Results from Two Online Surveys Comparing Sexual Risk Behaviors in Hispanic,Black, and White Men Who Have Sex with Men

Many men who have sex with men (MSM) are among those who increasingly use the internet to find sexual partners. Few studies have compared behavior by race/ethnicity in internet-based samples of MSM. We examined the association of race/ethnicity with HIV risk-related behavior among 10,979 Hispanic, black, and white MSM recruited online. Significant variations by race/ethnicity were found in: age, income level, sexual orientation, number of lifetime male and female sexual partners, and rates of unprotected anal intercourse (UAI). Black and Hispanic men were more likely to report anal intercourse during the last sexual encounter, but white men were more likely to report UAI. In multivariate analysis, UAI was associated with HIV infection and sex with a main partner. Significant risk behavior variations by race/ethnicity were found. Research is needed to better target online interventions to MSM who engage in UAI or have other risk factors for transmitting or acquiring HIV.     

Unprotected sex and associated risk factors among young Asian and Pacific Islander men who have sex with men.

Young Asian and Pacific Islander (API) men who have sex with men (MSM) are at high risk for HIV, but little is known about their risk behavior. We examined the patterns and predictors of unprotected anal intercourse among 253 API MSM aged 15-25 recruited from gay-identified venues in Seattle, Washington, and San Diego, California, from May to August 1999. Overall, 33% reported unprotected anal intercourse in the past 3 months. Multivariate analyses found that unprotected anal intercourse was associated with self-identifying as gay or bisexual, having multiple sexual partners, having sex with a steady partner, having been tested for HIV, and not perceiving peer norms supportive of safer sex. Young API MSM engage in unprotected sex at high rates. There is an urgent need to help these men reduce sexual risk behavior by implementing HIV prevention programs that address the issue of self-accepting sexual orientation, the potential problem with using HIV testing as a risk reduction strategy, the possible risk of HIV transmission in steady relationships and multiple sexual partnerships, and the importance of establishing safer sex practices as peer norms.     

Gay Asian men in San Francisco follow the international trend: increases in rates of unprotected anal intercourse and sexually transmitted diseases, 1999-2002.

Worldwide, studies of men who have sex with men (MSM) report increases in HIV risk-related behavior. Less is known about trends within minority subpopulations of MSM, particularly those of Asian and Pacific Islander (A&PI) ethnicity. A&PI MSM are underrepresented among AIDS cases (2.7%) with respect to their estimated makeup in the gay community of San Francisco (4.5%). However, recent trends in unprotected anal intercourse (UAI) and sexually transmitted diseases suggest a reversal in the relative risk for HIV among A&PI MSM compared with White MSM. Starting from lower levels in 1999, UAI with multiple partners, UAI with multiple partners of unknown HIV serostatus, the incidence of male rectal gonorrhea, and the incidence of early syphilis among A&PI MSM surpassed levels among White MSM by 2002. A window of opportunity to prevent further spread of HIV among A&PI MSM may be closing.     

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.     

The bisexual bridge revisited: sexual risk behavior among men who have sex with men and women, San Francisco, 1998-2003

From 1998 to 2003 in San Francisco, unprotected anal intercourse (UAI) with one or more partner of unknown HIV serostatus (potentially serodiscordant UAI) increased among bisexual men who have sex with men (MSM) in parallel and in magnitude compared with other MSM. Potentially serodiscordant UAI and unprotected vaginal intercourse increased from 1998 to 2001 then decreased from 2001 to 2003. Although elements of a 'bisexual bridge' are present, we note an encouraging decrease in risk from 2001 to 2003.     

Partner-Provided Social Support Influences Choice of Risk Reduction Strategies in Gay Male Couples

We investigated the influence of partner-provided HIV-specific and general social support on the sexual risk behavior of gay male couples with concordant, discordant, or serostatus-unknown outside partners. Participants were 566 gay male couples from the San Francisco Bay Area. HIV-specific social support was a consistent predictor for reduced unprotected anal intercourse (UAI) with both concordant outside partners (all couple types) and outside partners of discordant or unknown serostatus (concordant negative and discordant couples). General social support was associated with increased UAI with concordant outside partners for concordant negative and concordant positive couples (i.e., serosorting). Our findings suggest that prevention efforts should target couples and identify the level of HIV-specific support that partners provide. Partner-provided support for HIV-related behaviors could be an additional construct to consider in gay male relationships, akin to relationship satisfaction and commitment, as well as an important component of future HIV prevention interventions.     

