Sampling and Recruitment in Multilevel Studies among Marginalized Urban Populations: The IMPACT Studies

Illicit drug use in urban settings is a major public health problem. A range of individual level factors are known to influence drug use and its consequences, and a number of recent studies have suggested that the neighborhood in which an individual lives may also play a role. However, studies seeking to identify neighborhood-level determinants of drug use, particularly among marginalized urban populations, need to overcome significant challenges, particularly in the area of sampling and recruitment. One key issue is defining functional neighborhoods that are relevant to local residents. Another arises from the need to sample a representative or even a diverse population when studying marginalized groups such as illicit drug users. These are common problems that raise particular challenges when both need to be addressed in the same study. For example, many sampling approaches for neighborhood-level studies have included some form of random sample of households, but this may systematically overlook marginalized populations. On the other hand, the sampling approaches commonly used in studies of hidden populations such as chain referral, snow ball, and more recently, respondent-driven sampling, typically expand beyond a geographic “neighborhood.” We describe the organization and rationale for the IMPACT Studies in New York City as a case illustration on how such issues may be addressed. Ompad, Galea, Fuller, Weiss, Beard, Chan, Edwards, and Vlahov are with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY, USA; Galea is with the Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA; Marshall is with the RAND Corporation, Santa Monica, CA, USA; Fuller and Vlahov are with the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.     

Suicide Tourism in Manhattan,New York City, 1990–2004

Suicide accounts for over 30,000 deaths per year in the United States and is associated with psychiatric illness and substance abuse. Research suggests a strong relationship between method of suicide and the lethal means that are readily available in one’s community of residence. However, certain individuals may also seek the opportunity for suicide outside their proximal environment, often in well-known places. Whereas prevention efforts have been aimed at certain repeatedly used sites for suicide (i.e., Golden Gate Bridge), little research has studied “suicide tourism,” the phenomenon of out of town accompanied by suicide. We collected data on all suicide deaths in New York City (NYC) between 1990 and 2004 from the Office of the Chief Medical Examiner of NYC. We examined trends and correlates of out-of-town residents who committed suicide in NYC. Manhattan accounted for 274 of the 407 nonresident suicides in NYC, which represented over 10% of all suicides committed in Manhattan. The most common methods of suicide for the Manhattan nonresidents were long fall, hanging, overdose, drowning, and firearms; the most common locations included hotels and commercial buildings, followed by outside locations such as bridges, parks, and streets. Nonresident victims tended to be younger, more often white and Asian and less often black and Hispanic than their residential counterparts. An analysis of nonresident suicides in Manhattan revealed that it is a location where individuals travel and take their lives, often by similar means and in similar locations. A comparison with residential suicide implied that a different type of individual is at risk for nonresidential suicide, and further research and prevention efforts should be considered. Gross and Tardiff are with the Department of Psychiatry, Weill Cornell Medical College, Cornell University, New York, NY, USA; Gross is with the Subprogram in Clinical Psychology, The Graduate Center, City University of New York, New York, NY, USA; Markham Piper, Bucciarelli, Vlahov and Galea are with the Center of Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY, USA; Galea is with the Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA; Galea is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA.     

Men, Multiple Sexual Partners, and Young Adults’ Sexual Relationships: Understanding the Role of Gender in the Study of Risk

Heterosexual transmission of HIV and other sexually transmitted infections has become a primary health concern worldwide. Gender roles for heterosexual interactions appear to sanction men’s sexual risk-taking, especially the pursuit of multiple sexual partners. Using measures developed in this study, the current study assessed the associations between men’s and women’s relationship attitudes and experiences and their sexual risk encounters. Participants were 104 men and 103 women (18–24 years) from a large, urban college located in a high HIV risk neighborhood of New York City. All completed a survey assessing HIV risk and the battery of relationship measures assessing traditional sexual roles, sexual conflicts, significance of sex, relationship investment, need for relationship, and unwanted sex. For men, greater sexual conflict in their primary relationships was associated with more sexual partners and fewer unprotected vaginal intercourse encounters with a primary partner and across sex partners overall. In addition, men’s endorsement of more traditional sexual roles and lower relationship investment were associated with higher numbers of sexual partners. Among women, compliance with men to engage in unwanted sex was associated with higher levels of participation in unprotected sex. For both men and women, greater significance given to sex in a relationship was associated with fewer extradyadic partners. This study demonstrates the utility of measures of relationship attitudes and experiences to characterize sexual risk, especially among men. Findings are discussed in terms of implications for prevention program targeting young urban adults.O’Sullivan is with the Department of Family & Social Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Mazer 100, Bronx, NY 10461, USA; O’Sullivan, Hoffman, and Dolezal are with the HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY, USA; Hoffman is with the Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA; Harrison is with the Department of Medicine, Division of Infectious Diseases and Population Studies and Training Center, Brown University, Providence, RI 02912, USA.     

