Associations of adverse and protective childhood experiences with thwarted belongingness, perceived burdensomeness, and suicide risk among sexual minority men.

BACKGROUND: Sexual minority men (SMM) experience higher suicidal ideation and suicide attempts than the general population. We examined the associations of adverse childhood experiences (ACES) and protective and compensatory childhood experiences (PACES) with suicidal ideation and suicide attempts in adulthood via thwarted belongingness and perceived burdensomeness among SMM. METHODS: Data are from the UNITE study, a national longitudinal cohort study of HIV-negative SMM from the 50 U.S. states and Puerto Rico. Between 2017 and 2019, participants (N = 6303) completed web-based assessments at baseline and 12-month follow-up. ACES and PACES occurring before the age of 18, and current symptoms of thwarted belongingness and perceived burdensomeness were assessed at baseline. Past-week suicidal ideation and past-year suicide attempt were assessed at follow-up. RESULTS: 424 (6.7%) participants reported past-week suicidal ideation and 123 (2.0%) reported a past-year suicide attempt. The results of our multivariate model suggest that each additional adverse childhood experience was prospectively associated with 14% higher odds of past-week suicidal ideation (AOR = 1.14, 95% CI 1.09-1.19) and 19% higher odds of past-year suicide attempt (AOR = 1.19, 95% CI 1.11-1.29). Each additional protective childhood experience was prospectively associated with 15% lower odds of past-week suicidal ideation (AOR = 0.85, 95% CI 0.81-0.90) and 11% lower odds of past-year suicide attempt (AOR = 0.89, 95% CI 0.82-0.98). Perceived burdensomeness partially mediated these prospective associations. CONCLUSION: To reduce suicide, screening and treating perceived burdensomeness among SMM with high ACES may be warranted. PACES may decrease perceived burdensomeness and associated suicide risk.

Reactions to Testing HIV Negative: An Assessment of Measurement Invariance and Associations with Condomless Anal Sex among English and Spanish-speaking Latinx Sexual Minority Men in the United States.

Among the many effective prevention strategies, frequent HIV testing continues to be promoted to reduce the risk of HIV transmission among sexual minority men (SMM). Testing negative for HIV can result in varied reactions that influence subsequent HIV transmission behaviors, yet the extant research has primarily been conducted in English. The current study examined measurement invariance of a Spanish-translated Inventory of Reactions to Testing HIV Negative (IRTHN). The study also examined whether the IRTHN was associated with subsequent condomless anal sex. Data were drawn from 2,170 Latinx SMM subsample of the UNITE Cohort Study. We conducted a multigroup confirmatory factor analysis to test for measurement invariance between participants who opted to take the survey in English (n = 2,024) and those who opted to take it in Spanish (n = 128). We also examined if the IRTHN is associated with subsequent CAS. The results were suggestive of partial invariance. The subscales of Luck and Invulernability were associated with CAS at the 12-month follow-up. Practice and research-based implications are discussed.

Examining inequities in rates of undiagnosed HIV and rectal STIs in a large nationwide cohort study of sexual minority men.

OBJECTIVE: Sexual minority men (SMM) of colour are disproportionately impacted by HIV and bacterial STIs (bSTIs). To better understand within-group heterogeneity and differential risk factors by race and ethnicity, we sought to examine rates of undiagnosed HIV and rectal bSTI at the intersection of racial and ethnic identity with other sociodemographic factors. METHODS: We examined data from 8105 SMM conducting home-based self-testing at enrolment in a nationwide cohort study collected from November 2017 to August 2018. We conducted analyses stratified by racial and ethnic groups to examine within-group (ie, subgroup) unadjusted rates of HIV and rectal bSTI infection across a range of characteristics. RESULTS: Rates of undiagnosed HIV were highest among Black (4.3%, n=39) and Latino (2.4%, n=38) SMM, with lower rates among those identified as multiracial (1.6%, n=15), white (1.3%, n=56) and other races (1.3%, n=6). Across the stratified analyses of HIV infection, 15 significant associations emerged showing that age, region, insurance type, sexual positioning and incarceration history had differential impacts across racial and ethnic groups. In particular, private and public insurance were protective against HIV for white but not Black and Latino SMM, and incarceration was associated with substantially higher rates of HIV infection for Black and Latino SMM relative to white SMM. We found significant co-occurrence of HIV and bSTI rates for participants who identified as Latino (OR=7.5, 95% CI 2.12 to 26.54), white (OR=3.19, 95% CI 1.14 to 8.98) and multiracial (OR=5.5, 95% CI 1.08 to 27.90), but not those who identified as Black (OR=0.82, 95% CI 0.10 to 6.56) or other races (OR=3.56 95% CI 0.31 to 40.80). CONCLUSIONS: Stratified analyses showed differential rates of HIV infection at the intersection of racial and ethnic groups with other characteristics, particularly insurance status and incarceration history, pointing to structural inequities rather than individual behaviours underlying disproportionately high rates of HIV for Black and Latino SMM.

