To T or not to T: Differences in Testosterone Use and Discontinuation by HIV Serostatus among Men who Have Sex with Men.

OBJECTIVES: The aim of the study was to characterize contemporary patterns and correlates of testosterone therapy (TTh) use and discontinuation by HIV serostatus among men in the Multicenter AIDS Cohort Study (MACS). METHODS: Self-reported testosterone use data were collected semiannually from 2400 (1286 HIV-infected and 1114 HIV-uninfected) men who have sex with men. Multivariable Poisson regression was used to estimate prevalence ratios for TTh use and predictors of TTh discontinuation (2012-2015). RESULTS: Use was higher among HIV-infected compared with HIV-uninfected men in all age strata, with an age-adjusted prevalence of 17% vs. 5%, respectively (adjusted prevalence ratio 3.7; P < 0.001). Correlates of use in the multivariable model were similar by HIV serostatus: white race, the Los Angeles (LA) site, more than one recent sexual partner, non-smoking status, and higher American Heart Association/American College of Cardiology (AHA/ACC) cardiovascular disease (CVD) risk score category (approximately 70% of testosterone users were in the high-risk category). Compared with HIV-uninfected men, HIV-infected men more frequently reported building muscle mass as a motivation for testosterone use. The TTh discontinuation rate was 20.9/100 person-years [95% confidence interval (CI) 17.3, 25.0/100 person-years]. Relative to HIV-uninfected men, HIV-infected men were half as likely to discontinue (adjusted incidence rate ratio 0.4; P < 0.001). Discontinuation was 40% higher in the period after the US Food and Drug Administration (FDA) safety communication for testosterone in 2014, independent of co-factors (P = 0.06). CONCLUSIONS: Given the high prevalence of both TTh use and CVD risk among HIV-infected men, the benefits and risks of TTh should be examined in future studies of aging HIV-infected men and monitored routinely in clinical practice.

Anti-retroviral Therapy Based HIV Prevention Among a Sample of Men Who Have Sex with Men in Cape Town, South Africa: Use of Post-exposure Prophylaxis and Knowledge on Pre-exposure Prophylaxis.

Men who have Sex with Men (MSM) have been affected disproportionately by the global HIV pandemic. Rates of consistent condom-use are low and there is a need for further biomedical prevention interventions to prevent new HIV infections. Post exposure prophylaxis (PEP) can reduce the risk of HIV, but uptake among MSM is low. Pre-exposure prophylaxis (PrEP), an innovative anti-retroviral-based HIV prevention tool might be an appropriate intervention for MSM who have recently accessed PEP that involves HIV negative individuals taking daily tenofovir+emtricitabine for HIV prevention. 44 MSM, attending a primary health-care level MSM-focused sexual health clinic in Cape Town, South Africa, who had initiated PEP were enrolled in this study. Participants were followed up after 2, 4 and 12 weeks. Self-administered electronic surveys were completed at the initial, 4 and 12 week visit. Barriers and facilitators to accessing PEP and remaining adherent were examined, as was knowledge about PrEP. Thirty-two participants (80 %) were <40 years of age (range 20-65 years). 35 % of the participants reported their reason for requiring PEP as condomless receptive anal intercourse. A further 20 % required PEP following condomless penetrative anal intercourse; 27.5 % required PEP due to a broken condom during receptive anal sex and 2 participants during insertive anal sex. Three participants did not complete 28 days of PEP or were lost to follow up. Over half (58.5 %) of the participants reported being completely adherent to their regime; under a third (31.7 %) reported missing one PEP dose; and 9.8 % reported missing more than one dose. 36/40 (90 %) had heard of PrEP and 30/40 (75 %) indicated that they would use PrEP if it were accessible to them. That we enrolled 44 MSM who accessed PEP from a Department of Health affiliated clinic over 12 months, speaks to the low uptake by MSM of PEP services in South Africa. Adherence was high and demonstrates that adherence support is feasible from a state health clinic. Reported risk behaviors in some high-risk participants did not change over time, demonstrating the need for additional longer-term HIV preventions such as PrEP. PEP users could conceivably be transitioned from PEP to PrEP.

Knowledge, Attitudes and Beliefs regarding Post Exposure Prophylaxis among South African Men who have Sex with Men.

