence of HED); and are at lower risk for alcohol-related sexual assaults and suicidal ideation. Experiences of sexual assault and verbal threats are associated with greater HED occasions for transgender-identified people.

Evidence of Syndemics and Sexuality-Related Discrimination Among Young Sexual-Minority Women

PURPOSE

Syndemics, or the co-occurrence and interaction of health problems, have been examined extensively among young men who have sex with men, but their existence remain unexamined, to our knowledge, among sexual-minority (i.e., lesbian, gay, and bisexual) women. Thus, we investigated if syndemics were present among young sexual-minority women, and if sexual-orientation discrimination was an independent variable of syndemic production.

METHODS

A total of 467 sexual-minority women between the ages of 18 and 24 completed a cross-sectional online survey regarding their substance use, mental health, sexual behaviors, height, weight, and experiences of discrimination. We used structural equation modeling to investigate the presence of syndemics and their relationship to sexual-orientation discrimination.

RESULTS

Heavy episodic drinking, marijuana use, ecstasy use, hallucinogen use, depressive symptoms, multiple sexual partners, and history of sexually transmitted infections (STIs) comprised syndemics in this population (chi-square=24.989, P=.201; comparative fit index [CFI]=0.946; root mean square error of approximation [RMSEA]=0.023). Sexual-orientation discrimination is significantly and positively associated with the latent syndemic variable (unstandardized coefficient=0.095, P<.05), and this model fit the data well (chi-square=33.558, P=.059; CFI=0.914; RMSEA=0.029). The reverse causal model showed syndemics is not an independent variable of sexual-orientation discrimination (unstandardized coefficient=0.602, P>.05).

CONCLUSIONS

Syndemics appear to be present and associated with sexual-orientation discrimination among young sexual-minority women. Interventions aimed at reducing discrimination or increasing healthy coping may help reduce substance use, depressive symptoms, and sexual risk behaviors in this population.

Depression and sexual dysfunction among HIV-positive and HIV-negative men who have sex with men: mediation by use of antidepressants and recreational stimulants

Erectile dysfunction and other forms of sexual dysfunction are highly prevalent among HIV+ men who have sex with men (MSM). Research has not previously identified the mechanisms by which depression may be associated with sexual dysfunction among HIV-positive and HIV-seronegative (HIV-negative) MSM. The present study examined the role of antidepressant use, stimulant use, and smoking as mediators of the relation between depression and sexual dysfunction among HIV-positive and HIV-negative MSM. Participants enrolled in the Multicenter AIDS Cohort Study, an ongoing prospective study of the natural and treated histories of HIV infection among MSM in the United States, completed a modified version of the International Index of Erectile Function for MSM. The study sample included 1,363 participants, with 619 HIV-positive men and 744 HIV-negative men. A structural equation model examined depression as a predictor of subsequent sexual dysfunction, mediated by antidepressant use, stimulant use, and smoking. Depression predicted subsequent sexual function among both HIV-negative and HIV-positive MSM. This effect appeared to be both a direct effect and an indirect effect via antidepressant use. Findings suggest that antidepressant medication use may partially explain sexual dysfunction among MSM.

The cumulative effects of medication use, drug use, and smoking on erectile dysfunction among men who have sex with men

INTRODUCTION

Erectile dysfunction (ED) is highly prevalent among human immunodeficiency virus-seropositive (HIV+) men who have sex with men (MSM). There is a need for additional research to determine the correlates of HIV+ and HIV-seronegative (HIV-) MSM, especially regarding nonantiretroviral medication use.

AIMS

This study examined the prevalence of ED and the sociodemographic, medical conditions, medication use, and substance use correlates of ED among HIV+ and HIV- MSM.

METHODS

A modified version of the International Index of Erectile Function (IIEF) for MSM was self-administered by participants enrolled in the Multicenter AIDS Cohort Study, an ongoing prospective study of the natural and treated histories of HIV infection among MSM in the United States. The study sample included 1,340 participants, including 612 HIV+ and 728 HIV- men. Poisson regression with robust error variance was used to estimate prevalence ratios of ED in multivariable models in combined (HIV+/-) and separate analyses.

MAIN OUTCOME MEASURE

ED was determined by the summed scores of a modified version of the IIEF validated among MSM.

