Effects of Mirtazapine for Methamphetamine Use Disorder Among Cisgender Men and Transgender Women Who Have Sex With Men: A Placebo-Controlled Randomized Clinical Trial.

Importance: Methamphetamine use is increasingly prevalent and associated with HIV transmission. A previous phase 2a study of mirtazapine demonstrated reductions in methamphetamine use and sexual risk behaviors among men who have sex with men. Objective: To determine the efficacy of mirtazapine for treatment of methamphetamine use disorder and reduction in HIV risk behaviors. Design, Setting, and Participants: This double-blind randomized clinical trial of mirtazapine vs placebo took place from August 2013 to September 2017 in an outpatient research clinic in San Francisco, California. Participants were community-recruited adults who were sexually active; cisgender men, transgender men, and transgender women who (1) had sex with men, (2) had methamphetamine use disorder, and (3) were actively using methamphetamine were eligible. Participants were randomized to receive the study drug or placebo for 24 weeks, with 12 more weeks of follow-up. Data analysis took place from February to June 2018. Exposures: Mirtazapine, 30 mg, or matched placebo orally once daily for 24 weeks, with background counseling. Main Outcomes and Measures: Positive urine test results for methamphetamine over 12, 24, and 36 weeks (primary outcomes) and sexual risk behaviors (secondary outcomes). Sleep, methamphetamine craving, dependence severity, and adverse events were assessed. Results: Of 241 persons assessed, 120 were enrolled (5 transgender women and 115 cisgender men). The mean (SD) age was 43.3 (9.8) years; 61 (50.8%) were white, 31 (25.8%) were African American, and 15 (12.5%) were Latinx. A mean (SD) of 66% (47%) of visits were completed overall. By week 12, the rate of methamphetamine-positive urine test results significantly declined among participants randomized to mirtazapine vs placebo (risk ratio [RR], 0.67 [95% CI, 0.51-0.87]). Mirtazapine resulted in reductions in positive urine test results at 24 weeks (RR, 0.75 [95% CI, 0.56-1.00]) and 36 weeks (RR, 0.73 [95% CI, 0.57-0.96]) vs placebo. Mean (SD) medication adherence by WisePill dispenser was 38.5% (27.0%) in the mirtazapine group vs 39.5% (26.2%) in the placebo group (P = .77) over 2 to 12 weeks and 28.1% (23.4%) vs 38.5% (27.0%) (P = .59) over 13 to 24 weeks. Changes in sexual risk behaviors were not significantly different by study arm at 12 weeks, but those assigned to receive mirtazapine had fewer sexual partners (RR, 0.52 [95% CI, 0.27-0.97]; P = .04), fewer episodes of condomless anal sex with partners who were serodiscordant (RR, 0.47 [95% CI, 0.23-0.97]; P = .04), and fewer episodes of condomless receptive anal sex with partners who were serodiscordant (RR, 0.37 [95% CI, 0.14-0.93]; P = .04) at week 24. Participants assigned to mirtazapine had net reductions in depressive symptoms (Center for Epidemiologic Studies Depression Scale score, 6.2 [95% CI, 1.3-11.1] points lower; P = .01) and insomnia severity (Athens score, 1.4 [95% CI, 0.1-2.7] points lower; P = .04) at week 24. There were no serious adverse events associated with the study drug. Conclusions and Relevance: In this expanded replication trial, adding mirtazapine to substance use counseling reduced methamphetamine use and some HIV risk behaviors among cisgender men and transgender women who have sex with men, with benefits extending after treatment despite suboptimal medication adherence. Trial Registration: ClinicalTrials.gov identifier: NCT01888835.

Emergency Contraception.

Despite significant declines over the past 2 decades, the United States continues to experience birth rates among teenagers that are significantly higher than other high-income nations. Use of emergency contraception (EC) within 120 hours after unprotected or underprotected intercourse can reduce the risk of pregnancy. Emergency contraceptive methods include oral medications labeled and dedicated for use as EC by the US Food and Drug Administration (ulipristal and levonorgestrel), the "off-label" use of combined oral contraceptives, and insertion of a copper intrauterine device. Indications for the use of EC include intercourse without use of contraception; condom breakage or slippage; missed or late doses of contraceptives, including the oral contraceptive pill, contraceptive patch, contraceptive ring, and injectable contraception; vomiting after use of oral contraceptives; and sexual assault. Our aim in this updated policy statement is to (1) educate pediatricians and other physicians on available emergency contraceptive methods; (2) provide current data on the safety, efficacy, and use of EC in teenagers; and (3) encourage routine counseling and advance EC prescription as 1 public health strategy to reduce teenaged pregnancy.