The Soweto Men's Study (2008), demonstrated an overall HIV prevalence rate of 13.2 %, with 10.1 % among straight-identified Men-who-have-sex-with-men (MSM), 6.4 % among bisexual-identified MSM and 33.9 % among gay-identified MSM. Behavioral interventions are imperative, but insufficient to prevent new HIV infections. Biomedical prevention of HIV offers a variety of combination prevention tools, including Post-exposure prophylaxis (PEP). PEP studies amongst MSM have been conducted in Amsterdam, Brazil and San Francisco, but never before in Africa. A cross-sectional, Internet-based survey was initiated to measure knowledge, attitudes and beliefs regarding PEP among South African MSM. Recruitment commenced in June 2014 and ran until October 2015. Participants were recruited through banner advertisements on Facebook.com and mambaonline.com, advertisements in the local gay media and at Health4Men (H4M) MSM-targeted clinics. Outreach workers distributed flyers advertising the study in their local communities. The survey was also made available on a computer at the H4M clinics in Cape Town and Johannesburg to reach MSM who may not have Internet access. A total of 408 men completed the survey. The majority of these men were under the age of 40, identified as gay/homosexual and were employed; 51 % (208/408) self-identified as black or of mixed race. In multivariate analysis participants who identified as gay had greater odds of having previously heard of PEP (AOR 1.91, 95 % CI 1.04, 3.51; p = 0.036), as did those who reported their HIV status as positive (AOR 2.59, 95 % CI 1.47, 4.45; p = 0.001). Participants with medical insurance had greater odds of having used PEP previously (AOR 2.67, 95 % CI 1.11, 6.43; p = 0.029). Bivariate analysis showed that condomless sex in the past 6 months was not significantly associated with PEP knowledge (p = 0.75) or uptake (p = 0.56) of PEP. Our findings suggest a lack of PEP knowledge and uptake among non-gay identified, HIV negative and un-insured MSM. Focusing PEP programs on these men may potentially increase uptake. Increased knowledge needs to be provided to MSM who engage in risky sexual behaviors.

Perspectives on expedited partner therapy for chlamydia: a survey of health care providers.

There is a lack of research on health care providers' use of and perspectives on expedited partner therapy in a state where expedited partner therapy is not prohibited or explicitly allowed. The aim of our study was to understand if and how health care providers use expedited partner therapy, if specific demographic factors and knowledge contribute to increased use of expedited partner therapy, and to describe barriers and facilitators to the use of expedited partner therapy in Pittsburgh, Pennsylvania. A convenience sample of 112 health care providers from diverse disciplines who treat young women at risk for chlamydia completed an online survey. About 11% of health care providers used expedited partner therapy consistently. Those who self-reported that they were knowledgeable about expedited partner therapy were more likely to use expedited partner therapy (73% vs. 49%, p = .009) as were those who said no or were unsure about their institution's guidelines for expedited partner therapy (35% vs. 22%, p = 0.01) (62% vs. 57%, p = 0.01). The most commonly reported facilitator of expedited partner therapy was having clear legal guidelines (86%). This study finds that in a setting where expedited partner therapy is not expressly permitted, health care providers still use the practice but also experience barriers that limit uptake. Legislation expressly endorsing expedited partner therapy in the state and in medical institutions is needed to increase expedited partner therapy use.

Alcohol Use and Associated Sexual and Substance Use Behaviors Among Men Who Have Sex with Men in Moscow, Russia.

Alcohol use is a public health problem in the Russian Federation. This study explored relationships between alcohol use and behavioral risks for HIV transmission among men who have sex with men (MSM) in Moscow, Russia. Alcohol use disorder identification test (AUDIT) scores for 1367 MSM participating in a cross-sectional survey and HIV testing were categorized to: "abstinence/low use", "hazardous use", "harmful use/dependency". Multiple logistic regression models compared dependent variables for sexual and drug use behaviors across alcohol use strata. Hazardous and harmful/dependent alcohol use were significantly associated with high-risk sexual behaviors and drug use. Harmful use/dependency was associated with an increased odds of having more than five male sex partners (last 12 months; adjusted odds ratios-AOR 1.69; 95 % CI 1.25-2.27), inconsistent condom use during anal intercourse (AOR 2.19; 95 % CI 1.61-2.96) and, among those using recreational drugs, injection drug use (last month; AOR 4.38: 95 % CI 1.13-17.07) compared to abstinent/low-level users. Harmful/dependent use was marginally associated with HIV infection (AOR 1.48; 95 % CI 0.97-2.25). HIV prevention efforts for MSM in Moscow may benefit from addressing problem alcohol use to mitigate high-risk behaviors.

