Factors associated with the use of highly active antiretroviral therapy in patients newly entering care in an urban clinic

Ethnic minority, female, and drug-using patients may be less likely to receive highly active antiretroviral therapy (HAART), despite its proven benefits. We reviewed the medical records of a consecutive population of 354 patients entering care in 1998 at the Thomas Street Clinic, an academically affiliated, public, HIV-specialty clinic in Houston, to determine the factors associated with not receiving HAART as recorded in pharmacy records. Ninety-two patients (26.0%) did not receive HAART during at least 6 months of follow-up. Patients who did not receive HAART were more likely to be women and to have missed more than two physician appointments and were less likely to have a CD4 count <200 cells/microL or a viral load > or = 10 copies/mL. In multivariate logistic analysis, missed appointments (OR = 5.85, p<.0001), female sex (OR = 2.53, =.001), and CD4 count > or = 200 cells/microL (OR = 2.50, p=.001) were independent predictors of not receiving HAART. More than half the patients who never received HAART never returned to the clinic after their first appointment. Among patients new to care, women and those with poor appointment adherence were less likely to receive HAART. Efforts to improve clinic retention and further study of the barriers to HAART use in women are needed.     

Functional impairment and health care utilization among HIV-infected men who have sex with men: the relationship with depression and post-traumatic stress

This study examined the relationship of post-traumatic and depressive symptom severity with measures of health-related quality of life (HRQOL), and health care utilization in a sample of 503 HIV-infected men who have sex with men (MSM) recruited in their primary HIV care setting. Participants completed computer assisted assessments of mood and anxiety, HRQOL, and HIV treatment. Peripheral blood CD4 (T helper) lymphocyte count, plasma HIV RNA concentration, and number of medical appointments were extracted from an electronic medical record. Controlling for demographics, disease stage, and antiretroviral medication, post-traumatic stress and depression symptoms accounted for significant variation in general health estimates, and in pain, role, and work-related impairment. Additionally, in multivariable models, post-traumatic stress and depression severity accounted for significant variation in health care utilization whereas symptoms and indices of HIV disease progression did not. These results extend the current research by providing evidence of the relationship between post-traumatic stress and depression symptom severity with measures of functional impairment and health care utilization in a relatively healthy, urban cohort of HIV-infected MSM.     

Access to and utilization of primary care services among HIV-infected women.

OBJECTIVES: To identify factors associated with the use of medical services, and to test a model of access to care, among HIV-infected women. METHODS: A cross-sectional telephone survey was administered to 213 HIV-infected women. Outcomes were having a primary care provider, and use of primary care and emergency health services. Predictors included characteristics of the population-at-risk and of the health care system. RESULTS: Ninety-three percent of respondents had a primary care provider. Linear regression found age >45 years (p = .002), perceiving greater barriers to getting to a clinic (p = .04) and greater benefits from medications (p = .03), lack of problems with appointment times (p = .02), having AIDS (p = .01), shorter appointment waiting times (p = .0003), and greater cost of travel to care (p = .001) were associated with a greater number of primary care visits. Thirty-seven percent missed at least 1 primary care appointment. In logistic regression, lack of insurance (odds ratio [OR] = 2.76), current injection drug use (OR = 2.89) and difficulty remembering appointments (OR = 2.36) were associated with having missed any appointments. CONCLUSIONS: Characteristics of the population-at-risk and of the health care system both make important contributions to primary care service use.     

High HIV prevalence and risk behaviors in men who have sex with men in Chennai, India

OBJECTIVE: To estimate HIV and sexually transmitted disease (STD) prevalence and behavioral risk characteristics of men who have sex with men (MSM) in Chennai, India. METHODS: A cross-sectional population-based random sample survey was conducted in 2001. Randomly selected residents of 30 slums in Chennai were interviewed for behavioral risk factors through face-to-face interviews. Sera and urine were examined for syphilis, HIV-1, gonorrhea, and chlamydia. Logistic regression analyses were used to assess associations between MSM status and HIV infection and to identify risk characteristics of MSM. RESULTS: Of 774 men, 46 reported (5.9%) sex with other men. MSM were more likely to be seropositive for HIV (odds ratio [OR] = 8.57; 95% confidence interval [CI]: 1.83, 40.23) and were more likely to have a history of STD (OR = 2.66; 95% CI: 1.18, 6.02) than non-MSM. Men who used illicit drugs in past 3 months (adjusted odds ratio [AOR] = 4.01; 95% CI: 1.92, 8.41), ever exchanged money for sex (AOR = 3.93; 95% CI: 1.97, 7.84), or were ever tested for HIV (AOR = 3.72; 95% CI: 1.34, 10.34) were significantly more likely to report sex with men. CONCLUSIONS: MSM in Chennai slums are at high risk for HIV. HIV prevention strategies aimed at changing unsafe drug and sexual practices should target the general population of men, with specific attention to areas with high rates of MSM.     