Estimation of HIV Prevalence,Risk Factors,and Testing Frequency among Sexually Active Men Who Have Sex with Men,Aged 18–64 Years—New York City, 2002

Population-based estimates of human immunodeficiency virus (HIV) prevalence and risk behaviors among men who have sex with men (MSM) are valuable for HIV prevention planning but not widely available, especially at the local level. We combined two population-based data sources to estimate prevalence of diagnosed HIV infection, HIV-associated risk-behaviors, and HIV testing patterns among sexually active MSM in New York City (NYC). HIV/AIDS surveillance data were used to determine the number of living males reporting a history of sex with men who had been diagnosed in NYC with HIV infection through 2002 (23% of HIV-infected males did not have HIV transmission risk information available). Sexual behavior data from a cross-sectional telephone survey were used to estimate the number of sexually active MSM in NYC in 2002. Prevalence of diagnosed HIV infection was estimated using the ratio of HIV-infected MSM to sexually active MSM. The estimated base prevalence of diagnosed HIV infection was 8.4% overall (95% confidence interval [CI] = 7.5–9.6). Diagnosed HIV prevalence was highest among MSM who were non-Hispanic black (12.6%, 95% CI = 9.8–17.6), aged 35–44 (12.6%, 95% CI = 10.4–15.9), or 45–54 years (13.1%, 95% CI = 10.2–18.3), and residents of Manhattan (17.7%, 95% CI = 14.5–22.8). Overall, 37% (95% CI = 32–43%) of MSM reported using a condom at last sex, and 34% (95% CI = 28–39%) reported being tested for HIV in the past year. Estimates derived through sensitivity analyses (assigning a range of HIV-infected males with no reported risk information as MSM) yielded higher diagnosed HIV prevalence estimates (11.0–13.2%). Accounting for additional undiagnosed HIV-infected MSM yielded even higher prevalence estimates. The high prevalence of diagnosed HIV among sexually active MSM in NYC is likely due to a combination of high incidence over the course of the epidemic and prolonged survival in the era of highly active antiretroviral therapy. Despite high HIV prevalence in this population, condom use and HIV testing are low. Combining complementary population-based data sources can provide critical HIV-related information to guide prevention efforts. Individual counseling and education interventions should focus on increasing condom use and encouraging safer sex practices among all sexually active MSM, particularly those groups with low levels of condom use and multiple sex partners At the time this work was conducted, Manning and Marx were with the Epidemic Intelligence Service, Office of Workforce and Career Development, Centers for Disease Control and Prevention, Atlanta, GA, USA; Thorpe, Ramaswamy, Hajat, Marx, Karpati, Mostashari, and Pfeiffer are with the New York City Department of Health and Mental Hygiene, New York, NY, USA; Nash is with the Department of Epidemiology and International Center for AIDS Care and Treatment Programs, Columbia Mailman School of Public Health, New York, NY, USA; Manning is with the Massachusetts Department of Public Health, Bureau of Family and Community Health, Boston, MA, USA.     

Integrating HIV Prevention Activities into the HIV Medical Care Setting: A Report from the NYC HIV Centers Consortium

With the maturing of the HIV epidemic and availability of potent antiretroviral therapies in the US, priorities for HIV prevention have shifted from general population approaches to case finding, treatment, risk reduction and relapse prevention activities among those at greatest risk for acquiring or transmitting HIV infection. The challenges of this approach include ensuring access and adherence to HIV care and treatment and appropriate prevention activities to ensure adequate and sustained sexual and drug use risk reduction across diverse populations. Experience with approaches to address these issues, particularly in the context of primary care, has been limited. An agenda for future research and practice includes continued development and evaluation of interventions that can address this next generation of health care issues. Vlahov is with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, USA; Crystal is with the AIDS Research Group, Rutgers the State University of New Jersey, USA; Absalon is with the Center for Infectious Disease Epidemiologic Research, Mailman School of Public Health, Columbia University, USA; Klein and Agins are with the New York State Department of Health, AIDS Institute, USA; Remien is with the HIV Center for Clinical and Behavioral Studies, Columbia University and the NY State Psychiatric Institute, USA. An erratum to this article can be found at     

