High HIV Risk but Inadequate Prevention Services for Men in China Who Have Sex with Men: An Ethnographic Study

China is facing an emerging HIV epidemic among men who have sex with men (MSM). However, the HIV risk and prevention needs of these men are not well understood. We conducted in-depth qualitative interviews between August and October 2000 with 38 persons who identified as being MSM or knowledgeable about the MSM population in Beijing. Our ethnographic study identified 20 different segments of the population of MSM in Beijing and 14 distinct types of venues where these men congregate. Despite high levels of sexual risk taking, few men perceived themselves to be at risk for HIV. The main reasons cited for engaging in unsafe sex were economic survival, misconceptions about HIV, inaccurate assessment of a partner's risk, trusting a partner or needing to prove a partner trustworthy, meeting an attractive partner, and cruising in public sex environments. The HIV prevention services currently available in Beijing include mass media education, hotline information and counseling services, venue-based outreach, hospital-based services, and Internet sites, but few of these programs specifically targeted the MSM population. The major barriers to utilizing exiting services were lack of perceived risk, lack of privacy and anonymity, uninteresting program content, and distrust and questionable credibility of providers. Programs need to address issues broader than AIDS, be peer-designed and peer-led, be entertaining, and receive more government support. Our data suggest that many MSM are at high risk for HIV, but receive inadequate services. More effective and sustainable programs must be developed and implemented to prevent the further spread of HIV in this population.     

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.     

Substance Abuse Treatment as HIV Prevention for Men Who Have Sex with Men

Substance abuse is a prominent risk behavior associated with HIV transmission, particularly for men who have sex with men (MSM) and who engage in sex while using substances. This paper argues that substance abuse treatment has significant value as an HIV-prevention method to the extent that treatment outcome influences sexual risk behaviors for MSM, presumably toward lower risk. We review studies of treatment and HIV risk behaviors for MSM, and describe the current status of effective substance abuse treatments. Clinical issues important to MSM receiving treatment are discussed: gay-specific versus mainstream treatment, gay sexuality issues in substance abuse treatment, gay Alcoholics Anonymous, and ethnicity issues. Based on these arguments, we make the following policy recommendations: (1) develop treatment strategies that target substance use and high-risk sexual behavior simultaneously, (2) recognize treatment as HIV prevention in this population, and (3) educate counselors on cultural and sexual risk issues specific to substance-abusing MSM.     

Sexual Risk Profile of Young Men in Vancouver, British Columbia, Who Have Sex with Men and Inject Drugs

We compared sexual risk behaviors of men who have sex with men and inject drugs (MSM/IDU) with those of other men who have sex with men (MSM). Of 910 MSM surveyed, 106 (12%) injected drugs in the previous year. MSM/IDU were younger than MSM and more likely to be HIV-seropositive, Aboriginal, economically disadvantaged, engaged in the trade of sex for money or drugs, and to report having female sexual partners. MSM/IDU reported more casual sexual partners and in multivariate analyses were twice as likely to report unprotected receptive anal intercourse with casual partners. These results, combined with those from previous analyses, suggest that the higher risk for HIV seroconversion among MSM/IDU in this cohort is attributable mainly to sexual rather than injection-related exposures. Controlled assessments are needed to identify optimal sexual risk reduction strategies for MSM/IDU.     

Exchange Sex and HIV Infection Among Men Who Have Sex with Men: 20 US Cities, 2011

This study assessed the prevalence of exchanging sex for money or drugs among men who have sex with men (MSM) in the 2011 US National HIV Behavioral Surveillance system. Prevalence of HIV, being HIV-positive but unaware (HIV-positive–unaware), risk behaviors and use of services were compared between MSM who did and did not receive money or drugs from one or more casual male partners in exchange for oral or anal sex in the past 12 months. Among 8411 MSM, 7.0 % exchanged sex. MSM who exchanged sex were more likely to be non-Hispanic black, live in poverty, have injected drugs, have multiple condomless anal sex partners, be HIV-positive and be HIV-positive–unaware. In multivariable analysis, exchange sex was associated with being HIV-positive–unaware (aPR 1.34, 95 % CI 1.05–1.69) after adjusting for race/ethnicity, age, education, poverty, and injecting drugs. MSM who exchange sex represent an important group to reach with HIV prevention, testing, and care services as they were more likely to report behavioral risk factors that put them at risk of HIV.     

