Gay men's estimates of the likelihood of HIV transmission in sexual behaviours

In 3 studies we recorded gay men's estimates of the likelihood that HIV would be transmitted in various sexual behaviours. In Study 1 (data collected 1993, n=92), the men were found to believe that transmissibility is very much greater than it actually is; that insertive unprotected anal intercourse (UAI) by an HIV-infected partner is made safer by withdrawal before ejaculation, and very much safer by withdrawal before either ejaculation or pre-ejaculation; that UAI is very much safer when an infected partner is receptive rather than insertive; that insertive oral sex by an infected partner is much less risky than even the safest variant of UAI; that HIV is less transmissible very early after infection than later on; and that risk accumulates over repeated acts of UAI less than it actually does. In Study 2 (data collected 1997/8, n=200), it was found that younger and older uninfected men generally gave similar estimates of transmissibility, but that infected men gave somewhat lower estimates than uninfected men; and that estimates were unaffected by asking the men to imagine that they themselves, rather than a hypothetical other gay man, were engaging in the behaviours. Comparison of the 1993 and 1997/8 results suggested that there had been some effect of an educational campaign warning of the dangers of withdrawal; however, there had been no effect either of a campaign warning of the dangers of receptive UAI by an infected partner, or of publicity given to the greater transmissibility of HIV shortly after infection. In Study 3 (data collected 1999, n=59), men induced into a positive mood were found to give lower estimates of transmissibility than either men induced into a neutral mood or men induced into a negative mood. It is argued that the results reveal the important contribution made to gay men's transmissibility estimates by cognitive strategies (such as the 'availability heuristic' and 'anchoring and adjustment') known to be general characteristics of human information-processing. Implications of the findings for AIDS education are discussed.     

Evaluation of interventions for gay men: two desiderata

This paper was presented in a session at the AIDS Impact conference devoted to a debate on the methods that should be used to evaluate educational interventions. The paper highlights two desiderata for evaluation of interventions directed at gay men. First, the view is presented that there is no acceptable substitute for assessing the effect of an intervention on gay men's sexual behaviour (rather than, for example, their AIDS-related attitudes or beliefs). This view is justified in terms of (a) the differences that exist between AIDS-related thinking in the cold light of day and during actual sexual encounters; and (b) the often faulty nature of intuitions about the factors that contribute to sexual risk-taking and the ways in which it might be reduced. Second, it is argued that the randomized control study design represents the best means for ensuring that interventions will be as effective as possible. Criticisms which have been made of this design are discussed and the conclusion drawn that they do not amount to a strong case against it.     

AIDS education for gay men: towards a more cognitive approach

An approach to AIDS education is presented that focuses on the thinking processes which accompany gay men's decisions to engage in high-risk sex. It is proposed that: (1) at the time they are deciding to have high-risk sex, gay men generally engage in an 'internal dialogue' that justifies this decision to themselves; (2) the AIDS-related thinking underpinning such self-justifications can differ appreciably from the AIDS-related thinking that takes place outside the sexual context; and (3) AIDS education can profitably exploit this difference between 'heat of the moment' and 'cold light of day' thinking. Evidence supporting these proposals is drawn from studies in which gay men who had engaged in unprotected anal intercourse recalled the occasion concerned in detail, including any self-justifications they had used; and from controlled intervention studies, in which gay men who had engaged in unprotected anal intercourse were confronted with the thinking they had employed in the heat of the moment.     

Situational factors and thought processes associated with unprotected intercourse in young gay men.