Associations between Methamphetamine Use and HIV among Men Who Have Sex with Men: A Model for Guiding Public Policy

Among men who have sex with men (MSM) in Los Angeles County, methamphetamine use is associated with high rates of HIV prevalence and sexual risk behaviors. In four separate samples of MSM who differed in the range of their intensity of methamphetamine use, from levels of recreational use to chronic use to those for MSM seeking drug abuse treatment, the association between methamphetamine use and HIV infection increased as the intensity of use increased. The lowest HIV prevalence rate (23%) was observed among MSM contacted through street outreach who mentioned recent methamphetamine use, followed by MSM who used at least once a month for six months (42%), followed by MSM seeking intensive outpatient treatment (61%). The highest rate (86%) was observed among MSM seeking residential treatment for methamphetamine dependence. The interleaving nature of these epidemics calls for comprehensive strategies that address methamphetamine use and concomitant sexual behaviors that increase risk of HIV transmission in this group already at high risk. These and other data suggest that MSM who infrequently use methamphetamine may respond to lower intensity/lower cost prevention and early intervention programs while those who use the drug at dependence levels may benefit from high intensity treatment to achieve goals of reduced drug use and HIV-risk sexual behaviors. Shoptaw is with the Department of Family Medicine, University of California, Los Angeles, CA, USA; Shoptaw and Reback are with the Integrated Substance Abuse Programs (ISAP), Los Angeles, CA, USA; Shoptaw and Reback are with the Friends Research Institute, Inc., Los Angeles, CA, USA; Shoptaw and Reback are with the Center for HIV Identification, Prevention and Treatment Services (CHIPTS), University of California, Los Angeles, CA, USA; Reback is with the Van Ness Recovery House, Los Angeles, CA, USA.     

An Analysis of Respondent Driven Sampling with Injection Drug Users (IDU) in Albania and the Russian Federation

Internet access has caused a global revolution in the way people of all ages and genders interact. Many have turned to the Internet to seek love, companionship, and sex, prompting researchers to move behavioral studies online. The sexual behavior of men who have sex with men (MSM) has been more closely studied than that of any other group online given the abundance of gay-oriented websites and concerns about increasing transmission of HIV and other sexually transmitted infections. Not only does the Internet provide a new medium for the conduct of behavioral research and for participant recruitment into an array of research studies, it has the as yet unrealized potential to reach huge numbers of MSM with innovative harm reduction and prevention messages tailored to individualized needs, interests, and risk behavior. Internet-based research on sexual behavior has many advantages in rapidity of recruitment of diverse samples which include individuals unreachable through conventional methods (i.e., non-gay identified and geographically and socially isolated MSM, etc.). Internet-based research also presents some new methodologic challenges in study design, participant recruitment, survey implementation, and interpretation of results. In addition, there are ethical issues unique to online research including difficulties in verifying informed consent, obstacles to surveying minors, and the ability to assure anonymity. This paper presents a review of Internet-based research on sexual behavior in MSM, a general discussion of the methodologic and ethical challenges of Internet-based research, and recommendations for future interdisciplinary research. Dr. Parsons is with the Center for HIV/AIDS Educational Studies and Training (CHEST), Hunter College and the Graduate Center of the City University of New York, NY; Dr. Tesoriero is with the Office of Program Evaluation and Research, New York State Department of Health AIDS Institute, Menands, NY; Dr. Carballo-Dieguez is with the HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY; Dr. Remien is with the HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY.     

Challenges and Facilitating Factors in Sustaining Community-Based Participatory Research Partnerships: Lessons Learned from the Detroit, New York City and Seattle Urban Research Centers

