A longitudinal analysis of HIV treatment adherence among men who have sex with men: a cognitive escape perspective.

HIV is best managed by adhering to both medication and HIV care appointment schedules. Nonetheless, many HIV-positive men who have sex with men (MSM) report low levels of adherence to both. To explain this, we tested a cognitive escape model whereby drug and alcohol use mediate the effects of depression on HIV medication and appointment adherence. We used longitudinal data (n=856) from a behavioral intervention promoting increased treatment adherence among HIV-positive MSM. All model variables predicted appointment adherence, and our mediation hypotheses were supported. Conversely, although depression related to medication adherence, substance use did not mediate this relationship, as predicted. Self-reported appointment, but not medication, adherence related to changes in viral load over time. Therefore, cognitive escape characterizes appointment, but not medication, adherence within this sample. Future behavioral interventions for this population should target HIV appointment adherence, given its relationship to important clinical, psychological, and behavioral outcomes.

Depression is associated with sexual risk among men who have sex with men, but is mediated by cognitive escape and self-efficacy.

Men who have sex with men (MSM) show high rates of HIV infection, and higher rates of depression than non-MSM. We examined the association between depression and sexual risk among "high risk" MSM. Evidence has been mixed regarding the link between depression and risky sex, although researchers have rarely considered the role of psychosocial vulnerabilities such as self-efficacy for sexual safety or "escape" coping styles. In a national sample (N = 1,540) of HIV-positive and HIV-negative MSM who reported unprotected sex and drug use with sex partners, we found evidence that depression is related to HIV transmission risk. Self-efficacy for sexual safety and cognitive escape mediated the link between depression and risk behavior, suggesting that psychosocial vulnerability plays an important role in the association of depression with sexual risk. These findings may help us construct more accurate theories regarding depression and sexual behavior, and may inform the design of sexual safety interventions.

Ethnic differences in HIV-disclosure and sexual risk.

Little is known about ethnic differences in HIV-disclosure to sexual partners or the relationship between HIV-disclosure and sexual risk. Differences in HIV-disclosure rates between African-American and White men who have sex with men (MSM) were analyzed using data from the Treatment Advocacy Program. In general, the findings suggest that African-Americans are less likely than Whites to disclose their HIV status to sexual partners. The findings also suggest that the African-American participants who disclosed to HIV-negative partners were significantly less likely to engage in unprotected anal sex with HIV-negative partners and partners whose HIV status was unknown than those participants who did not disclosure to HIV-negative partners. Although HIV-disclosure appears to be an important factor to consider in HIV-prevention efforts, there are unique factors that influence HIV-disclosure decisions for African-American MSM. Interventions should consider these unique challenges before focusing on HIV-disclosure as a primary tool for reducing the transmission of HIV.

An intervention to reduce HIV risk behavior of substance-using men who have sex with men: a two-group randomized trial with a nonrandomized third group.

BACKGROUND: Substance use during sex is associated with sexual risk behavior among men who have sex with men (MSM), and MSM continue to be the group at highest risk for incident HIV in the United States. The objective of this study is to test the efficacy of a group-based, cognitive-behavioral intervention to reduce risk behavior of substance-using MSM, compared to a randomized attention-control group and a nonrandomized standard HIV-testing group. METHODS AND FINDINGS: Participants (n = 1,686) were enrolled in Chicago, Los Angeles, New York City, and San Francisco and randomized to a cognitive-behavioral intervention or attention-control comparison. The nonrandomized group received standard HIV counseling and testing. Intervention group participants received six 2-h group sessions focused on reducing substance use and sexual risk behavior. Attention-control group participants received six 2-h group sessions of videos and discussion of MSM community issues unrelated to substance use, sexual risk, and HIV/AIDS. All three groups received HIV counseling and testing at baseline. The sample reported high-risk behavior during the past 3 mo prior to their baseline visit: 67% reported unprotected anal sex, and 77% reported substance use during their most recent anal sex encounter with a nonprimary partner. The three groups significantly (p<0.05) reduced risk behavior (e.g., unprotected anal sex reduced by 32% at 12-mo follow-up), but were not different (p>0.05) from each other at 3-, 6-, and 12-mo follow-up. Outcomes for the 2-arm comparisons were not significantly different at 12-mo follow-up (e.g., unprotected anal sex, odds ratio = 1.14, confidence interval = 0.86-1.51), nor at earlier time points. Similar results were found for each outcome variable in both 2- and 3-arm comparisons. CONCLUSIONS: These results for reducing sexual risk behavior of substance-using MSM are consistent with results of intervention trials for other populations, which collectively suggest critical challenges for the field of HIV behavioral interventions. Several mechanisms may contribute to statistically indistinguishable reductions in risk outcomes by trial group. More explicit debate is needed in the behavioral intervention field about appropriate scientific designs and methods. As HIV prevention increasingly competes for behavior-change attention alongside other "chronic" diseases and mental health issues, new approaches may better resonate with at-risk groups. TRIAL REGISTRATION: ClinicalTrials.gov NCT00153361. Please see later in the article for the Editors' Summary.

