Recruiting an underserved, difficult to reach population into a cancer trial: Strategies from the Restore-2 Rehabilitation Trial for gay and bisexual prostate cancer patients.

BACKGROUND/AIMS: Sexual minorities are small and under-researched populations that are at disproportionate risk for cancer and poor cancer outcomes. Described as a "hidden population," the principal research challenge has been to develop effective methods to identify and recruit such cancer patients into cancer studies. Online recruitment strategies, as well as targeted clinic recruitment using patient-entered sexual orientation and gender identity data from electronic medical records have potential to transform recruitment, but studies testing the effects of how to recruit using these have not been published. METHODS: In 2019, we conducted a naturalistic, three-arm, stratified prospective study to compare three recruitment strategies: (a) clinic based recruitment of prostate cancer patients from gay health and urology clinics; (b) directly from the gay community; and (c) online recruitment (through cancer support, sex/dating, and social sites). For each strategy, we estimated time, workload, and direct costs involved. To study how recruitment strategy may affect sampling, we tested for retention rates, demographic and outcome differences across sites. Using these methods, we successfully recruited 401 gay and bisexual prostate cancer patients into a randomized, controlled, 24-month trial testing an online sexual and urinary rehabilitation curriculum tailored for this population. RESULTS: There were seven key results. First, it is possible to recruit substantial numbers of sexual minority men into prostate cancer studies provided online recruitment methods are used. Second, we observed big differences in dropout during study onboarding by recruitment source. Third, within online recruitment, the online sex/dating application (app) was the most successful and efficient, followed by the cancer support site, and then the social networking site. Fourth, while clinics were the cheapest source of recruitment, they were time intensive and low in yield. Fifth, the cancer support site and sex/dating app recruits differed by several characteristics, with the former being more rehabilitation-focused while the latter were younger and more sexually active. Sixth, we found almost no differences in outcomes across the three online recruitment sites. Seventh, because retention in online studies has been a concern, we confirm very low attrition at 3- and 6 months into the trial. CONCLUSION: For sexual minority cancer research, more research on how to use sexual orientation and gender identity electronic medical record data for clinic-based recruitment is needed. For other small or hard-to-reach populations, researchers should compare and publish online versus offline recruitment strategies.

Harassment and Violence Among Men Who Have Sex with Men (MSM) and Hijras After Reinstatement of India's "Sodomy Law".

On December 11, 2013, the Indian Supreme Court recriminalized non-peno-vaginal sex under Sec. 377 of the Indian Penal Code (IPC), overturning a 2009 ruling that deemed IPC Sec. 377 unconstitutional. Similar "sodomy laws" in other countries have been associated with increased violence, harassment, and other discrimination against men who have sex with men (MSM) and transgender women. However, few studies have looked at the effects of such a law in an Indian context. This study examined experiences of victimization among MSM and hijra/transgender women (MSM-H) in the State of Maharashtra using a mixed-method approach. Data came from a quantitative survey and qualitative focus groups and interviews from an HIV prevention study as well as qualitative media and case reports from a local MSM-H-serving community-based organization. MSM-H in Maharashtra reported experiencing a high frequency of harassment, violence, and extortion, particularly from male sex partners met online and police. IPC Sec. 377 was implicated across qualitative sources as creating a culture of protection for harassment against MSM-H by being used directly as a tool for harassment, hindering victims of harassment from seeking legal recourse, and adversely impacting HIV and healthcare services. The reinstated IPC Sec. 377 may directly and indirectly facilitate negative health outcomes among MSM-H. Health agencies and advocates should continue to monitor the impact of IPC Sec. 377, incorporate rights-based approaches to protect MSM-H identities while addressing their health and well-being, and explore avenues to initiate discussions with the government to work toward repealing the law.

Recruitment Strategies of Indian Men Who Have Sex with Men in the State of Maharashtra Into an Online Survey.

In this manuscript, we report lessons learned from our efforts to recruit Indian men and transgender women/hijras who have sex with men into an online cross sectional study. Between September 2013 and May 2014, we implemented a seven-phased recruitment strategy that included the use of online and offline strategies to enroll a total of 449 participants into an online survey about recent sexual behavior and various psychosocial measures. The phases were implemented sequentially and cost-per-eligible participant was calculated. Using social media and collaborating with organizers of community events proved the most effective strategies for recruiting Indian MSM into online research.

Recruitment Strategies of Methamphetamine-Using Men Who Have Sex with Men into an Online Survey.