OBJECTIVES: To investigate (1) the types of justifications, if any, that young gay men give themselves at the time they make the decision to have unprotected anal intercourse and (2) the types of occasion on which they are most at risk of having unprotected intercourse. DESIGN AND METHODS: In structured interviews, gay men aged 15-21 years were asked to recall two sexual encounters from the preceding 6 months: one in which they had had unprotected anal intercourse ('unsafe' encounter) and one in which they had resisted a strong temptation to have unprotected intercourse ('safe' encounter). We studied both types of encounter to enable identification of situational variables distinguishing between them. RESULTS: The first two factors that emerged from a Factor Analysis of the self-justification data ('unsafe' encounter, n = 219) involved, respectively, high-risk behaviour in response to a negative mood state and inferring from perceptible characteristics that the partner was unlikely to be infected. The most commonly reported self-justification was of this latter type. In respondents recalling both encounters (n = 115), sexual desires, mood, communication, and use of 'dirty talk' distinguished between the encounters. In contrast, type of partner, consumption of alcohol or drugs, desire for excitement, and use of pornography did not. CONCLUSIONS: Results are discussed in relation to those obtained in our earlier study of older gay men. Young gay men appear to be more single-minded about what they want to do sexually, and more likely to infer from perceptible characteristics that their partner is unlikely to be infected. In young gay men, a negative mood state is associated with unsafe sex, an opposite finding to that obtained with older gay men. The results also suggest the possible importance of failure to communicate about desires concerning safe sex and the use of 'dirty talk'; these may help to facilitate the occurrence of unsafe sex.     

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

OBJECTIVE: To examine patterns and factors that correlate with unprotected anal intercourse (UAI) practices among San Francisco gay men, including UAI with partners of unknown or different HIV antibody status. DESIGN: A longitudinal cohort recruited for the San Francisco Young Men's Health Study in 1992; re-assessed annually. Participants and methods: A sample of 510 unmarried gay men who were 18 to 29 years at baseline were originally recruited as part of a larger population and referral-based sample. Subjects participated in four consecutive waves of data collection. RESULTS: The prevalence of reported unprotected anal intercourse (UAI) increased from 37% to 50% between 1993-1994 and 1996-1997. Almost half of all men who reported UAI in 1996-1997 indicated that it occurred with a partner of unknown or discordant HIV antibody status. This high-risk practice correlated with greater numbers of male sex partners, use of nitrite inhalants, sex in commercial sex environments, perceived difficulty controlling sexual risk-taking, and negative emotional reactions following UAI. CONCLUSIONS: These data on increasing rates of sexual risk-taking further confirm trends in sexual behavior previously suggested by rising rates of rectal gonorrhea in this population. Additional and sustained prevention efforts are urgently needed in light of the very high background rates of HIV infection found among gay men in San Francisco.     

Unrealistic optimism about becoming infected with HIV: different causes in different populations

People tend to believe that their chance of experiencing undesirable events is lower and their chance of experiencing desirable events is higher than that of the average person like them. Two explanatory models of such 'unrealistic optimism' (UO) have been proposed: While the motivational account holds that UO serves the function of bringing comfort, the cognitive account holds that UO serves no particular function, being simply a by-product of normal cognitive strategies. UO for HIV infection was studied in samples of uninfected students (Study 1, n = 68) and gay men (Study 2, n = 63). In each case, participants rated either their relative likelihood of becoming infected (negative valence condition) or their relative likelihood of remaining uninfected (positive valence condition). As predicted, in Study 1 UO was greater where valence was negative and in Study 2 valence had no effect. The findings suggest that the students' UO is better explained by the motivational account, while the gay men's UO is better explained by the cognitive account. Implications for AIDS education are discussed.     

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.     

Context matters: the educational potential of gay bars revisited.

Gay bars have been frequently identified as suitable environments in which to conduct HIV prevention activities among homosexually active men. In theory, they provide easy access to a relatively diverse group of men. However, gay bars are environments in which the primary purpose is a social one. Gay men use them to take time out, to socialize, and, on occasions, to find new sexual partners. They are also settings in which social reputations often have to be managed. This study examined the HIV/AIDS educational potential of four gay bars in London, Britain. Semistructured observations and interviews took place in four contrasting bars with a focus on men's perceptions of HIV/AIDS-related health promotion activities including condom promotion, the use of posters and small media, and understandings of safer sex. Respondents were ambivalent about AIDS-related health education activities being undertaken. The implications of such responses for the development of HIV primary prevention activities in such settings are discussed.     