In order to address the social, physical and economic determinants of urban health, researchers, public health practitioners, and community members have turned to more comprehensive and participatory approaches to research and interventions. One such approach, community-based participatory research (CBPR) in public health, has received considerable attention over the past decade, and numerous publications have described theoretical underpinnings, values, principles and practice. Issues related to the long-term sustainability of partnerships and activities have received limited attention. The purpose of this article is to examine the experiences and lessons learned from three Urban Research Centers (URCs) in Detroit, New York City, and Seattle, which were initially established in 1995 with core support from the Centers for Disease Control and Prevention (CDC). The experience of these Centers after core funding ceased in 2003 provides a case study to identify the challenges and facilitating factors for sustaining partnerships. We examine three broad dimensions of CBPR partnerships that we consider important for sustainability: (1) sustaining relationships and commitments among the partners involved; (2) sustaining the knowledge, capacity and values generated from the partnership; and (3) sustaining funding, staff, programs, policy changes and the partnership itself. We discuss the challenges faced by the URCs in sustaining these dimensions and the strategies used to overcome these challenges. Based on these experiences, we offer recommendations for: strategies that partnerships may find useful in sustaining their CBPR efforts; ways in which a Center mechanism can be useful for promoting sustainability; and considerations for funders of CBPR to increase sustainability. Israel, Lichtenstein, and McGranaghan are with the University of Michigan, School of Public Health, Ann Arbor, MI, USA; Krieger and Ciske are with the Epidemiology, Planning and Evaluation Unit, Public Health—Seattle & King Country, Seattle, WA, USA; Vlahov is with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY, USA; Foley is with the Department of Community and Preventive Medicine, Mt. Sinai Medical School, New York, NY, USA; Fortin is City Research Scientist, New York City Department of Health, New York, NY, USA; Guzman is with the Community Health and Social Services, Inc., Detroit, MI, USA; Palerno is with the Center for Multicultural and Community Affairs, Mount Sinai School of Medicine, New York, NY, USA; Tang is with the Aging and Adult Services Company, Asian Counseling and Referral Services, Seattle, WA, USA. The first three authors are the Principal Investigators of the three Urban Research Centers. The other coauthors from the three Centers are listed in alphabetical order. See the acknowledgements at the end for a list of all of the partner organizations involved.     

Perceptions Towards Condom Use, Sexual Activity, and HIV Disclosure among HIV-Positive African American Men Who Have Sex with Men: Implications for Heterosexual Transmission

Disproportionately high HIV/AIDS rates and frequent non-gay identification (NGI) among African American men who have sex with men or with both men and women (MSM/W) highlight the importance of understanding how HIV-positive African American MSM/W perceive safer sex, experience living with HIV, and decide to disclose their HIV status. Thirty predominately seropositive and non-gay identifying African American MSM/W in Los Angeles participated in three semi-structured focus group interviews, and a constant comparison method was used to analyze responses regarding condom use, sexual activity after an HIV diagnosis, and HIV serostatus disclosure. Condom use themes included its protective role against disease and pregnancy, acceptability concerns pertaining to aesthetic factors and effectiveness, and situational influences such as exchange sex, substance use, and suspicions from female partners. Themes regarding the impact of HIV on sexual activity included rejection, decreased partner seeking, and isolation. Serostatus disclosure themes included disclosure to selective partners and personal responsibility. Comprehensive HIV risk-reduction strategies that build social support networks, condom self-efficacy, communication skills, and a sense of collective responsibility among NGI African American MSM/W while addressing HIV stigma in the African American community as a whole are suggested.Harawa is with the Charles B. Drew University of Medicine and Sciences, University of California, Los Angeles, CA, USA. Williams is with the Semel Institute of Neuroscience & Human Behavior, Suite C8-871C, 760 Westwood Plaza, Los Angeles, CA 90024-1759, USA. Williams and Ramamurthi are with the Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles, CA, USA; Bingham is with the Los Angeles Department of Health Services, HIV Epidemiology Program, Los Angeles, CA, USA.     

HIV-Positive Men Sexually Active with Women: Sexual Behaviors and Sexual Risks

This study examines patterns of sexual behavior, sexual relating, and sexual risk among HIV-positive men sexually active with women. A total of 278 HIV-positive men were interviewed every 6–12 months between 1994 and 2002 and reported considerable variability in sexual behaviors over time. Many were not sexually active at all for months at a time; many continued to have multiple female and at times male partners. Over one-third of the cohort had one or more periods when they had engaged in unprotected sex with a female partner who was HIV-negative or status unknown (unsafe sex). Periods of unsafe sex alternated with periods of safer sex. Contextual factors such as partner relations, housing status, active drug use, and recently exchanging sex showed the strongest association with increased odds of unsafe sex. A number of predictors of unsafe sex among African American men were not significant among the Latino sub-population, suggesting race/ethnic differences in factors contributing to heterosexual transmission. Implications for prevention interventions are discussed.Aidala, Lee, Howard, Caban, Abramson, and Messeri are with the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, 722 W. 168th St, Suite 1119, New York, NY 10032, USA.     

