Cost-Effectiveness of an HIV/AIDS Prevention Intervention for Gay Men

The present study sought to determine the cost per discounted quality-adjusted-life-year (QALY) saved by a small group workshop-format, cognitive-behavioral HIV-prevention intervention for gay men. The methodology employed was a retrospective cost-utility analysis of the behavioral intervention. The ability of the intervention to effect HIV-related behavior change was previously assessed in a randomized controlled trial. In the original trial, clients were recruited from gay bars, health department clinics, and other community settings in metropolitan area of 400,000 residents; the intervention was delivered in a medical school outreach setting. The participants were 104 gay men; 87% of the clients identified their race/ethnicity as White, 13% as ethnic minority. The experimental intervention was comprised of 12 sessions and provided HIV-related risk behavior education, self-management and sexual assertion training, and development of reliable and positive social support networks. The comparison condition was a wait-list control group. The main outcome measure in our retrospective cost-utility analysis was “cost per discounted QALY saved.” Under base case assumptions, the cost of the intervention was $24,000 (rounded to the nearest thousand). The discounted medical costs averted by preventing HIV infection were $42,000. Approximately 5.5 discounted QALYs were saved. Hence the intervention is cost-saving under base case assumptions (i.e., the cost per discounted QALY saved ratio is less than zero). The results are generally robust to changes in cost-utility analysis model parameters and assumptions. Because the intervention is cost-saving under base case assumptions, it compares favorably to other health service interventions in which society currently invests. Behavioral interventions such as the one examined here should receive serious consideration for investment by public health decision makers allocating fiscal resources for health services.     

Developing an Online Health Intervention for Young Gay and Bisexual Men

Young gay and bisexual men continue to experience increases in HIV incidence in the US highlighting a need for competent health services, while the prominence of the internet in their social and sexual lives calls for novel preventive modalities. Toward this goal, we adapted an efficacious in-office HIV risk reduction intervention for online delivery. This paper describes the development of the online intervention and highlights the results of interviews and focus groups with the original intervention participants regarding effective adaptation and online delivery recommendations. The final intervention incorporates strategies for overcoming barriers to online intervention with this population and capitalizes on the unique strengths of online intervention delivery. The systematic process described in this paper can be used as a template for other researchers to develop online risk reduction programs and fills an important gap in the field’s ability to maximally reach a critical risk group.     

Resilience as a Research Framework and as a Cornerstone of Prevention Research for Gay and Bisexual Men: Theory and Evidence

This commentary presents the content and results of a recent symposium held to discuss how resiliencies among gay and bisexual men, and other men who have sex with men, could inform HIV prevention interventions. We outline the argument for including resiliencies in prevention work and present a critique of the deficit-based approached to public health research as it applies to this line of inquiry. The commentary makes the case that HIV prevention work would be more efficacious if it were designed to incorporate naturally occurring resiliencies that manifest among gay male communities rather than primarily using interventions that address vulnerabilities among men who continue to reside in high risk contexts. The commentary concludes by listing a set of resiliency variables and constructs proposed at the meeting that could be tested in theoretically-based investigations to raise resiliencies among gay and bisexual men thereby lowering HIV risks in this population.     

Adapting the VOICES HIV Behavioral Intervention for Latino Men Who Have Sex with Men

Latino men who have sex with men (MSM) are disproportionately impacted by HIV/AIDS, but few behavioral interventions address their prevention needs. Adaptation of evidence-based interventions is a pragmatic strategy that builds upon lessons learned and has the potential to fill gaps in prevention programming. Yet there are few reports of how transfers are executed and whether effectiveness is achieved. This research reports on the adaptation of VOICES/VOICES, a single-session intervention designed for heterosexual adults, into No Excuses/Sin buscar excuses for Latino MSM. To test the adapted intervention, 370 at-risk Latino MSM were enrolled in a randomized trial. At a three-month follow-up, there was a sharper decrease in unprotected intercourse in the intervention group compared to controls (59 % vs. 39 %, ANOVA p < 0.05, F = 4.10). Intervention participants also reported more condom use at last intercourse (AOR = 1.69; 95 % CI 1.02–2.81, p < 02). Findings support use of adapted models for meeting prevention needs of high-priority populations.     

Psychosocial Factors Associated with Resilience in a National Community-Based Cohort of Australian Gay Men Living with HIV

HIV-positive gay men may experience multiple sources of adversity and stress, related both to their HIV diagnosis and sexual identity. Most of these men, however, do not experience mental health problems. Little is known about factors that help them achieve resilience in the face of life challenges. This study examined psychosocial factors associated with resilience in a national community-based sample of 357 Australian HIV-positive gay men. Resilience was measured using the Connor–Davidson Resilience Scale. Higher levels of resilience were linked with experiencing low or no internalized HIV-related stigma, having no previous history of mental health problems, and a number of socioeconomic indicators. In addition to providing a more complete picture of the mental health of HIV-positive gay men, findings from this study can be used to inform strength-based approaches to mental health prevention and support.     

