Effects of familial and non-familial warmth during childhood and adolescence on sexual-orientation disparities in alcohol use trajectories and disorder during emerging adulthood.

BACKGROUND: We investigated sexual-orientation differences in typologies of self-reported familial and non-familial warmth in childhood (before age 11) and adolescence (ages 11-17); and tested whether warmth explained sexual minority emerging adults' (ages 18-25) heightened odds of having heavier alcohol use trajectories (AUTs) and heightened risk for past-year alcohol use disorder (AUD) compared to completely heterosexuals. METHODS: Using self-reported data from the U.S.-based Growing Up Today Study cohort, latent class analyses identified typologies of familial and non-familial warmth during childhood and adolescence. Multivariable regression models tested our objectives. RESULTS: Six warmth classes emerged, including: High-High (i.e., high familial and high non-familial warmth, respectively); High-Moderate; Moderate-Moderate; Moderate-Occasional; Occasional-Occasional; and Low-Low. Among women, sexual minorities had higher odds than completely heterosexuals of being in the Moderate-Moderate, Moderate-Occasional, and Occasional-Occasional versus the High-High warmth class. There were not significant associations between sexual orientation and warmth classes for men. Lower warmth classes were generally associated with greater past-year AUD, and mediated heightened disparities in AUD for sexual minority women versus completely heterosexual women (4.3% mediated), but not among men. Warmth classes were generally unassociated with AUTs, and did not mediate sexual-orientation differences in AUTs. CONCLUSIONS: Lower warmth was associated with greater alcohol-related problems, but not alcohol use itself. Warmth explained a small proportion of AUD disparities for sexual minority women-but not for men.

Sexual-orientation differences in alcohol use trajectories and disorders in emerging adulthood: results from a longitudinal cohort study in the United States.

AIMS: We estimated sexual-orientation differences in alcohol use trajectories during emerging adulthood, and tested whether alcohol use trajectories mediated sexual-orientation differences in alcohol use disorders (AUDs). DESIGN: Longitudinal self-reported survey data from the Growing Up Today Study. SETTING: United States. PARTICIPANTS: A total of 12 493 participants aged 18-25 during the 2003, 2005, 2007 or 2010 surveys. MEASUREMENTS: Stratified by gender, longitudinal latent class analyses estimated alcohol use trajectories (using past-year frequency, quantity and binge drinking from 2003 to 2010). Multinomial logistic regression tested differences in trajectory class memberships by sexual orientation [comparing completely heterosexual (CH) participants with sexual-minority subgroups: mainly heterosexual (MH), bisexual (BI) and gay/lesbian (GL) participants]. Modified Poisson regression and mediation analyses tested whether trajectories explained sexual-orientation differences in AUDs (past-year DSM-IV abuse/dependence in 2010). FINDINGS: Six alcohol use trajectory classes emerged for women and five for men: these included heavy (23.5/36.9% of women/men), moderate (31.8/26.4% of women/men), escalation to moderately heavy (9.7/12.0% of women/men), light (17.0% for women only), legal (drinking onset at age 21; 11.1/15.7% of women/men) and non-drinkers (7.0/9.1% of women/men). Compared with CH women, MH and BI women had higher odds of being heavy, moderate, escalation to moderately heavy and light drinkers versus non-drinkers (odds ratios = 2.02-3.42; P-values < 0.01-0.04). Compared with CH men, MH men had higher odds of being heavy, moderate and legal drinkers versus non-drinkers (odds ratios = 2.24-3.34; P-values < 0.01-0.01). MH men and women, BI women and GLs had higher risk of AUDs in 2010 than their same-gender CH counterparts (risk ratios = 1.34-2.17; P-values < 0.01). Alcohol use trajectories mediated sexual-orientation differences in AUDs for MH and GL women (proportion of effect mediated = 30.8-31.1%; P-values < 0.01-0.02), but not for men. CONCLUSIONS: In the United States, throughout emerging adulthood, several sexual-minority subgroups appear to have higher odds of belonging to heavier alcohol use trajectories than completely heterosexuals. These differences partially explained the higher risk of alcohol use disorders among mainly heterosexual and gay/lesbian women but not among sexual-minority men.

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.

Stability of Bisexual Behavior and Extent of Viral Bridging Behavior Among Men Who Have Sex with Men and Women.