Congruence of Home,Social and Sex Neighborhoods among Men Who Have Sex with Men,NYCM2M Study

Substantial literature demonstrates the influence of the neighborhood environment on health behaviors and outcomes. But limited research examines on how gay and bisexual men experience and exist in various geographic and virtual spaces and how this relates to their sexual behavior. New York City Men 2 Men (NYCM2M) was a cross-sectional study designed to identify neighborhood-level characteristics within the urban environment that influence sexual risk behaviors, substance use, and depression among men who have sex with men (MSM) living in NYC. The sample was recruited using a modified venue-based time-space sampling methodology and through select websites and mobile applications. Whether key neighborhoods of human activity, where a participant resided (termed home), socialized (termed social), or had sex most often (termed sex), were the same or different was evaluated. “Congruence” (or the sameness) of home, social, and most often sex neighborhood was reported by 17 % of men, while 30 % reported that none of their neighborhoods were the same. The largest group of men (39 %) reported that their home and sex neighborhoods were the same but their social neighborhood was different while 10 % reported that their home neighborhood was different than their social and sex neighborhood; 5 % men reported same home and social neighborhoods with a different sex neighborhood. Complete neighborhood incongruence was highest among men who were Black and/or Latino, had lower education and personal income levels, and had greater financial insecurity. In adjusted analysis, serodiscordant condomless anal intercourse and condomless anal intercourse with partners from the Internet or mobile applications were significantly associated with having the same social and sex (but not home) neighborhoods. Understanding the complexity of how different spaces and places relate to the health and sexual behavior of MSM is essential for focusing interventions to best reach various populations of interest.     

A Social Network Profile and HIV Risk Among Men on Methadone: Do Social Networks Matter?

The paper describes structural and HIV-related network characteristics and examines associations between these various social network domains and HIV risk behaviors among a sample of 356 men randomly selected from a methadone maintenance treatment program (MMTP) in New York City. Multiple logistic regression analyses suggest that (1) a higher level of perceived sexual risk among network members, referred to as “alters” in this study, was associated with an increased likelihood of the participant engaging in sexual risk behaviors; (2) participants who indicated that they exchanged encouragement with a higher number of network alters about using condoms were less likely to report engaging in unprotected sex; and (3) participants who indicated that they talked about HIV risks with a higher number of network alters were less likely to engage in unprotected sex in the past 6 months. Collectively, these findings support the notion that networks may influence the adoption of risk reduction strategies in this population. Implications of the findings for HIV prevention network interventions for men in MMTPs are discussed.El-Bassel, Gilbert, Wu, and Chang are with the Social Intervention Group, Columbia University School of Social Work, New York, NY, USA.     

Pilot Survey of Subway and Bus Stop Noise Levels

Excessive noise exposure is a serious global urban health problem, adversely affecting millions of people. One often cited source of urban noise is mass transit, particularly subway systems. As a first step in determining risk within this context, we recently conducted an environmental survey of noise levels of the New York City transit system. Over 90 noise measurements were made using a sound level meter. Average and maximum noise levels were measured on subway platforms, and maximum levels were measured inside subway cars and at several bus stops for comparison purposes. The average noise level measured on the subway platforms was 86 ± 4 dBA (decibel-A weighting). Maximum levels of 106, 112, and 89 dBA were measured on subway platforms, inside subway cars, and at bus stops, respectively. These results indicate that noise levels in subway and bus stop environments have the potential to exceed recommended exposure guidelines from the World Health Organization (WHO) and U.S. Environmental Protection Agency (EPA), given sufficient exposure duration. Risk reduction strategies following the standard hierarchy of control measures should be applied, where feasible, to reduce subway noise exposure.Gershon and Barrera are with the Department of Sociomedical Sciences, Columbia University, Mailman School of Public Health, 600 West 168th Street, 4th Floor, New York, NY 10032, USA; Neitzel is with the Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA 98105, USA; Akram is with the Department of Environmental Health Sciences, Columbia University, Mailman School of Public Health, New York, NY 10032, USA.     