Differences in HIV Risk and Prevention Among Cisgender Latino Sexual Minority Men by Language of Online Survey Completion: Analysis of National and Washington State Data.

Internet-based surveys can be programmed and advertised in multiple languages to reach non-English-speaking individuals, but it is unclear the extent to which this enhances the diversity of participants and supports inclusion of individuals at higher risk for HIV. We sought to examine how language of survey completion (English or Spanish) was associated with sociodemographic characteristics and indicators of HIV risk and prevention among cisgender Latino sexual minority men (SMM). We analyzed national and Washington State data using the Understanding New Infections through Targeted Epidemiology (UNITE) Cohort Study (2017 and 2018) and the Washington HIV/STI Prevention Project (WHSPP) survey (2017 and 2018/2019), respectively. Latino SMM who completed online surveys in Spanish differed from those who completed surveys in English across several sociodemographic characteristics including age, education, and income. After adjusting for sociodemographic characteristics and HIV-related risk factors, Spanish language respondents in UNITE were less likely to have tested for HIV in the past year, and those in WHSPP were more likely to report a recent STI diagnosis. Findings suggest that Latino SMM who complete surveys in Spanish comprise a unique subgroup that may have a specific HIV health and risk behavior profile. Our results suggest a need for increased and tailored efforts to recruit and include Spanish-speaking Latino SMM for local and national research and public health programming.

RESUMEN: Encuestas por internet pueden ser programadas y anunciadas para alcanzar a personas que no hablan inglés, pero no queda claro si esto pueda mejorar la diversidad de los participantes de investigación y apoyar la inclusión de los individuos de alto riesgo a infección con el VIH. En este estudio examinamos la relación del idioma de completar la encuesta en línea (inglés o español) entre hombres Latinos de minorías sexuales (HLMS) cisgénero con características sociodemográficas y determinantes para el riesgo y prevención del VIH. Analizamos los datos nacionales y estatales con el estudio de cohorte de Understanding New Infections through Targeted Epidemiology (UNITE) (2017 y 2018) y El Proyecto de Washington para la Prevención del VIH/Infecciones de Transmisión Sexual (WHSPP) (2017 y 2018/2019), respectivamente. Los HLSM quienes completaron las encuestas por internet en español fueron diferentes a los que completaron las encuestas en inglés por varias características sociodemográficas incluso la edad, la educación, y el ingreso. Después de ajustar por las características sociodemográficas y los factores de riesgo asociados con el VIH, los participantes de UNITE que respondieron en español tuvieron menos probabilidad de haberse hecho la prueba de VIH en el año pasado y los que participaron en el WHSPP eran más probable que reportaran un diagnóstico de ITS. Los resultados indican que los HLSM quienes completan las encuestas en español representan un subgrupo distinto que tiene un perfil específico de comportamiento de riesgo y salud respecto al VIH. Los resultados demuestran la necesidad de mayores esfuerzos especializados para reclutar e incluir los HLSM quienes hablan español para que participen en las investigaciones en línea a nivel local y nacional y la programación de la salud pública.

Intersecting Structural Oppression and Suicidality Among Black Sexual Minority Male Adolescents and Emerging Adults.