Bisexual men experience significant health disparities likely related to biphobia. Biphobia presents via several preconceptions, including that bisexuality is transitory, and that bisexual men act as viral bridges between men who have sex with men and heterosexual populations. We analyzed data from a prospective cohort of gay and bisexual men, the Multicenter AIDS Cohort Study, to test these preconceptions. Men reporting both male and female sexual partners (MSMW) between 2002 and 2009 (n = 111) were classified as behaviorally bisexual. We assessed five hypotheses over two domains (transience of bisexual behavior and viral bridging). No evidence was found supporting the transitory nature of bisexuality. Trajectories of bisexual behavior were not transient over time. We found little evidence to support substantial viral bridging behavior. Notably, HIV-positive MSMW reported lower proportions of female partners than HIV-negative MSMW. Our results provide no empirical support for bisexual transience and scant support for viral bridging hypotheses. Our results provide key data showing that male bisexual behavior may be stable over long time periods and that behaviorally bisexual men's risk to female sexual partners may be lower than expected.

Someone to count on: social support as an effect modifier of viral load suppression in a prospective cohort study.

Though functional social support has been shown to serve as a protective factor for HIV viral load suppression in other populations, scant research has examined this relationship among men who have sex with men (MSM) in the United States. We assessed characteristics of social support, effects of social support on HIV viral load, and moderation by social support of the relationship between psychosocial indicators of a synergistic epidemic (syndemic) and HIV viral load. We analyzed longitudinal data from HIV-positive MSM using antiretroviral therapy who were enrolled in the Multicenter AIDS Cohort Study between 2002 and 2009 (n = 712). First, we conducted reliability assessments of a one-item social support measure. Then, we conducted a series of generalized longitudinal mixed models to assess our research questions. Moderation was assessed using an interaction term. A three-level (low/medium/high) social support variable demonstrated high reliability (intraclass correlation coefficients = 0.72; 95% CI: 0.70, 0.75). Black and Hispanic MSM reported lower social support than their White counterparts (p < .0001). Recent sero-conversion was associated with higher social support (p < .05). Higher numbers of concomitant syndemic indicators (depression, polysubstance use, and condomless anal sex) were associated with lower social support (p < .0001). Medium and high social support levels were associated with greater viral load suppression and lower viral load means (p < .0001). Social support moderated the relationships between syndemic and HIV viral load (p < .05). HIV-positive MSM, particularly those of color, may benefit greatly from interventions that can successfully boost functional social support. Creating strengths-based interventions may also have particularly high impact among HIV-positive MSM with the highest psychosocial burdens.

Effects of syndemics on HIV viral load and medication adherence in the multicentre AIDS cohort study.

OBJECTIVES: The objective of this study is to determine associations between intertwining epidemics (syndemics) and HIV medication adherence and viral load levels among HIV-positive MSM and to test whether adherence mediates the relationship between syndemics and viral load. DESIGN: We analysed participant data collected between 2003 and 2009 from the Multicenter AIDS Cohort Study, a prospective HIV/AIDS cohort study in four U.S. cities. METHODS: We conducted longitudinal analyses (repeated measures mixed models) to assess whether differences in viral load levels, undetectable viral load and self-reported HIV medication adherence were associated with count of syndemic conditions (substance use, depression symptoms and sexual risk behaviour, range 0-3), adjusting for race/ethnicity, age and income. Mediation analyses were conducted using structural equation modelling and the SAS %mediate macro. RESULTS: Syndemics count was associated with higher viral loads (P < 0.0001) and lower adherence (P < 0.0001). Increased counts of concomitant syndemics were associated with viral load (P < 0.01), detectable viral load (P < 0.05) and adherence (P < 0.001). Black MSM experienced worse outcomes across domains than white MSM (P < 0.0001) and experienced higher overall rates of syndemics (P < 0.01). Adherence significantly mediated the relationship between syndemics and viral load, accounting for an estimated 32.3% of the effect (P < 0.05). CONCLUSION: Effectively lowering viral load levels among MSM has implications for both HIV/AIDS prevention and care. Our findings suggest that integrating substance use interventions, mental healthcare and sexual risk prevention into standard HIV care may be necessary to optimize treatment and Treatment as Prevention (TasP) models.

Stuck in the middle: longitudinal HIV-related health disparities among men who have sex with men and women.