Self-Esteem in HIV-Positive and HIV-Negative Gay and Bisexual Men: Implications for Risk-Taking Behaviors with Casual Sex Partners

Research suggests that self-esteem in gay and bisexual men may be linked with sexual risk-taking behaviors. As part of a larger investigation into the sexual practices of gay and bisexual men, we assessed serostatus, self-esteem, condom use, and HIV disclosure to sexual partners. Among HIV-negative men, no relationships were found between their self-esteem and tendency to discuss their and their partners’ HIV status. However, among HIV-positive men, there was a positive relationship between self-esteem and disclosure to receptive and insertive anal sex partners. These results suggest greater attention to the self-esteem of HIV-positive men by attending healthcare workers and social support groups.     

Social Support and Mood in Gay Caregivers of Men with AIDS

The objectives of the study were to compare different aspects of social support between caregiving partners of men with AIDS and partners of healthy men and to examine the association of social support with positive and negative mood. Data were collected in a longitudinal study of 244 gay male caregivers and 61 comparison gay male noncaregivers. Measures included perceived positive support; social conflict; sought support; amount, types, and sources of received support; relationships with family; and positive and negative mood. Cross-sectional analyses and changes between baseline and 2 years were examined. No significant differences were found between the caregivers and noncaregivers in most aspects of social support. Regression analyses showed (a) caregiver status was associated with positive and negative mood (caregivers reported lower positive mood and higher negative mood) at baseline, but not at 2 years; (b) perceived support was the only variable significantly associated with positive mood at baseline and at 2 years; and (c) social conflict (at both times) and perceived support, amount of received support, and having a family confidant (at one of the time periods) were associated with negative mood. The findings support the importance of distinguishing between perceptual and behavioral aspects of social support and their relation to both positive and negative mood.     

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

OBJECTIVE: To examine the impact of the availability of postexposure prevention (PEP) for sexual exposures to HIV on sexual risk behavior among gay men. METHODS: Two cross-sectional samples of 529 gay men in San Francisco (June 1998, January 1999) completed face-to-face street interviews assessing sexual risk behavior and whether they had heard of PEP in general as well as whether they knew that PEP was available in San Francisco. The second sample was collected after a community-wide outreach campaign had been conducted to increase people's knowledge that PEP was available in San Francisco. RESULTS: Of those who had heard of PEP at Time 1, 24% had recently had unprotected anal intercourse, versus 26% of those who had not heard of PEP. At Time 2, 37% of those who had heard of PEP had recently engaged in unprotected anal intercourse versus 26% of those who had not heard of PEP (chi2, 4.06; P = 0.03). At both time points, however, men who actually knew that PEP was available in San Francisco did not report more risk behavior than men who did not know PEP was available in San Francisco. In addition, only a small percentage at both time points self-reported that PEP had the effect of increasing their sexual risk behavior. CONCLUSIONS: There is little evidence that the availability of PEP for sexual exposures may be related to increased sexual risk-taking among gay men in San Francisco. The potential impact of PEP on risk behavior must, however, still be considered as part of the larger context of HIV/AIDS treatment optimism and possibly escalating levels of risk behavior among gay men.     

Factors associated with sexual problems in HIV-positive gay men

Our objective was to determine factors associated with sexual problems in a sample of HIV-seropositive gay male clinic patients. Using a cross-sectional survey design a volunteer sample of 78 outpatient HIV-seropositive gay male service users completed a self-report questionnaire. This examined sexual problems, their perceived causes and associated factors including demographics, health status, sexual behaviour, self-justifications for sexual risk-taking and mood state (Hospital Anxiety and Depression Scale). Fifty (69%) of 78 HIV-positive gay men reported one or more sexual problems. Erectile dysfunction (ED) was reported by 38% rising to 51% in the context of trying to use condoms. Loss of interest in sex was reported by 41% and 24% experienced delayed ejaculation. The presence of sexual problems affected condom use in that 33 (90%) of the 37 gay men who had ED associated with condom use were inconsistent condom users in insertive sex compared to 28% of those not having this type of ED (P < 0.001). The presence of ED did not reduce the frequency of anal intercourse but those with ED associated with condoms were significantly more likely to have had receptive anal sex in the past three months (62%) compared to men without ED with condoms (38%) (P = 0.05). Risk cognitions such as wanting to lose oneself in sex, leaving responsibility for condom use to the active partner and perceptions that condoms interfere with pleasure were significantly more likely to be endorsed by those who report ED with condoms. Other factors associated with sexual problems included low T-cell counts (i.e. < 200). Psychological explanations were the most frequently cited causes of sexual problems, whether alone or in interaction with HIV disease itself, and combination therapy. A high incidence of sexual problems was found amongst this sample of HIV-positive gay men. Untreated sexual dysfunctions may contribute to sexual risk-taking and therefore HIV clinics need to address both issues. Further research is required to better understand the role of psychological factors, HIV disease itself and combination therapy in the incidence and treatment of sexual problems.     

