Ambivalent tales of HIV disclosure in San Francisco

In light of rising levels of unprotected anal intercourse (UAI) among men who have sex with men (MSM) in San Francisco, we sought to understand disclosure practices, the calculus of risk and attitudes about HIV seroconversion. In 2000, 150 MSM participated in interviews pivoting around a detailed narrative of a recent incident of UAI. In order to understand the relationship between individual and community norms, we analyzed the narratives as accounts situated within the respondents' experience of the HIV epidemic and the gay community in San Francisco. In justifying their risky sexual practices, MSM cited a community-wide shift toward non-disclosure and barebacking since the advent of highly active anti-retroviral therapy (HAART). Fearing rejection by HIV-positive partners who refuse to use condoms, HIV-negative men saw little advantage in disclosing to casual partners whom they perceived as overwhelmingly HIV-positive. By contrast, HIV-positive men appeared eager to disclose their positive status to release themselves from responsibility for transmission and facilitate "bareback" or unprotected sex. Disavowal of individual responsibility for safer sex in deference to community norms may contribute to the recent spiraling of risk behavior and HIV incidence. Implications for prevention policy are discussed.     

Private funders fall short in HIV prevention, study says

A study conducted by the Center for AIDS Prevention Studies at the University of California, San Francisco concluded that private funders are reluctant to support needle-exchange or condom distribution programs. The study found strong funding support for public policy, outreach, and community mobilization, but major gaps remain in terms of harm reduction programs. Most grants were found to be targeted toward the general populations, rather than at-risk groups such as gay men, ethnic minorities, or drug users.     

High-risk sexual behavior and condom use among gay and bisexual African-American men.

OBJECTIVES. Little is known about the human immunodeficiency virus (HIV) high-risk sexual practices of gay and bisexual African-American men. These data are needed so that better interventions can be developed and implemented in this population. METHODS. The frequency and correlates of unprotected anal intercourse were examined among 250 gay and bisexual African-American men in the San Francisco Bay Area. The cohort was recruited in 1990 from bars, bathhouses, and erotic bookstores, and through African-American gay organizations, street outreach, advertisements in gay mainstream and African-American newspapers, health clinics, and personal referral from other participants. RESULTS. More than 50% of the men in our sample reported having unprotected anal intercourse in the past 6 months, a considerably higher percentage than that among gay White men in San Francisco through 1988 and 1989. Men who practiced unprotected anal intercourse were more likely to be poor, to have been paid for sex, or to have used injection drugs; to have a higher perceived risk of HIV infection; and to report less social support for concerns about risky sexual behavior. Condom norms, condom efficacy, and negative expectations about using condoms predicted these men's failure to use them. CONCLUSION. In the second decade of the acquired immunodeficiency syndrome epidemic, risk reduction programs are still needed for gay and bisexual African-American men.     

New HIV treatments appear to encourage riskier sex

Researchers at the University of California, San Francisco believe that recent advances in the treatment of HIV disease may be giving gay men a false sense of security that in turn prompts them to stop practicing safe sex. Twenty-six percent of gay men participating in this survey reported that they were less concerned about becoming infected because of the successful new treatment options. These findings suggest that scientific advances are impacting sexual decision-making in the gay community.     

Gender-specific Correlates of Sex Trade among Homeless and Marginally Housed Individuals in San Francisco

Objective: Sex exchange is a well-established risk factor for HIV infection. Little is known about how correlates of sex trade differ by biologic sex and whether length of homelessness is associated with sex trade. We conducted a cross-sectional study among a sample of 1,148 homeless and marginally housed individuals in San Francisco to assess correlates of exchanging sex for money or drugs. Key independent variables included length of homelessness; use of crack, heroin or methamphetamine; HIV status; and sexual orientation. Analyses were restricted by biologic sex. In total, 39% of women and 30% of men reported a lifetime history of sex exchange. Methamphetamine use and greater length of homelessness were positively associated with a history of sex trade among women, while heroin use, recent mental health treatment, and homosexual or bisexual orientation were significantly associated with sex trade for men. Crack use was correlated with sex trade for both genders. Correlates of sex trade differ significantly according to biologic sex, and these differences should be considered in the design of effective HIV prevention programs. Our findings highlight the critical need to develop long-term services to improve housing status for homeless women, mental health services for homeless men, and drug treatment services for homeless adults involved in sex work.Weiser, Dilworth, and Neilands are with the Center for AIDS Prevention Studies, University of California, San Francisco (UCSF), San Francisco, CA, USA. Cohen, Bangsberg, and Riley are with Epidemiology and Prevention Interventions (EPI) Center, Division of Infectious Diseases, San Francisco General Hospital, UCSF; Bangsberg is with the Positive Health Program, San Francisco General Hospital, UCSF.The Epidemiology and Prevention Interventions Center, Positive Health Program and Center for AIDS Prevention Studies are programs of the UCSF AIDS Research Institute.     

