Lifetime Prevalence and Sociodemographic Correlates of Multifactorial Discrimination Among Middle-Aged and Older Adult Men Who Have Sex with Men.

This study describes multifactorial discrimination (discrimination attributed to multiple social identities) among middle-aged and older adult MSM. MSM aged 40+ years (N = 1,193) enrolled in the Multicenter AIDS Cohort Study completed behavioral surveys ascertaining experiences of discrimination and their social identity attributions. Non-proportional odds regressions assessed multifactorial discrimination by age, race/ethnicity, HIV status, and covariates. Twenty-seven percent of participants reported multifactorial discrimination. Adjusted models indicated that middle-aged men were more likely to report multifactorial discrimination compared to older adult men. Racial/ethnic minorities were more likely to report multifactorial discrimination compared to non-Hispanic white participants. These same patterns emerged among the sub-sample of participants living with HIV. To our knowledge, this is the first assessment of multifactorial discrimination in middle-aged and older MSM. Our findings support the deleterious association between multiple-marginalization and multifactorial discrimination. Multilevel interventions targeting interconnected experiences of stigma may improve the health of MSM in transition to older age.

Evidence for HIV transmission across key populations: a longitudinal analysis of HIV and AIDS rates among Black people who inject drugs and Black heterosexuals in 84 large U.S. metropolitan areas, 2008-2016.

PURPOSE: To assess cross-population linkages in HIV/AIDS epidemics, we tested the hypothesis that the number of newly diagnosed AIDS cases among Black people who inject drugs (PWID) was positively related to the natural log of the rate of newly diagnosed HIV infections among Black non-PWID heterosexuals in 84 large U.S. metropolitan statistical areas (MSAs) in 2008-2016. METHODS: We estimated a multilevel model centering the time-varying continuous exposures at baseline between the independent (Black PWID AIDS rates) and dependent (HIV diagnoses rate among Black heterosexuals) variables. RESULTS: At MSA level, baseline (standardized ß = 0.12) Black PWID AIDS rates and change in these rates over time (standardized ß = 0.11) were positively associated with the log of new HIV diagnoses rates among Black heterosexuals. Thus, MSAs with Black PWID AIDS rates that were 1 standard deviation= higher at baseline also had rates of newly diagnosed HIV infections among Black non-PWID heterosexuals that were 10.3% higher. A 1 standard deviation increase in independent variable over time corresponded to a 7.8% increase in dependent variable. CONCLUSIONS: Black PWID AIDS rates may predict HIV rates among non-PWID Black heterosexuals. Effective HIV programming may be predicated, in part, on addressing intertwining of HIV epidemics across populations.

Characterizing Experiences of Conversion Therapy Among Middle-Aged and Older Men Who Have Sex with Men from the Multicenter AIDS Cohort Study (MACS).

Conversion therapies are practices that attempt to change an individuals' same-sex attractions through psychotherapeutic and aversive therapeutic techniques. Conversion therapies were developed based on homophobic beliefs that same-sex attractions are a mental illness. We sought to describe the prevalence and characteristics of conversion therapy experienced among middle-aged and older men who have sex with men in the United States. Given associations of homophobic stigma and HIV risk, we hypothesized that HIV-positive men would report higher odds of conversion therapy compared to HIV-negative men. We analyzed data from 1,237 middle-aged and older MSM enrolled in the Multicenter AIDS Cohort Study. Among participants, 17.7% reported lifetime conversion therapy, of which the average start of therapy age was 22.67 (sd = 10.56) years, 25.8% reported therapy durations of 6+ months, 37.7% reported session frequencies 1+ session per week, and 35.9% indicated that undergoing therapy was either a little or not at all their decision. We observed no statistically significant association between reporting lifetime conversion therapy and HIV status. Future efforts should continue to assess the magnitude of harm conversion therapies impose on MSM's health across the life course as well as test potential, indirect associations that may link these practices to HIV.

Multifactorial discrimination, discrimination salience, and prevalent experiences of internalized homophobia in middle-aged and older MSM.