This study examined associations between structural racism, anti-LGBTQ policies, and suicide risk among young sexual minority men (SMM). Participants were a 2017-2018 Internet-based U.S. national sample of 497 Black and 1536 White SMM (ages 16-25). Structural equation modeling tested associations from indicators of structural racism, anti-LGBTQ policies, and their interaction to suicide risk factors. For Black participants, structural racism and anti-LGBTQ policies were significantly positively associated with depressive symptoms, heavy drinking, perceived burdensomeness, thwarted belongingness, self-harm, and suicide attempt. There were significant interaction effects: Positive associations between structural racism and several outcomes were stronger for Black participants in high anti-LGBTQ policy states. Structural racism, anti-LGBTQ policies, and their interaction were not significantly associated with suicide risk for White SMM.

Leveraging Technology to Blend Large-Scale Epidemiologic Surveillance With Social and Behavioral Science Methods: Successes, Challenges, and Lessons Learned Implementing the UNITE Longitudinal Cohort Study of HIV Risk Factors Among Sexual Minority Men in the United States.

The use of digital technologies to conduct large-scale research with limited interaction (i.e., no in-person contact) and objective endpoints (i.e., biological testing) has significant potential for the field of epidemiology, but limited research to date has been published on the successes and challenges of such approaches. We analyzed data from a cohort study of sexual minority men across the United States, collected using digital strategies during a 10-month period from 2017 to 2018. Overall, 113,874 individuals were screened, of whom 26,000 were invited to the study, 10,691 joined the study, and 7,957 completed all enrollment steps, including return of a human immunodeficiency virus-negative sample. We examined group differences in completion of the steps towards enrollment to inform future research and found significant differences according to several factors, including age and race. This study adds to prior work to provide further proof-of-concept for this limited-interaction, technology-mediated methodology, highlighting some of its strengths and challenges, including rapid access to more diverse populations but also potential for bias due to differential enrollment. This method has strong promise, and future implementation research is needed to better understand the roles of burden, privacy, access, and compensation, to enhance representativeness and generalizability of the data generated.

Heterosexual Cisgender Men Partnered with Transgender Women Exhibit Higher HIV/STI Sexual Risk than Their Gay, Bisexual, and Queer Counterparts: Findings from a U.S.-Based Convenience Sample Recruited Online.

Cisgender men are frequently vectors for HIV transmission among transgender women. Despite this, the correlates of sexual risk among these men remain under-examined. The purpose of the present study was to explore potential differences in relationship characteristics, sexual risk-taking, and risk-reduction strategies among cisgender men partnered with transgender women. The study utilized secondary screening data provided by adult cis men who reported being in a primary relationship with a trans woman (N = 710). Gay men (18%) were comparatively older, and most likely to report both HIV seropositivity and committed pairings. Heterosexual men (14%) were more likely to report exchange sex, briefer relationships, extra-dyadic sex, lesser serostatus awareness or PrEP uptake. Queer men (7%) were youngest, and most likely to access PrEP. Heterosexual cis men with trans women partners may be subject to unique socio-cultural drivers of sexual risk, such as heteronormative pressures and relationship stigma.

Modeling Adherence Interventions Among Youth with HIV in the United States: Clinical and Economic Projections.

The Adolescent Medicine Trials Network for HIV/AIDS Interventions is evaluating treatment adherence interventions (AI) to improve virologic suppression (VS) among youth with HIV (YWH). Using a microsimulation model, we compared two strategies: standard-of-care (SOC) and a hypothetical 12-month AI that increased cohort-level VS in YWH in care by an absolute ten percentage points and cost $100/month/person. Projected outcomes included primary HIV transmissions, deaths and life-expectancy, lifetime HIV-related costs, and incremental cost-effectiveness ratios (ICERs, $/quality-adjusted life-year [QALY]). Compared to SOC, AI would reduce HIV transmissions by 15% and deaths by 12% at 12 months. AI would improve discounted life expectancy/person by 8 months at an added lifetime cost/person of $5,300, resulting in an ICER of $7,900/QALY. AI would be cost-effective at $2,000/month/person or with efficacies as low as a 1 percentage point increase in VS. YWH-targeted adherence interventions with even modest efficacy could improve life expectancy, prevent onward HIV transmissions, and be cost-effective.