RESULTS

Twenty-one percent of HIV+ MSM and 16% of HIV- MSM reported ED. Being >55 years of age, black race, cumulative pack years of smoking, cumulative antihypertensive use, and cumulative antidepressant use had significant positive associations with the prevalence of ED in the total sample. Among HIV+ men, duration of antihypertensive use and antidepressant use were significantly associated with increasing prevalence of ED. Among HIV- men, being >55 years of age, black race, and cigarette smoking duration were associated with increased prevalence of ED.

CONCLUSION

Predictors of ED may differ by HIV status. Although smoking cessation and effective medication management may be important as possible treatment strategies for ED among all MSM, there may be a burden on sexual functioning produced by non-HIV medications for HIV+ men.

Adolescent experiences of discrimination, harassment, connectedness to community and comfort with sexual orientation reported by adult men who have sex with men as a predictor of adult HIV status

Using data from a probability based sample of adult men who have sex with men (MSM) we examined the association of negative life factors during adolescence and adult HIV status. 521 MSM reported on experiences of connectedness to community, comfort with sexuality, harassment and discrimination due to their sexual orientation at ages 12-18 years. HIV status was determined by serological testing. Overall, men reported moderate levels of being harassed, being discriminated against and high levels of feeling disconnected from gay communities while reporting high levels of being uncomfortable with their sexuality at those ages. However, in analyses of scores on these factors, higher experiences of harassment, higher levels of discrimination and more discomfort with sexuality at these ages are associated with HIV-negative status as adults. This study suggests that the relationship between negative adolescent experiences among MSM and adult HIV infection may not be straightforward, but may also dependent upon aspects of the intensity of the negative experiences, the relationship of the victim and the perpertrator(s), the sexual identity of the victim at the time and/or the number of these experiences or the length of time over which they occurred. Studies investigating specific multiple stressors in adolescent gay development and their effect on adult health outcomes are needed.

Sex while intoxicated: a meta-analysis comparing heterosexual and sexual minority youth

BACKGROUND

The social marginalization and victimization experienced by sexual minority youth (SMY) may lead to increased risk behaviors and higher rates of negative health outcomes compared with their heterosexual peers.

METHODS

We conducted a meta-analysis to examine whether SMY reported higher rates of sex while intoxicated. Studies that report rates of substance use during sex in both SMY and heterosexual youth and had a mean participant age of 18 or less were included in our meta-analysis. Effect sizes were extracted from six studies (nine independent data sets and 24 effect sizes) that met study criteria and had high inter-rater reliability (.98).

RESULTS

Results indicated that SMY were almost twice as likely to report sex while intoxicated as compared with heterosexual peers. A random-effects meta-analysis showed a moderate ([overall weighted effect OR] = 1.91, p < .0001) weighted effect size for the relationship between sexual orientation and the use of drugs at the time of sexual intercourse, with the mean effect size for each study ranging from 1.21 to 3.50 and individual effect sizes ranging from .35 to 9.86.

DISCUSSION

Our findings highlight the need for healthcare providers to screen SMY for participation in substance use during sexual intercourse and to offer risk reduction counseling during office visits.

Home-based antiretroviral care is associated with positive social outcomes in a prospective cohort in Uganda

BACKGROUND

Home-based antiretroviral therapy (ART) care in Africa has expanded; but social outcomes of home-based ART programs are unknown.

METHODS

Social experiences of participants in an antiretroviral therapy program involving weekly home visits in Uganda were assessed through interviews at enrollment and after 3 months and analyzed using generalized estimating equations.

RESULTS

Of 654 participants, 72% were women; median baseline CD4 cell-count was 123 cells/muL. At follow-up, participants were more likely to report community support (adjusted odds ratio [OR] 2.10, 95% confidence interval [CI]: 1.46 to 3.03, P < 0.001), family support (OR 2.65, CI: 2.01 to 3.49, P < 0.001), and relationship strengthening (OR 2.10, CI: 1.46 to 3.03, P = 0.001) than at baseline; 84% attributed these experiences to antiretroviral therapy program participation. There was no change in incidence of negative experiences (P = 0.3). Forty-six percent of women reported a history of partner abuse, but abuse rates 3 months before and after program initiation were low (1% vs. 2%, OR 3.20, CI: 0.94 to 10.9, P = 0.063). Of five women who reported abuse associated with program participation, all had history of domestic violence. Of all participants reporting outcomes associated with antiretroviral therapy program participation at follow-up, 464 (79%) had only positive experiences, 35 (6%) had both positive and negative experiences, and <1% had only negative experiences.