Resistance to HIV Infection

The biological correlates of an effective immune response that could contain or prevent HIV infection remain elusive despite substantial scientific accomplishments in understanding the interactions among the virus, the individual and the community. The observation that some individuals appear to possess resistance to HIV infection or its consequences has generated a host of epidemiologic investigations to identify biological or behavioral characteristics of these individuals. These data might hold the keys to developing appropriate strategies for mimicking the effective responses of those who appear immune. In this paper we review genetic mechanisms including the role of chemokines and their receptors, cytokines, host genetic immune response to HIV infection, local immune response correlating with behavioral variables, co-infection and immune based mechanisms that have been elucidated so far. We offer suggestions for how to use these observations as platforms for future research to further understand natural resistance to HIV infection through cohort studies, population genotype sampling, mathematical modeling of virus–host interactions and behavioral analyses. Marmor, Hertzmark and Thomas are with the Department of Environmental Medicine, New York University School of Medicine, 650 First Avenue, Room 560, New York, NY 10016, USA; Marmor is with the Department of Medicine, New York University School of Medicine, New York, NY, USA; Marmor, Hertzmark, Thomas, and Halkitis are with the The Center for AIDS Research, New York University School of Medicine, New York, NY, USA. Halkitis is with the Department of Applied Psychology, New York University Steinhardt School of Education, New York, NY, USA; Vogler is with the Division of International Medicine and Infectious Diseases, Weill Cornell College of Medicine, New York, NY, USA.     

Unprotected Sexual Behavior Among Heterosexual HIV-Positive Injection Drug Using Men: Associations by Partner Type and Partner Serostatus

Few studies have examined sexual risk behaviors of HIV-positive, heterosexual, injection drug using (IDU) men. We investigated such behaviors and associations with risk among sexually active, HIV-positive IDU men who reported only female sex partners in the 3 months prior to baseline interview. We examined associations separately for four non-exclusive groups of men by crossing partner type (main or casual) and partner serostatus (HIV-positive or HIV-negative/unknown). Of 732 male participants, 469 (64%) were sexually active with only female partners. Of these 469 men, 155 (33%) reported sex with HIV-positive main partners, 127 (27%) with HIV-negative or unknown serostatus main partners, 145 (31%) with HIV-positive casual partners, and 192 (41%) with HIV-negative/unknown serostatus casual partners. Significant multivariate associations for unprotected sex with HIV-negative or unknown serostatus main partners were less self-efficacy to use condoms, weaker partner norms supporting condoms, and more negative condom beliefs. Similar correlates were found for unprotected sex with HIV-positive main and casual partners. In addition, alcohol or drug use during sex was a significant correlate of unprotected sex with HIV-positive main partners, while depression was significant for HIV-positive casual partners. For unprotected sex with HIV-negative/unknown status casual partners, self-efficacy for condom use, sex trade, and education were significant multivariate correlates. A combination of broad and tailored intervention strategies based on the relationship pattern of men's lives may provide the most benefit for reducing unprotected sex with female partners.Purcell and Mizuno are with the Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA; Metsch is with the University of Miami, Miami, FL, USA; Garfein is with the Department of Family and Preventive Medicine, University of California at San Diego, San Diego, CA, USA; Tobin is with the Bloomberg School of Public Health, Baltimore, MD, USA; Knight is with the University of California at San Francisco, San Francisco, CA, USA; Latka is with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY, USA.The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.     

Evaluation of an Intervention to Increase Screening Colonoscopy in an Urban Public Hospital Setting

Only 50% of New Yorkers aged 50 and over reported ever being screened for colorectal cancer by any modality according to a recent household survey. The objective of this investigation was to assess the impact of a hospital-based intervention aimed at eliminating health care system barriers to timely colorectal cancer screening at Lincoln Medical Center, a large, urban public hospital in one of the nation's poorest census tracts. We conducted a retrospective analysis of all colonoscopies performed over an 11-month period, during which a multi-pronged intervention to increase the number of screening colonoscopies took place. Two “patient navigators” were hired during the study period to provide continuity for colonoscopy patients. A Direct Endoscopic Referral System (DERS) was also implemented. Enhancements to the gastrointestinal (GI) suite were also made to improve operational efficiency. Immediately following the introduction of the patient navigators, there was a dramatic and sustained decline in the broken appointment rates for both screening and diagnostic colonoscopy (from 67% in May of 2003 to 5% in June of 2003). The likelihood of keeping the appointment for colonoscopy after the patient navigator intervention increased by nearly 3-fold (relative risk = 2.6, 95% CI 2.2–3.0). The rate of screening colonoscopies increased from 56.8 per month to 119 per month. The screening colonoscopy coverage provided by this facility among persons aged 50 and over in surrounding Zip codes increased from 5.2 to 15.6% (RR 3.0, 95% CI 1.9–4.7). Efforts to increase the number of screening colonoscopies were highly successful, due in large part to the influence of patient navigators, a streamlined referral system, and GI suite enhancements. These findings suggest that there are significant health-care system barriers to colonoscopy that, when addressed, could have a significant impact on screening colonoscopy rates in the general population. Nash is with the Center for Urban Epidemiologic Studies, The New York Academy of Medicine, New York, NY, USA, the Department of Epidemology, International Center for AIDS Care and Treatment Programs, Columbia University, Mailman School of Public Health, New York, NY, USA; Azeez is with the Department of Gastroenterology, Lincoln Medical Center, Bronx, NY, USA; Vlahov is the Director of the Center for Urban Epidemiologic Studies at the New York Academy of Medicine, New York, NY, USA; Schori is with the Office of the Medical Director, Lincoln Medical Center, Bronx, NY, USA. An erratum to this article can be found at     