RESUMEN: La Red de Ensayos Médicos sobre Adolescentes para Realizar Intervenciones sobre el VIH/SIDA está evaluando intervenciones de adherencia (IAs) al tratamiento para mejorar la supresión virológica (SV) entre los jóvenes con VIH (JCV). Usando un modelo de microsimulación, comparamos dos estrategias: cuidado convencional (CC) y una intervención de adherencia hipotética durando 12 meses que aumentaría la SV a nivel de cohorte entre JCV en tratamiento por 10 puntos de porcentuales y que costaría US$ 100/mes/persona. Resultados proyectados incluyeron transmisiones de VIH primarias, muertes y esperanza de vida, costos de por vida asociados con el VIH, y razones incrementales de costo-efectividad (RICEs, $/año de vida ajustado por la calidad [AVAC]). Comparado al CC, la IA reduciría transmisiones de VIH por 15% y muertes por 12% a los 12 meses. La IA mejoraría esperanza de vida descontada/persona por 8 meses a un costo de por vida adicional/persona de US$ 5.300, resultando en una RICE de US$ 7.900/AVAC. La IA sería costo-efectiva a un costo de US$ 2.000/mes/persona o si mejorara SV por al menos un punto porcentual. Intervenciones de adherencia dirigidas a jóvenes con una eficacia incluso modesta podrían mejorar esperanza de vida, prevenir transmisiones de VIH, y ser costo-efectivas.

Sexual Subcultures and HIV Prevention Methods: An Assessment of Condom Use, PrEP, and TasP Among Gay, Bisexual, and Other Men Who Have Sex with Men Using a Social and Sexual Networking Smartphone Application.

Despite being grouped together in epidemiological risk categories, gay, bisexual, and other men who have sex with men (GBM) are not a homogenous group. In addition to traditional segmentation along race, ethnicity, and socioeconomic status, many GBM also identify with sexual subcultural communities. Previous research has shown differences across a variety of health outcomes between these sexual subcultural communities. The purpose of this study was to determine whether HIV prevention practices among GBM differed according to sexual subcultural community. The study was conducted in collaboration with a popular social and sexual networking smartphone application company. A total of 23,577 GBM responded to the survey. A latent class analysis identified 6 distinct classes related to sexual subcultural community identification. We found significant differences across sociodemographic characteristics, HIV prevention practices, and condomless anal sex in the past 6 months related to sexual subculture identification. Findings suggest that sexual subcultural identity is related to decision-making around HIV prevention among GBM. Differences in HIV prevention strategies are likely a function of group norms, unique shared experiences among GBM identifying with a particular sexual subculture community, and sociodemographic characteristics associated with these groups. As such, sexual subculture identity should be considered in developing interventions and social marketing campaigns to increase uptake of biomedical HIV prevention tools among GBM. Identifying group norms and shared experiences related to HIV prevention practices among sexual subcultures is necessary to understand the role these identities play in lives of GBM, especially as it relates to their sexual health and well-being.

Sociodemographic and behavioural factors associated with testing for HIV and STIs in a US nationwide sample of transgender men who have sex with men.