CONCLUSIONS

Participation in a home-based antiretroviral therapy program was associated with multiple positive social outcomes.

A meta-analytic review of HIV behavioral interventions for reducing sexual risk behavior of men who have sex with men

This meta-analysis examines the efficacy of international HIV prevention interventions designed to reduce sexual risk behavior of men who have sex with men (MSM). We performed a comprehensive search of published and unpublished English-language reports of HIV prevention interventions that focus on MSM and evaluated changes in risky sexual behavior or biologic outcomes related to sexual risk. Data from 33 studies described in 65 reports were available as of July 2003. Studies with insufficient data to calculate effect sizes were excluded from the meta-analysis. Interventions were associated with a significant decrease in unprotected anal intercourse (odds ratio [OR] = 0.77, 95% confidence interval [CI]: 0.65-0.92) and number of sexual partners (OR = 0.85, 95% CI: 0.61-0.94) and with a significant increase in condom use during anal intercourse (OR = 1.61, 95% CI: 1.16-2.22). Interventions successful in reducing risky sexual behavior were based on theoretic models, included interpersonal skills training, incorporated several delivery methods, and were delivered over multiple sessions spanning a minimum of 3 weeks. Behavioral interventions provide an efficacious means of HIV prevention for MSM. To the extent that proven HIV prevention interventions for MSM can be successfully replicated in community settings and adapted and tailored to different situations, the effectiveness of current HIV prevention efforts can be increased.

The continuing HIV epidemic among men who have sex with men

OBJECTIVES

This study characterized the AIDS epidemic among urban men who have sex with men (MSM).

METHODS

A probability sample of MSM was obtained in 1997 (n = 2881; 18 years and older) from New York, Los Angeles, Chicago, and San Francisco, and HIV status was determined through self-report and biological measures.

RESULTS

HIV prevalence was 17% (95% confidence interval = 15%, 19%) overall, with extremely high levels in African Americans (29%), MSM who used injection drugs (40%), "ultraheavy" noninjection drug users (32%), and less educated men (< high school, 37%). City-level HIV differences were non-significant once these other factors were controlled for. In comparing the present findings with historical data based on public records and modeling, HIV prevalence appears to have declined as a result of high mortality (69%) and stable, but high, incidence rates (1%-2%).

CONCLUSIONS

Although the findings suggest that HIV prevalence has declined significantly from the mid-1980s, current levels among urban MSM in the United States approximate those of sub-Saharan countries (e.g., 14%-25%) and are extremely high in many population subsegments. Despite years of progress, the AIDS epidemic continues unabated among subsegments of the MSM community.

Correlates of heavy substance use among young gay and bisexual men: The San Francisco Young Men's Health Study

Correlates of heavy substance use among a household-based sample of young gay and bisexual men (n=428) were identified and the odds ratio (OR) was calculated. A total of 13.6% reported frequent, heavy alcohol use and 43% reported polydrug use. Compared with men employed in professional occupations, men in service positions (OR=3.77) and sales positions (OR=2.51) were more likely to be heavy alcohol consumers. Frequent gay bar attendance and multiple sex partners were related to heavy alcohol use, as well as to polydrug use. Polydrug users were more likely to be HIV seropositive (OR=2.05) or of unknown HIV serostatus (OR=2.78). HIV serostatus was similarly related to frequent drug use. These correlates of heavier substance use among young gay and bisexual men could be used to identify and intervene early with members of this population who are at risk of substance misuse, as well as HIV/AIDS risk.

Is offering post-exposure prevention for sexual exposures to HIV related to sexual risk behavior in gay men?

OBJECTIVE

To examine the impact of the availability of postexposure prevention (PEP) for sexual exposures to HIV on sexual risk behavior among gay men.

METHODS

Two cross-sectional samples of 529 gay men in San Francisco (June 1998, January 1999) completed face-to-face street interviews assessing sexual risk behavior and whether they had heard of PEP in general as well as whether they knew that PEP was available in San Francisco. The second sample was collected after a community-wide outreach campaign had been conducted to increase people's knowledge that PEP was available in San Francisco.