Relationship characteristics associated with anal sex among female drug users.

BACKGROUND: Anal sex is an important yet little studied HIV risk behavior for women. METHODS: Using information collected on recent sexual encounters, we examined the influence of sex partner and relationship characteristics on the likelihood of engaging in anal sex among women with a high risk of HIV infection. RESULTS: Anal sex was nearly 3 times more common among actively bisexual women (OR = 2.96, 95% CI: 2.17-4.03). Women were more likely to have anal sex with partners who injected drugs (OR = 2.32, 95% CI: 1.44-3.75), were not heterosexual (OR = 1.85, 95% CI: 1.18-2.90), and with whom they exchanged money or drugs for sex (OR = 1.79, 95% CI: 1.10-2.90). The likelihood of anal sex also increased with the number of nights sleeping together (OR = 1.15, 95% CI: 1.06-1.24). In contrast, emotional closeness and social closeness were not associated with anal sex. Condom use during anal sex was uncommon, and did not vary according to partner or relationship characteristics. CONCLUSIONS: Our findings support the need for HIV prevention interventions that target anal sex among heterosexuals, particularly in drug-using populations residing in neighborhoods with elevated levels of HIV prevalence.

Differences in sexual identity, risk practices, and sex partners between bisexual men and other men among a low-income drug-using sample.

Men who have sex with men and women (MSMW) represent an important target population for understanding the spread of HIV because of the inherent bridging aspect of their sexual behavior. Despite their potential to spread HIV between gender groups, relatively little recent data have been reported about this population as a subgroup distinct from men who have sex with men only. This paper analyzes data from the Chicago site of Sexual Acquisition and Transmission of HIV Cooperative Agreement Program to characterize 343 MSMW in terms of their demographics, drug use, sexual risk behavior, sexual identity, and sex partners. Results show the MSMW sample to be extremely disadvantaged; to have high rates of drug use, including injection and crack use; to report more female than male sex partners; to not differ from gay and heterosexual men in rates of condom use; and, for the most part, to report sexual identities that are consistent with their sex behavior. MSMW represent an important subpopulation in the HIV epidemic and should be targeted for risk reduction interventions.

Methamphetamine and young men who have sex with men: understanding patterns and correlates of use and the association with HIV-related sexual risk.

OBJECTIVE: To examine patterns, consequences, and correlates of methamphetamine use among adolescent and young adult men who have sex with men (YMSM). DESIGN: Descriptive, bivariate, and hierarchical regression analyses of cross-sectional data. SETTING: Howard Brown Health Center, a community-based facility in Chicago, Ill, from August 2004 to September 2005. PARTICIPANTS: Three hundred ten YMSM who completed an anonymous, computer-assisted survey. MAIN OUTCOME MEASURE: Methamphetamine use in the past year. RESULTS: Participants ranged in age from 16 to 24 years (mean age, 20.3 years); 30% were white and 70% were of other race/ethnicity (African American, 33%; Hispanic, 26%; Asian or Pacific Islander, 3%; and other, 8%). Participants reported many high-risk sexual and substance use behaviors. Thirteen percent used methamphetamine in the past year. Methamphetamine use was more common among human immunodeficiency virus-infected participants (odds ratio, 2.8; 95% confidence interval, 1.3-5.3) and varied by age and race/ethnicity; substantially higher prevalence was reported by older and non-African American YMSM (P<.001). Compared with other illicit substance users, methamphetamine users reported more memory difficulties, impairments in daily activities, and unintended risky sex resulting from substance use (all P<.01). Hierarchical regression identified sexual risk (unprotected intercourse and multiple partners), sexualized social context (eg, Internet sex, sex in a bathhouse or sex club, sex with older partners, and commercial sex), lower self-esteem, and psychological distress as correlated with methamphetamine use among participants (P<.05). CONCLUSIONS: A substantial percentage of YMSM in this sample used methamphetamine. Methamphetamine use is a public health problem with significant implications for the health and well-being of YMSM. Methamphetamine use was associated with human immunodeficiency virus-related risk, and patterns of use were predicted by demographic data, sexualized social contexts, and psychological variables.

Alcohol use and high-risk sexual behavior among men who have sex with men: the effects of consumption level and partner type.