Alcohol Use and Risk of HIV infection among Men Who Have Sex with Men

In the United States, men who have sex with men (MSM) currently represent more than 50% of those living with HIV and over 70% of HIV+ men (CDC 2007, ). Male-to-male sexual contact has been identified as the predominant route of transmission among this sub-group, which underscores the need for research that targets risk factors associated with risky sex-related HIV acquisition. Along these lines, research has shown that one potentially important predictor variable for risky sex among MSM is alcohol use. The major aim of this paper is to review and integrate empirical evidence on the association of alcohol use and risky sex among MSM. A summary of the quantitative research is provided first, followed by a critique of the reviewed literature, a discussion of the consistency of the existing empirical evidence with predictions of current theories, and finally, recommendations for future research designed to evaluate alcohol-related sexual risk in MSM.     

Differences in Risk Behavior and Sources of AIDS Information Among Gay, Bisexual, and Straight-Identified Men Who Have Sex with Men

At public sex environments in four U.S. cities, 1,369 men who have sex with men (MSM) were asked about sexual self-identification, recent HIV risk behaviors, and exposures to HIV information. Half of respondents (n = 687) self-identified as gay, 40% (n = 546) as bisexual, and 10% (n = 136) as straight. Ninety-nine percent of both gay and bisexual MSM and 96% of straight MSM reported oral sex with men; 94%, 68%, and 46%, respectively, reported anal sex with men, while 62%, 98%, and 97%, respectively, reported vaginal sex with women. Recent exposure to any HIV information was reported by 96%, 91%, and 89% respectively of gay, bisexual, and straight MSM; gay MSM were most likely to get HIV information from talking with someone. However, television was the only medium to reach more than half of gay, bisexual, and straight MSM. Non-gay-identified MSM and their partners are at high risk for HIV transmission, but more study is needed to identify the most effective channels for conveying risk reduction messages to this population.     

Peer Social Support is Associated with Recent HIV Testing Among Young Black Men Who Have Sex with Men

Resiliency factors such as social support have been associated with more frequent HIV testing among MSM. We examined the association between social support and delayed HIV testing in the context of structural discrimination and individual factors among young Black MSM. We combined two independent cross-sectional samples recruited 1 year apart from a venue-based, modified time-location sampling study of young Black MSM aged 18–29 years in the US South. Our subsample (N = 813) was men who self-reported not being HIV positive and who indicated they had one or more male sex partners in the past 2 months. Using a social epidemiology framework we estimated associations of structural (racism and homophobia), social (social support from other Black MSM friends) and individual factors with delayed HIV testing (>6 months ago) using logistic regression. Bivariate analyses demonstrated that individual level variables as well as experiences of racism (OR 1.20, 95% CI 1.02–1.41) and homophobia (OR 1.49, 95 % CI 1.02–2.17) were associated with higher risk of delayed HIV testing. Receiving social support from other Black MSM friends was associated with lower risk of delayed HIV testing (OR 0.80, 95 % CI 0.67–0.95). In multivariable models, social support remained significantly associated with lower risk of delayed HIV testing after inclusion of structural and individual level variables. Social support has a positive and robust association with HIV testing among young Black MSM. Whether community building and development of resiliency factors can overcome structural, social, and individual-level barriers to HIV prevention and care for young Black MSM warrants further study.     