Objectives: We sought to test whether discrimination salience and multifactorial discrimination were associated with prevalent experiences of internalized homophobia among middle-aged and older men who have sex with men (MSM).Methods: We analyzed data from 498 middle-aged and older MSM from the Multicenter AIDS Cohort Study (MACS) who reported any lifetime discrimination experience. We estimated the prevalence ratio of current internalized homophobia using multivariable Poisson regressions, accounting for discrimination salience, multifactorial discrimination, and covariates. We then assessed whether multifactorial discrimination moderated the association between discrimination salience and internalized homophobia.Results: Over half (56.4%) of our sample reported any current experience of internalized homophobia. More than two-thirds reported multifactorial discrimination (68.2%) and more than one-third (36.7%) reported moderate-to-high discrimination salience. Increases in discrimination salience (PR = 1.11; 95% CI: 1.03-1.20) were associated with any current internalized homophobia among middle-aged and older MSM. Multifactorial discrimination was not statistically associated with internalized homophobia and did not moderate the association between discrimination salience and internalized homophobia.Conclusions: Our study underscores internalized homophobia as a persisting concern among MSM in midlife and older adulthood. Our findings suggest that salience, as a characteristic of discrimination experiences, may have a greater impact on internalized homophobia compared with exposure. Future research efforts should assess facets of discrimination salience, such as severity, frequency, and chronicity, to better understand how discrimination shapes psychosocial well-being across the life course. Mental health advocates at policy, organizational, and community levels should aim to reduce intersectional stigma and address individual experiences of internalized homophobia.

Injection drug use, unknown HIV positive status, and self-reported current PrEP use among Black men who have sex with men attending U.S. Black pride events, 2014-2017.

OBJECTIVE: Black gay, bisexual, and other men who have sex with men (BMSM) are at elevated risk for HIV infection in the United States. BMSM who inject drugs may be face even higher HIV risk. METHODS: Random time-location sampling was used to survey BMSM attending Black Pride events in 6 U.S. cities about HIV risk and protective behaviors, including injection drug use, prior HIV testing, and pre-exposure prophylaxis (PrEP). 3429 individuals who reported a HIV negative/unknown serostatus at enrollment were included in the analysis. HIV status was determined by in-field rapid HIV testing. RESULTS: 3.6% of BMSM had injected drugs in their lifetime and 58.5% of BMSM who had injected drugs reported sharing syringes in the past six months. BMSM who had injected drugs more commonly reported current PrEP use than BMSM who had never injected (32.5% vs. 8.2%, p < 0.001). BMSM who had injected drugs were 3.6-fold (95% CI: 2.4, 5.4) more likely to report currently using PrEP than BMSM who had never injected after adjustment for sociodemographic, substance use, and sexual risk characteristics. Among BMSM who reported ever injecting drugs (n = 123), 31.7% tested HIV positive. HIV prevalence did not differ by self-reported PrEP use among BMSM who had injected drugs (p = 0.59). CONCLUSIONS: BMSM who inject drugs who reported currently using PrEP were no less likely to test positive for HIV than those who did not use PrEP. Wrap-around services to support consistent PrEP use and long-acting PrEP formulations may improve the effectiveness of PrEP among BMSM who inject drugs.

Black Men Who Have Sex with Men and Lifetime HIV Testing: Characterizing the Reasons and Consequences of Having Never Tested for HIV.

HIV testing remains a critical point of entry to HIV treatment services and now biomedical prevention as well. Yet despite the high HIV prevalence among Black men who have sex with men (MSM), insufficient attention has been given to factors associated with those Black MSM in the United States who have never received an HIV test in their lifetime. Promoting Our Worth, Equality, & Resilience (POWER) is a cross-sectional observational study that recruited Black MSM at Black Pride events across six cities in the United States from 2014 to 2017. Participants completed an anonymous questionnaire and were offered free, confidential HIV testing. Of the 4174 Black MSM without a prior HIV diagnosis, 404 (9.68%) had never tested for HIV (mean age = 31.03 years). Lower education and greater internalized homophobia were associated with never having tested for HIV. Higher age (AOR = 1.05, 95%, 1.02-1.07) and assumption of HIV-positivity (AOR = 3.24, 95% CI 1.53-6.84) were both associated with increased odds of an HIV-positive test result (n = 119; 36%). To compare, HIV prevalence among Black MSM who had received at least one HIV test before study participation was 23%. While a minority of Black MSM had never received an HIV test, this group had a significantly higher likelihood of HIV infection. Alternative HIV testing strategies are needed to facilitate HIV testing initiation among Black MSM for whom conventional HIV testing modalities are insufficient.