RESULTS

Of those who had heard of PEP at Time 1, 24% had recently had unprotected anal intercourse, versus 26% of those who had not heard of PEP. At Time 2, 37% of those who had heard of PEP had recently engaged in unprotected anal intercourse versus 26% of those who had not heard of PEP (chi2, 4.06; P = 0.03). At both time points, however, men who actually knew that PEP was available in San Francisco did not report more risk behavior than men who did not know PEP was available in San Francisco. In addition, only a small percentage at both time points self-reported that PEP had the effect of increasing their sexual risk behavior.

CONCLUSIONS

There is little evidence that the availability of PEP for sexual exposures may be related to increased sexual risk-taking among gay men in San Francisco. The potential impact of PEP on risk behavior must, however, still be considered as part of the larger context of HIV/AIDS treatment optimism and possibly escalating levels of risk behavior among gay men.

Substance use and HIV risk profile of gay/bisexual males who drop out of substance abuse treatment

This analysis was undertaken to identify (a) the level of HIV sexual risk behaviors of men who drop out of treatment and (b) baseline variables associated with later treatment dropout. A cross-sectional sample of 340 gay/bisexual men were recruited from an outpatient substance abuse treatment facility in San Francisco. We compared participants who completed less than 15 visits with participants who graduated from the program. Men who dropped out were more likely than treatment graduates to report injection drug use, social problems related to substance use, self-blaming coping strategies, and more recent substance use prior to entering treatment and less likely to have a college degree, report using sex for tension relief, and have previously attended Alcoholics Anonymous or Narcotics Anonymous. Given the strong link between the substance abuse and HIV epidemics, substance abuse treatment agencies have been forced into addressing the issues of HIV sexual risk taking with their clients. Strategies toward reducing substance use relapse and HIV risk reduction are offered.

Cigarette smoking among gay and bisexual men

OBJECTIVES

This study measured the prevalence of cigarette smoking among gay men and identified associations with smoking.

METHODS

Household-based (n = 696) and bar-based (n = 1897) sampling procedures yielded 2593 gay male participants from Portland, Ore, and Tucson, Ariz, in the spring of 1992.

RESULTS

Forty-eight percent of the combined sample reported current smoking, a rate far above prevalence estimates for men in Arizona (z = 14.11, P < .001) or Oregon (z = 24.24, P < .001). Significant associations with smoking included heavy drinking, frequent gay bar attendance, greater AIDS-related losses, HIV seropositivity, lower health rating than members of same age cohort, lower educational attainment, and lower income.

CONCLUSIONS

Rates of cigarette smoking are very high among gay men. Tobacco prevention and cessation campaigns should be designed to reach the gay male community.

An outcome evaluation to measure changes in sexual risk-taking among gay men undergoing substance use disorder treatment

OBJECTIVE

To evaluate the effects of safe sex intervention at a substance use disorder treatment agency designed to serve gay men.

METHOD

Of all eligible men, 456 (78%) were recruited as they entered treatment for a substance use disorder. This cohort was followed for five waves of data collection, each wave measuring the previous 90 days. Assigned to the experimental condition (treatment for substance use disorder plus a safe sex intervention) were 82 men; 65 were assigned to the regular substance use disorder treatment.

RESULTS

Although levels of risk within each wave were never significantly different between the two treatment groups, reductions in unprotected anal intercourse (UAI) with a nonmonogamous partner for both groups from the baseline Wave-1 levels were uniformly significant (all p's < .05). Such high-risk sex in the year-long follow-up period was correlated with UAI reported at intake, enjoyment of UAI, relative youth, heavier concurrent use of alcohol or amphetamines and greater numbers of sexual partners.

CONCLUSIONS

We conclude that: (1) substantial HIV risk reductions can occur after initiation of treatment for substance use disorder among gay men; (2) risk reductions begin soon after treatment begins; (3) lapses to unsafe sex are common during treatment; (4) continued UAI is most likely among those men who are riskier at intake, who continue to be more sexually active and who are more likely to combine substance use and sexual behavior; (5) AIDS prevention activities conducted at treatment agencies cannot reach all high-risk substance-using gay men.

Gay men report high rates of unprotected anal sex with partners of unknown or discordant HIV status

OBJECTIVE

To examine patterns and factors that correlate with unprotected anal intercourse (UAI) practices among San Francisco gay men, including UAI with partners of unknown or different HIV antibody status.