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

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

Men who have sex with men: estimated population sizes and mortality rates by race/ethnicity, Miami-Dade County, Florida

BACKGROUND: Estimated numbers of men who have sex with men (MSM) by race/ethnicity and mortality rates among such MSM with HIV/AIDS are unavailable. This hampers efficient targeting of HIV/AIDS prevention and care resources. METHODS: An existing estimation methodology was adapted to develop MSM population estimates by race/ethnicity for Miami-Dade County, Florida. We ascertained and characterized deaths that occurred during 2003 to 2005 among MSM HIV/AIDS cases, matching HIV/AIDS surveillance and vital statistics registries. We calculated estimated average annual racial/ethnic-specific mortality rates and rate ratios (RRs) among MSM HIV/AIDS cases. RESULTS: An estimated 63,020 men aged > or =18 years in the county are MSM (7.5% of all men aged > or =18 years; point estimate). Among 754 MSM HIV/AIDS deaths, point-estimate mortality rates per 100,000 MSM were higher for blacks (733.5) than for whites (229.2) (P < 0.01) and Hispanics (360.5) (P < 0.01). The best estimate of the black/white MSM mortality RR among HIV/AIDS cases was 3.20:1 (P < 0.01); for Hispanic/white MSM, it was 1.57:1 (P < 0.01). Sensitivity analyses suggested the estimates were reasonably robust to biases that we examined. CONCLUSIONS: Black and Hispanic MSM were more likely to die with HIV/AIDS than white MSM. Plausible racial/ethnic-specific MSM population and mortality rate estimates can inform effective HIV/AIDS prevention efforts and program planning.     

Predicting HIV transmission risk among HIV-infected men who have sex with men: findings from the healthy living project

OBJECTIVE: To examine the predictors of transmission risk among HIV-infected men who have sex with men (MSM) in 4 US cities. METHOD: Individual computer-assisted interviews assessing psychologic measures and sexual behavior with the 5 most recent male and female partners were conducted with a diverse sample of 1910 HIV-infected MSM recruited from community and clinic settings in San Francisco, New York, Los Angeles, and Milwaukee. Transmission-risk events were defined as unprotected vaginal or anal sex with a partner who was HIV negative or of unknown status. RESULTS: A small but not insignificant proportion of MSM (12.7%) reported at least 1 transmission-risk event in the previous 3 months, with 57% of those events taking place with casual as opposed to steady partners. Multivariate predictors of transmission risk with casual partners were stimulant (eg, crystal methamphetamine) and other drug use, having low coping self-efficacy, and not having disclosed one's HIV serostatus to all partners. Stimulant use and failing to disclosing one's serostatus to all partners were associated with risk in primary relationships. CONCLUSIONS: Responding to HIV transmission risk in MSM requires different strategies for primary and casual partners.     

Factors associated with recent sildenafil (viagra) use among men who have sex with men in the United States

BACKGROUND: Previous studies reported associations between sildenafil (Viagra; Pfizer, New York, NY) use and risk behaviors among men who have sex with men (MSM) in limited geographic areas or special populations. The purpose of the present study was to examine Viagra use among a broader MSM population. METHODS: The 2002 HIV Testing Survey data from MSM recruited at bars in 10 US states was used to examine Viagra use in the 12 months preceding the interview. Independent correlates of Viagra use were identified using logistic regression. RESULTS: Eleven percent (131/1177) of MSM reported recent Viagra use. Users were older (adjusted odds ratios [aOR] = 2.4 to 6.2, 95% CI: 1.2 to 13.6); were more likely be infected with HIV (aOR = 2.0, CI: 1.0 to 3.9); reported more male sex partners (aOR = 2.4 to 2.7, CI: 1.2 to 5.4); were twice as likely to have unprotected anal intercourse with a nonprimary male partner (aOR = 2.1, CI: 1.2 to 3.5); and were 3 times more likely to report illicit drug usage (aOR = 3.1, CI: 1.9 to 5.2). Fifty-three percent (70/131) of Viagra users simultaneously took illicit drugs. CONCLUSIONS: Among MSM from numerous US cities, Viagra use is common and is associated with several high-risk behaviors. These findings are consistent with previous reports and emphasize the need for additional prevention counseling for MSM that incorporates messages targeting Viagra usage and risk behavior.     