Elevated HIV Prevalence and Correlates of PrEP Use Among a Community Sample of Black Men Who Have Sex With Men.

BACKGROUND: The HIV epidemic among black men who have sex with men (BMSM) demands urgent public health attention. Pre-exposure prophylaxis (PrEP) is a highly efficacious option for preventing HIV, but characteristics of PrEP use among community samples of BMSM are not well-understood. METHODS: A serial cross-sectional survey assessment (N = 4184 BMSM reporting HIV-negative/unsure status) and HIV testing were conducted at Black Gay Pride events in 6 US cities in 2014, 2015, 2016, and 2017. RESULTS: HIV prevalence was higher among BMSM self-reporting current PrEP use (1 of 3 participants) than BMSM not self-reporting current PrEP use (1 of 5 participants) [32.3%, N = 103/319 vs. 20.0%, N = 639/3,193, adjusted odds ratio (aOR) = 1.68, 95% confidence interval (CI): 1.31 to 2.15]. BMSM reporting current PrEP use (N = 380) were more likely to report having a greater number of male sex partners (aOR = 1.02, 95% CI: 1.01 to 1.03), a sexually transmitted infection diagnosis (aOR = 2.44, 95% CI: 1.88 to 3.16), and stimulant drug use (aOR = 2.05, 95% CI, 1.21 to 3.47) when compared with BMSM not reporting current PrEP use (N = 3804). PrEP use increased from 4.7% (2014) to 15.5% (2017) (aOR = 1.19, 95% CI: 1.13 to 1.25). Among PrEP users, inability to afford health care coverage was associated with testing HIV-positive (aOR = 2.10, 95% CI: 1.24 to 3.56). CONCLUSIONS: The high prevalence of HIV infection among BMSM reporting PrEP use is concerning. It does not, however, challenge the efficacy of PrEP itself but rather the uptake of the surrounding preventative package including behavioral risk reduction support, sexually transmitted infection treatment, and medication adherence counseling. Further research to understand barriers to fully effective PrEP is needed to guide operational and behavioral interventions that close the gap on incident infection.

Assessing HIV Stigma on Prevention Strategies for Black Men Who Have Sex with Men in the United States.

The deleterious effects of HIV stigma on HIV+ Black MSM care continuum outcomes have been well-documented. How HIV stigma shapes HIV prevention for HIV- persons in this community is poorly understood. We sought to test the relationship of HIV stigma with HIV- Black MSM on HIV testing, pre-exposure prophylaxis (PrEP) awareness, and PrEP use. We recruited 772 participants at Black Pride events across five US cities in 2016. Multivariable logistic regression models assessed the association of external HIV stigma on prevention outcomes adjusting for sociodemographic variables. Stigma was positively associated with PrEP awareness (AOR = 1.34; 95% CI = 1.09, 1.66; p value = 0.005), and not associated with PrEP use or HIV testing in our sample. These findings highlight the complex nature of HIV stigma among BMSM and include results for PrEP, which can affect uptake other prevention methods. We support anti-HIV stigma efforts and advise further exploration on HIV stigma among BMSM and prevention outcomes.

High HIV incidence among young black men who have sex with men: constructing a retrospective cohort from a community health programme.

OBJECTIVES: We sought to calculate HIV incidence in a retrospective cohort of young (13-29 years old) black men who have sex with men (YBMSM) accessing repeated HIV-antibody testing in a mid-size city in the USA. METHODS: We aggregated site-specific HIV-antibody testing results from the project's inception among YBMSM who received an initial negative result and accessed at least one additional HIV-antibody test. From these data, we assessed number of seroconversions and person-years and calculated HIV incidence using a mid-P exact test to estimate 95% CIs. RESULTS: Five seroconversions were documented over 42.3 person-years (the mean age at first onsite test: 19.7 years), resulting in an HIV incidence rate of 11.8% (95% CI 4.3% to 26.2%). The mean age at seroconversion was 20.4 (±3.0) years. CONCLUSIONS: Even in mid-size cities with low HIV prevalence rates in the general population, HIV incidence among YBMSM may be high. Community-based HIV-antibody testing organisations serving YBMSM should be encouraged and trained to track repeated HIV testing and calculate HIV incidence rates. Increased resources should be deployed to develop and encourage regular HIV testing in community health sites serving YBMSM.

