Patterns of client behavior with their most recent male escort: an application of latent class analysis.

Research examining interactions between male escorts and clients has relied heavily on data from escorts, men working on the street, and behavioral data aggregated over time. In the current study, 495 clients of male escorts answered questions about sexual behavior with their last hire. Latent class analysis identified four client sets based on these variables. The largest (n = 200, 40.4 %, labeled Typical Escort Encounter) included men endorsing behavior prior research found typical of paid encounters (e.g., oral sex and kissing). The second largest class (n = 157, 31.7 %, Typical Escort Encounter + Erotic Touching) included men reporting similar behaviors, but with greater variety along a spectrum of touching (e.g., mutual masturbation and body worship). Those classed BD/SM and Kink (n = 76, 15.4 %) reported activity along the kink spectrum (BD/SM and role play). Finally, men classed Erotic Massage Encounters (n = 58, 11.7 %) primarily engaged in erotic touch. Clients reporting condomless anal sex were in the minority (12.2 % overall). Escorts who engage in anal sex with clients might be appropriate to train in HIV prevention and other harm reduction practices-adopting the perspective of "sex workers as sex educators."

Motivational interviewing targeting risky sex in HIV-positive young Thai men who have sex with men.

Motivational interviewing (MI) has been shown to reduce sexual risks among HIV-positive men who have sex with men (HMSM) in the US. We conducted a randomized trial of Healthy Choices, a 4-session MI intervention, targeting sexual risks among 110 HIV-positive youth ages 16-25 years in Thailand. Risk assessments were conducted at baseline, 1 month, and 6 months post-intervention. This report presents the analysis of 74 HMSM in the study. There were 37 HMSM in the Intervention group and 37 in the control group. The proportions of participants having anal sex and having sex with either HIV-uninfected or unknown partners in past 30 days were significantly lower in Intervention group than in Control group at 6 months post-intervention (38 vs. 65 %, p = .04; and 27 vs. 62 %, p < .01, respectively). There were no significant differences in general mental health scores and HIV stigma scores between the two groups at any study visit. Thirty-five (95 %) HMSM in the Intervention group vs. 31 (84 %) in control group attended ≥ 3 sessions. Loss to follow-up was 8 and 30 %, respectively (p = .04). Healthy Choices for young Thai HMSM was associated with sexual risk reduction. Improvements in mental health were noted in Intervention group. Healthy Choices is a promising behavioral intervention and should be further developed to serve the needs of young HMSM in resource-limited countries.

Male clients' behaviours with and perspectives about their last male escort encounter: comparing repeat versus first-time hires.

Research on men who have sex with men suggests that condomless anal intercourse occurs more frequently in established sexual relationships. While comparable data regarding male-for-male escorting is unavailable, research implies that many clients seek emotional as well as physical connections with the men they hire. In 2012, 495 male clients, recruited via daddysreviews.com completed an online survey about their last hiring experience. Most participants were from the USA (85.7%), the UK and Canada (3.2% each). In total, 75% of encounters involved an escort hired for the first time; 25% were with a previously hired escort ('repeat encounter'). The client's age, lifetime number of escorts hired and number hired in the past year were positively associated with the last encounter being a repeat encounter. Cuddling, sharing a meal, drinking alcohol, taking a walk, watching a show and shopping were also positively associated with repeat encounters. Conversely, none of the sexual behaviours were significantly associated with repeat encounters. Repeat encounters were significantly more likely to include non-sexual behaviours alongside sexual activities, but no more likely to involve condomless anal intercourse. Moreover, clients' knowledge of escorts' HIV status was not significantly associated with engaging in condomless anal intercourse with repeat encounters.

Motivational interviewing targeting risk behaviors for youth living with HIV in Thailand.

Healthy Choices, a four-session motivational interviewing-based intervention, reduces risk behaviors among US youth living with HIV (YLWH). We randomized 110 Thai YLWH (16-25 years) to receive either Healthy Choices or time-matched health education (Control) over 12 weeks. Risk behaviors were assessed at baseline, 1, and 6 months post-session. The pilot study was not powered for between-group differences; there were no statistical differences in sexual risks, alcohol use, and antiretroviral adherence between the two groups at any visit. In within-group analyses, Healthy Choices group demonstrated decreases in the proportion of HIV-negative partners (20 vs 8.2%, P = 0.03) and HIV sexual risk scores (4.3 vs 3.3, P = 0.04), and increased trends in the proportion of protected sex (57 vs 76.3%, P = 0.07) from baseline to 1 month post-session. These changes were not sustained 6 months later. No changes were observed in Control group. Healthy Choices has potential to improve sexual risks among Thai YLWH.

Perspectives on substance use and disclosure among behaviorally bisexual black men with female primary partners.

Black men who have sex with men and women (MSMW) are believed to be a bridge to HIV infection among heterosexual Black women, and substance use can increase the risk of infection among men. However, empirical evidence on the social context of MSMW's sexual behavior and substance use is needed. This study examines the perspectives of Black MSMW with female primary partners on the role of substance use in their sexual encounters with men and their reasons for disclosing or not disclosing this behavior to their female partners. Findings can inform culturally relevant HIV prevention interventions for this population.