Recruiting hidden populations into online research remains challenging. In this manuscript, we report lessons learned from our efforts to recruit methamphetamine-using men who have sex with men. Between July and October 2012, we implemented a four-phase recruitment strategy to enroll a total of 343 methamphetamine-using MSM into an online survey about recent substance use, sexual behavior, and various psychosocial measures. The four phases were implemented sequentially. During phase one, we placed advertisements on mobile applications, and during phase two, we placed advertisements on traditional websites formatted for browsers. During phase three, we used e-mail to initiate snowball recruitment, and during phase four, we used social media for snowball recruitment. Advertisements on mobile devices and websites formatted for browsers proved to be expensive options and resulted in few eligible participants. Our attempts to initiate a snowball through e-mail also proved unsuccessful. The majority (n=320) of observations in our final dataset came from our use of social media. However, participant fraud was a concern, requiring us to implement a strong participant verification protocol. For maximum recruitment and cost-effectiveness, researchers should use social media for recruitment provided they employ strong participant verification protocols.

Weight-related disparities for transgender college students.

OBJECTIVE: The objective of this study was to explore disparities in weight and weight-related behaviors by transgender identity. METHODS: Cross-sectional regression models were fit using 2007-2011 College Student Health Survey data. RESULTS: Compared to non-transgender, transgender subjects (N=53) were more likely to be either underweight [adjusted relative risk (95% CI): 4.78 (1.61-14.18)] or obese [2.45 (1.21-4.93)], and less likely to meet recommendations for strenuous physical activity [1.16 (1.01-1.34)], strengthening physical activity [1.32 (1.11-1.56)], and screen time [1.20 (1.02-1.41)]. CONCLUSIONS: More research is needed to understand the unique social contexts of transgender college students with regard to weight status, physical activity, and screen time in order to effectively inform intervention and policy development and implementation.

A Brief Scale to Measure Problematic Sexually Explicit Media Consumption: Psychometric Properties of the Compulsive Pornography Consumption (CPC) Scale among Men who have Sex with Men.

Although the phenomenon of hypersexuality has been described in the literature, and scales of compulsive sexual behavior have been published, the existing measures do not assess compulsive sexually explicit media (SEM) consumption. This study tested the psychometric properties of a new scale, the Compulsive Pornography Consumption (CPC). Exploratory and confirmatory factor analyses results showed good psychometric performance of a five item two factor preoccupation-compulsivity solution. As hypothesized, the scale correlates positively with compulsive sexual behavior, internalized homonegativity, and negatively with sexual self-esteem. The scale will enable researchers to investigate the etiologic factors of compulsive SEM use, and enable clinicians to assess problematic consumption.

Associations between partner-venue specific personal responsibility beliefs and transmission risk behavior by HIV-positive men who have sex with men (MSM).

Personal responsibility beliefs of HIV-positive individuals to protect sex partners are an important determinant of engagement in transmission risk behavior. However, the degree to which such beliefs vary across different partners is unknown. HIV-positive men who have sex with men (n = 248) completing an online survey rated their personal responsibility beliefs for partners met in up to four different ways: (a) in a bar; (b) through the internet; (c) in a public sex environment (PSE); or (d) through friends or family. For those reporting two or more partner-meeting venues in the prior 3 months (n = 98), about a third reported variation in responsibility ratings. Means among the venues were compared in pairwise fashion, with the strongest beliefs accruing to partners met through friends or family and the least with partners met in PSEs. These results provide further evidence that identifying ways to increase personal responsibility beliefs is an important goal, as well as is the application of Bandura's theory of moral agency to HIV transmission risk behavior.

Technology use and reasons to participate in social networking health websites among people living with HIV in the US.

Online social media and mobile technologies hold potential to enhance adherence to antiretroviral therapy (ART), although little is known about the current use of these technologies among people living with HIV (PLWH). To address this gap in understanding, 312 PLWH (84% male, 69% White) US adults completed an online survey in 2009, from which 22 persons accepted an invitation to participate in one of two online focus groups. Results showed that 76% of participants with lower ART adherence used social networking websites/features at least once a week. Their ideal online social networking health websites included one that facilitated socializing with others (45% of participants) and ones with relevant HIV informational content (22%), although privacy was a barrier to use (26%). Texting (81%), and to a lesser extent mobile web-access (51%), was widely used among participants. Results support the potential reach of online social networking and text messaging intervention approaches.

Online and offline sexual health-seeking patterns of HIV-negative men who have sex with men.