INTRODUCTION: Men who have sex with men and women (MSMW) have been shown in cross-sectional studies to suffer HIV-related health disparities above and beyond those found among men who have sex with men only (MSMO). We conducted a secondary data analysis over a 7-year time frame of participants in the Multicenter AIDS Cohort Study, a long-standing prospective cohort study, to examine whether MSMW had persistently higher rates of depression symptoms, polydrug use, and (among HIV-positive men who have sex with men) HIV viral load levels compared with MSMO. METHODS: Men were behaviorally defined as bisexual if they reported sexual activity with at least 1 male and 1 female partner between study waves 38 and 50. We used generalized mixed modeling with repeated measures to test differences in CES-D score, polydrug use, and viral load between sexually active MSMO (n = 1514) and MSMW (n = 111), adjusting for age, income, race/ethnicity, and recent seroconversion. RESULTS: MSMW were significantly more likely than MSMO to have higher CES-D scores, polydrug use, and viral load levels (all P < 0.01). Outcome trajectories did not differ significantly over time between these groups. Black and Hispanic HIV-positive MSMW had higher viral load levels relative to white HIV-positive MSMW (P < 0.01). DISCUSSION: Compared with MSMO, MSMW in the Multicenter AIDS Cohort Study suffer from profound and persistent HIV-related health disparities across biological, behavioral, and psychosocial domains. Further qualitative and quantitative research contextualizing the pathways underlying these disparities is recommended for intervention development targeting MSMW at risk for HIV acquisition and transmission.

HIV infection and sexual risk among men who have sex with men and women (MSMW): a systematic review and meta-analysis.

OBJECTIVES: To estimate the number of men who have sex with men and women who are HIV-positive in the United States, and to compare HIV prevalence rates between men who have sex with men and women, men who have sex with men only, and men who have sex with women exclusively. METHODS: Following PRISMA guidelines, we conducted a systematic review and meta-analysis of reports referencing HIV prevalence and men who have sex with men and women. We searched PubMed and Ovid PsycINFO for peer-reviewed, U.S.-based articles reporting on HIV prevalence among men who have sex with men and women. We conducted event rate, effect size, moderation and sensitivity analyses. RESULTS: We estimate that 1.0% of U.S. males are bisexually-behaving, and that 121,800 bisexually-behaving men are HIV-positive. Men who have sex with men and women are less than half as likely to be HIV-positive as men who have sex with men only (16.9% vs. 33.3%; OR = 0.41, 95% CI: 0.31, 0.54), but more than five times as likely to be HIV-positive as men who have sex with women exclusively (18.3% vs. 3.5%; OR = 5.71, 95% CI: 3.47, 9.39). They are less likely to engage in unprotected receptive anal intercourse than men who have sex with men only (15.9% vs. 35.0%; OR = 0.36, 95% CI: 0.28, 0.46). Men who have sex with men and women in samples with high racial/ethnic minority proportions had significantly higher HIV prevalence than their counterparts in low racial/ethnic minority samples. CONCLUSIONS: This represents the first meta-analysis of HIV prevalence in the U.S. between men who have sex with men and women and men who have sex with men only. Data collection, research, and HIV prevention and care delivery specifically tailored to men who have sex with men and women are necessary to better quantify and ameliorate this population's HIV burden.

HIV risk among substance-using men who have sex with men and women (MSMW): findings from South Florida.

Compared with men who have sex with men only (MSMO), men who have sex with men and women (MSMW) consistently report higher rates of two HIV risk behaviors: transactional sex (TS) and concurrent substance use and sex (CSS). Within MSMW, little is known about how synergistic epidemics ("syndemics") affect TS and CSS. Using a sample of substance-using MSM (n = 515) in South Florida, we compared TS and CSS among MSMO and MSMW; examined whether, within MSMW (n = 86), TS and CSS predict unprotected anal intercourse with partners of serodiscordant/unknown HIV status (SU-UAI); and tested whether syndemics predict TS and CSS. MSMW reported higher rates of engaging in both TS and CSS (AOR = 1.7; 95 % CI 1.0-3.0). Within MSMW, engagement in both TS and CSS predicted SU-UAI (AOR = 3.3; 95 % CI 1.2-9.6); and syndemics predicted TS and CSS involvement (p < 0.01). Substance-using MSMW may benefit from interventions targeting TS, CSS, and background syndemics.