OBJECTIVES: Transgender men who have sex with men (TMSM) represent an understudied population in relation to screening for HIV and sexually transmitted infections (STIs). We examined HIV and STI testing prevalence among TMSM along with the factors associated with testing in a diverse US nationwide sample of TMSM. METHODS: Data from a cross-sectional online convenience sample of 192 TMSM were analysed using multivariable binary logistic regression models to examine the association between sociodemographic and behavioural factors and lifetime testing for HIV, bacterial STIs and viral STIs, as well as past year testing for HIV. RESULTS: More than two-thirds of TMSM reported lifetime testing for HIV (71.4%), bacterial STIs (66.7%), and viral STIs (70.8%), and 60.9% had received HIV testing in the past year. Engaging in condomless anal sex with a casual partner whose HIV status is different or unknown and having fewer than two casual partners in the past 6 months were related to lower odds of lifetime HIV, bacterial STI, viral STI and past year HIV testing. Being younger in age was related to lower probability of testing for HIV, bacterial STIs and viral STIs. Furthermore, TMSM residing in the South were less likely to be tested for HIV and viral STIs in their lifetime, and for HIV in the past year. Finally, lower odds of lifetime testing for viral STIs was found among TMSM who reported no drug use in the past 6 months. CONCLUSIONS: These findings indicate that a notable percentage of TMSM had never tested for HIV and bacterial and viral STIs, though at rates only somewhat lower than among cisgender MSM despite similar patterns of risk behaviour. Efforts to increase HIV/STI testing among TMSM, especially among those who engage in condomless anal sex, are needed.

High willingness to use novel HIV and bacterial sexually transmitted infection partner notification, testing, and treatment strategies among gay and bisexual men.

OBJECTIVES: We sought to determine willingness of gay and bisexual men (GBM) to give HIV self-testing (HIVST) kits with patient-delivered partner therapy (PDPT) and engage in geosocial sexual networking (GSN) app-based partner notification. METHODS: A nationwide sample of GBM who self-tested HIV negative (n=786) were asked about their willingness to give recent sex partners (main and casual) PDPT with an HIVST kit (PDPT+HIVST) after hypothetical bacterial STI (BSTI) diagnosis. Men were also asked about their willingness to notify sexual partners met on GSN apps using an anonymous app function after BSTI diagnosis. We examined associations of relationship status and condomless anal sex with casual partners, recent BSTI diagnosis and perceived risk of HIV on PDPT+HIVST and anonymous app-based partner notification willingness (dichotomised) using binary logistic regressions, adjusting for age, race/ethnicity, education and US region. From the partner's perspective after receiving an app-based referral, frequency measures were used to report intentions for obtaining subsequent HIV/BSTI counselling and testing, engaging in HIVST if provided a free voucher, and obtaining BSTI treatment from a pharmacy with prescription voucher. RESULTS: Most (90.1%) were willing to give PDPT+HIVST to recent sex partners after STI diagnosis, and nearly all (96.4%) were willing to notify sex partners met online using an anonymous function within GSN apps. Regardless of casual partner condomless anal sex engagement, partnered GBM had higher odds of reporting willingness to give PDPT+HIVST compared with single men who recently engaged in condomless anal sex with a casual partner. If anonymously notified via an app, 92.5% reported they would likely obtain counselling and testing, 92.8% would engage in HIVST if provided a free voucher, and 93.4% would obtain treatment from a pharmacy with prescription voucher. CONCLUSIONS: GBM generally found novel partner notification, testing, and treatment strategies acceptable, indicating the need for feasibility and cost-effectiveness evaluations.

Rates of Pre-exposure Prophylaxis Use and Discontinuation Among a Large U.S. National Sample of Sexual Minority Men and Adolescents.

Pre-exposure prophylaxis (PrEP) is highly effective in the prevention of HIV acquisition and was recently approved for those under 18 years of age. The primary goal of the present study was to understand the prevalence of and factors associated with PrEP use among a large sample of young and adult sexual minority men (Y/SMM). Participants came from a larger national sample of SMM. Data collected included demographics, substance use, PrEP use, and sexual risk. Participants were recruited via sexual networking/dating applications and resided in the U.S. including Puerto Rico, were at least 13 years old, self-reported being HIV-negative, and identified as male. The sample was divided into two groups: YSMM (13-24 years of age) and adult SMM (25 years of age and up). Multinomial logistic regressions examining associations with never, current, and former PrEP use were run with all variables of interest simultaneously entered into the models. Age was positively associated with both former and current PrEP use among YSMM. Additionally, YSMM who identified as gay (vs. bisexual), lived in the Northeast, Midwest, and West (vs. South), had their own health insurance (vs. those on their parent's), had recently been diagnosed with an STI, and had recently used a drug all had higher odds of being a current PrEP user compared to those that had never used PrEP. Among adult SMM, those who were older did not have higher odds of current PrEP use compared to those that had never used PrEP. Those who identified as queer (vs. gay), single, had their own or were on their partner's insurance (vs. parent's), recent condomless anal sex, recent STI diagnosis, recent drug use, and recent substance use all had higher odds of being a current PrEP user compared to those that had never used PrEP. Research is needed to address the disparities in PrEP uptake among YSMM. Interventions for PrEP access among those on their parents' insurance may also be necessary.