Intertwining Epidemics: A Review of Research on Substance Use Among Men Who Have Sex with Men and Its Connection to the AIDS Epidemic

This paper reviews the (1) literature on substance use among men who have sex with men (MSM), (2) data that test whether connections between substance use and abuse and high-risk sexual behavior exist among MSM, and (3) ways that HIV interventions might address the effects of substance use on high-risk sexual behavior. We conclude that while alcohol use patterns are not substantially different between gay and heterosexual men, gay men do use more kinds of other drugs. Although there is considerable evidence to support the view that substance use patterns have declined among gay men since the mid-1980s, substance use should still be regarded as a health risk in this population. Although the associations between substance use and sexual risk-taking for HIV are complex, the inclusion of interventions to disentangle substance use and high-risk sexual practices may increase the efficacy of AIDS prevention efforts among gay men.     

Having Supportive Social Relationships is Associated with Reduced Risk of Unrecognized HIV Infection Among Black and Latino Men who Have Sex with Men

We examined the hypothesis that black and Latino men who have sex with men (MSM) who have supportive social relationships with other people are less likely to have unrecognized HIV infection compared with MSM of color who report lower levels of social support. We interviewed 1286 black and Latino MSM without known HIV infection in three metropolitan areas who were recruited using respondent driven sampling. Participants completed a computer-administered questionnaire and were tested for HIV. Unrecognized HIV infection was found in 118 men (9.2%). MSM who scored higher on the supportive relationship index had significantly lower odds of testing HIV-positive in the study. The mediation analysis identified two possible behavioral pathways that may partially explain this association: men who had strong supportive relationships were more likely to have had a test for HIV infection in the past 2 years and less likely to have recently engaged in high-risk sexual behavior. The findings illuminate the protective role of social relationships among MSM of color in our sample.     

Perceptions of Lifetime Risk and Actual Risk for Acquiring HIV Among Young Men Who Have Sex with Men

Among young men who have sex with men (MSM) surveyed in six US cities, we evaluated the magnitude and correlates of perceived lifetime risk for acquiring HIV, and missed opportunities to increase risk perception by providers of health-care and HIV-testing services. Overall, approximately one quarter of young MSM perceived themselves at moderate/high risk for acquiring HIV. Adjusting for demographic, prior testing, and behavioral characteristics, moderate/high perceived risk had the strongest association with unrecognized HIV infection. However, half of the 267 young MSM with unrecognized infection perceived themselves at low lifetime risk for acquiring HIV, and many young MSM with low-risk perception reported considerable risk behaviors. Providers of health-care and HIV-testing services missed opportunities to assess risks and recommend testing for young MSM. To increase HIV testing, prevention providers should intensify efforts to assess, and to increase when needed, perceptions of lifetime risks for acquiring HIV among young MSM.     

HIV Prevalence and Correlates of Unprotected Anal Intercourse Among Men Who Have Sex with Men, Jinan, China

China’s HIV epidemic may be shifting towards predominantly sexual transmission and emerging data point to potential increases in HIV prevalence among men who have sex with men (MSM). There is particular need to assess the extent of risk behavior among MSM outside of China’s most cosmopolitan cities. We conducted a respondent-driven sampling survey (N = 428) to measure HIV seroprevalence and risk behavior among MSM in Jinan, China, the provincial capital of Shandong. HIV prevalence was 0.5% (95% confidence interval [CI] 0.1–1.0). Unprotected anal intercourse (UAI) in the last 6 months (reported by 61.4%) was associated with buying or selling sex to a man in the last 6 months, syphilis infection, multiple partners in the last month, low HIV knowledge and migrant status. No participant had previously tested for HIV. Risk for HIV transmission is widespread among MSM throughout China; basic prevention programs are urgently needed.     

Psychosocial,Behavioral, and Cultural Predictors of Sexual Risk for HIV Infection Among Latino Men Who Have Sex with Men

This study sought to replicate and extend an investigation by Diaz et al. (1999) on determinants of HIV risk among Latino gay and bisexual men living in San Francisco who were predominantly English-speaking. Compared to the Diaz et al. study, the current study sample consisted of predominantly Spanish-speaking MSM, who resided outside of HIV/AIDS epicenters and whose countries of origin were primarily Central & South American. The relationships of unprotected anal sex and multiple sexual partners with demographic, developmental, behavioral, cultural and psychosocial variables were examined. Data were collected in a convenience sample of 250 participants (primarily immigrants from El Salvador) residing in Virginia. Most men in the sample had more than one sexual partner in the last 3 months (62%) and more than a third had unprotected anal sex with a casual partner in the same time period. Communication about HIV, sexual attraction, machismo, and experiences of discrimination based on homosexual behavior were predictive of HIV risk behaviors. The findings support an integrative approach to investigating HIV risk among Latino MSM. Implications for prevention programs are discussed.     