An operational research approach to estimating the age distribution of residence time in an HIV/AIDS core group

An operational research approach is used to estimate the age distribution of residence time in an HIV/AIDS core group of gay men, employing only good public health data for administration, planning and decision-making. Any HIV/AIDS modelling involving a high-activity high-risk core group must allow for a restricted but variable residence time in the group. An earlier steady-state approximation by Bailey assumed an arrival process with negligible departures, followed by a departure process with negligible arrivals. That conjecture naturally overestimated the average residence time. An improved model, using age-dependent public health data on AIDS for some 4129 cases in gay men in San Francisco, has now been reanalysed to present the distribution of age at a fixed point of time close to the peak of the underlying HIV epidemic. It is important to note that these data, at any rate, have no appreciable age-dependence in the observed incubation periods. We have adopted the underlying infection dynamics of Jacquez et al. that recognizes an initial concentrated period of high infectivity in all HIV positives leading to a well-marked primary HIV epidemic. Maximum-likelihood estimation has been used to identify five major parameters with small standard errors. The residence model as a whole gives a good fit to the reanalysed data with chi(2)(4)=2.83.     

Attitudes toward online HIV/sexually-transmitted infection prevention programs and Internet user profiles among men who have sex with men

Objectives

To describe the attitudes of men who have sex with men (MSM) toward online HIV/sexually-transmitted infection (STI) prevention programs and to identify and characterize user profiles with regard to their attitudes toward online prevention programs.

Method

A survey in gay venues or via the internet was completed by 2,044 participants from Madrid, Barcelona, Bilbao and San Sebastián (Spain). The survey explored socio-demographic variables, sexual behavior and other risk behaviors associated with HIV infection, as well as attitudes toward online prevention programs. The statistical analysis included factor analysis and non-hierarchical cluster analysis.

Results

Most MSM had positive attitudes towards online HIV/STI prevention programs. Factor analysis revealed two factors: online prevention aimed at interaction and online prevention aimed at information. Based on these factors, three user profiles were identified: users oriented toward informative and interactive online prevention (53.5%), users oriented toward interactive online prevention (25.9%) and users were not oriented toward online prevention (20.7%). On characterizing these profiles, we observed a significant presence of men who were not interested in online prevention among those with a lower educational level, bisexual men and HIV-positive men. Conversely, those most receptive to online prevention were men self-identified as gay, those with a bachelors degree, those who had been tested for HIV and those who were HIV-negative.

Conclusion

The internet can facilitate sexual health promotion among MSM. Characterization of user profiles offers the possibility of segmenting prevention programs and of combining online and offline strategies.     

Minorities and AIDS

A common misconception is held among many ethnic minoritiesin San Francisco that AIDS is exclusively a ‘gay whitemale disease’. This myth is false, but dangerous. To assistethnic minorities in understanding their risks for AIDS, successfuleducational programs for these populations must recognize thediversity within these communities, including their differingcultures, languages and religious backgrounds. San Franciscohas adopted a model that utilizes well-established and well-respectedcommunity-based organizations to provide the education and riskreduction programs. Utilizing these organizations allows foreducation of diverse populations that is culturally and linguisticallyrelevant, thus allowing San Francisco an opportunity to preventthe national minority AIDS statistics from occurring withinits boundaries.     