DESIGN

A longitudinal cohort recruited for the San Francisco Young Men's Health Study in 1992; re-assessed annually.

PARTICIPANTS AND METHODS

A sample of 510 unmarried gay men who were 18 to 29 years at baseline were originally recruited as part of a larger population and referral-based sample. Subjects participated in four consecutive waves of data collection.

RESULTS

The prevalence of reported unprotected anal intercourse (UAI) increased from 37% to 50% between 1993-1994 and 1996-1997. Almost half of all men who reported UAI in 1996-1997 indicated that it occurred with a partner of unknown or discordant HIV antibody status. This high-risk practice correlated with greater numbers of male sex partners, use of nitrite inhalants, sex in commercial sex environments, perceived difficulty controlling sexual risk-taking, and negative emotional reactions following UAI.

CONCLUSIONS

These data on increasing rates of sexual risk-taking further confirm trends in sexual behavior previously suggested by rising rates of rectal gonorrhea in this population. Additional and sustained prevention efforts are urgently needed in light of the very high background rates of HIV infection found among gay men in San Francisco.

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.

Self-reports of alcohol use, drug use and sexual behavior: expanding the Timeline Follow-back technique

OBJECTIVE

The purpose of this study is to compare reports of alcohol use, drug use and sexual behavior from 30-day Summary measures with an expanded version of a Timeline Follow-back (Timeline) interview technique among gay/bisexual men entering outpatient substance abuse treatment at a gay-identified agency.

METHOD

Respondents (N = 418) first completed self-administered questionnaires covering the 30-day period prior to their last use of alcohol or drugs. Summary measures included alcohol use, number of days of use for five categories of drugs and number of episodes of anal intercourse (with and without condoms) by partner type (primary or secondary). Participants then completed the Timeline interview procedure to recall their daily drinking, drug use and sexual behavior during the same 30-day period.

RESULTS

The findings indicate that the Timeline method yielded significantly lower estimates of mean number of drinks consumed when heavier than usual drinking days is included in the Summary measure (124.0 vs 147.0 drinks), mean number of days drugs were used (9.3 vs 10.7) and mean number of episodes of anal intercourse with a primary partner (1.2 vs 2.2). Differences generally remained significant when assessed by length of time between the study interview and last use of alcohol or drugs, with the exception of number of anal sex episodes with primary partners.

CONCLUSIONS

These findings indicate that Timeline estimates are lower than estimates using a more standard method (Summary measures). Discrepancies between these findings and those reported by other researchers indicate a need for further exploration of the effects of the mode of administration on various populations.

Evaluating an AIDS sexual risk reduction program for young adults in public night schools in São Paulo, Brazil

OBJECTIVES

To describe sexual risk for HIV infection among adult night school students in São Paulo, Brazil, and to evaluate the effect of an HIV/AIDS prevention workshop to reduce sexual risk.

SUBJECTS AND METHODS

A longitudinal study was conducted among four demographically similar public night schools in the inner city of São Paulo. Schools were randomized into intervention and control conditions. Of 394 young adults who took part in the baseline survey, 304 (77%) completed a postintervention questionnaire.

INTERVENTIONS

In a workshop consisting of four sessions of 3 h each, the students discussed AIDS symbolism, the impact of AIDS on their lives, risk perception, the way in which sexual norms shape knowledge and attitudes, AIDS-related knowledge, reproduction and sexual pleasure, and condom use negotiation. We fostered community-building through AIDS training courses for teachers in the schools, peer support programs and public events.

RESULTS

At baseline, 87% had been sexually active at some time and 76% had had sex in the past 6 months. Among those who reported vaginal intercourse and/or anal intercourse, condom use was low. The workshops were positively process-evaluated and supported by the community, the students, their teachers and their parents. We obtained statistically significant effects from the workshops for females only, who reported improved communication with partners about sex and AIDS and less unprotected sex with non-monogamous partners after the intervention.

CONCLUSION

These data show that the sexual risk of HIV infection can be lowered when Brazilian disenfranchized communities support AIDS prevention workshops. Even more impressive results may be achieved if the need to address socioeconomic obstacles and gendered sexual roles is emphasized through further long-term community development programs.