Psychosocial health conditions and HIV prevalence and incidence in a cohort of men who have sex with men in Bangkok, Thailand: evidence of a syndemic effect.

Men who have sex with men (MSM) in Bangkok may experience multiple psychosocial health conditions, such as substance use, suicidality, and a history of sexual abuse. These factors may contribute to HIV vulnerability in a syndemic way. A syndemic is defined as a number of synergistically interacting health conditions producing excess disease in a population. The objective of this study is to examine whether psychosocial health conditions among MSM have a syndemic association with HIV prevalence and HIV incidence. To do this, we evaluated psychosocial health conditions and their associations with unprotected sex, HIV prevalence and HIV incidence in a cohort of Thai MSM (N = 1,292). There was a positive and significant association between the number of psychosocial health conditions and increased levels of unprotected sex and HIV prevalence at study baseline. The number of psychosocial health conditions at baseline was also associated with increased HIV incidence during follow-up (no conditions, HIV incidence = 15.3 %; one to three conditions, 23.7 %; four to five conditions, 33.2 %). The number of psychosocial health conditions was positively associated with HIV risk behavior and HIV prevalence and incidence. Prevention efforts among MSM need to address the existence of multiple psychosocial health conditions and their synergy to effectively decrease the spread of HIV infection.

Cumulative exposure to stimulants and immune function outcomes among HIV-positive and HIV-negative men in the Multicenter AIDS Cohort Study.

We examined associations between stimulant use (methamphetamine and cocaine) and other substances (nicotine, marijuana, alcohol and inhaled nitrites) with immune function biomarkers among HIV-seropositive (HIV +) men taking highly active antiretroviral therapy (ART) and HIV-seronegative (HIV-) men in the Multicenter AIDS Cohort Study. Among HIV + men, cumulative adherence to ART (4.07, 95% confidence interval [CI]: 3.52, 4.71, per 10 years of adherent ART use), and recent cohort enrolment (1.38; 95% CI: 1.24, 1.55) were multiplicatively associated with increase in CD4+/CD8+ ratios. Cumulative use of methamphetamine (0.93; 95% CI: 0.88, 0.98, per 10 use-years), cocaine (0.93; 95% CI: 0.89, 0.96, per 10 use-years) and cumulative medical visits (0.99; 95% CI: 0.98, 0.99, per 10 visit-years), each showed small negative associations with CD4+/CD8+ ratios. Among HIV- men, cumulative medical visits (0.996; 95% CI: 0.993, 0.999), cumulative number of male sexual partners (0.999; 95% CI: 0.998, 0.9998, per 10 partner-years) and cigarette pack-years (1.10; 95% CI: 1.02, 1.18, per 10 pack-years) were associated with CD4+/CD8+ ratios over the same period. ART adherence is associated with a positive immune function independent of stimulant use, underscoring the influence of ART on immune health for HIV+ men who engage in stimulant use.

Control of Citrus Canker and Citrus Bacterial Spot with Bacteriophages.

Bacteriophages, alone or in combination with copper bactericides, were evaluated for managing Asiatic citrus canker and citrus bacterial spot incited by Xanthomonas axonopodis pathovars citri and citrumelo, respectively. In a set of five greenhouse experiments, phage treatment provided consistent control of citrus canker, causing an average of 59% reduction in disease severity. However, treatment with phage was ineffective if applied with skim milk, a protective formulation, which increases phage residual activity. In nursery settings, phage treatment also reduced disease but was less effective than copper-mancozeb, a chemical bactericide. The integration of phage and copper-mancozeb resulted in equal or less control than copper-mancozeb application alone. Phage treatments were evaluated in a commercial citrus nursery for reducing citrus bacterial spot caused by natural inoculum. Phage treatment provided significant disease reduction on moderately sensitive Valencia oranges in two trials (48 and 35%); however, on the highly susceptible grapefruit host it was ineffective. In an experimental citrus nursery, phage treatment provided significant control of citrus bacterial spot caused by a phage-sensitive strain, but was equally or less effective than copper-mancozeb. The combination of phage and copper-mancozeb did not increase control compared with copper-mancozeb alone.

Functional analysis of the early chlorosis factor gene.