A Multi-US City Assessment of Awareness and Uptake of Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Black Men and Transgender Women Who Have Sex with Men.

The HIV epidemic among Black men and transgender women who have sex with men (BMTW) demands an urgent public health response. HIV point prevalence among this population ranges from 25 to 43%-a rate far exceeding any other group. Pre-exposure prophylaxis (PrEP) for HIV prevention is a very promising prevention tool; however, its full potential to slow the epidemic has yet to be realized. For the current study, random time-location sampling at Black Gay Pride Events was used to collect data from N = 1274 BMTW, from five US cities, reporting HIV-negative/unknown status. In-field HIV testing was also provided to participants. Participants were assessed on awareness and use of PrEP, health care factors, HIV testing history, psychosocial variables, and sex behaviors. About one third of participants were aware of PrEP (39%), and a small percentage of participants were users of PrEP (4.6%). In multivariable analyses, being in a relationship, testing for HIV in the past 6 months, and others being aware of one's sexuality were positively associated with PrEP awareness. Higher levels of internalized homophobia and greater numbers of female sex partners were positively associated with PrEP use, while education and condom use were negatively associated. Based on study findings, messaging and uptake of PrEP needs greater expansion and requires novel approaches for scale-up. Improving linkage to HIV testing services is likely critical for engaging BMTW with PrEP. The potential for PrEP to slow the HIV epidemic is high; however, we must strengthen efforts to ensure universal availability and uptake.

Interpersonal Attacks on the Dignity of Members of HIV Key Populations: A Descriptive and Exploratory Study.

Attacks on peoples' dignity help to produce and maintain stigmatization and interpersonal hostility. As part of an effort to develop innovative measures of possible pathways between structural interventions or socially-disruptive Big Events and HIV outbreaks, we developed items to measure dignity denial. These measures were administered to 300 people who inject drugs (PWID), 260 high-risk heterosexuals who do not inject drugs, and 191 men who have sex with men who do not inject drugs (MSM). All of the PWID and many of the high risk heterosexuals and MSM were referred to our study in 2012-2015 by a large New York city study that used respondent-driven sampling; the others were recruited by chain-referral. Members of all three key populations experienced attacks on their dignity fairly often and also reported frequently seeing others' dignity being attacked. Relatives are major sources of dignity attacks. MSM were significantly more likely to report having their dignity attacked by police officers than were the other groups. 40 % or more of each key population reported that dignity attacks are followed "sometimes" or more often both by using more drugs and also by using more alcohol. Dignity attacks and their health effects require more research and creative interventions, some of which might take untraditional forms like social movements.

Associations between LGBTQ-affirmative school climate and adolescent drinking behaviors.

BACKGROUND: We investigated whether adolescents drank alcohol less frequently if they lived in jurisdictions with school climates that were more affirmative of lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals. METHODS: Data from the 2010 School Health Profile survey, which measured LGBTQ school climate (e.g., percentage of schools with safe spaces and gay-straight alliances), were linked with pooled data from the 2005 and 2007 Youth Risk Behavior Survey, which measured sexual orientation identity, demographics, and alcohol use (number of drinking days, drinking days at school, and heavy episodic drinking days) in 8 jurisdictions. Two-level Poisson models tested the associations between school climate and alcohol use for each sexual-orientation subgroup. RESULTS: Living in jurisdictions with more (versus less) affirmative LGBTQ school climates was significantly associated with: fewer heavy episodic drinking days for gay/lesbian (incidence-rate ratio [IRR]=0.70; 95% confidence interval [CI]: 0.56, 0.87; p=0.001) and heterosexual (IRR=0.80; 95% CI: 0.76, 0.83; p<0.001) adolescents; and fewer drinking days at school for adolescents unsure of their sexual orientation (IRR=0.57; 95% CI: 0.35, 0.93; p=0.024). CONCLUSIONS: Fostering LGBTQ-affirmative school climates may reduce certain drinking behaviors for gay/lesbian adolescents, heterosexual adolescents, and adolescents unsure of their sexual orientation.

Sexual-Orientation Differences in Positive Youth Development: The Mediational Role of Bullying Victimization.