Willingness to Distribute HIV Self-Testing Kits to Recent Sex Partners Among HIV-Negative Gay and Bisexual Men and an Examination of Free-Response Data from Young Men Participating in the Nationwide Cohort.

Sexual minority men (SMM)-and young SMM in particular-are disproportionately affected by HIV. Secondary distribution of HIV self-testing (HIVST) kits-wherein patients deliver kits to partners-is a novel strategy to increase HIV testing access. Using quantitative data, we assessed willingness to distribute HIVST kits to recent sex partners among a U.S. national sample of HIV-negative SMM (n = 786). A thematic analysis was then conducted to identify barriers and facilitators of kit distribution to partners among young SMM (M age = 25.75 years; range: 20-29; n = 165). Overall, 93.5% of SMM (and 97.0% of young SMM) were willing to deliver HIVST kits to recent sex partners. Among young SMM, main barriers and facilitators included concerns about their partners' reaction, availability and cost, protection beliefs for others, HIV stigma and perceived infidelity, packaging and support, communication skill needs, inability to contact partners, requests for anonymity, and dyadic self-testing with their partners. The findings highlight the need for supportive intervention strategies such as informational content for HIVST, using motivational interviewing when providing the testing kits to index clients and providing skills-based training through role-playing exercises. Secondary distribution of HIVST kits through index patients is a potentially acceptable approach that could be used to expand access to HIV testing and aid in efforts to end the HIV epidemic in the U.S.

The Mediating Role of Psychological Distress in the Association between Harassment and Alcohol Use among Lesbian, Gay, and Bisexual Military Personnel.

BACKGROUND: The purpose of this study was to examine the mediating role of psychological distress on the associations between two forms of harassment, military sexual trauma (MST) and sexual orientation-based discrimination (SOBD), and alcohol use in a sample of lesbian, gay, and bisexual (LGB) military personnel. Methods: Data were analyzed from 254 LGB military service members in the United States. Bivariate associations were examined between MST, SOBD, anxiety and depression, distress in response to stressful military events, and alcohol use. A latent psychological distress factor was estimated using anxiety and depression, and distress in response to stressful military events. Path analyses were used to estimate the direct effects of MST and SOBD on alcohol use and the indirect effects of MST and SOBD on alcohol use through psychological distress. Results: All bivariate associations were positive and significant between MST, SOBD, anxiety and depression, distress in response to military events, and alcohol use. In multivariable analyses, after adjusting for demographic covariates, a significant indirect effect was observed for SOBD on alcohol use through psychological distress. MST was not directly or indirectly associated with alcohol use when SOBD was included in the path model. Conclusion: Overall, findings suggest SOBD is associated with poorer mental health, which in turn places LGB military personnel at greater risk of alcohol use and associated problems. These results affirm the need for interventions that reduce SOBD in the military and suggest that these interventions will have a positive impact on the health of LGB military personnel.

Club drug users had higher odds of reporting a bacterial STI compared with non-club drug users: results from a cross-sectional analysis of gay and bisexual men on HIV pre-exposure prophylaxis.