Mental health and HIV risk in men who have sex with men

Evidence-based HIV prevention interventions with men who have sex with men (MSM) in the United States have moderate effect sizes in reducing HIV sexual risk behavior. Mental health and psychosocial problems, which both disproportionately affect MSM populations and are implicated in HIV transmission risk behaviors, also likely interfere with the uptake of HIV behavioral interventions. Moreover, given that mental health and psychosocial problems such as depression, substance use, and violence frequently co-occur for many MSM (eg, as syndemic conditions), what is probably needed are combination prevention efforts, or prevention "cocktails," similar to treatment "cocktails," that address the psychological and behavioral mechanisms that interact to produce elevated risk for HIV. Such interventions should incorporate a holistic framework to address the sexual health and overall well being of MSM. Addressing co-occurring psychosocial risk factors is apt to improve effect sizes of current HIV prevention interventions and allow for more effective uptake by MSM.     

Prevalence and risk factors of HIV and syphilis,and knowledge and risk behaviors related to HIV/AIDS among men who have sex with men in Chongqing,China

High HIV prevalence and incidence burdens have been reported in men who have sex with men (MSM) in Chongqing, China. We aimed to estimate the prevalence of HIV and other sexually transmitted infections (STIs), to appraise the knowledge and risk behaviors related to HIV/AIDS among MSM, and to analyze the possible causes of deviation between behavior and knowledge to make better strategies. We recruited 617 MSM from February to July in 2008 by using a respondent-driven sampling (RDS) method in Chongqing, China. Through the collection of questionnaire-based data and biological testing results from all objects, we launched a cross-sectional survey. STATA/SE was used for data analysis by frequency, ANOVA, rank sum test and logistic regression models. MSM with syphilis (OR=4.16, 95%CI: 2.35-7.33, P<0.0001) were more likely to be HIV infected. Being a company employee (OR=3.64, 95%CI: 1.22-10.08, P<0.0001) and having bought male for sex (OR=3.52, 95%CI: 1.10-11.32, P < 0.034) were associated with a higher probability of syphilis. MSM with younger age, higher education and greater monthly income had a higher mean knowledge score. MSM who had HIV testing had a higher mean knowledge score than those who never had. Students, venues for finding sex partners by Internet and homosexuals in MSM had a higher mean knowledge score compared to other occupations, venues for finding sex partners and sexual orientation. There is an urgent need for delivery of barrier and biomedical interventions with coordinated behavioral and structural strategies to improve the effect of HIV interventions among MSM.     

Unprotected anal intercourse and substance use among men who have sex with men with recent HIV infection

OBJECTIVES: To examine within-subjects and combined between- and within-subjects associations between substance use and unprotected anal intercourse (UAI) among men who have sex with men (MSM) with recent HIV infection. METHODS: One hundred ninety-four MSM who were recently infected with HIV completed a computer-assisted questionnaire regarding sexual behaviors and substance use with their last 3 partners. Associations between UAI and substance use were assessed using conditional logistic regression (CLR) to assess associations among the 116 MSM reporting UAI with some but not all partners and generalized linear mixed effects models (GLMMs) to examine a combination of within- and between-subjects associations in the entire sample (N = 194). RESULTS: In multivariate CLR models and GLMMs, UAI was associated with the use of methamphetamine (odds ratio [OR] = 4.9 and OR = 3.5, respectively), marijuana (OR = 4.0 and OR = 2.2, respectively) and erectile dysfunction medications (EDMs) when used with a main partner (OR = 13.8 and OR = 10.1, respectively). CONCLUSIONS: Results indicate that a direct association may exist between specific substances and UAI and provide evidence that the use of methamphetamine and EDMs may contribute to HIV transmission.     