Copper intrauterine device placement 6-14 days after unprotected sex.

OBJECTIVE: To evaluate pregnancy risk following copper (CuT380A) intrauterine device (IUD) placement 6-14 days after unprotected intercourse. STUDY DESIGN: We used a combined dataset from four protocols in which participants had received a CuT380A IUD regardless of recent unprotected intercourse. At entry, participants had negative point of care urine pregnancy testing and reported all acts of unprotected intercourse in the two weeks prior to IUD placement. We identified a subset of women who had placement 6-14 days after unprotected intercourse and provided follow-up information on pregnancy status 2-4 weeks after IUD insertion. This follow-up within the four protocols included self -administered home urine pregnancy test (UPT) results 2-4 weeks after IUD placement or continued contact for up to 6 months. RESULTS: We identified 134 women who had a CuT380A IUD placed 6-14 days after unprotected intercourse and provided follow-up information on pregnancy status. Ninety-five (71%) participants reported UPT results 2-4 weeks after placement and the other 39 women were followed for 6 months after IUD placement to assess pregnancy status. Zero (97.5% CI 0-2.7%) participants reported a pregnancy within four weeks of CuT380A IUD placement. CONCLUSION: In these collected data, no women with recent unprotected intercourse became pregnant within 1 month of CuT380A IUD placement. IMPLICATION: These data indicate a low likelihood of pregnancy among women who reported unprotected intercourse 6-14 days preceding IUD insertion. For many women and their providers, these data may be sufficient to support same-day placement of a copper IUD rather than delaying IUD placement until the next menses.

Moderated Mediation of Perceived Intoxication and Sexual Arousal on Determinants of Sexual Risk Behavior in Men Who Have Sex with Men.

Behavioral interventions remain the preferred strategy for reducing HIV-related risk behavior among men who have sex with men (MSM), one of the populations most affected by HIV. To improve intervention efforts, research is needed to identify cognitive-motivational factors that may play a role in sexual risk behaviors among MSM. This study sought to replicate and extend previous work from a heterosexual population that identified a serial mediation effect of perceived intoxication and subjective sexual arousal in the relationship between alcohol consumption and determinants of sexual risk in a population of MSM. Exploratory moderated mediation analyses tested subjective sexual arousal as a moderator of the indirect effect of alcohol consumption on determinants of sexual risk via perceived intoxication. Participants (N = 117 MSM, ages 21-50) were randomly assigned to one of six experimental conditions based on two manipulations: beverage condition (alcohol, placebo, or control) and sexual arousal (low or high). Dependent measures were likelihood to engage in risky sex and condom negotiation skills. Results did not support the serial mediation effect but showed some support for the moderated mediation model in the prediction of behavioral skills. Implications for alcohol and arousal myopia theories of risky behavior and HIV prevention efforts are discussed.

Chemsex among gay, bisexual, and other men who have sex with men in Singapore and the challenges ahead: A qualitative study.