HIV risk among Latino gay men in the Southwestern United States

Using two different methods-bar and community household sampling-159 Latino gay men were recruited in the city of Tucson, Arizona. In addition to demographics, the study questionnaire assessed participants' sexual activity during the last 30 days with primary and nonprimary partners, condom use in the last year, and eight psychosocial constructs that have been predictive of HIV risk in different studies of (mostly white) gay/bisexual men. Questionnaires were available only in English; this Latino sample is thus likely to overrepresent highly acculturated, English-speaking men. Results show that 22% of the sample engaged in unprotected anal intercourse with nonmonogamous partners during the last 30 days; 51% of the sample reported at least one instance of unprotected anal intercourse during the last year. Of those men who practiced any anal intercourse during the last 30 days, 67% practiced unprotected anal intercourse with primary partners and 44% practiced unprotected intercourse with casual partners. Thus, the majority of Latino gay men who practiced anal intercourse in the month prior to the interview were not using condoms. Men who practiced unprotected intercourse with nonmonogamous partners reported lower annual incomes and were less educated. Two cognitive variables (behavioral intentions and perceptions of self-efficacy and self-control) and two behavioral variables (sex under the influence of alcohol and/or drugs and sex in public environments) emerged as the most important correlates of HIV risk.

Longitudinal changes in alcohol and drug use among men seen at a gay-specific substance abuse treatment agency

OBJECTIVE

This study describes changes over a 12-month period in prevalence and frequency of alcohol and other drug use and correlates of change at 12 months in a sample of gay/bisexual men entering gay-identified outpatient substance abuse treatment.

METHOD

A sequential sample of gay/bisexual men (n = 455) were recruited for a study in which substance use, sexual risk and psychological factors were assessed every 3 months. Changes in substance use were evaluated in 321 men who used in the 90 days before entering treatment and who completed at least one follow-up interview, whether or not they continued in treatment.

RESULTS

At baseline, 95% of the sample reported alcohol use in the prior 90 days; 64%, marijuana/hashish use; 46%, amphetamine use; 33%, inhalant nitrites use; and 31%, cocaine use. Most men were polydrug users: 10% reported using only one drug (including alcohol); 39% used > or = 4 drugs. A marked reduction occurred in prevalence of use over time; declines on the order of 50% occurred in the first 90 days; prevalence then stabilized in remaining assessments. Frequency of usage by those reporting use of any given class of drugs also declined. No consistent predictors of reduction or cessation of use across different drug categories were found at 1 year.

CONCLUSIONS

Substance use declined considerably in this sample. Given the scope of substance abuse problems among gay/bisexual men, and linkages to the HIV epidemic, considerable resources need to be focused on treatment and prevention for gay/bisexual men.

Condom use among gay/bisexual male substance abusers using the timeline follow-back method

Sexual risk for HIV transmission under the influence of alcohol and/or other drugs is not simply a cause-effect relationship: not everyone who drinks or uses other drugs has unprotected sex. The purpose of this study is to explore differences between substance using gay/bisexual men who use condoms during anal sex from those who do not. These differences are identified by comparing men whose anal sex while under the influence of alcohol and/or drugs is consistently protected to men whose anal sex while under the influence of alcohol and/or drugs is consistently unprotected. Gay/bisexual men entering substance abuse treatment at a gay-identified agency in San Francisco were recruited to complete surveys and to be interviewed about sexual behavior, substance use, and related variables using an extended version of the Timeline Follow-back (TL). The TL procedure uses a blank calendar form and a series of questions to cue recall of drinking, drug use, and anal intercourse on each of the 30 days prior to the last date of alcohol and/or drug use. Men whose anal sex while under the influence of alcohol and/or drugs is consistently unprotected were significantly more likely to report having less than a college education (p = .04), more likely to have an income of less than $20,000 (p = .01), more likely to use amyl nitrite (p = .01) and cocaine (p = .02), and more likely to report a higher frequency of anal sex (p = .007). In addition, they were less likely to approve of sex without love (p = .003), less likely to perceive that safer sex is the community norm (p < .001), and less likely to have encouragement from friends to practice safer sex (p = .001). However, HIV status did not differentiate between the two groups. These two groups provide clear and interesting contrasts in terms of behavior, thus comparisons of the factors influencing sexual safety in these subgroups may enhance our understanding of risk taking. A better understanding of possible mediating variables can be important both in guiding future research in this area and in formulating intervention strategies to target gay men who drink or use drugs in combination with sexual activity.