OBJECTIVES: To examine sexual-orientation differences in positive youth development, and how bullying victimization mediated these differences in a sample of adolescents. METHODS: In 2007 to 2008, positive youth development was measured in 1870 adolescents from US schools and after-school programs in 45 states by using the validated Five Cs model of competence, confidence, connection, character, and caring/compassion. Sexual-minority youths (6.8%) reported having same- or both-gender sexual attractions. Nonattracted youths (4.2%) reported having no sexual attractions. RESULTS: Compared with sexual-minority youths, heterosexual and nonattracted youths had lower odds of being a victim of bullying. Heterosexual and nonattracted youths also had higher average scores in competence, confidence, and connection, but these associations between sexual orientation and positive youth development scores were partly attributable to lack of bullying victimization. CONCLUSIONS: Designing, implementing, and evaluating interventions that reduce bullying can give sexual-minority youths access to several building blocks of health and well-being.

Running Backwards: Consequences of Current HIV Incidence Rates for the Next Generation of Black MSM in the United States.

Black men who have sex with men (MSM) in the United States are disproportionately impacted by HIV. To better understand this public health problem, we reviewed the literature to calculate an estimate of HIV incidence among Black MSM. We used this rate to model HIV prevalence over time within a simulated cohort, which we subsequently compared to prevalence from community-based samples. We searched all databases accessible through PubMed, and Conference on Retroviruses and Opportunistic Infections abstracts for HIV incidence estimates among Black MSM. Summary HIV incidence rates and 95 % confidence intervals (CIs) were calculated using random effects models. Using the average incidence rate, we modeled HIV prevalence within a simulated cohort of Black MSM (who were all HIV-negative at the start) from ages 18 through 40. Based on five incidence rates totaling 2898 Black MSM, the weighted mean incidence was 4.16 % per year (95 % CI 2.76-5.56). Using this annual incidence rate, our model predicted that 39.94 % of Black MSM within the simulated cohort would be HIV-positive by age 30, and 60.73 % by 40. Projections were similar to HIV prevalence found in community-based samples of Black MSM. High HIV prevalence will persist across the life-course among Black MSM, unless effective prevention and treatment efforts are increased to substantially reduce HIV transmission among this underserved and marginalized population.

Differences in alcohol use and alcohol-related problems between transgender- and nontransgender-identified young adults.

BACKGROUND: Little is known about differences in alcohol use and alcohol-related problems between transgender- and nontransgender-identified populations. Using data from a large-scale health survey, we compare the drinking patterns and prevalence of alcohol-related problems of transgender-identified individuals to nontransgender-identified males and females. For transgender-identified people, we examine how various forms of victimization relate to heavy episodic drinking (HED). METHODS: Cross-sectional surveys were completed by 75,192 students aged 18-29 years attending 120 post-secondary educational institutions in the United States from 2011 to 2013. Self-reported measures included alcohol use, alcohol-related problems, victimization, and sociodemographics, including 3 gender-identity groups: transgender-identified individuals; nontransgender-identified males; and nontransgender-identified females. RESULTS: Compared to transgender-identified individuals, nontransgender-identified males were more likely to report HED in the past 2 weeks (relative risk=1.42; p=0.006); however, nontransgender-identified males and females reported HED on fewer days than transgender-identified people (incidence-rate ratios [IRRs] ranged from 0.28 to 0.43; p-values<0.001). Compared to transgender-identified people, nontransgender-identified males and females had lower odds of past-year alcohol-related sexual assault and suicidal ideation (odds ratios ranged from 0.24 to 0.45; p-values<0.05). Among transgender-identified people, individuals who were sexually assaulted (IRR=3.21, p=0.011) or verbally threatened (IRR=2.42, p=0.021) in the past year had greater HED days than those who did not experience those forms of victimization. CONCLUSIONS: Compared to transgender-identified people, nontransgender-identified males and females: have fewer HED occasions (despite nontransgender-identified males having greater prevalence of HED); and are at lower risk for alcohol-related sexual assaults and suicidal ideation. Experiences of sexual assault and verbal threats are associated with greater HED occasions for transgender-identified people.

Evidence of Syndemics and Sexuality-Related Discrimination Among Young Sexual-Minority Women.