Labor force participation and health-related quality of life in HIV-positive men who have sex with men: the Multicenter AIDS Cohort Study.

Too many people with HIV have left the job market permanently and those with reduced work capacity have been unable to keep their jobs. There is a need to examine the health effects of labor force participation in people with HIV. This study presents longitudinal data from 1,415 HIV-positive men who have sex with men taking part in the Multicenter AIDS Cohort Study. Generalized Estimating Equations show that employment is associated with better physical and mental health quality of life and suggests that there may be an adaptation process to the experience of unemployment. Post hoc analyses also suggest that people who are more physically vulnerable may undergo steeper health declines due to job loss than those who are generally healthier. However, this may also be the result of a selection effect whereby poor physical health contributes to unemployment. Policies that promote labor force participation may not only increase employment rates but also improve the health of people living with HIV.

Middle-aged and older men who have sex with men exhibit multiple trajectories with respect to the number of sexual partners.

This study aimed to examine trajectories with respect to the number of sexual partners among older men who have sex with men and to determine characteristics associated with trajectory groups. Nagin's group-based modeling was used to identify trajectories for 237 men from the Pitt Men's Study with respect to the number of male intercourse partners from age 50.0 to 59.5. Three distinct trajectory groups were identified. Most men (69.2%) had a median of two sexual partners in the past 6 months across the age range of the study. A smaller group (19.4%) had low or no sex partners. The smallest group (11.4%) had 30 or more sexual partners in the past 6 months at age 50. The groups were statistically different with respect to race, HIV status, drug use (marijuana, poppers, crack cocaine, and Viagra), the number of unprotected anal sex partners, and personal attitudes towards sex.

Sexual, behavioral, and quality of life characteristics of healthy weight, overweight, and obese gay and bisexual men: findings from a prospective cohort study.

While there have been attempts to explore the association of obesity and risky sexual behaviors among gay men, findings have been conflicting. Using a prospective cohort of gay and bisexual men residing in Pittsburgh, we performed a semi-parametric, group-based analysis to identify distinct groups of trajectories in body mass index slopes over time from 1999 to 2007 and then correlated these trajectories with a number of psychosocial and behavioral factors, including sexual behaviors. We found many men were either overweight (41.2%) or obese (10.9%) in 1999 and remained stable at these levels over time, in contrast to recent increasing trends in the general population. Correlates of obesity in our study replicated findings from the general population. However, we found no significant association between obesity and sexual risk-taking behaviors, as suggested from several cross-sectional studies of gay men. While there was not a significant association between obesity and sexual risk-taking behaviors, we found high prevalence of overweight and obesity in this population. Gay and bisexual men's health researchers and practitioners need to look beyond HIV and STI prevention and also address a broader range of health concerns important to this population.

Lower HIV prevalence among Asian/Pacific Islander men who have sex with men: a critical review for possible reasons.

We conducted a critical literature review for possible reasons that may explain the lower HIV prevalence observed among API MSM compared to MSM of other races/ethnicities. Trends emerging from the literature suggest that traditional individual-level factors-unprotected anal intercourse, substance use, STD prevalence, rates and frequency of HIV testing, and utilization of HIV prevention services-do not appear to be related to the lower HIV prevalence among API MSM. Some evidence suggests that socio-cultural and structural factors might be the more critical forces in determining racial/ethnic disparities of HIV among MSM. For API MSM, these factors include structures of sexual networks, access to and reception of medical care and treatment among HIV-positive MSM, and influences of different levels and types of acculturation. Moreover, emerging risk reduction strategies, such as seroadaptive behaviors, could play a role. Future research should address these factors in intervention design. In addition, better theories of resilience and measurement of strengths and protective factors are needed to enhance the efficacy of HIV interventions.

Intimate partner violence among HIV-positive persons in an urban clinic.

While the intersection of HIV/AIDS and intimate partner violence (IPV) has gained increased attention, little focus has been given to the relationship among minority men and men who have sex with men (MSM). This pilot study, conducted at an urban clinic, explores the IPV experiences of HIV-positive persons involved in both heterosexual and homosexual relationships. Fifty-six HIV-positive individuals were interviewed to assess for verbal, physical, and sexual IPV, and for HIV-related abuse and attitudes regarding routine IPV screening. Approximately three quarters (73%) of the sample reported lifetime IPV and 20% reported current abuse. Physical IPV (85%) was cited the most by abused participants. IPV rates were highest among African-Americans and MSM. More than one-fourth (29%) of those abused felt the abuse was related to their HIV status. A majority of participants favored IPV screening by providers, but felt it might increase risk of IPV. IPV and its association to HIV are significant issues among this sample. Findings support the need for developing new programs that address these epidemics simultaneously.