Circumcision and penile human papillomavirus prevalence in human immunodeficiency virus-infected men: heterosexual and men who have sex with men

Male circumcision is associated with a lower risk of penile human papillomavirus (HPV) infection in human immunodeficiency virus (HIV) uninfected men. Few studies have evaluated the role of male circumcision in penile HPV infection in HIV-infected men. The aim of this cross-sectional study was to examine the association between male circumcision and the prevalence of penile HPV infection among HIV-infected men—both men who have sex with men (MSM) and heterosexual men. Samples from 706 consecutive men included in the CARH-MEN cohort (overall 24% circumcised: 26% of MSM, 18% of heterosexual men) were examined by Multiplex-PCR. In the overall group (all HIV-infected men included), the prevalence of any penile HPV infection was 22% in circumcised men and 27% in uncircumcised men (OR = 1.0, 95% CI 0.6–1.6, adjusted analysis). In the circumcised group the overall prevalence of HPV infection was 22% in MSM and 24% in the heterosexual men, whereas in the uncircumcised group the prevalence was 26% and 28%, respectively. The prevalence of high-risk HPV types tended to be lower in the circumcised MSM (14% vs 21%, OR = 0.6, 95% CI 0.3–1.1, p 0.088), but it was similar in the heterosexual men (18% in circumcised vs 20% in uncircumcised). These results suggest that male circumcision may be associated with a lower prevalence of oncogenic high-risk penile HPV infection in HIV-infected MSM.     

Prevention with HIV-seropositive men who have sex with men: lessons from the Seropositive Urban Men's Study (SUMS) and the Seropositive Urban Men's Intervention Trial (SUMIT)

SUMMARY: Men who have sex with men (MSM) are disproportionately affected by HIV, and HIV-seropositive (HIV-positive) MSM are an especially important group for prevention efforts. This article describes findings from the Seropositive Urban Men's Study (SUMS, N = 456) and the Seropositive Urban Men's Intervention Trial (SUMIT, N = 1168). These studies were conducted from 1996 to 2002 with racially diverse samples from New York and San Francisco. Patterns of sexual behavior often reflected an understanding of the relative risks of specific sexual practices and were generally consistent with harm reduction strategies to reduce the risk of HIV transmission to uninfected partners. Some men, however, continued to engage in behaviors that placed themselves and their partners at risk for exposure to HIV and other sexually transmitted infections. Correlates of unprotected sex included self-efficacy, personal responsibility, substance use, mental health, and contextual influences. Disclosure of HIV status was a difficult issue for many HIV-positive MSM. Most participants had disclosed to their main partner, but they disclosed to less than half of their non-main partners before first sex. The interest of HIV-positive MSM in prevention efforts, the design of the SUMIT intervention trial, and implications for future research and programmatic efforts are discussed.     

Importance of sex partner HIV status in HIV risk assessment among men who have sex with men

Clinical HIV risk assessments have not typically integrated questions about sex partners' HIV status with questions about condom use and type of sex. Since 2001, we have asked all men who have sex with men (MSM) evaluated in an urban sexually transmitted disease (STD) clinic how often in the preceding 12 months they used condoms for anal sex with partners who were HIV-positive, HIV-negative, and of unknown HIV status. Overall, MSM displayed a pattern of assortative mixing by HIV status, particularly for unprotected anal intercourse (UAI). Nevertheless, 433 (27%) of 1580 MSM who denied knowing they were HIV-positive and 93 (43%) of 217 HIV-positive MSM reported having UAI with a partner of opposite or unknown HIV status. Among men who denied previously knowing they were HIV-positive, 24 (9.6%) of 251 MSM who reported having UAI with an HIV-positive partner or partner of unknown HIV status compared with 11 (1.7%) of 620 MSM who denied such exposure tested HIV-positive (odds ratio=5.8, 95% confidence interval: 2.8-12.1). UAI with an HIV-positive partner or partner with unknown HIV status was 69% sensitive and 73% specific in identifying men with previously undiagnosed HIV infection; UAI regardless of partner HIV status was 80% sensitive but only 45% specific. The positive predictive value was highest for risk assessments that included partner HIV status. Integrating questions about anal sex partner HIV status and condom use identifies MSM at greatest risk for HIV acquisition and transmission. These risk criteria might be effectively used to triage MSM into more intensive prevention interventions.     