Alcohol use may increase HIV sexual risk behavior, although findings have varied across study populations and methods. Using event-level data from 1,712 seronegative men who have sex with men, the authors tested the hypothesis that social context would moderate the effect of alcohol consumption on unprotected anal sex (UAS). For encounters involving a primary partner, rates of UAS did not vary as a function of alcohol use. However, consumption of 4 or more drinks tripled the likelihood of UAS for episodes involving a nonprimary partner. Thus, the effects of alcohol vary according to the context in which it is used. Interventions to reduce substance-related risk should be tailored to the demands of maintaining sexual safety with nonprimary partners.

Viral load and HIV treatment attitudes as correlates of sexual risk behavior among HIV-positive gay men.

OBJECTIVES: People living with HIV who achieve an "undetectable" viral load may assume that they are less infectious, leading to increased sexual risk. We examined the relation between perceiving that one has an undetectable viral load and sexual risk taking among gay men. METHODS: HIV-positive participants (N=60) completed measures assessing HIV serostatus, perceived HIV viral load (detectable vs. undetectable), sexual risk and treatment attitudes. RESULTS: Contrary to hypotheses, HIV-positive men with detectable viral loads were more likely to report unprotected anal sex with a nonprimary partner than were men reporting undetectable viral loads. Although a significant minority endorsed the belief that an HIV-positive partner with an undetectable viral load is less infectious, this belief was unrelated to sexual risk. Multivariate analyses showed that the strongest predictor of sexual risk was a measure assessing participants' reduced concern over HIV stemming from the availability of improved HIV treatments. After controlling for reduced HIV concern, viral load status was no longer a significant predictor of risk. CONCLUSIONS: Results suggest that reduced concern about the consequences of HIV infection may be more important than perceived health status as a determinant of risky sex and highlight the need for continued prevention efforts among people who are HIV-positive.

Depressive Symptoms, Illicit Drug Use and HIV/STI Risk Among Sexual Minority Young Adults.

This study examined the interaction of depressive symptoms and drug use on HIV/STI risk among sexual minority young adults. Analyses tested the interactive effect of depressive symptoms and drug use on unprotected sex. Among drug users, more depressive symptoms were associated with higher rates of unprotected sex with a male partner (for both male and female participants) but this was non-significant for non-users. Interventions with these groups should incorporate content on depression and drug use to reduce HIV/STI risk. Prevention efforts also should not neglect the vulnerability of young women that have sex with women and/or identify as non-heterosexual.

Health care access and health behaviors among men who have sex with men: the cost of health disparities.

Men who have sex with men (MSM) appear to experience barriers to health care compared with general population men. This report examines individual differences in health care access within a diverse sample of urban MSM (N = 871). The authors examined demographic differences in health care access and the relation between access and health-related attitudes, health behaviors, and HIV transmission risk. They operationalized health care access in terms of three indicators: perceived barriers, insurance status, and recent medical visit. Twenty-seven percent (n = 227) of MSM reported zero or one health care access indicator. African American and Latino race/ethnicity, lower income, and HIV-unknown status were associated with limited health care access. Limited health care access was related to health care attitudes (mistrust in the health care system and difficulty disclosing MSM status to providers), general health behaviors (smoking, never being HIV-tested, and drug abuse), and sexual risk-related variables (low self-efficacy for sexual safety, consistent drug use during sex, and HIV transmission risk). Overall, among MSM, less health care access relates to several adverse psychological constructs and health behaviors. Researchers and public health officials should address limited health care access, and its consequences, in this population.

Assessing treatment motivation among patients receiving antiretroviral therapy: a multidimensional approach.

Using multidimensional scaling (MDS) analysis, this study examined how patient conceptualisations of treatment motivation compare with theoretically based assumptions used in current assessment approaches. Patients undergoing antiretroviral therapy for HIV/AIDS (n=39) rated for similarity between all possible pairings of 23 treatment descriptions, including descriptors of intrinsic, extrinsic, approach and avoidance motivation. MDS analyses revealed that patient perceptions of intrinsic and extrinsic motivations often differ from those based on definitions derived from common interpretations of self-determination theory. Findings also showed that patients reported motivation for avoiding treatment when they associated their medication regimens with side effects and other negatively valenced outcomes. The study describes new applications of MDS in assessing how patients perceive the relationship between treatment behaviours and specific forms of motivation, such as intrinsic and extrinsic motivations. In addition, the study suggests how MDS may be used to develop behavioural strategies aimed at helping patients follow their regimens consistently by identifying treatment conceptualisations and contexts that facilitate or impede adherence.

The Treatment Advocacy Program: a randomized controlled trial of a peer-led safer sex intervention for HIV-infected men who have sex with men.