Provigil (Modafinil) Plus Cognitive Behavioral Therapy for Methamphetamine Use in HIV+ Gay Men: A Pilot Study

Objectives: To evaluate the efficacy of modafinil combined with cognitive behavioral therapy (CBT) for treatment of methamphetamine (MA) dependence among HIV+ gay men. Methods: In a single blind trial, modafinil was administered for 12 weeks, followed by a 4-week placebo phase. CBT was conducted for 18 sessions over the 16-week study. Primary outcome measures were self-reported use of days per week plus urine toxicology assays. Additional measures included the Beck Depression Inventory, Cravings Scale, and O/C Crystal Use Scale. Response was defined as > 50% decline in days used per week. Thirteen patients were enrolled over an 18-month period. Results: Ten patients (77%) completed the trial, although two discontinued modafinil due to side effects. Six of the ten study completers reduced their MA use by > 50%. Conclusions: These preliminary results suggest good retention using combined medication and psychotherapy, and support further examination of modafinil and CBT in double-blind placebo controlled trials.     

Gay Men Who Are Not Getting Tested for HIV

Using data from Australian Gay Community Periodic Surveys 1998-2010, we assessed the prevalence, trends and characteristics of gay men not tested for HIV. In 2010, one in eight Australian gay socially-engaged men were never tested for HIV, most of them sexually active and 56.5?% reporting unprotected anal intercourse. The proportion of not tested men was significantly higher in men younger than 30, of non-European origin and living outside of gay metropolitan areas. Although frequency of testing was associated with sexual practices, significant proportions of men with multiple sex partners and reporting unprotected anal intercourse were not tested as recommended. There were issues with using gay-friendly testing services in gay metropolitan areas. Despite Australia's success in HIV testing, improvement is needed for early detection of HIV infections. Interventions should encourage regular testing, engage with young gay men, improve access and convenience of testing, train service providers and expand testing options.     

Gay and Bisexual Men in Kampala,Uganda

HIV/AIDS disproportionately affects gay and bisexual men around the world; however, little is known about this population in sub-Saharan Africa. We conducted a respondent-driven sampling survey of gay and bisexual men in Kampala, Uganda (N = 224). Overall, 61% reported themselves as “gay” and 39% as “bisexual”. Gay and bisexual men were 92% Ugandan; 37% had unprotected receptive anal sex in the last six months, 27% were paid for sex, 18% paid for sex, 11% had history of urethral discharge. Perception that gay and bisexual men are at risk for HIV infection was low. Gay and bisexual men in Kampala are overwhelmingly Ugandan nationals from all parts of society. Recognition of gay and bisexual men in local HIV prevention programs and education messages are urgently needed. Our study demonstrates that gay and bisexual men in Uganda are willing to identify themselves and participate in research.     

Developing an HIV-Prevention Intervention for HIV-Infected Men Who Have Sex with Men in HIV Care: Project Enhance

Men who have sex with men (MSM) represent the largest group with HIV in the U.S. (CDC 2005). Interventions for prevention with HIV-infected MSM are urgently needed, and integrating prevention into HIV care represents one opportunity for this advancement. This article describes the development and results of initial pilot testing of a behavioral intervention to reduce HIV sexual risk transmission behavior for HIV-infected MSM that is integrated into HIV care. To illustrate our intervention development process, we describe the setting and population (HIV-infected MSM patients at Fenway Community Health in Boston) for the project, the initial conceptualization of the project including its guiding conceptual model (information, motivation, and behavioral skills model, IMB: Fisher and Fischer 1993), the iterative process of attaining and integrating input from stakeholders, the use of peer interventionists, the open phase pilot and participant input, an overview of the intervention content, and, finally, lessons learned. The result of this process is an example of an intervention developed with strong input from the community and other stakeholders, which is ready for further testing in a randomized controlled trial.     

Drug Use and HIV Prevention With Young Gay and Bisexual Men: Partnered Status Predicts Intervention Response

The Young Men’s Health Project (YMHP) has shown efficacy in reducing drug use and condomless anal sex (CAS) with casual partners among young gay, bisexual and other men who have sex with men (YGBMSM). The study examined whether relationship status at the time of intervention predicted response to YMHP by comparing baseline (pre-intervention) and follow-up (3, 6, 9, and 12 months post-intervention) data from the original trial. A group of 13 partnered YGBMSM who received YMHP was compared to a matched subsample of single YGBMSM. Among single men, drug use declined significantly at all follow-ups. Among partnered men, drug use was largely stable. While significant reductions were observed at 9 month assessment, 3, 6, and 12 month use did not differ significantly from baseline. Regardless of relationship status, CAS with casual partners declined significantly at 12 month follow-up. Results suggest the incorporation of components which address relationship factors, particularly those associated with drug use, may enhance benefits of YMHP for partnered YGBMSM.     