Barriers to adherence to asthma management guidelines among inner-city primary care providers

BACKGROUND: Health care provider adherence to national asthma guidelines is critical in translating evidence-based recommendations into improved outcomes. Unfortunately, provider adherence to the National Heart, Lung, and Blood Institute (NHLBI) guidelines remains low. OBJECTIVE: To identify barriers to guideline adherence among primary care professionals providing care to inner-city, minority patients with asthma. METHODS: We surveyed 202 providers from 4 major general medicine practices in East Harlem in New York, New York. The study outcome was self-reported adherence to 5 NHLBI guideline components: inhaled corticosteroid (ICS) use, peak flow (PF) monitoring, action plan use, allergy testing, and influenza vaccination. Potential barriers included lack of agreement with guideline, lack of self-efficacy, lack of outcome expectancy, and external barriers. RESULTS: Most providers reported adhering to the NHLBI guidelines for ICS use (62%) and for influenza vaccinations (73%). Self-reported adherence was 34% for PF monitoring, 9% for asthma action plan use, and 10% for allergy testing. Multivariate analyses showed that self-efficacy was associated with increased adherence to ICS use (odds ratio [OR], 2.8; P = .03), PF monitoring (OR, 2.3; P = .05), action plan use (OR, 4.9; P = .03), and influenza vaccinations (OR, 3.5; P = .05). Conversely, greater expected patient adherence was associated with increased adherence to PF monitoring (OR, 3.3; P = .03) and influenza vaccination (OR, 3.5; P = .01). Familiarity with specific guideline components and higher level of training were also predictors of adherence. CONCLUSIONS: Lack of outcome expectancy and poor provider self-efficacy prevent providers from adhering to national asthma guidelines. Efforts to improve provider adherence should address these specific barriers.     

Transmission behaviors of recently HIV-infected men who have sex with men

OBJECTIVES: Analyze postdiagnosis behaviors of recently HIV-infected men who have sex with men (MSM). METHODS: Recently HIV-infected MSM were interviewed at 6 weeks (n = 153) and 3 months (n = 113) after diagnosis. Behaviors from baseline to follow-up were compared; multivariate logistic regression identified associations between baseline characteristics and behavior at follow-up. RESULTS: At follow-up, MSM reported a significantly lower mean of partners (7.9 vs. 5.2) and lower means of 1-time (1.9 vs. 0.8), unknown (3.7 vs. 2.6), and acquaintance (1.1 vs. 0.5) partners than at baseline. In multivariate analyses, unprotected anal intercourse (UAI) with the last partner at follow-up was more likely if the last partner at baseline was a main partner (odds ratio [OR] = 2.94, 95% confidence interval [CI]: 1.04 to 8.33) or HIV-positive partner (OR = 3.36, 95% CI: 1.27 to 8.88) but less likely if, at follow-up, the last partner was HIV-negative (OR = 0.28, 95% CI: 0.08 to 1.00) or of unknown HIV status (OR = 0.23, 95% CI: 0.08 to 0.71), the participant had a history of nonconsensual sex (OR = 0.25, 95% CI: 0.09 to 0.72), or the participant had more than 1 partner (OR = 0.28, 95% CI: 0.09 to 0.86). More than 1 partner at follow-up was associated with no main partner at baseline or follow-up (OR = 2.76, 95% CI: 1.12 to 6.78), more partners in the last 12 months (OR = 1.02, 95% CI: 1.01 to 1.04), and UAI with the last partner (OR = 0.36, 95% CI: 0.14 to 0.90). CONCLUSIONS: After diagnosis, some but not all recently HIV-infected MSM reduced risky sexual behavior permitting potential HIV transmission.     

Internalized heterosexism among HIV-positive, gay-identified men: implications for HIV prevention and care

Internalized heterosexism (IH), or the internalization of societal antihomosexual attitudes, has been consistently linked to depression and low self-esteem among gay men, and it has been inconclusively associated with substance use and sexual risk in gay and bisexual men. Using structural equation modeling, the authors tested a model framed in social action theory (C. K. Ewart, 1991, 2004) in which IH is associated with HIV transmission risk and poor adherence to HIV antiretroviral therapy (ART) through the mechanisms of negative affect and stimulant use. Data from a sample of 465 gay-identified men interviewed as part of an HIV risk reduction behavioral trial were used to test the fit of the model. Results support the hypothesized model in which IH was associated with unprotected receptive (but not insertive) anal intercourse with HIV-negative or unknown HIV status partners, and with ART nonadherence indirectly via increased negative affect and more regular stimulant use. The model accounted for 15% of the variance in unprotected receptive anal intercourse and 17% of the variance in ART nonadherence. Findings support the potential utility of addressing IH in HIV prevention and treatment with HIV-positive gay men.     