Increasing proportions of Australian gay and homosexually active men engage in unprotected anal intercourse with regular and with casual partners

We examined trends in sexual practice among gay and homosexually active men in Australia. Self-complete questionnaires were distributed with mail-order sex video catalogues in 2000 and returned anonymously through a reply-paid facility. The data were compared with those from men who responded to promotional material sent out with the same catalogues and who participated in national telephone surveys of men who have sex with men conducted in 1992 and 1996. A key independent variable was gay community attached (GCA) versus non-GCA (NGCA) derived from two items about number of gay friends and amount of free time spent with gay men. Responses came from 1,832 men ranging in age from 16 to 80 (median = 39) years. HIV status was 73% negative, 5% positive, 22% untested; 1,181 men were GCA and 651 men were NGCA. Overall, from 1992 to 2000 there was a significant upward trend in the proportion of men reporting any unprotected anal intercourse (UAI) in the previous six months with regular partners: 21.5%, 24.7%, 46.4% of the total sample (p < 0.001). And similarly for UAI with casual partners: 12.4%, 16.2%, 25.5% (p < 0.001). The upward trends in UAI-regular and UAI-casual were similar and significant (p < 0.001) for both GCA and NGCA men. These nationwide Australian data provide evidence of continuing increases in unprotected anal intercourse with regular and with casual partners. Whereas the majority of men do not engage in any unprotected anal intercourse during a defined interval, ever increasing proportions of them do.     

Assessing sexual risk behaviour of young gay men in primary relationships: the incorporation of negotiated safety and negotiated safety compliance

OBJECTIVES: To establish the actual rate of risky unprotected anal intercourse (UAI) among young gay men in steady relationships by correcting for negotiated safety (NS) and NS compliance. In addition, to examine whether the rate of UAI with steady partners, after correction for NS and NS compliance, is higher than the rate of UAI during sexual contacts with casual partners. METHODS: A total of 435 young gay men completed questionnaires regarding relationship status, HIV status, NS agreements, and sexual behaviour with steady and casual partners in the preceding 6 months. RESULTS: Twelve per cent of the participants in a relationship practised NS. The non-compliance rate with NS agreements reached 10%. The rate of UAI with steady partners stood at 54%. After correction for NS and NS compliance, the actual risky UAI rate with steady partners dropped to 39%. Chi square tests showed that even after correction for NS and NS compliance, the rates of UAI with steady partners remained significantly higher than the rates of UAI with casual partners. CONCLUSION: It is imperative to correct the rates of UAI with steady partners for NS and NS compliance in order to estimate accurately the rates of risky UAI. The higher rates of risky UAI found with steady partners, even after correcting for NS, support the assumption that steady relationships provide a context that facilitates sexual risk-taking behaviour. We should therefore specifically target primary relationships as a source of risk for HIV transmission, and take into consideration non-compliance with NS agreements.     

Gay Asian men in Sydney resist international trend: no change in rates of unprotected anal intercourse, 1999-2002.

Against a background of increasing unprotected anal intercourse (UAI) in the Sydney gay community (and internationally), complementary cross-sectional surveys of sexual practice were conducted among gay men of Asian background in 1999 (N = 319) and 2002 (N = 457). Self-complete questionnaires were used with recruitment at gay bars, gay social functions, and gay sex-on-premises venues. In 2002, self-report HIV status was 73.7% HIV-negative, 3.6% HIV-positive, and 22.8% unknown status (no significant change from 1999). Over time, the proportion of gay Asian men who reported any UAI with regular partners (in the previous 6 months) did not change significantly: 27.9% in 1999; 24.3% in 2002. Similarly, rates of any UAI with casual partners remained steady: 16.3% in 1999; 14.4% in 2002. Only one factor, more extensive engagement in esoteric practices (fisting, sadomasochism, group sex, rimming), was independently associated with sexual risk practice. This suggests that risk in this population of gay men, as in others, has more to do with the sexual cultures in which men are embedded rather than individual-level differences.     