Chlorosis is one of the symptoms of bacterial spot disease caused by Xanthomonas campestris pv. vesicatoria, which induces chlorosis before any other symptoms appear on tomato. We report characterization of a 2.1-kb gene called early chlorosis factor (ecf). The gene ecf encodes a hydrophobic protein with similarity to four other proteins in plant pathogens, including HolPsyAE, and uncharacterized gene products from X. campestris pv. campestris and X. axonopodis pv. citri, and, at the tertiary structure level, to colicin Ia from Escherichia coli. We demonstrate that the associated phenotype is hrp dependent, and that the ecf gene product appears to be translocated to host cells. The gene ecf has no impact on electrolyte leakage or on bacterial growth in planta in response to infection. Concentrated culture filtrates do not produce chlorosis. Study of its role in Xanthomonas spp.-tomato interactions will forward our understanding of symptom production by plant pathogens and allows further investigation into the mechanisms of bacterial virulence and production of symptoms.

Importance of opgHXcv of Xanthomonas campestris pv. vesicatoria in host-parasite interactions.

Tn5 insertion mutants of Xanthomonas campestris pv. vesicatoria were inoculated into tomato and screened for reduced virulence. One mutant exhibited reduced aggressiveness and attenuated growth in planta. Southern blot analyses indicated that the mutant carried a single Tn5 insertion not associated with previously cloned pathogenicity-related genes of X. campestris pv. vesicatoria. The wild-type phenotype of this mutant was restored by one recombinant plasmid (pOPG361) selected from a genomic library of X. campestris pv. vesicatoria 91-118. Tn3-gus insertion mutagenesis and sequence analyses of a subclone of pOPG361 identified a 1,929-bp open reading frame (ORF) essential for complementation of the mutants. The predicted protein encoded by this ORF was highly homologous to the previously reported pathogenicity-related HrpM protein of Pseudomonas syringae pv. syringae and OpgH of Erwinia chrysanthemi. Based on homology, the new locus was designated opgHXcv. Manipulation of the osmotic potential in the intercellular spaces of tomato leaves by addition of mannitol at low concentrations (25 to 50 mM) compensates for the opgHXcv mutation.

Bacteriocin-Like Substances from Tomato Race 3 Strains of Xanthomonas campestris pv. vesicatoria.

ABSTRACT Tomato race 3 (T3) strains of Xanthomonas campestris pv. vesicatoria are antagonistic in vitro to tomato race 1 (T1) strains of the bacterium. All T1 strains and 11 strains of other X. campestris pathovars tested were inhibited by T3 strains. Sensitivity of tomato race 2 (T2) strains was variable. No strains from other bacterial genera tested were inhibited. Cell-free filtrates from T3 strains were inhibitory to sensitive strains. The inhibitory activity of these filtrates was lost after treatment at temperatures above 80 degrees C and with selected protease enzymes. However, treatment with trypsin or DNase had no effect on their activity. Seven cosmid clones from a genomic library of a T3 strain were selected for their ability to consistently inhibit a sensitive indicator strain in plate assays. Southern hybridization analysis placed these into three bacteriocin (BCN)-producing groups designated BCN-A, BCN-B, and BCN-C. The BCN-like groups could be differentiated by variations in inhibitory spectra and levels of activity in plate assays. Mutations that inactivated expression of each BCN group individually in a wild-type T3 strain had inhibitory activity confirming that multiple BCNs are present in the T3 strain. T3 strains were inhibitory to a sensitive indicator strain in tomato leaf tissue, but this effect was observed only when T3 strains were applied in advance of the sensitive strain. BCN-A was the major BCN-like substance involved in the suppression of the sensitive indicator strain in tomato leaf tissues.

A non-hypersensitive resistance in pepper to the bacterial spot pathogen is associated with two recessive genes.

ABSTRACT The pepper genotype, ECW-12346, was developed with bacterial spot resistance derived from Pep13, PI 271322, and ECW123 (Early Calwonder containing Bs1, Bs2, and Bs3 genes). For genetic analysis of this resistance, ECW12346, ECW123, F(1), F(2), and backcrosses were inoculated with a pepper race 6 (P6) strain. Two recessive genes were identified that determined resistance. The genes are designated bs5 and bs6 for the resistance derived from PI 271322 and Pep13, respectively. In greenhouse and field studies, ECW12346 was highly resistant, whereas ECW123 had significant defoliation. In growth-room studies, electrolyte leakage and population dynamics were determined. Following infiltration of both genotypes with 10(8) CFU/ml of a P6 strain, there was no rapid increase in electrolyte leakage within 72 h, whereas a rapid increase in electrolyte leakage occurred within 24 h when a similar concentration of a P3 strain (containing the avrBs2 gene) was infiltrated into the intercellular spaces of the leaf. When 10(5) CFU/ml of a P6 strain was infiltrated into leaves, complete tissue collapse was evident in ECW123 10 days later as determined by visual assessment and electrolyte leakage data, but no confluent necrosis was detected in ECW12346. Internal populations were at least two logarithmic units higher in ECW123 than in ECW12346. Therefore, ECW12346 inhibits population build-up without inducing the typical hypersensitive reaction characterized by an increase in electrolyte leakage.