To inform health information targeting, we used cross-sectional data from 2577 HIV-negative MSM to identify groups of men who access similar sources. Offline, more men reported talking to a physician about HIV than about having sex with men; fewer than half attended a safer sex workshop. Online, men sought information primarily through Internet search engines, GLBT websites, or health websites. A latent class analysis identified four groups of health seekers: minimal health seekers, those who accessed online sources only, those who sought information mostly from health professionals, and those who sought information from diverse sources. Minimal health seekers, 9% of the sample, were the group of greatest concern. They engaged in unprotected anal sex with multiple partners but infrequently testing for HIV or sought sexual health information. By encouraging health seeking from diverse sources, opportunities exist to increase men's knowledge of HIV/STI prevention and, when necessary, access to medical care.

Ascertaining partner HIV status and its association with sexual risk behavior among internet-using men who have sex with men.

The aims of this study were to understand strategies and consistency of strategy used by HIV-negative and HIV-positive men who have sex with men (MSM) to ascertain the HIV status of their male sexual partners and their associations with unprotected anal intercourse (UAI) and serodiscordant UAI (SDUAI) in the past 3 months. Participants (n = 640) completed an online survey in December 2007. The most commonly reported strategy was checking online profiles (85%), followed by talking before sex (82%), talking after sex (42%), and guessing (29%). Adjusting for demographic and behavioral factors, guessing the HIV status of sex partners was associated with greater UAI and SDUAI partners, as was using an inconsistent strategy. Ascertaining HIV status before having sex was associated with fewer SDUAI partners. Prevention should target MSM who guess the HIV status of their sex partners and emphasize explicit safer sex agreements.

Comparison of substance use and risky sexual behavior among a diverse sample of urban, HIV-positive men who have sex with men.

The purpose of this study was to examine substance use among a racially and ethnically diverse group of HIV-positive men who have sex with men (MSM) living in six U.S. cities, model associations between drug use and serodiscordant unprotected anal intercourse (SDUAI), and characterize users of the substances strongly associated with risky sexual behavior. Baseline questionnaire data from 675 participants of the Positive Connections intervention trial were analyzed. Overall, substance use was common; however, the highest percentage of stimulant (30%), methamphetamine (27%), and popper (i.e., amyl nitrite) (46%) use was reported among white MSM and crack/cocaine (38%) use was highest among African American MSM. Popper use versus non-use (odds ratio = 2.46; 95% confidence interval = 1.55-3.94) and condom self-efficacy (1 standard deviation (sd) increase on scale; odds ratio = .58; 95% confidence interval = .46-.73) were significantly associated with SDUAI after adjusting for key demographic and psychosocial factors. These results highlight the importance of addressing drug use in the context of sex for possible HIV transmission risk.

Predictors of HIV disclosure to secondary partners and sexual risk behavior among a high-risk sample of HIV-positive MSM: results from six epicenters in the US.

This study sought to identify predictors of HIV disclosure and serodiscordant unprotected anal intercourse (SDUAI) among HIV-positive men who have sex with men (MSM). Between January 2005 and April 2006, 675 HIV-positive MSM were recruited into the Positive Connections intervention trial held in six US cities with intentional over-sampling of HIV-positive MSM of Color (74%) and men engaging in unprotected anal intercourse (UAI) in the previous year. Baseline survey data showed 30 and 31%, respectively, of participants disclosed to none or some of their secondary sex partners in the last 90 days. Greater disclosure to secondary partners was associated with having fewer sexual partners, being extremely out as MSM, longer HIV diagnosis, knowledge of CD4 count, detectable viral load and being white. Disclosure to all secondary partners was associated with lower SDUAI. Recommendations for prevention for HIV-positive MSM include the promotion of serodisclosure to all secondary partners and increasing comfort with, and outness about, one's sexuality.

Are gay communities dying or just in transition? Results from an international consultation examining possible structural change in gay communities.

This study sought to identify how urban gay communities are undergoing structural change, reasons for that change, and implications for HIV prevention planning. Key informants (N=29) at the AIDS Impact Conference from 17 cities in 14 countries completed surveys and participated in a facilitated structured dialog about if gay communities are changing, and if so, how they are changing. In all cities, the virtual gay community was identified as currently larger than the offline physical community. Most cities identified that while the gay population in their cities appeared stable or growing, the gay community appeared in decline. Measures included greater integration of heterosexuals into historically gay-identified neighborhoods and movement of gay persons into suburbs, decreased number of gay bars/clubs, less attendance at gay events, less volunteerism in gay or HIV/AIDS organizations, and the overall declining visibility of gay communities. Participants attributed structural change to multiple factors including gay neighborhood gentrification, achievement of civil rights, less discrimination, a vibrant virtual community, and changes in drug use. Consistent with social assimilation, gay infrastructure, visibility, and community identification appears to be decreasing across cities. HIV prevention planning, interventions, treatment services, and policies need to be re-conceptualized for MSM in the future. Four recommendations for future HIV prevention and research are detailed.