Psychosocial predictors of unprotected anal intercourse in a sample of HIV positive gay men who volunteer for a sexual risk reduction intervention.

This study used logistic regression analysis to identify psychosocial predictors of unprotected anal intercourse in a sample of 212 HIV positive gay men who were enrolled in a sexual risk reduction intervention. A combination of five psychosocial variables (i.e., age, avoidant coping, loneliness, depressive symptoms, and impulsivity) reliably discriminated between men who had engaged in unprotected anal intercourse (UAI) with HIV negative or serostatus unknown partners and those who had not engaged in this high risk behavior. Avoidant coping emerged as the best psychosocial predictor that distinguished between the two groups. Men who had UAI during the previous 4 months had significantly higher scores on avoidant coping as compared with the no-UAI group. These findings suggest the need to design intervention programs for HIV positive gay men that addresses coping strategies in the context of high-risk sexual behaviors.     

Drug Use, Interpersonal Attraction, and Communication: Situational Factors as Predictors of Episodes of Unprotected Anal Intercourse among Latino Gay Men

It is important to understand situational factors linked to episodes of unprotected sexual intercourse among Latino gay men (LGM), who are disproportionately affected by HIV/AIDS in the U.S. Past research has suggested that participation in difficult sexual situations mediates the relationship between socio-cultural factors and sexual risk behaviors among LGM. This study examined drug use by self and sex partners, interpersonal factors, and other key variables, each examined at the situation-level of analysis, as predictors of episodes of unprotected anal intercourse (UAI) among LGM. Study participants included 270 LGM living in New York City, Miami, and Los Angeles who reported inconsistent condom use during anal intercourse in the last year. Men participated in structured interviews in which they were asked sets of detailed questions about their most recent episode of anal intercourse in which they used condoms, and their most recent anal intercourse episode in which they did not use condoms. Conditional logistic regression was used to compare the relevance of specific situational factors to participants’ episodes of UAI and protected anal intercourse. We found that drug use by a sex partner and lacks of discussions about condom use with partners, among other situational factors, were significantly related to episodes of UAI. The findings highlight the importance of considering the impact of sexual situations and interactions with sex partners when studying HIV risk among LGM and when designing interventions.     

Substance use and high-risk sex among men who have sex with men: a national online study in the USA

This paper describes drug and sexual risk behaviors during a six-month period in 2001 of 2,916 gay and bisexual men who were recruited online. Bivariate and multivariate analyses examined correlates of unprotected anal intercourse (UAI). Drug and alcohol use were also examined by US region. UAI was associated with using alcohol or drugs, including poppers, crystal methamphetamine, cocaine, marijuana and Viagra before or during sex. Meeting sex partners both online and offline and having multiple sex partners were also predictive of UAI. Significant regional differences were seen in the prevalence of drug use and alcohol use. Findings are discussed in relation to the need to integrate messages about the relationship between drug use and sexual behavior into HIV prevention programs.     

Gay men who look for sex on the Internet: is there more HIV/STI risk with online partners?

OBJECTIVE: To examine whether the excess risk for HIV and sexually transmitted infection (STI) seen among gay men who look for sex through the Internet occurs with men they meet online (through the Internet) rather than offline (in bars, clubs, etc). METHODS: In 2002-2003, 4225 London gay men were surveyed in an HIV treatment clinic, HIV testing clinic, gyms and on UK Internet sites (gaydar and gay.com). All men completed a self-administered questionnaire concerning Internet use and sexual risk behaviour. Unprotected anal intercourse (UAI) with a partner of unknown or discordant HIV status was classified as non-concordant. RESULTS: Between 40 and 50% of men surveyed in the clinics and gyms used the Internet to look for sex. HIV-positive men who looked for sex through the Internet were more likely to report UAI with HIV-positive casual partners they met online rather than offline (clinic sample: met online only 9.9%, met offline only 3.8%, McNemar P < 0.05). Regardless of HIV status, however, men who looked for sex through the Internet were no more likely to report UAI with non-concordant casual partners they met online than offline (eg, HIV-negative men, Internet sample: met online only 9.7%, offline only 11.1%, McNemar P = 0.6). CONCLUSIONS: In London, HIV-positive gay men appear to meet casual UAI partners of the same status through the Internet. This presents a risk for STI transmission. However, gay men were no more likely to meet casual UAI partners of unknown or discordant HIV status--which presents a risk for HIV transmission--online rather than offline.     