OBJECTIVE: Primary care may be an effective venue for delivering behavioral interventions for sexual safety among HIV-positive men who have sex with men (MSM); however, few studies show efficacy for such an approach. We tested the efficacy of the Treatment Advocacy Program (TAP), a 4-session, primary-care-based, individual counseling intervention led by HIV-positive MSM "peer advocates" in reducing unprotected sex with HIV-negative or unknown partners (HIV transmission risk). METHOD: We randomized 313 HIV-positive MSM to TAP or standard care. HIV transmission risk was assessed at baseline, 6 months, and 12 months (251 participants completed all study waves). We conducted intent-to-treat analyses using general estimating equations to test the interaction of group (TAP vs. standard care) by follow-up period. RESULTS: At study completion, TAP participants reported greater transmission risk reduction than did those receiving standard care, χ2(2, N = 249) = 6.6, p = .04. Transmission risk among TAP participants decreased from 34% at baseline to about 20% at both 6 and 12 months: Transmission risk ranged from 23% to 25% among comparison participants. CONCLUSIONS: TAP reduced transmission risk among HIV-positive MSM, although results are modest. Many participants and peer advocates commented favorably on the computer structure of the program. We feel that the key elements of TAP-computer-based and individually tailored session content, delivered by peers, in the primary care setting-warrant further exploration.

Intimate partner abuse among gay and bisexual men: risk correlates and health outcomes.

Little is known about the patterns and types of intimate partner abuse in same-sex male couples, and few studies have examined the psychosocial characteristics and health problems of gay and bisexual men who experience such abuse. Using a cross-sectional survey sample of 817 men who have sex with men (MSM) in the Chicago area, this study tested the effect of psychological and demographic factors generally associated with intimate partner abuse and examined their relationship to various health problems. Overall, 32.4% (n = 265) of participants reported any form of relationship abuse in a past or current relationship; 20.6% (n = 168) reported a history of verbal abuse ("threatened physically or sexually, publicly humiliated, or controlled"), 19.2% (n = 157) reported physical violence ("hit, kicked, shoved, burned, cut, or otherwise physically hurt"), and 18.5% (n = 151) reported unwanted sexual activity. Fifty-four percent (n = 144) of men reporting any history of abuse reported more than one form. Age and ethnic group were unrelated to reports of abuse. Depression and substance abuse were among the strongest correlates of intimate partner abuse. Men reporting recent unprotected anal sex were more likely to also report abuse, Wald (1, n = 773) = 9.02, p < .05, Odds Ratio (OR) = 1.61, Confidence Interval (CI) = 1.18-2.21. We discuss psychosocial issues faced by gay and bisexual men who experience intimate partner abuse as they may pertain to interventions among this group.

Elevated risk for tobacco use among men who have sex with men is mediated by demographic and psychosocial variables.

Men who have sex with men (MSM) may be more likely to smoke than general population men. Such population comparisons typically do not control for demographic differences and have not tested reasons for MSMs' greater tobacco use. We compared MSM with general population men in data that allowed us to control demographic differences, and hypothesized that MSM would report more tobacco use, due to elevated levels of three psychosocial variables that generally predict tobacco use: depression symptoms, alcohol use, and limited health access. Data were from a 2001 survey of MSM in Chicago (n = 817) and from the 2001 National Health Interview Study (n = 7,783). Significantly more MSM used tobacco, particularly younger MSM. Depression symptoms, alcohol use, and limited health access were more common among MSM and partially accounted for their elevated smoking risk. The lower health access and greater vulnerability of MSM to depression and alcohol use contributed to their higher smoking rate and must be considered in further smoking research and prevention. Younger MSM show very high rates of smoking and are a particular intervention target. Limitations of this cross-sectional study are noted.

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.

Herpes simplex virus type 2 infection as a risk factor for human immunodeficiency virus acquisition in men who have sex with men.

The association of human immunodeficiency virus (HIV) acquisition with herpes simplex virus type 2 (HSV-2) was assessed among men who have sex with men (MSM) in a nested case-control study of 116 case subjects who seroconverted to HIV during follow-up and 342 control subjects who remained HIV seronegative, frequency-matched by follow-up duration and report of HIV-infected sex partner and unprotected anal sex. The baseline HSV-2 seroprevalence was higher among case (46%) than control (34%) subjects (P=.03); the HSV-2 seroincidence was 7% versus 4% (P=.3). Only 15% of HSV-2-infected MSM reported herpes outbreaks in the past year. HIV acquisition was associated with prior HSV-2 infection (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1-2.9), reporting >12 sex partners (OR, 2.9; 95% CI, 1.4-6.3), and reporting fewer herpes outbreaks in the past year (OR, 0.3; 95% CI, 0.1-0.8). HSV-2 increases the risk of HIV acquisition, independent of recognized herpes lesions and behaviors reflecting potential HIV exposure. HSV-2 suppression with antiviral therapy should be evaluated as an HIV prevention strategy among MSM.