Individual,Psychosocial, and Social Correlates of Unprotected Anal Intercourse in a New Generation of Young Men Who Have Sex With Men in New York City

Objectives. We examined associations of individual, psychosocial, and social factors with unprotected anal intercourse (UAI) among young men who have sex with men in New York City.Methods. Using baseline assessment data from 592 young men who have sex with men participating in an ongoing prospective cohort study, we conducted multivariable logistic regression analyses to examine the associations between covariates and likelihood of recently engaging in UAI with same-sex partners.Results. Nineteen percent reported recent UAI with a same-sex partner. In multivariable models, being in a current relationship with another man (adjusted odds ratio [AOR] = 4.87), an arrest history (AOR = 2.01), greater residential instability (AOR = 1.75), and unstable housing or homelessness (AOR = 3.10) was associated with recent UAI. Although high levels of gay community affinity and low internalized homophobia were associated with engaging in UAI in bivariate analyses, these associations did not persist in multivariable analyses.Conclusions. Associations of psychosocial and socially produced conditions with UAI among a new generation of young men who have sex with men warrant that HIV prevention programs and policies address structural factors that predispose sexual risk behaviors.Young men who have sex with men (MSM) continue to be at increased risk for the acquisition and transmission of HIV. Nationally, among those aged 13 to 24 years, the estimate of new HIV infections attributed to male-to-male sexual contact increased from 61% in 2006 to 71% in 2009.1 In New York City between 2001 and 2008, 73% of HIV diagnoses among male adolescents and young adults were among young MSM.2 These national and local surveillance data confirm that a third generation of MSM, a generation that did not witness the heightened morbidity and mortality of the early AIDS epidemic, continue to bear a disproportionate burden of HIV/AIDS. In addition to these epidemiological trends, adolescents and young adults are at heightened risk for HIV/AIDS because the periods of adolescence and young adulthood are marked by a higher prevalence of HIV-related risk behaviors such as unprotected sex and illicit drug use.3,4 Moreover, these periods are often characterized by significant transitions and challenges for young MSM, specifically around the formation of sexual identity as well as coming out to family members and peers that may all coalesce to increase vulnerability for HIV.To date, research related to HIV risk among MSM, and more specifically young MSM, has generally focused on understanding the influence of individual-level characteristics on risk-taking behaviors. For example, it is well established that factors such as educational attainment,5 race/ethnicity,6–8 sexual orientation,9 age at sexual onset,8,10 and relationship status11,12 are associated with sexual risk-taking behaviors, such as engaging in unprotected anal intercourse (UAI). In addition, previous research indicates that those with a history of arrest and incarceration are more likely to engage in greater sexual risk behaviors than are those without such a history.13,14More recently, research efforts have moved beyond examining individual-level characteristics by considering both protective and harmful psychosocial states that may either buffer against or exacerbate vulnerabilities that function as drivers of HIV-related sexual risk behaviors.15,16 For instance, experiences of homophobia can often lead to discomfort with one’s sexual identity and may act as a significant psychosocial stressor linked to increased sexual risk taking.17,18 Conversely, young MSM with positive attitudes about homosexuality are less likely to have multiple sex partners and may be less likely to engage in UAI.19 Finally, gay community affiliation may function to either protect against or exacerbate the risk for HIV transmission and acquisition.Exposure and access to gay neighborhoods with norms promoting safer sexual behaviors may lead to safer sexual practices, such as consistent condom use, among MSM20 as well as greater awareness about HIV education and services available to MSM.21 However, higher gay community affinity among a younger generation of MSM may be associated with greater sexual risk taking in the absence of norms promoting safer sexual behaviors.22Increasingly, empirical research has examined the impact of social factors for their association with sexual risk taking among MSM overall.23 For example, several studies have linked poverty and economic disadvantage as socially produced risk factors associated with sexual risk taking among MSM.24,25 These associations may be more pronounced among individuals with higher levels of residential or housing instability or homelessness because they may engage in sex work to secure vital material resources and therefore be at an increased risk for HIV transmission and acquistion.24,26–28 Because of the need to understand the effect of individual, psychosocial, and social factors on HIV risk among young MSM, we sought to characterize how these factors influence sexual risk behaviors, specifically UAI, in a sample of young MSM. These findings have the potential to inform novel HIV/AIDS-related prevention and intervention efforts for this new generation of men.     