A Twenty-Two-Year-Old Community Advisory Board: Health Research as an Opportunity for Social Change.

Conducting health research often requires a partnership between marginalized communities and researchers. Community organizers can broker this partnership in a way that not only produces important scientific discoveries but also brings needed resources to the communities. This article is a description of a community advisory board established in 1984 to advise researchers on a longitudinal study of the natural history of AIDS among gay men. The Board successfully guided the recruitment of more than 3,000 gay and bisexual male volunteers and, at the same time worked as a powerful change agent. An analysis of minutes from all Board meetings between 1984-2006 indicates that significant social change as well as important research findings resulted from Board actions. Community organizers who work to create a mutually beneficial partnership between communities and researchers may find new opportunities to support community growth and social justice.

Impact of early sexual debut on gay men's tobacco use.

Young men's sexual experiences with men are different from their sexual experiences with women because of homophobia. Early sexual debut with another man could lead to tobacco use as a result. The study assessed 691 HIV-negative gay men recruited from southwestern Pennsylvania. Early sexual experiences with men and women were associated with participants' smoking behaviors. It is thought that the early sexual debut with men may place these individuals at risk for homophobia as well as for being socialized in environments that will influence their smoking behavior. To be effective, tobacco control programs need to be culturally competent regarding issues that affect gay men.

Recruiting minority men who have sex with men for HIV research: results from a 4-city campaign.

We describe the efforts of a 4-city campaign to recruit Black and Hispanic men who have sex with men into an established HIV epidemiological study. The campaign used community organizing principles and a social marketing model that focused on personnel, location, product, costs and benefits, and promotion. The campaign was developed at the community, group, and individual levels to both increase trust and reduce barriers.The proportion of Hispanic men recruited during the 2002-2003 campaign doubled compared with the 1987 campaign, and the proportion and number of White men decreased by 20%. The proportion of Black men decreased because of the large increase in Hispanic men, although the number of Black men increased by 56%. Successful recruitment included training recruitment specialists, involving knowledgeable minority community members during planning, and having an accessible site with convenient hours.

The impact of gender-role nonconforming behavior, bullying, and social support on suicidality among gay male youth.

This study hypothesized that gender-role nonconformity is associated with suicidality, and bullying mediates this relationship. Gay males retrospectively answered questions pertaining to elementary, middle, and high school. Support for the hypotheses was found. Results can help screen gay youth for suicidality and support the need for policies prohibiting harassment based on sexual orientation.

Adolescents define sexual orientation and suggest ways to measure it.

Researchers disagree on how to assess adolescent sexual orientation. The relative importance of various dimensions (e.g. attraction, relationships, behavior, self-labeling) is unknown, which calls into question the validity of studies assessing adolescent sexual orientation. To address this issue, 50 male and female adolescents of varied sexual orientations participated in focus groups and interviews. Two types of sexual attraction-one a physiologic reaction and the other a cognitive response-were central to adolescent sexual orientation. Participants did not perceive sexual behavior and self-identification as necessarily relevant. Preliminary items to measure sexual attraction were developed based on these adolescents' perceptions.

Mental health case management as a locus for HIV prevention: results from case-manager focus groups.

HIV infection among people with severe mental illness (SMI) is a growing concern, and interventions have been designed to address HIV prevention among these individuals. However, little is known about the preparedness of mental health providers to support these interventions. This study concentrated on mental health case management as a locus for HIV-prevention services. Focus groups of case managers were conducted to learn participants' motivation to adopt HIV-prevention services and barriers/facilitators to such adoption. Participants reported they would be motivated to offer HIV prevention if services were to be presented in the context of existing client relationships and case-management tasks. Barriers and facilitators were discussed at client, provider, and community levels, and recommendations for training were offered. Findings have implications for diffusion of HIV-prevention services in case management, and the line of questioning in focus groups provides a basis for learning about other behavioral health service contexts as loci for disease prevention.