Differential HIV risk in bathhouses and public cruising areas.

OBJECTIVES: This report investigates differences in risk behaviors among men who have sex with men (MSM) who went to gay bathhouses, public cruising areas, or both. METHODS: We used a probability sample of MSM residing in 4 US cities (n = 2,881). RESULTS: Men who used party drugs and had unprotected anal intercourse with nonprimary partners were more likely to go to sex venues than men who did not. Among attendees, MSM who went to public cruising areas only were least likely, and those who went to both public cruising areas and bathhouses were most likely to report risky sex in public settings. CONCLUSIONS: Distinguishing between sex venues previously treated as a single construct revealed a significant association between pattern of venue use and sexual risk. Targeting HIV prevention in the bathhouses would reach the segment of men at greatest risk for HIV transmission.

The continuing HIV epidemic among men who have sex with men.

OBJECTIVES: This study characterized the AIDS epidemic among urban men who have sex with men (MSM). METHODS: A probability sample of MSM was obtained in 1997 (n = 2881; 18 years and older) from New York, Los Angeles, Chicago, and San Francisco, and HIV status was determined through self-report and biological measures. RESULTS: HIV prevalence was 17% (95% confidence interval = 15%, 19%) overall, with extremely high levels in African Americans (29%), MSM who used injection drugs (40%), "ultraheavy" noninjection drug users (32%), and less educated men (< high school, 37%). City-level HIV differences were non-significant once these other factors were controlled for. In comparing the present findings with historical data based on public records and modeling, HIV prevalence appears to have declined as a result of high mortality (69%) and stable, but high, incidence rates (1%-2%). CONCLUSIONS: Although the findings suggest that HIV prevalence has declined significantly from the mid-1980s, current levels among urban MSM in the United States approximate those of sub-Saharan countries (e.g., 14%-25%) and are extremely high in many population subsegments. Despite years of progress, the AIDS epidemic continues unabated among subsegments of the MSM community.

Health-related characteristics of men who have sex with men: a comparison of those living in "gay ghettos" with those living elsewhere.

OBJECTIVES: This study investigated the limitations of probability samples of men who have sex with men (MSM), limited to single cities and to the areas of highest concentrations of MSM ("gay ghettos"). METHODS: A probability sample of 2881 MSM in 4 American cities completed interviews by telephone. RESULTS: MSM who resided in ghettos differed from other MSM, although in different ways in each city. Non-ghetto-dwelling MSM were less involved in the gay and lesbian community. They were also less likely to have only male sexual partners, to identify as gay, and to have been tested for HIV. CONCLUSIONS: These differences between MSM who live in gay ghettos and those who live elsewhere have clear implications for HIV prevention efforts and health care planning.

Understanding childhood sexual abuse as a predictor of sexual risk-taking among men who have sex with men: The Urban Men's Health Study.

OBJECTIVE: The prevalence and characteristics of childhood sexual abuse (CSA) among men who have sex with men (MSM), and links with sexual risk are explored. A model linking CSA and sexual risk among MSM is proposed. METHOD: A telephone probability sample of urban MSM (n = 2881) was recruited and interviewed between November 1996 and February 1998. The interview covered numerous health issues, including history of sexual victimization. RESULTS: One-fifth reported CSA, primarily by non-family perpetrators. Initial CSA experiences are characterized by high levels of force (43% involved physical force/weapons), and penetrative sex (78%; 46% reported attempted or actual anal intercourse). Such men are more likely than nevercoerced men to engage in high risk sex (unprotected anal intercourse with a non-primary partner or with a serodiscordant male). In multivariate analyses, the effect of childhood sexual coercion on sexual risk is mediated by substance use, patterns of sexual contacts, and partner violence, but not by adult sexual revictimization or by depression. CONCLUSIONS: Findings are interpreted within the context of social learning theory and prior research on sexual risk-taking. The high risk for CSA among MSM, which can predispose such men to patterns of HIV sexual risk, warrants new approaches in HIV prevention.