A Comparison of the Social and Sexual Networks of Crack-Using and Non-Crack Using African American Men who Have Sex with Men

The role of crack cocaine in accelerating the HIV epidemic among heterosexual populations has been well documented. Little is known about crack use as an HIV risk factor among African American men who have sex with men (AA MSM), a group disproportionately infected with HIV. We sought to compare the social and sexual network characteristics of crack-using and non-crack using AA MSM in Baltimore, MD, USA and to examine associations of crack use with sexual risk. Participants were recruited using street-based and internet-based outreach, printed advertisements, word of mouth. Inclusion criteria were being aged 18 years or older, African American or of black race/ethnicity, and have self-reported sex with another male in the prior 90 days. Crack use was operationalized as self-report of crack in the prior 90 days. Logistic regression was used to identify variables that were independently associated with crack use. Of 230 enrolled AA MSM, 37% (n = 84) reported crack use. The sexual networks of crack-using AA MSM were composed of a greater number of HIV-positive sex partners, exchange partners, and partners who were both sex and drug partners and fewer networks with whom they always use condoms as compared to non-crack using AA MSM. Crack use was independently associated with increased odds of bisexual identity and networks with a greater number of exchange partners, overlap of drug and sex partners, and lesser condom use. Results of this study highlight sexual network characteristics of crack-smoking AA MSM that may promote transmission of HIV. HIV interventions are needed that are tailored to address the social context of crack-smoking AA MSM risk behaviors.     

Finding Sex Partners Through Social Media Among Men Who Have Sex with Men in Hanoi,Vietnam

Many men who have sex with men (MSM) in low and middle income countries search for male sexual partners via social media in part due to societal stigma and discrimination, yet little is known about the sexual risk profiles of MSM social media users. This cross-sectional study investigates the prevalence of social media use to find male sex partners in Hanoi, Vietnam and examines associations between social media use and sociodemographic and behavioral characteristics, including levels of internalized, perceived and enacted stigma, high-risk sexual behaviors, and HIV testing. 205 MSM were recruited from public venues where MSM congregate as well as through snowball sampling and completed an anonymous survey. MSM who found their male sexual partners using social media in the last year were more likely to have completed a university or higher degree (aOR 2.6; 95% CI 1.2–5.7), experience high levels of MSM-related perceived stigma (aOR 3.0; 95% CI 1.1–8.0), and have more than ten lifetime male sexual partners (aOR 3.2; 95% CI 1.3–7.6) compared to those who did not use social media. A niche for social media-based interventions integrating health and stigma-reduction strategies exists in HIV prevention programs for MSM.     

Sexual Risk Behavior In Men Attending Mardi Gras Celebrations In New Orleans,Louisiana

Previous research with travelers points to higher risk behaviors during vacations. Relative to their day-to-day lives, leisure travelers have more free time to pursue sexual activities and are likely to engage in higher rates of substance use than when at home. Risk behaviors during vacation have not been thoroughly examined in men who have sex with men (MSM), a key group at risk for HIV. The present investigation examined substance use, sexual risk behaviors, and components of the Information-Motivation-Behavioral Skills (IMB) Model in MSM attending Mardi Gras celebrations in New Orleans. Almost half of the sexually active men reported having sex with a partner of unknown HIV status while in New Orleans and a similar number did not disclose their own HIV status to all of their sexual partners. Drug use and excessive alcohol use were associated with unprotected sex (ps < .05). Components of the IMB model also predicted sexual risk behavior: individuals with more accurate HIV transmission information reported fewer unprotected sex acts, and motivation to engage in sexual activity on vacation was associated with more unprotected sex (ps < .05). Findings suggest that some MSM on vacation are placing themselves at risk for HIV. Traditional HIV prevention interventions do not readily lend themselves for use with transient populations. New intervention approaches are needed to reduce sexual risk behaviors in persons traveling for leisure.