具有同性性接触的男性调查

目的 了解有同性性接触男性的与可能传播艾滋病、性病有关的性行为。方法 采用自拟的问卷对35例有同性性接触男性进行调查。结果 所有被访者中口交发生率94.3％,肛交68.6％,吻肛28.6％;他们中71.4％有异性性接触。结论 口交和肛交在他们的性接触中占重要位置,应加强防病意识教育。     

Risk Behaviors and Psychosocial Stressors in the New York City House Ball Community: A Comparison of Men and Transgender Women Who Have Sex with Men

The New York City House Ball community consists of social networks of racial/ethnic minority gay, lesbian or bisexual men and women, and transgender persons. HIV seroprevalence and interview data were obtained from a sample of community members to identify statistical differences in HIV prevalence, risk behavior, and psychosocial stressors between men who have sex with men (MSM) and transgender women. Of 301 MSM and 60 transgender women, 20% were HIV-infected and 73% were unaware of their infection, but rates did not differ by gender. Risk behavior and stressors were common in both groups, but transgender women were more likely to report exchange sex, stigmatization, and stressful life events. High rates of risk behavior and HIV in this special community warrant relevant HIV testing and prevention services. Transgender women in the community may be at even greater risk for HIV infection due to behaviors compounded by substantial psychosocial stressors.     

The Role of the Primary Romantic Relationship in HIV Care Engagement Outcomes Among Young HIV-Positive Black Men Who Have Sex with Men

The primary romantic relationship plays a fundamental role in health maintenance, but little is known about its role in HIV care engagement among young Black men who have sex with men (MSM) living with HIV. We examined how HIV care engagement outcomes (i.e., having a primary healthcare provider, receiving HIV treatment, taking antiretroviral medication, and medication adherence) vary by partnership status (single vs. concordant-positive vs. discordant) in a sample of young Black MSM living with HIV. Results showed mixed findings. Partnership status was significantly associated with HIV care engagement, even after adjusting for individual, social, and structural factors. While partnered men were consistently more likely than their single counterparts to have a regular healthcare provider, to receive recent treatment, and to have ever taken antiretroviral medication, they were less likely to report currently receiving antiretroviral therapy. Moreover, men with a discordant partner reported better adherence compared to men with a concordant or no partner. The association between partnership status and HIV care engagement outcomes was not consistent across the stages of the HIV Care Continuum, highlighting the complexity in how and why young Black men living with HIV engage in HIV healthcare. Given the social context of HIV disease management, more research is needed to explicate underlying mechanisms involved in HIV care and treatment that differ by relational factors for young Black MSM living with HIV.     

Changes in Stimulant Drug Use Over Time in the MACS: Evidence for Resilience Against Stimulant Drug Use Among Men Who Have Sex with Men

Stimulant drug use is associated with numerous health problems among men who have sex with men (MSM). This paper describes how stimulant drug use changes over a four and one-half year period from 2003 until 2008. Participants were 2,389 men (17,222 person-visits) from The Multicenter AIDS Cohort Study (MACS)—an ongoing, prospective study of HIV infection among MSM. Group-based trajectory analyses of data from these men over the study period yielded a four groups solution: consistent users (9.8%), men whose use increased (5.4%), men whose use declined (6.9%), and abstinent or rarely-using men (77.9%). There were significant differences between groups in terms of demographic, behavioral risk and HIV serostatus. Men who increased or decreased stimulant drug use over time reported congruent changes in sexual risk taking. The fact that sexual risk levels parallel stimulant drug use over time suggests that finding ways to lower rates of stimulant drug use among MSM could be a tool in HIV prevention.     