PURPOSE: Syndemics, or the co-occurrence and interaction of health problems, have been examined extensively among young men who have sex with men, but their existence remain unexamined, to our knowledge, among sexual-minority (i.e., lesbian, gay, and bisexual) women. Thus, we investigated if syndemics were present among young sexual-minority women, and if sexual-orientation discrimination was an independent variable of syndemic production. METHODS: A total of 467 sexual-minority women between the ages of 18 and 24 completed a cross-sectional online survey regarding their substance use, mental health, sexual behaviors, height, weight, and experiences of discrimination. We used structural equation modeling to investigate the presence of syndemics and their relationship to sexual-orientation discrimination. RESULTS: Heavy episodic drinking, marijuana use, ecstasy use, hallucinogen use, depressive symptoms, multiple sexual partners, and history of sexually transmitted infections (STIs) comprised syndemics in this population (chi-square=24.989, P=.201; comparative fit index [CFI]=0.946; root mean square error of approximation [RMSEA]=0.023). Sexual-orientation discrimination is significantly and positively associated with the latent syndemic variable (unstandardized coefficient=0.095, P<.05), and this model fit the data well (chi-square=33.558, P=.059; CFI=0.914; RMSEA=0.029). The reverse causal model showed syndemics is not an independent variable of sexual-orientation discrimination (unstandardized coefficient=0.602, P>.05). CONCLUSIONS: Syndemics appear to be present and associated with sexual-orientation discrimination among young sexual-minority women. Interventions aimed at reducing discrimination or increasing healthy coping may help reduce substance use, depressive symptoms, and sexual risk behaviors in this population.

Depression and sexual dysfunction among HIV-positive and HIV-negative men who have sex with men: mediation by use of antidepressants and recreational stimulants.

Erectile dysfunction and other forms of sexual dysfunction are highly prevalent among HIV+ men who have sex with men (MSM). Research has not previously identified the mechanisms by which depression may be associated with sexual dysfunction among HIV-positive and HIV-seronegative (HIV-negative) MSM. The present study examined the role of antidepressant use, stimulant use, and smoking as mediators of the relation between depression and sexual dysfunction among HIV-positive and HIV-negative MSM. Participants enrolled in the Multicenter AIDS Cohort Study, an ongoing prospective study of the natural and treated histories of HIV infection among MSM in the United States, completed a modified version of the International Index of Erectile Function for MSM. The study sample included 1,363 participants, with 619 HIV-positive men and 744 HIV-negative men. A structural equation model examined depression as a predictor of subsequent sexual dysfunction, mediated by antidepressant use, stimulant use, and smoking. Depression predicted subsequent sexual function among both HIV-negative and HIV-positive MSM. This effect appeared to be both a direct effect and an indirect effect via antidepressant use. Findings suggest that antidepressant medication use may partially explain sexual dysfunction among MSM.

The effect of psychosocial syndemic production on 4-year HIV incidence and risk behavior in a large cohort of sexually active men who have sex with men.

BACKGROUND: Cross-sectional studies have suggested that co-occurring epidemics or "syndemics" of psychosocial health problems may accelerate HIV transmission among men who have sex with men (MSM) in the United States. We aimed to assess how 5 syndemic conditions (depressive symptoms, heavy alcohol use, stimulant use, polydrug use, and childhood sexual abuse) affected HIV incidence and sexual risk behavior over time. METHODS: Eligible men in a large prospective cohort of sexually active HIV-uninfected MSM completed HIV testing and behavioral surveys at baseline and every 6 months for 48 months. We examined interrelationships between psychosocial problems and whether these interactions increased the odds of HIV risk behaviors and risk of seroconversion over study follow-up. RESULTS: Among 4295 men, prevalence of psychosocial conditions was substantial at baseline and was positively associated with each other. We identified a statistically significant positive dose-response relationship between numbers of syndemic conditions and HIV seroconversion for all comparisons (with the greatest hazard among those with 4-5 conditions, adjusted hazard ratio = 8.69; 95% confidence interval: 4.78 to 15.44). The number of syndemic conditions also predicted increased HIV-related risk behaviors over time, which mediated the syndemic-HIV seroconversion association. CONCLUSIONS: The accumulation of syndemic psychosocial problems predicted HIV-related sexual risk behaviors and seroconversion in a large sample of US MSM. Given the high prevalence of syndemic conditions among MSM and the moderate effect sizes attained by traditional brief behavioral interventions to date, the HIV prevention agenda requires a shift toward improved assessment of psychosocial comorbidities and stronger integration with mental health and substance abuse treatment services.