OBJECTIVES: Pre-exposure prophylaxis (PrEP) can reduce HIV transmission risk for many gay, bisexual and other men who have sex with men. However, bacterial STI (BSTI) associated with decreasing condom use among HIV PrEP users is a growing concern. Determining the characteristics of current PrEP users at highest BSTI risk fills a critical gap in the literature. METHODS: Gay and bisexual men (GBM) in New York City on HIV PrEP for 6 or more months (n=65) were asked about chlamydia, gonorrhoea and syphilis diagnoses in the past 6 months. By design, half (51%) of the sample were club drug users. We examined the associations of length of time on PrEP, type of PrEP care provider, PrEP adherence, number of sexual partners, number of condomless anal sex acts and club drug use on self-reported BSTI using multivariable, binary logistic regressions, adjusting for age, race/ethnicity, education and income. RESULTS: Twenty-six per cent of GBM on HIV PrEP reported a diagnosis of BSTI in the past 6 months. Men who reported club drug use (adjusted OR (AOR)=6.60, p<0.05) and more frequent condomless anal sex in the past 30 days (AOR=1.13, p<0.05) had higher odds of reporting a BSTI. No other variables were significantly associated with self-reported BSTI in the multivariable models. CONCLUSIONS: Club drug users could be at a unique BSTI risk, perhaps because of higher risk sexual networks. Findings should be considered preliminary, but suggest the importance of ongoing BSTI screening and risk-reduction counselling for GBM on HIV PrEP.

Determining the Roles that Club Drugs, Marijuana, and Heavy Drinking Play in PrEP Medication Adherence Among Gay and Bisexual Men: Implications for Treatment and Research.

Researchers have established that substance use interferes with anti-retroviral medication adherence among gay and bisexual men (GBM) living with HIV. There is limited parallel examination of pre-exposure prophylaxis (PrEP) adherence among HIV-negative GBM. We conducted retrospective 30-day timeline follow-back interviews and prospective semi-weekly diary data for 10 weeks with 104 PrEP-using GBM, half of whom engaged in club drug use (ketamine, ecstasy, GHB, cocaine, or methamphetamine)-generating 9532 days of data. Participants reported their day-by-day PrEP, club drug, marijuana, and heavy alcohol use (5 + drinks in one sitting). On average, club drug users were no more likely to miss a dose of PrEP than non-club drug users (M = 1.6 doses, SD = 3.0, past 30 days). However, we found that club drug use (at the event level) increased the odds of missing a dose on the same day by 55% and the next day (e.g., a "carryover effect") by 60%. Further, missing a dose on one day increased the odds of missing a dose the following day by eightfold. We did not identify an event-level effect of marijuana use or heavy drinking on PrEP adherence. Our data suggest club drug users could have greater protective effects from daily oral or long-acting injectable PrEP compared to a time-driven PrEP regimen because of the concurrence of club drug use and PrEP non-adherence.

The Role of Gay-Related Stigma in HIV-Risk Behavior Among Sexual Minority Men in Europe.

Sexual orientation stigma stems from discriminatory social contexts and may ultimately impact the behavioral health of stigmatized individuals through stress-related pathways. Sexual minority stigma is of particular concern in Europe given the diversity of social contexts on the continent and sexual minority men's rapidly increasing risk of HIV infection, especially in Central and Eastern Europe, potentially rooted in stigma. This study assesses whether stigma in the ubiquitous social contexts surrounding sexual minority men (e.g., family, workplace, government) may place them at higher risk for HIV contraction across six countries. We utilized a large cross-sectional survey sample of HIV-negative sexual minority men (N = 2087; mean age = 31.6, SD = 9.7) from six European countries to test whether those who reported sexual orientation stigma also engaged in more HIV risk-related behaviors, including condomless sex with casual partners (in the absence of PrEP) and substance use before and during sex. Regression analyses were performed in Mplus. We found that a one standard deviation increase in reported sexual orientation stigma was significantly associated with the following during the last sexual encounter: a 19% increase in odds of sex under the influence of alcohol, 27% increase in odds of sex under the influence of cannabis, 49% increase in odds of sex under the influence of illicit drugs, an 11% increase in odds of condomless sex with casual partners in the past 6 months, and a 26% increase in odds of knowing where to receive an HIV test. Sexual minority men who reported perceiving greater sexual orientation-related stigma within their ubiquitous social contexts were significantly more likely to report sexual risk and alcohol and drug use during their last sexual encounter, yet reported more knowledge of preventive services. Contextual stigma might serve as a precursor to behavioral risks of HIV infection, generating maladaptive stress responses capable of being modified through individually-focused interventions. Structural interventions are also needed to ultimately reduce stigma at its source.