Associations Between Drug and Alcohol Use Patterns and Sexual Risk in a Sample of African American Men Who Have Sex with Men

Men who have sex with men (MSM) are the largest risk group in the US HIV epidemic and African American MSM (AA MSM) are disproportionately affected. Substance-abusing sexual minorities warrant attention as they are at elevated risk for HIV, yet are not a homogeneous risk group. The purpose of this study was to use latent class analysis to identify patterns of drug and alcohol use in a sample of 359 AA MSM and examine associations with sexual risk. Three classes were identified: Individuals who used multiple substances (poly-users) (18 %), alcohol/marijuana users (33 %) and individuals who had low probability of reporting drug or problematic alcohol use (50 %). Results from multivariate analysis indicate that poly-users were older and more likely to report sex exchange and recent sexually transmitted infection compared to the other classes. Alcohol and poly-users were more likely to report sex under the influence. Identifying and defining substance use patterns can improve specification of risk groups and allocation of prevention resources.     

HIV Testing and Preventive Services Accessibility Among Men Who Have Sex With Men at High Risk of HIV Infection in Beijing,China

The HIV epidemic among men who have sex with men (MSM) has been increasing at an alarming rate in most areas of China in recent years. Many Chinese MSM still lack sufficient access to HIV prevention services, despite ongoing scale-up of comprehensive HIV testing and intervention services. The purpose of this study was to investigate utilization of HIV testing and prevention services, and related factors that influence the MSM people to access HIV test or other services to prevent HIV among MSM in Beijing, China.Three successive cross-sectional surveys of MSM were conducted in Beijing from September 2009 to January 2010, September 2010 to January 2011, and September 2011 to January 2012. Demographic and behavioral data were collected and analyzed. Blood samples were tested for HIV and syphilis. Three models were established to analyze factors associated with HIV testing and preventive services.Of the 1312 participants, prevalence of HIV and syphilis was 7.9% and 15.4%, respectively. Sixty-nine percent ever had an HIV test, 56.2%, 78.7%, and 46.1% received HIV test, free condom/lubricants, and sexually transmitted infection services in the past 12 months (P12M), respectively. MSM with larger social networks and who knew someone infected with HIV were more likely to receive HIV testing and preventive services; lower degrees of stigma and discriminatory attitudes toward HIV/AIDS were positively associated with having an HIV test, whereas unprotected anal intercourse in the past 6 months (P6M) was associated with less preventive services participation. The most reported barriers to HIV testing were fear of testing HIV positive (79.3%) and perceiving no risk for HIV (75.4%). Almost all participants felt that ensuring confidentiality would encourage more MSM to have an HIV test. The two main reasons for not seeking HIV test was not knowing where to go for a test (63.2%) and perceiving low risk of HIV infection (55.1%).Given a high prevalence of HIV, syphilis, and risky behaviors and a relatively low HIV testing rate among MSM in Beijing, more efforts are urgently needed to address barriers to HIV testing and improve accessibility of prevention services.     

HIV Prevention Altruism and Sexual Risk Behavior in HIV-Positive Men Who Have Sex with Men

An understanding of men's motivations to avoid risk behavior is needed to create efficacious HIV prevention programs for HIV-positive men who have sex with men (MSM). This study investigates the relationship between sexual risk behavior and HIV prevention altruism, which is defined as the values, motivations, and practices of caretaking towards one's sexual partners to prevent the transmission of HIV. In a sample of 637 HIV-positive MSM, HIV prevention altruism significantly protects against serodiscordant unprotected anal intercourse (SDUAI) in crude analysis, but not after adjustment for drug use and compulsive sexual behavior. HIV prevention altruism is also related to not engaging in anal intercourse, but is not related to serodisclosure to secondary partners. Lack of altruism appears related to sexual risk behavior in HIV-positive MSM, although other psychological and contextual factors play significant roles. The promotion of HIV prevention altruism may provide a formidable new direction for HIV prevention programs.