AIDS and Adolescents: School Health Education Must Begin Now

Teenagers must be educated about AIDS. Because thousands of teenagers are at risk because of their behaviors, target groups for special programs should include those who are drug users, gay and bisexual, homeless, or into solicitation and prostitution. Educational material should be developed that includes a culturally sensitive approach for minority teenagers. Certain areas with high prevalence rates of AIDS need special attention because they pose greater risks for teenagers, such as Houston, Los Angeles, Miami, New York City, northern New Jersey, San Francisco, and Washington, DC. Studies show that most teenagers are misinformed or lack of basic knowledge about transmitting or protecting against AIDS. Education should be aimed at countering this misinformation and reducing the panic about the disease. Teenagers need this health-related information for sharing with their siblings and parents as well as for learning for themselves. Most existing school-based education programs are inadequate because few exist, most are only for junior and senior high levels, and may do not focus on prevention information. Ideally, AIDS education should be integrated into existing health or sexuality education programs. The programs should emphasize information on how AIDS is transmitted, how AIDS is not transmitted, and how to protect oneself from HIV.     

Our lives: An examination of sexual health issues using photovoice by non‐gay identified African American men who have sex with men

African American men who have sex with men and who do not identify as gay are at high risk for HIV infection. This paper presents the results of the photovoice component, a participatory action research method, of a two‐tiered qualitative study design that explored the perceptions of non‐gay identified African American men who have sex with men living or working in the San Francisco Bay Area regarding the social, cultural, community, and family influences associated with their HIV risk and their general sexual health. Major themes that emerged from the photographs and discussions fell into three main categories: (1) The importance of a black identity, (2) factors inhibiting HIV prevention, and (3) factors that maintain health or promote health. Through their photographs, the men in this study explored the challenges and difficulties associated with maintaining their sexual health, in addition to describing the health promoting factors that reinforce wise choices in their everyday lives.     

Rapid HIV testing among racial/ethnic minority men at gay pride events--nine U.S. cities, 2004-2006

In the United States, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) disproportionately affect men from racial/ethnic minority groups. Approximately half of the HIV/AIDS cases among non-Hispanic black and Hispanic males reported by 33 states using name-based HIV surveillance during 2001-2005 were among men who have sex with men (MSM). Each year, approximately 100 gay pride events are held in cities across the United States to celebrate diversity, demonstrate solidarity of the gay community, and heighten awareness of topics of importance to the gay community. These events are attended by several hundred to several hundred thousand MSM. Certain gay pride events are focused on celebrating solidarity in the minority gay community and are attended primarily by MSM from racial/ethnic minority groups. These events offer an opportunity for community-based organizations (CBOs) and health departments to provide HIV-prevention education and outreach. In 2004, CBOs and health departments, with technical assistance from CDC, began conducting rapid behavioral assessments at gay pride events and at minority gay pride events. This report describes the results of assessments and rapid HIV testing conducted at 11 events in nine U.S. cities during 2004-2006; most of these events were attended primarily by MSM from racial/ethnic minority groups. A total of 543 attendees who participated in the assessments reported at the time of the event that they had not had HIV infection diagnosed previously. Of these, 133 (24%) were tested for HIV during the event, and eight (6%) of those tested during the event had a positive rapid test result. All eight were subsequently confirmed to be HIV positive by Western blot testing. Testing at gay pride events provides an opportunity to identify new HIV infections among MSM outside of health-care settings, particularly those from racial/ethnic minority groups.     

Assessing the feasibility of harm reduction services for MSM: the late night breakfast buffet study

Background  

Despite the leveling off in new HIV infections among men who have sex with men (MSM) in San Francisco, new evidence suggests that many recent HIV infections are linked with the use of Methamphetamine (MA). Among anonymous HIV testers in San Francisco, HIV incidence among MA users was 6.3% compared to 2.1% among non-MA users. Of particular concern for prevention programs are frequent users and HIV positive men who use MA. These MSM pose a particular challenge to HIV prevention efforts due to the need to reach them during very late night hours.     