Is 'knowing people with HIV/AIDS' associated with safer sex in men who have sex with men?

OBJECTIVE: To examine the sexually protective role of knowing person(s) with HIV/AIDS (PWHA) by conducting a multidimensional analysis distinguishing the number of PWHA known (by disease status and relationship category) and aspects of the relationship with the closest PWHA (emotional closeness, length of time known, disease status, type of relationship). DESIGN: Cross-sectional study of white, Latino, and African-American men who have sex with men recruited at street locations in West Hollywood, California, in 1997. METHODS: The analyses conducted with linear regression models focused on men (n = 334) who reported that they were seronegative or of unknown serostatus and thus at risk for HIV infection. Unprotected sex was defined as percentage of anal intercourse partners in the past 12 months with whom unprotected anal intercourse (UAI) occurred at least once. RESULTS: The number of PWHA known was not associated with the percentage of UAI partners in multivariate or univariate analyses. Greater emotional closeness to a person who was HIV-positive without AIDS was associated with reduced UAI in multivariate models even after excluding participants whose close PWHA was a lover or sex partner. Younger men (18-25 years) knew fewer PWHA, reported less emotional closeness to a PWHA, and had a higher level of UAI than did older men. CONCLUSIONS: Emotional closeness to a seropositive person without AIDS may be a sexually protective factor. The results suggest the possibility that lower levels of emotional closeness to a PWHA may partially underlie the elevated sexual risk behavior of younger men who have sex with men.     

Associations of unprotected anal intercourse with Grindr-met partners among Grindr-using young men who have sex with men in Los Angeles

Grindr, a geosocial smartphone application, is a networking medium for men who have sex with men. Although three quarters of young men who have sex with men (YMSM) Grindr users report having sex with a Grindr-met partner, the correlates of risky sexual behavior with Grindr-met partners are unknown. A randomly selected sample of 18- to 24-year-old, Grindr-using YMSM completed an anonymous online questionnaire assessing patterns of Grindr use and sexual behavior with their last Grindr-met partners. Of the 146 YMSM who reported having sex with Grindr-met partners, 20% had unprotected anal intercourse (UAI) at last sex with their Grindr-met partner. In the multivariable model, YMSM who used Grindr for at least one year showed naked chest/abs in their profile photo, and reported more past month Grindr-met partners were more likely to report UAI. These findings suggest that familiarity with the app was associated with YMSM's UAI with Grindr-met partners. Moreover, sexualized profile photos (i.e., naked chest/abs) may be associated with sexual risk-taking behaviors. HIV prevention interventions delivered or linked through such apps should target individuals who are longer/frequent users and who present sexualized profiles.     

Sexual Behavior and HIV Testing Among Bisexual Men: A Nationwide Comparison of Australian Bisexual-Identifying and Gay-Identifying Men

Men who have sex with men (MSM) are typically studied as though they were a homogeneous population. This has resulted in a lack of knowledge about the sexual health and behavior of bisexual men as distinct from gay men. In this study, patterns of sexual behavior and rates of HIV testing were compared between 854 gay-identifying and 164 bisexual-identifying men who participated in an Australian nationwide online survey. Approximately half of both groups engaged in unprotected anal intercourse (UAI) at their most recent sexual encounter, but bisexual-identifying men were more likely to have had sex with a partner who was either serodiscordant or with whom their seroconcordance was unknown. Despite these patterns, only 62% of bisexual-identifying men had ever been tested for HIV compared to 84% of gay-identifying men. Multivariate logistic regression focused on rates of UAI and HIV testing among bisexual-identifying men. Patterns were similar across all age groups and educational backgrounds. However, bisexual-identifying men were less likely to engage in UAI with a casual partner and were more likely to have been tested for HIV if they had multiple partners or had disclosed their sexual orientation to their social networks. In all, these data reveal important differences between gay- and bisexual-identifying men, particularly with regard to HIV testing, and highlight a need for HIV prevention strategies to focus more strategically on finding ways of promoting safer sex and HIV testing among all MSM.     