Partner-specific sexual behavioral differences between phase 3 HIV vaccine efficacy trial participants and controls: Project VISION

OBJECTIVE: To assess and compare sexual behaviors using partner-specific data between HIV-negative men who have sex with men (MSM) recruited for an HIV vaccine efficacy trial and a control group. METHODS: HIV-negative MSM from an HIV vaccine trial (n = 525) and controls (n = 732) were recruited by similar strategies and interviewed about behaviors with the 3 most recent partners in the past 6 months, obtained by audio computer-assisted self-interview (A-CASI). RESULTS: Vaccine trial participants were more likely than controls to report an HIV-positive partner (24.7% and 14.1%, respectively) or an HIV-positive primary partner (16.1% and 6.8%, respectively) and were less likely to report occasional or single-time partners of unknown HIV status (51.6% and 63.2%, respectively; P < 0.05 for each comparison). Vaccine trial participants more often reported receptive unprotected anal intercourse (UAI) during their last sexual encounter with an HIV-positive partner (adjusted odds ratio [OR] = 2.7, 95% confidence interval [CI]: 1.0 to 7.9). Most believed their HIV-positive partners were receiving antiretroviral treatment (ART), however, and after adjustment for perceived ART use, the association between vaccine study participation and receptive UAI with an HIV-positive partner was not significant. CONCLUSIONS: High-risk sexual behavior was reported by many VAX004 participants and controls. Differences between vaccine trial and control participants in the highest risk per contact behavior, receptive UAI with HIV-positive partners, was partly accounted for by perceived ART use. Partner level data are useful in refining risk assessment, which is important in the evaluation of HIV vaccine and other prevention trials.     

A comparison of on-line and off-line sexual risk in men who have sex with men: an event-based on-line survey

OBJECTIVE: To assess whether men who have sex with men (MSM) are more likely to report unprotected anal intercourse (UAI) with partners met on-line compared with those met off-line. METHODS: A total of 6122 individuals consented to participate in an anonymous behavioral survey on-line. This event-based analysis is limited to the 1683 men from the United States and Canada who had sex in the 3 months before the study and reported that their last sexual encounter included a new or casual male partner or partners. Prevalence and predictors of UAI were analyzed separately for the 386 men reporting more than 1 partner (multiple) and the 1297 men reporting only 1 (single) partner in their last encounter. RESULTS: Of the 1683 MSM recruited on-line, 51% met their partner(s) in their last sexual encounter on-line and 23% reported UAI. No difference in risk for UAI was found for partners met on-line versus off-line in the bivariate or multivariate analyses. In a multivariate analysis of men with multiple-partner encounters, UAI was significantly associated with being HIV-seropositive (adjusted odds ratio [OR] = 2.87; P = 0.02) in a model that included age; education; whether partners were met on-line or off-line; and use of crystal methamphetamine, sildenafil, or alcohol before sex. Using the same model, significant predictors of UAI in men reporting a single-partner encounter were use of crystal methamphetamine (adjusted OR = 5.67; P = 0.001) and no college degree (adjusted OR = 1.63; P = 0.01). CONCLUSIONS: MSM recruited on-line who reported a new or casual sex partner(s) in the prior 3 months are at considerable risk of HIV or other sexually transmitted infections, but they are equally likely to report UAI whether sex partners were met on-line or off-line. The Internet may be an ideal venue for reaching high-risk MSM.     

The HIV epidemic among older men who have sex with men

The authors present HIV prevalence and risk behavior data for urban men who have sex with men (MSM) aged 50 years or older. Data are based on a probability sample of MSM conducted in 1997 (n = 2881 total; 507 older MSM) in New York, Los Angeles, Chicago, and San Francisco. The authors determined HIV status through self-report and biologic measures. Risk behavior was assessed through self-report. The authors found that HIV prevalence was 19% (95% CI: 14, 25) for men in their 50s and 3% (95% CI: 1, 10) for men in their 60s. No men in their 70s were HIV-positive. Prevalence was at high levels for older blacks (30%), MSM who are injection drug users (21%), moderately heavy drug users (35%), and less closeted men (21%). High-risk sex between serodiscordant partners was relatively constant (4%-5%) across age groups older than 30 years of age and decreased among MSM in their 70s. Current levels of HIV among older urban MSM in the United States are very high, particularly among those in their 50s. High mortality rates among MSM with AIDS up to 1996 (before highly active antiretroviral therapy [HAART]) would account for the lower levels among men in their 60s and 70s. Because of HAART, we would expect HIV levels to increase in these age groups. Given high levels of risk behavior among MSM through the sixth decade of life, the authors would expect an older MSM epidemic of substantially larger proportion than that observed in the 1980s and 1990s.