Sexual risk trajectories among MSM in the United States: implications for pre-exposure prophylaxis delivery.

BACKGROUND: Despite evidence supporting pre-exposure prophylaxis (PrEP) efficacy, there are concerns regarding the feasibility of widespread PrEP implementation among men who have sex with men (MSM). To inform the development of targeted PrEP delivery guidelines, sexual risk trajectories among HIV-negative MSM were characterized. METHODS: At semiannual visits from 2003 to 2011, HIV-negative MSM (N = 419) participating in the Multicenter AIDS Cohort Study provided data on sexual risk behaviors (SRBs) since their last visit. Based on their reported behaviors, participants were assigned a SRB score at each visit as follows: 0 = no insertive or receptive anal intercourse, 1 = no unprotected insertive or receptive anal intercourse, 2 = only unprotected insertive anal intercourse, 3 = unprotected receptive anal intercourse with 1 HIV-negative partner, 4 = condom serosorting, 5 = condom seropositioning, and 6 = no seroadaptive behaviors. Group-based trajectory modeling was used to examine SRB scores (<4 vs. ≥4) and identify groups with distinct sexual risk trajectories. RESULTS: Three sexual risk trajectory groups were identified: low-risk (n = 264; 63.0%), moderate-risk (n = 96; 22.9%; mean duration of consecutive high-risk intervals ∼1 year), and high-risk (n = 59; 14.1%; mean duration of consecutive high-risk intervals ∼2 years). Compared to low-risk group membership, high-risk group membership was associated with younger age (in years) [adjusted odds ratio (AOR) = 0.92, 95% confidence interval (CI): 0.88 to 0.96], being White (AOR = 3.67, 95% CI: 1.48 to 9.11), earning an income ≥$20,000 (AOR = 4.98, 95% CI: 2.13 to 11.64), distress/depression symptoms (Center for Epidemiologic Studies Depression Scale ≥ 16) (AOR = 2.36, 95% CI: 1.14 to 4.92), and substance use (AOR = 2.00, 95% CI: 1.01 to 3.97). CONCLUSIONS: Screening for the sociodemographic and behavioral factors described above may facilitate targeted PrEP delivery during high-risk periods among MSM.

The cumulative effects of medication use, drug use, and smoking on erectile dysfunction among men who have sex with men.

INTRODUCTION: Erectile dysfunction (ED) is highly prevalent among human immunodeficiency virus-seropositive (HIV+) men who have sex with men (MSM). There is a need for additional research to determine the correlates of HIV+ and HIV-seronegative (HIV-) MSM, especially regarding nonantiretroviral medication use. AIMS: This study examined the prevalence of ED and the sociodemographic, medical conditions, medication use, and substance use correlates of ED among HIV+ and HIV- MSM. METHODS: A modified version of the International Index of Erectile Function (IIEF) for MSM was self-administered by participants enrolled in the Multicenter AIDS Cohort Study, an ongoing prospective study of the natural and treated histories of HIV infection among MSM in the United States. The study sample included 1,340 participants, including 612 HIV+ and 728 HIV- men. Poisson regression with robust error variance was used to estimate prevalence ratios of ED in multivariable models in combined (HIV+/-) and separate analyses. MAIN OUTCOME MEASURE: ED was determined by the summed scores of a modified version of the IIEF validated among MSM. RESULTS: Twenty-one percent of HIV+ MSM and 16% of HIV- MSM reported ED. Being >55 years of age, black race, cumulative pack years of smoking, cumulative antihypertensive use, and cumulative antidepressant use had significant positive associations with the prevalence of ED in the total sample. Among HIV+ men, duration of antihypertensive use and antidepressant use were significantly associated with increasing prevalence of ED. Among HIV- men, being >55 years of age, black race, and cigarette smoking duration were associated with increased prevalence of ED. CONCLUSION: Predictors of ED may differ by HIV status. Although smoking cessation and effective medication management may be important as possible treatment strategies for ED among all MSM, there may be a burden on sexual functioning produced by non-HIV medications for HIV+ men.