AIDS risk-taking behavior during carnival in São Paulo, Brazil

OBJECTIVE

The Brazilian Carnival is thought to be a time when the risk of HIV infection is likely to be high. We therefore compared the risk during Carnival to risk in the past month among male samba school participants in São Paulo, Brazil.

SUBJECTS AND METHODS

A cross-sectional study was conducted among 380 male samba school drummers randomly sampled during rehearsal for the 1993 Carnival in São Paulo by means of a 20-min interviewer-administered questionnaire. The main outcome variable was condom use with non-steady partners.

RESULTS

The sexual behavior of 36.1% of subjects risked HIV infection, but only 9.7% of all subjects were at risk only during Carnival. Subjects with a sexual risk of HIV differed from those without risk in substance use, attitudes towards condoms and expectations about Carnival; those who were at risk only during Carnival did not differ from those who were at risk at other times. About half of the subjects had been given free condoms during Carnival, although few of the men at risk had actually used them.

CONCLUSIONS

Though more than a third of the drummers were at risk of HIV infection, only a small per cent were at risk only during Carnival. The level of sexual risk of HIV infection is probably better explained by factors in the men's daily lives, rather than through information on risks taken during Carnival. These results raise questions concerning the efficacy of universal condom distribution during Carnival, since about half of the men were given condoms but few of those at risk actually used them. A targeted distribution of condoms to populations with a high demonstrated risk may be more effective in preventing new HIV infection.

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.

Depressive symptoms and CD4 lymphocyte decline among HIV-infected men

OBJECTIVE

To investigate whether high levels of depressive symptomatology at baseline predict more rapid decline of CD4 lymphocyte counts and progression of clinical disease in persons infected with the human immunodeficiency virus (HIV).

DESIGN

Prospective cohort study with semiannual data collection waves and up to 66 months of follow-up.

SETTING

Population-based probability sample of single men in areas of San Francisco with high case rates of the acquired immunodeficiency syndrome (AIDS).

SUBJECTS

All 330 homosexual or bisexual men who by January 1985 had serological evidence of HIV infection but had not had an AIDS diagnosis. Analysis of CD4 lymphocyte change was performed for 277 subjects (83.9%) who had three or more CD4 lymphocyte counts recorded during the study period January 1985 through July 1990.

OUTCOME MEASURES

Depressive symptoms were assessed using the Center for Epidemiologic Studies-Depression scale (CES-D). All subjects were classified according to two indicators of depression: (1) as overall depressed using a cut point of 16 or higher on the complete CES-D, and (2) as affectively depressed using a cut point of more than 1 SD above the mean on a subscale of the CES-D measuring affective depression. Laboratory and symptom measures, antiretroviral use, demographics, and behavioral measures were also used. The primary outcome measure was the rate of change of the CD4 lymphocyte count. Secondary outcomes were AIDS-free survival and mortality.

RESULTS

At baseline 65 subjects (19.7%) were classified as depressed on the overall scale and 53 (16.1%) were classified as depressed on the affective scale. The unadjusted mean rate of CD4 change was 38% greater for overall depressed subjects than for the overall nondepressed (-0.0812 vs -0.0588 x 10(9)/L [-81.2 vs -58.8/microL per year; P = .07) and 34% greater for affectively depressed subjects than for the affectively nondepressed (-0.0804 vs -0.0598 x 10(9)/L per year; P = .06). In hierarchical multivariate analysis controlling for antiretroviral use, symptoms, and other predictors, baseline overall depression was associated with an excess decline in CD4 count of -0.0285 x 10(9)/L per year (95% confidence interval, -0.0496 to -0.0073), and baseline affective depression was associated with an excess decline in CD4 count of -0.0236 x 10(9)/L per year (95% confidence interval, -0.0464 to -0.0008). Neither overall depression nor affective depression was significantly associated with earlier AIDS diagnosis or earlier mortality.

CONCLUSIONS

Overall depression and affective depression predicted a more rapid decline in CD4 lymphocyte counts; this association was not attributable to baseline physiological differences. While the mechanism of the association remains unknown and cannot be addressed directly by this study, the data suggest that it can be explained neither as simply a reflection of perceived somatic symptoms nor as the result of differences in recreational drug and alcohol use. Further study is necessary to determine whether treating depression can alter the course of HIV infection.