Use of antiretroviral therapies among HIV-infected men who have sex with men: a household-based sample of 4 major American cities.

OBJECTIVES: This study sought to determine the prevalence and determinants of use of recommended antiretroviral regimens among urban seropositive men who have sex with men (MSM). METHODS: A probability telephone sample of MSM was taken within regions of Chicago, Los Angeles, New York, and San Francisco. Analysis focused on use of antiretroviral therapies. RESULTS: Although the majority of seropositive MSM with CD4 counts below 500 per microliter were using recommended antiretroviral regimens, 26% of seropositive MSM were not receiving such care. Men who were younger, who reported a sexual orientation other than homosexual, who had a more recent interview date, who were at middle levels of affiliation with the gay community, and who reported higher levels of perceived exclusivity on the part of the gay community were less likely to be using recommended antiretroviral regimens. CONCLUSIONS: Although current efforts to make antiretroviral therapies available to HIV-seropositive MSM are reasonably effective, additional efforts are needed for MSM characterized by relative youth and lower social support.

Phenotypic and genotypic characterization of human and nonhuman Escherichia coli.

Estuarine waters receive fecal pollution from a variety of sources, including humans and wildlife. Escherichia coli is one of several fecal coliform bacteria that inhabit the intestines of many warm-blooded animals that sometimes contaminate water. Its presence does not specifically implicate human fecal input, therefore it is necessary to differentiate contamination sources to accurately assess health risks. E. coli were isolated from human sources (HS) and nonhuman sources (NHS) in the Apalachicola National Estuarine Research Reserve and analyzed for fatty acid methyl ester (FAME), O-serogroup, and pulsed-field gel electrophoresis (PFGE) profiles. For FAME and PFGE analyses, there was no relationship between profile and isolate source. Human source PFGE profiles were less diverse than NHS isolates, and conversely for FAME. In contrast, O-serogrouping showed less diversity for HS vs. NHS isolates, and the predominant HS O-serogroups differed significantly (P < 0.01) from those of NHS isolates.

Correlates of heavy substance use among young gay and bisexual men: The San Francisco Young Men's Health Study.

Correlates of heavy substance use among a household-based sample of young gay and bisexual men (n=428) were identified and the odds ratio (OR) was calculated. A total of 13.6% reported frequent, heavy alcohol use and 43% reported polydrug use. Compared with men employed in professional occupations, men in service positions (OR=3.77) and sales positions (OR=2.51) were more likely to be heavy alcohol consumers. Frequent gay bar attendance and multiple sex partners were related to heavy alcohol use, as well as to polydrug use. Polydrug users were more likely to be HIV seropositive (OR=2.05) or of unknown HIV serostatus (OR=2.78). HIV serostatus was similarly related to frequent drug use. These correlates of heavier substance use among young gay and bisexual men could be used to identify and intervene early with members of this population who are at risk of substance misuse, as well as HIV/AIDS risk.

Alcohol use, drug use and alcohol-related problems among men who have sex with men: the Urban Men's Health Study.

AIMS: To measure the prevalence and independent associations of heavy and problematic use of alcohol and recreational drugs among a household-based sample of urban MSM (men who have sex with men). DESIGN: Cross-sectional survey. PARTICIPANTS: Men who identified as being gay or bisexual or who reported sex with another man in the prior 5 years were included in this analysis (n = 2172). SETTING: A probability telephone sample of MSM was taken within Zip Codes of four large American cities (Chicago, Los Angeles, New York and San Francisco) estimated to have total concentrations of at least 4% of all households with one resident MSM. MEASUREMENTS: Standard measures of alcohol use, problems associated with alcohol use, and recreational drug use were administered by trained telephone interviewers. FINDINGS: Both recreational drug (52%) and alcohol use (85%) were highly prevalent among urban MSM, while current levels of multiple drug use (18%), three or more alcohol-related problems (12%), frequent drug use (19%) and heavy-frequent alcohol use (8%) were not uncommon. The associations of heavy and/or problematic substance use are complex, with independent multivariate associations found at the levels of demographics, adverse early life circumstances, current mental health status, social and sexual practices and connection to gay male culture. CONCLUSIONS: The complex pattern of associations with heavy and/or problematic substance use among urban MSM suggests that heavy and/or problematic substance use is grounded in multiple levels: the individual, the interpersonal and the socio-cultural.