Safer sex maintenance and reduction of unsafe sex among homosexually active men: a new therapeutic approach

To date, publicly funded HIV/AIDS prevention efforts for homosexually active men have largely been limited to two traditional public health strategies: mass media information campaigns and HIV testing/contact notification programs. Health educators using either of these strategies have addressed the spread of HIV as they would many other infectious diseases and have relied heavily upon fear tactics or moral arguments to 'sell' the concept of safer sex. Grass-roots gay community efforts to prevent HIV transmission have also largely relied upon these two strategies, as well as upon more informal individual and group counseling activities. In general, however, strategies used by the gay community have tried to present more positive approaches to AIDS prevention, including eroticizing safer sex practices. This article reviews the efficacy of traditional public health approaches as well as the educational models underlying them, and argues that a major shift in focus is needed. A comprehensive health care and sexuality education model for homosexually active men based on the 'PLISSIST' sex therapy model is described and advocated. This model is presented as a more useful one for identifying populations at risk, reducing unsafe sexual behavior and promoting safer sex maintenance. The model identifies five sub-populations among homosexually active men and recommends specialized interventions appropriate to each. Adequate funding for the services included in this model is also advocated.     

Health officials refuse to lift bathhouse ban

An effort to persuade the city Health Commission to reopen gay bathhouses in San Francisco has failed. A group of AIDS activists led by Michael Petrelis also failed to obtain enough signatures to have the issue placed on the November ballot. The Health Commission said that only the public health director, Dr. Mitch Katz, and not the Commission, had the authority to make that decision. Katz is adamantly opposed to reopening the bathhouses. San Francisco currently allows sex clubs to operate; those clubs allow participants to gather in common rooms and they must adhere to safer-sex practices. Bathhouses allow sexual activity to take place in private rooms where activity cannot be monitored, which, Katz says, contributes to the spread of HIV.     

AIDS and sexual behavior reported by gay men in San Francisco.

In November 1983, we surveyed 655 gay men in San Francisco regarding their sexual practices during the previous month and the same month one year ago. The sample was selected to include men in situations that would lead to high risk of sexual activities related to AIDS (acquired immune deficiency syndrome) transmission (i.e., men frequenting bathhouses and gay bars) as well as men in low-risk situations (those going to neither place and men in primary relationships). The Bath group showed little change in frequency of bathhouse use and in number of sexual partners from that location. The other groups showed substantial reductions in frequency of sexual contacts from bars, baths, T-rooms, or parks. Men in monogamous relationships showed little change in sexual behavior within their relationship. Men in non-monogamous relationships and men not in relationships reported substantial reductions in high-risk sexual activity, but not a corresponding increase in low-risk sexual behavior. Knowledge of health guidelines was quite high, but this knowledge had no relation to sexual behavior. Using sex to release tension, use of sex to express gay identity, and knowledge of persons with AIDS in the advanced stages of disease were related to frequency and type of sexual behavior.     

HIV prevalence and risk behaviors among men who have sex with men and inject drugs in San Francisco

The dual risks of male-to-male sex and drug injection have put men who have sex with men and inject drugs (MSM-IDU) at the forefront of the HIV epidemic, with the highest rates of infection among any risk group in the United States. This study analyzes data collected from 357 MSM-IDU in San Francisco between 1998 and 2002 to examine how risk behaviors differ by HIV serostatus and self-identified sexual orientation and to assess medical and social service utilization among HIV-positive MSM-IDU. Twenty-eight percent of the sample tested HIV antibody positive. There was little difference in risk behaviors between HIV-negative and HIV-positive MSM-IDU. Thirty percent of HIV-positive MSM-IDU reported distributive syringe sharing, compared to 40% of HIV negatives. Among MSM-IDU who reported anal intercourse in past 6 months, 70% of positives and 66% of HIV negatives reported unprotected anal intercourse. HIV status varied greatly by self-identified sexual orientation: 46% among gay, 24% among bisexual, and 14% among heterosexual MSM-IDU. Heterosexual MSM-IDU were more likely than other MSM-IDU to be homeless and to trade sex for money or drugs. Gay MSM-IDU were more likely to have anal intercourse. Bisexual MSM-IDU were as likely as heterosexual MSM-IDU to have sex with women and as likely as gay-identified MSM-IDU to have anal intercourse. Among MSM-IDU who were HIV positive, 15% were currently on antiretroviral therapy and 18% were currently in drug treatment, and 87% reported using a syringe exchange program in the past 6 months. These findings have implications for the development of HIV interventions that target the diverse MSM-IDU population.     