Behavioral and cognitive barriers to safer sex between men in steady relationships: implications for prevention strategies.

Steady partners are a major source of HIV infection among gay men. To better understand sexual risk taking in steady relationships, we examined characteristics of the first incident of unprotected anal intercourse (UAI) between steady male partners. We also examined cognitive barriers to safer sex by way of associating beliefs regarding UAI with protective behavior. Questionnaires assessing sexual behavior and related cognitions were completed by 324 gay men, aged 18-34. Of the men who had UAI with their steady partners, 55% (103/189) did so within the first 3 months of the relationship, and 46% did not discuss having UAI with their partner before it occurred. Analyses revealed that perceiving UAI as a symbol of trust and believing that the partner desired UAI were associated with less condom use but also with a higher likelihood that men established HIV-negative seroconcordance and made sexual agreements (i.e., practiced negotiated safety). Perceiving UAI as more gratifying was associated with having risky UAI. Our findings suggest that interventions can make use of beliefs regarding trust and partner's desire for UAI to promote negotiated safety. In relationships where negotiated safety cannot be implemented, HIV prevention should regard the above beliefs, in particular the perception that UAI is more gratifying, as important barriers to safer sex. Furthermore, our findings regarding the early onset of risk in relationships emphasize how little time is at hand to prevent sexual risk before it occurs. One solution could be to target single gay men for promoting safer sex with future steady partners.     

Partner type and sexual risk behavior among HIV positive gay and bisexual men: social cognitive correlates.

This study used elements of social cognitive theory to examine the relationship between partner type and sexual risk behavior in a sample of HIV positive gay and bisexual men. Self-efficacy captures one's perceived ability to perform a behavior; outcome expectancies are estimations that a behavior will result in a given outcome. An examination of sexual risk behavior revealed that men with steady partners and men with anonymous partners had the most unprotected anal intercourse (UAI), while men with casual partners had the least. Men with anonymous partners had the lowest scores on self-efficacy and outcome expectancies for condom use, negotiation, and disclosure. Outcome expectancies for negotiation of safer sex were inversely related to UAI for men with steady partners. Self-efficacy for condom use and negotiation were inversely related to UAI for men with casual partners. These findings suggest the need to consider partner type in the development of sexual risk reduction interventions.     

Gay Men Who Engage in Group Sex are at Increased Risk of HIV Infection and Onward Transmission

Among 746 participants in the Three or More Study (TOMS) of gay men who engaged in group sex in the previous 6 months, 22.4% reported unprotected anal intercourse (UAI) with any partners they did not know to be the same HIV serostatus as themselves. Not knowing oneself to be HIV-negative, not having a clear intention to use condoms, and more frequent group sex were independently associated with UAI. This study shows that gay men who engage in group sex represent an important priority for targeted HIV prevention activities and research.     

HIV risk behaviour among gay and bisexual men in Budapest, Hungary

HIV is a growing public health threat in Central and Eastern Europe. In Hungary and a number of other countries, men who have sex with men (MSM) account for a high proportion of HIV infections. However, there has been very little systematic study of the sexual risk practices and characteristics of MSM in this region. This study surveyed 469 MSM recruited in Budapest gay community venues in June 2001. Half the men (50%) engaged in unprotected anal intercourse (UAI) in the past 3 months. Of these, 40% of men's insertive and 50% of their receptive acts were unprotected, and 25% had multiple AI partners in the past 3 months. 17% of MSM exchanged sex for money, 26% had female partners in the past year, and condoms were used in only 23% of their vaginal intercourse occasions. Multivariate analyses showed that high-risk behaviour was predicted by not having condoms available when needed, weak risk reduction intentions, negative attitudes toward safer sex, being in a steady relationship, and having a bisexual orientation. Community-based HIV prevention programmes focused on the needs of gay or bisexual men in Central and Eastern Europe are urgently needed.