Community attitudes towards sexual activity and childbearing by HIV-positive people in South Africa

While the ability to lead a healthy sexual life and to choose whether and when to have children are well-established features of reproductive health and human rights, issues surrounding sexual activity and childbearing among HIV-infected women and men have received little attention in sub-Saharan Africa. We conducted a semi-structured, cross-sectional survey at 26 primary health care clinics in South Africa to investigate community attitudes towards sexual activity and reproduction by HIV-infected individuals. Of the 843 women interviewed, slightly less than half (43%, n = 361) thought that people living with HIV/AIDS should remain sexually active if they choose, while 13% (n = 113) said they thought that people living with HIV/AIDS should have children if they wished to do so. In multivariate analysis, negative attitudes towards both sexuality and childbearing were persistently associated with not knowing someone infected with HIV (p = 0.001 and 0.043, respectively). These findings suggest that the sexual and reproductive health rights of HIV-infected women and men may be an important target as part of efforts to reduce HIV/AIDS-related stigma. Health policies and services are required to reinforce the reproductive rights of HIV-infected individuals in South Africa and other countries in sub-Saharan Africa where HIV is most prevalent.     

Gay men, social support and HIV disease: a study of social integration in the gay community

As part of a large study of the effects of HIV and AIDS on gay male sexual behaviour, we investigated the extent to which gay men in the UK have access to social support and informal care at times of illness. The study sample (n = 502) demonstrated high levels of willingness to disclose sexuality to others, sociability and social integration. Over 90% reported that they had access to people whom they could turn for practical help at times of temporary incapacity. Between 42% and 46% have known a person, or persons, with HIV symptomatic disease, AIDS or someone who has died of AIDS, although men recruited in larger towns and cities were more likely to know people at every stage of HIV infection and AIDS than those from smaller towns. Twenty-five per cent had provided practical help and support to at least one person with AIDS; men in this situation were more likely to have had a close friend, lover or former lover who had died of AIDS. It is argued that it is not possible to expect the gay community to provide fully for the non-medical care of its members and, whilst some needs can be fulfilled on an informal care basis, the demands of long-term serious illness are such that adequate support services should be available in the community.     

Stigmatization and discrimination towards people living with or affected by HIV/AIDS by the general public in Malaysia

Globally, HIV/AIDS-related stigma and discriminatory attitudes deter the effectiveness of HIV prevention and care programs. This study investigated the general public's perceptions about HIV/AIDS-related stigma and discrimination towards people living with or affected by HIV/AIDS in order to understand the root of HIV/AIDS-related stigma and discriminatory attitudes. Study was carried out using qualitative focus group discussions (FGD). An interview guide with semi-structured questions was used. Participants were members of the public in Malaysia. Purposive sampling was adopted for recruitment of participants. A total 14 focus group discussions (n = 74) was carried out between March and July 2008. HIV/AIDS-related stigma and discrimination towards people living with HIV/AIDS (PLWHA) was profound. Key factors affecting discriminatory attitudes included high-risk taking behavior, individuals related to stigmatized identities, sources of HIV infection, stage of the disease, and relationship with an infected person. Other factors that influence attitudes toward PLWHA include ethnicity and urban-rural locality. Malay participants were less likely than other ethnic groups to perceive no stigmatization if their spouses were HIV positive. HIV/AIDS-related stigma and discrimination were stronger among participants in rural settings. The differences indicate attitudes toward PLWHA are influenced by cultural differences.     