Three Reasons to Consider the Role of Tiredness in Sexual Risk-Taking Among Gay and Bisexual Men.

Numerous factors have been shown to increase sexual risk-taking-especially among gay and bisexual men (GBM), who remain disproportionately affected by HIV and STIs. We present three lines of evidence that highlight the need to consider a previously under-explored situational factor in sexual risk-taking: tiredness. While tiredness has been shown, in sleep science literature, to impair cognition, emotional functioning, and decision-making in a wide range of behaviors, it has yet to be considered in-depth as a risk factor in sexual behavior. Counter to the common-sense assumption that being tired should impede the performance of active, effortful behaviors such as sex, we propose that tiredness may actually increase sexual risk-taking. Analyzing data from an online survey of 1113 HIV-negative GBM, we found that sex with casual partners most commonly occurred at night, especially among younger GBM and those with an evening chronotype, and that sex without condoms more often occurred at or later than one's usual time of feeling tired (as was reported by 44.2% of men) than did sex with condoms (reported by 36.6%). We also found that tiredness can increase sexual desire in many GBM (endorsed by 29.9%), and increases the likelihood of engaging in receptive positioning in anal sex (endorsed by almost 40% of men with a versatile sexual positioning identity). These findings highlight the importance of considering tiredness as a situational risk factor in sexual health-especially among younger GBM-and of counting sex among the behaviors that can be adversely impacted by poor or overdue sleep.

The Somatic Marker Hypothesis and Sexual Decision Making: Understanding the Role of Iowa Gambling Task Performance and Daily Sexual Arousal on the Sexual Behavior of Gay and Bisexual Men.

Background: The sexual decision-making literature suggests that sexual arousal and behavior are associated. The somatic marker hypothesis suggests that individual neuropsychological differences in decision making, as measured by the Iowa Gambling Task (IGT), may moderate these associations; however, this hypothesis has yet to be tested with event-level sexual behavior data. Purpose: We hypothesized that (a) daily sexual arousal would be positively associated with likelihood of engaging in sex and condomless anal sex (CAS) and (b) IGT scores would moderate these associations such that the associations would be stronger among those with higher IGT scores. Methods: We used daily diary data from 334 highly sexually active gay and bisexual men to examine the main and interaction effects of sexual arousal and IGT scores on sexual engagement and CAS. Results: As hypothesized, daily sexual arousal was positively associated with greater odds of both sexual engagement and CAS with casual male partners. Individual-level IGT performance significantly moderated the day-level association between arousal and sexual engagement, which was stronger for men with higher IGT scores. There was no main effect of IGT scores on either sexual behavior outcome, nor did it moderate the association between arousal and CAS. Conclusions: These findings highlight the influence of sexual arousal on sexual engagement, which differed by IGT scores; the effect of arousal on CAS was much less variable and may not be moderated by neurocognitive factors. This study supports the importance of exploring integrated behavioral/biomedical interventions to improve individual decision making to prevent HIV infection.

Will Gay and Bisexual Men Taking Oral Pre-exposure Prophylaxis (PrEP) Switch to Long-Acting Injectable PrEP Should It Become Available?

Oral pre-exposure prophylaxis (PrEP) is highly effective at reducing HIV transmission risk and is CDC recommended for many gay, bisexual, and other men who have sex with men (GBM). We sought to investigate awareness of and preference for using long-acting injectable PrEP (LAI-PrEP) among GBM currently taking oral PrEP (n = 104), and identify their concerns. About half of GBM had heard of LAI-PrEP, and 30.8% specifically preferred LAI-PrEP. GBM with more concerns about the level of protection and drug half-life of LAI-PrEP had lower odds of preferring LAI-PrEP. Given that daily pill adherence is a challenge for some on PrEP, it is important to investigate the degree to which those on PrEP might consider LAI-PrEP as an alternative.