Pilot Randomized Trial of an Expressive Writing Intervention to Reduce Sexual HIV-Transmission Risk and Substance Use Among Emerging Adult Gay and Bisexual Men

AIDS and Behavior - This pilot randomized controlled trial evaluated the feasibility, acceptability, and preliminary efficacy of expressive writing to reduce HIV-related sexual risk taking and...     

Evaluation of an HIV Prevention Intervention for Men Who Have Sex with Men at Cruising Areas in the Netherlands

This study collected data from 362 men who had sex with men at cruising areas in the Netherlands, and measured characteristics of respondents, sexual risk behavior, and risk perceptions. Furthermore, the study assessed whether outreach activities at cruising areas promote safe sex behavior. Almost one in five respondents reported having sex with both men and women, and 18.5% of respondents reported sexual risk behavior at cruising areas. Men who had a conversation about safe sex with a volunteer used condoms more consistently than men who had not spoken with a volunteer. Finally, it was found that behaviorally bisexual men used condoms less frequently at cruising areas. The relatively high levels of risk-taking sex stress the importance of HIV prevention at cruising areas. Furthermore, special attention could be given to cruising area visitors who have sex with both men and women, because they report higher levels of risk behavior and have less access to safer sex information regarding homosexual behavior.     

Willingness to Participate in Future HIV Prevention Studies Among Gay and Bisexual Men in Scotland, UK: A Challenge for Intervention Trials

This article examines willingness to participate in future HIV prevention research among gay and bisexual men in Scotland, UK. Anonymous, self-complete questionnaires and Orasure? oral fluid samples were collected in commercial gay venues. 1,320 men were eligible for inclusion. 78.2% reported willingness to participate in future HIV prevention research; 64.6% for an HIV vaccine, 57.4% for a behaviour change study, and 53.0% for a rectal microbicide. In multivariate analysis, for HIV vaccine research, greater age, minority ethnicity, and not providing an oral fluid sample were associated with lower willingness; heterosexual orientation and not providing an oral fluid sample were for microbicides; higher education and greater HIV treatment optimism were for behaviour change. STI testing remained associated with being more willing to participate in microbicide research and frequent gay scene use remained associated with being more willing to participate in behaviour change research. Having an STI in the past 12 months remained significantly associated with being willing to participate in all three study types. There were no associations between sexual risk behaviour and willingness. Although most men expressed willingness to participate in future research, recruitment of high-risk men, who have the potential to benefit most, is likely to be more challenging.     

Predictors of Day-Level Sexual Risk for Young Gay and Bisexual Men

As HIV infection rates remain high among young gay and bisexual men, investigations into determinants of sexual risk are paramount. This study examined independent and interactive effects of substance use, mental health, perceived benefits of unprotected sex, and type of sex partner on odds of not using condoms. Analyses included 188 high-risk substance using HIV-negative and unknown status young gay and bisexual men (ages 18–29). Substance use and endorsing favorable attitudes towards unprotected sex strongly predicted sexual risk. Mental health moderated the relationship between partner type (main vs. casual) and condom use such that increased anxiety and depression were associated with increased odds of using condoms with main partners and not using condoms with casual partners. Understanding how these determinants of HIV risk converge to predict unprotected anal sex can identify essential risk relationships for prevention, obtain effects sizes of greater magnitude and prolonged sustainability, and build robust couples-based interventions.     

A Systematic Review to Identify Challenges of Demonstrating Efficacy of HIV Behavioral Interventions for Gay, Bisexual, and Other Men Who Have Sex with Men (MSM)

Gay, bisexual, and other men who have sex with men (MSM) are disproportionately affected by HIV but few MSM-specific evidence-based interventions (EBIs) have been identified for this vulnerable group. We conducted a systematic review to identify reasons for the small number of EBIs for MSM. We also compared study, intervention and sample characteristics of EBIs versus non-EBIs to better understand the challenges of demonstrating efficacy evidence. Thirty-three MSM-specific studies were evaluated: Nine (27 %) were considered EBIs while 24 (73 %) were non-EBIs. Non-EBIs had multiple methodological limitations; the most common was not finding a significant positive effect. Compared to EBIs, non-EBIs were less likely to use peer intervention deliverers, include sexual communication in their interventions, and intervene at the community level. Incorporating characteristics associated with EBIs may strengthen behavioral interventions for MSM. More EBIs are needed for substance-using MSM, MSM of color, MSM residing in the south and MSM in couples.     

Resilience as an untapped resource in behavioral intervention design for gay men

Men who have sex with men experience high rates of psychosocial health problems such as depression, substance use, and victimization that may be in part the result of adverse life experiences related to cultural marginalization and homophobia. These psychosocial health conditions interact to form a syndemic which may be driving HIV risk within this population. However, MSM also evidence great resilience to both the effects of adversity and the effects of syndemics. Investigating and harnessing these natural strengths and resiliencies may enhance HIV prevention and intervention programs thereby providing the additional effectiveness needed to reverse the trends in HIV infection among MSM.