Patterns and Correlates of Sexual Activity and Condom Use Behavior in Persons 50-Plus Years of Age Living with HIV/AIDS

This study characterized rates of sexual activity and identified psychosocial and behavioral correlates of sexual activity and condom use in a metropolitan sample of 290 HIV-infected adults 50-plus years of age. Thirty-eight percent of participants were sexually active in the past three months, 33% of whom had at least one occasion of anal or vaginal intercourse that was not condom protected. Rates and correlates of sexual activity and condom use differed between gay/bisexual men, heterosexual men, and heterosexual women. In the past three months, 72% of heterosexual men were sexually active compared to only 36% of gay/bisexual men and 21% of heterosexual women. However, among sexually active persons, only 27% of heterosexual men reported inconsistent condom use compared to 37% of gay/bisexual men and 35% of heterosexual women. As the number of older adults living with HIV/AIDS in the U.S. continues to increase, age-appropriate secondary risk-reduction interventions are urgently needed.     

From Networks to Populations: The Development and Application of Respondent-Driven Sampling Among IDUs and Latino Gay Men

One of the challenges in studying HIV-risk behaviors among gay men is gathering information from a non-biased sample, as traditional probability sampling methods cannot be applied in gay populations. Respondent-Driven Sampling (RDS) has been proposed as a reliable and bias-free method to recruit “hidden” populations, such as gay men. The aim of this study is to assess the feasibility and effectiveness of RDS to sample Latino gay men and transgender persons. This was carried out when we used RDS to recruit participants into a study that investigated community involvement on HIV/AIDS sexual risk behaviors among Latino gay and bisexual men, and transgender (male-to-female) persons in Chicago and San Francisco. The population coverage of RDS was then compared to simulated time-location sampling (TLS). Recruitment differences were observed across cities, but the samples were comparable. RDS showed broader population coverage than TLS, especially among individuals at high risk for HIV.     

Gender differences in behavioural and psychosocial predictors of HIV testing and return for test results in a high-risk population

We assessed gender differences in psychosocial and behavioural predictors of HIV testing and returning for results in a high-risk sample of 1,049 predominately minority, impoverished, homeless and/or drug-abusing women (n = 621) and men (n = 428). Predictors included latent variables representing injection drug use, self-esteem, social support, AIDS knowledge, poor access to health services, perceived risk for AIDS, sexual risk behaviour and the mediators of positive and negative coping styles. Significant predictors of test and return for women included injection drug use, greater social support, more AIDS knowledge, a higher perceived risk for AIDS and a positive coping style. Significant predictors for the men included injection drug use, greater AIDS knowledge, a higher perceived risk for AIDS and a positive coping style. Although greater social support was not significant for the men, the significant predictors of HIV testing and return were generally similar for the men and women. However, the men evaluated their risk of AIDS significantly lower than the women, although they reported more sexual risk behaviours and equally risky injection drug use behaviours. Results suggest that interventions designed to increase AIDS knowledge, to raise the perception of risk and to promote a positive coping style would be effective in encouraging more HIV testing for both men and women, but raising perceptions of what constitutes personal risk behaviours may need special emphasis when delivering prevention programmes to men.     

Gay-related Development, Early Abuse and Adult Health Outcomes Among Gay Males

This study examined relationships between timing of gay-related developmental milestones, early abuse, and emergence of poor health outcomes in adulthood among 1,383 gay/bisexual men in the Urban Men’s Health Study. Latent Profile Analysis grouped participants as developing early, middle or late based on the achievement of four phenomena including age of first awareness of same-sex sexual attractions and disclosure of sexual orientation. Participants who developed early were more likely, compared to others, to experience forced sex and gay-related harassment before adulthood. They were more likely to be HIV seropositive and experience gay-related victimization, partner abuse and depression during adulthood. Early forced-sex, gay-related harassment and physical abuse were associated with several negative health outcomes in adulthood including HIV infection, partner abuse, and depression. This analysis suggests that the experience of homophobic attacks against young gay/bisexual male youth helps to explain heightened rates of serious health problems among adult gay men.