Looking beyond HIV: eliciting individual and community needs of male internet escorts.

In evaluating the needs of male sex workers (MSWs), past research and community-based outreach efforts have assumed they should receive counseling and be educated regarding drug abuse and HIV/STI prevention. These assumptions have been based upon studies that predominantly sampled heterosexually identified men who work on the street as 'hustlers.' The purpose of this study was to set aside previous assumptions, and elicit directly from MSWs their perceived needs. Semi-structured interviews were conducted with 46 gay and bisexual male escorts who advertise on the Internet, an understudied group that is expected to differ greatly from street-based MSWs. The men identified several areas where attention should be directed beyond safer sex, such as business advice (e.g., taxes, income investment) and assistance with navigating legal issues. These findings have direct implications for community-based organizations, advocates for MSWs, and men in the commercial sex industry.

A cross-cultural three-step process model for assessing motivational interviewing treatment fidelity in Thailand.

The provision of culturally relevant yet evidence-based interventions has become crucial to global HIV prevention and treatment efforts. In Thailand, where treatment for HIV has become widely available, medication adherence and risk behaviors remain an issue for Thai youth living with HIV. Previous research on motivational interviewing (MI) has proven effective in promoting medication adherence and HIV risk reduction in the United States. However, to test the efficacy of MI in the Thai context a feasible method for monitoring treatment fidelity must be implemented. This article describes a collaborative three-step process model for implementing the MI Treatment Integrity (MITI) across cultures while identifying linguistic issues that the English-originated MITI was not designed to detect as part of a larger intervention for Thai youth living with HIV. Step 1 describes the training of the Thai MITI coder, Step 2 describes identifying cultural and linguistic issues unique to the Thai context, and Step 3 describes an MITI booster training and incorporation of the MITI feedback into supervision and team discussion. Throughout the process the research team collaborated to implement the MITI while creating additional ways to evaluate in-session processes that the MITI is not designed to detect. The feasibility of using the MITI as a measure of treatment fidelity for MI delivered in the Thai linguistic and cultural context is discussed.

Applying the information-motivation-behavioral skills model in medication adherence among Thai youth living with HIV: a qualitative study.

With disproportionately higher rates of HIV/AIDS among youth and increasing access to antiretroviral therapy (ART) in Thailand, there is a growing urgency in understanding the challenges to medication adherence confronting this population and in developing theory-based interventions to address these challenges. One potentially relevant model, the information-motivation-behavioral skills (IMB) model of adherence, was developed in Western settings characterized by a more individualistic culture in contrast to the more collectivistic culture of Thailand. We explored the application and adaptability of IMB on ART adherence among HIV-positive Thai youth through the analysis of qualitative data from a pilot motivational interviewing study. Twenty-two interview sessions from 10 HIV-positive Thai youth (17-24 years) were analyzed; 6 youth were on ART. Data support the utility of IMB as a potential framework for understanding ART adherence in this population. However, data indicate a consideration to expand the motivation construct of IMB to incorporate youths' perceived familial and social responsibilities and the need to adhere to medications for short- and long-term well-being of self, family, and society in a context of Buddhist values. These modifications to IMB could be relevant in other cultural settings with more collectivistic worldviews.

Experiences of familial acceptance-rejection among transwomen of color.

Because of the stigma associated with transgenderism, many transwomen (biological males who identify as female or transgender) experience rejection or abuse at the hands of their parents and primary caregivers as children and adolescents. The Parental Acceptance-Rejection (PAR) theory indicates that a child's experience of rejection may have a significant impact on their adult lives. The purpose of this study was to conduct a qualitative analysis of adult transwomen of color's experiences with caregivers, guided by PAR theory. Twenty transwomen of color completed semi-structured interviews exploring the reaction of their parents and primary caregivers to their gender. While many participants reported that at least one parent or close family member responded with warmth and acceptance, the majority confronted hostility and aggression; reports of neglect and undifferentiated rejection were also common. Many transwomen were forced out of their homes as adolescents or chose to leave, increasing their risk of homelessness, poverty, and associated negative sequelae. Future research is needed to explore how families come to terms with having a transgender child and how best to promote acceptance of such children.

Factors related to childhood sexual abuse among gay/bisexual male Internet escorts.

This exploratory investigation examined the relationship between childhood sexual abuse (CSA) and related psychosocial characteristics and sexual behaviors among 46 gay/bisexual male escorts who advertise via the Internet. More than a quarter of men (28.3%) reported some history of CSA. Men reporting CSA were more likely to be from an ethnic minority group, identify as bisexual, have a primary male partner, and were less likely to identify an anal receptive ("bottom") sexual role preference. Men with a history of CSA were more likely to report unprotected sex with work-related partners, increased internalized homophobia, and decreased adolescent isolation. Interventions designed for male escorts with a history of CSA should emphasize safer sex strategies with work partners and reducing internalized homophobia.