"It's one of the better drugs to use": perceptions of cocaine use among gay and bisexual Asian American men

Research on drug use among gay and bisexual men has primarily focused on examining the link between drug use- most notably, methamphetamine-sexual practices, and risk of HIV transmission. Drawing on in-depth qualitative data from 40 interviews with gay and bisexual Asian American men, we examine perceptions and meanings associated with cocaine use in the San Francisco Bay Area gay community. We found that the participants, in contrast to their negative perceptions of methamphetamine use, believed that cocaine enhanced sociability and was acceptable for use in most social situations. Furthermore, participants perceived little connection between cocaine use and risky sexual practices, emphasizing the drug's safety relative to other illicit substances. Based on these findings, we suggest that an increase in the favorability of cocaine use might be an unintended consequence of methamphetamine prevention campaigns targeting the gay community, with their emphasis on the harmful effects of drug use, unsafe sex, and HIV risk.     

HIV seroprevalence and risk behaviors among lesbians and bisexual women in San Francisco and Berkeley, California.

Few data are available on human immunodeficiency virus (HIV) infection and risk behaviors among lesbians and bisexual women. A total of 498 lesbians and bisexual women was sampled from public venues in San Francisco and Berkeley, Calif, during 1993. The overall HIV seroprevalence was 1.2%. Ten percent of participants reported injecting drugs since 1978. Forty percent of the participants reported unprotected vaginal or anal sex with men during the past 3 years, including unprotected sex with gay and bisexual men and male injection drug users. The high rates of injection drug use and unsafe sexual behaviors suggest that lesbians and bisexual women frequenting public venues in San Francisco and Berkeley are at risk for HIV infection.     

The Social/Sexual Environment of Gay Men Residing in a Rural Frontier State: Implications for the Development of HIV Prevention Programs

CONTEXT: The incidence and prevalence of HIV/AIDS is increasing among rural men who have sex with men (MSM). Yet little is known about the social/ sexual environment of rural frontier areas. PURPOSE: The purpose of this study was to assess the social/sexual environment of gay men living in rural areas and how this environment contributes to the development of HIV/AIDS prevention programs. METHODS: A qualitative study was conducted in Wyoming. In-depth guided interviews were conducted with 39 self-identified gay men. Data were analyzed for emergent themes using constant comparative analysis. FINDINGS: Four broadly related themes emerged. Participants perceive that they live in a hostile social environment in which the potential for becoming a target of violence is present. In order to cope with this social reality, men adopt strategies to assimilate into the predominant heterosexual culture and to look for sex partners. These, in turn, are related to their attitudes about HIV/AIDS and prevention activities. Notably, the Internet was discussed by participants as a means for men to connect to a larger gay society and look for sex partners and as a potential venue to HIV/AIDS prevention programs. CONCLUSIONS: Data provided a number of implications for developing HIV/AIDS prevention programs targeting rural MSM. Especially apparent was the need for programs to be mindful of the desire to keep one's sexual preferences shielded from public knowledge and the effect this may have on recruiting rural MSM to participate in prevention activities. The Internet, because men can access it privately, might provide a venue for prevention projects.     

HIV infection in homosexual and bisexual men 18 to 29 years of age: the San Francisco Young Men's Health Study.

OBJECTIVES. Recent studies suggest very high human immunodeficiency virus (HIV) infection rates in some populations of younger homosexual men, but these studies may represent only particularly high-risk populations. The current study obtained population-based data on the HIV epidemic in young homosexual/bisexual men. METHODS. A household survey of unmarried men 18 through 29 years of age involved a multistage probability sample of addresses in San Francisco. A follow-up interview and HIV test for men who were HIV negative at baseline were completed; the median follow-up was 8.9 months. RESULTS. Sixty-eight of 380 homosexual/bisexual men (17.9%) tested HIV seropositive. Sixty-three percent of men reported one or more receptive anal intercourse partners in the previous 12 months, and 41% of those men did not use condoms consistently. The HIV seroincidence rate among those seronegative at first study was 2.6% per year. CONCLUSIONS. HIV infection rates in young homosexual men in San Francisco are lower than those in the early 1980s; however, the rate of infection in these men, most of whom became sexually active after awareness of AIDS had become widespread, threatens to continue the epidemic in the younger generation at a level not far below that of a decade ago.