BACKGROUND: Sexualised substance use, or 'chemsex' has been shown to be a major factor driving the syndemic of HIV/AIDS in communities of gay, bisexual, and other men who have sex with men (GBMSM) around the world. However, there is a paucity of research on chemsex among GBMSM in Singapore due to punitive drug laws and the criminalisation of sexual behaviour between men. This qualitative descriptive study is the first to explore perceptions towards, motivators to engaging in, and the barriers to addressing the harms associated with chemsex among GBMSM in Singapore. METHODS: We conducted 30 semi-structured in-depth interviews with self-identifying GBMSM between the ages of 18-39 in Singapore following a purposive sampling strategy. Interview topics included participants' perceptions of drug use among GBMSM in Singapore, perceptions towards chemsex, reasons for drug use and chemsex, and recommendations to address the harms associated with chemsex in Singapore. Interviews were audio-recorded, transcribed, coded, and analysed using thematic analysis. RESULTS: Participants reported that it was common to encounter chemsex among GBMSM in Singapore as it could be easily accessed or initiated using social networking phone apps. Enhancement and prolongation of sexual experiences, fear of rejection from sexual partners and peers, and its use as a means of coping with societal rejection were three main reasons cited for engaging in chemsex. The impact of punitive drug laws on disclosure and stigmatisation of GBMSM who use drugs were reported to be key barriers towards addressing chemsex. Participants suggested using gay-specific commercial venues as avenues for awareness and educational campaigns, and social media to reach out to younger GBMSM. CONCLUSIONS: This study highlights the complexities behind chemsex use among GBMSM in Singapore, and the range of individual to institutional factors to be addressed. We recommend that community-based organisations and policy-makers find ways to destigmatise discussion of chemsex and provide safe spaces to seek help for drug use.

Sexualised drug use among sexual minority young adults in the United States: The P18 cohort study.

BACKGROUND: Substance use and condomless sexual behaviours are both well studied in sexual minority men, but few researchers have used event-level data collection to examine sexualised drug use in sexual and gender minority young adults. The aim of this study is to describe the co-occurrence of sex under the influence of substances and condomless sexual behaviours, using nuanced event-level data, in a racially/ethnically and socioeconomically diverse sample in New York City. METHODS: Data from one wave of a cohort of sexual and gender minority young adults who were assigned male at birth (n = 500) were used to characterise co-occurrence of sex under the influence of drugs and condomless sexual behaviours (oral receptive, anal insertive, and anal receptive sex), in the last 30 days. Logistic regression models were constructed to assess associations between sex while high and condomless sexual behaviours, controlling for sociodemographic factors. RESULTS: Preliminary analyses indicated significant associations between engaging in sex while high and condomless sexual behaviours. In unadjusted regression models, sexualised and non-sexualised drug use were both significantly associated with increased odds of condomless sexual behaviours. In adjusted models, sexualised drug use remained significantly associated with condomless anal insertive sex (AOR = 3.57) and condomless anal receptive sex (AOR = 4.98). Having multiple sexual partners was also significantly associated with greater odds of condomless sexual activity in all three adjusted models. CONCLUSION: Multivariable analyses indicated that engaging in sex while high on any drug was associated with increased condomless sexual behaviour, but that sexualised drug use was associated with particularly elevated condomless anal sex. These findings provide insight for understanding the co-occurrence of substance use and condomless sex, and suggest a need for HIV/STI risk reduction strategies that address the role of sexualised drug use.

Sexualised drug use in the United Kingdom (UK): A review of the literature.

BACKGROUND: Sexualised drug use (SDU) refers to the use of drugs in a sexual context. This includes 'Chemsex'- the use of drugs (specifically crystal methamphetamine, GHB/GBL and mephedrone) before or during planned sexual activity to sustain, enhance, disinhibit or facilitate the experience. Here we aimed to synthesise available UK prevalence data for Chemsex, SDU and the use of Chemsex drugs in an undefined context (CDU) in men who have sex with men (MSM). METHODS: Papers published between January 2007 and August 2017 reporting Chemsex, SDU and/or Chemsex drug use (CDU) prevalence in MSM were identified through PubMed. Citations were searched for further eligible publications. We also conducted a review of national surveillance data, extracting prevalence data for Chemsex, SDU or CDU. Synthesized data were then assessed to determine the time at which these drugs were taken, in this case just prior to or during sexual activity (event-level). RESULTS: Our search identified 136 publications, of which 28 were included in the final data synthesis. Three of the four surveillance systems assessed provided SDU or CDU data in MSM. Few publications included event-level data for Chemsex (n = 4), with prevalence estimates ranging from 17% among MSM attending sexual health clinics (SHC) to 31% in HIV-positive MSM inpatients. Prevalence estimates for SDU (n = 7 publications) also varied considerably between 4% in MSM receiving HIV care to 41% among MSM attending SHC for HIV post-exposure prophylaxis (PEP). Eighteen publications provided data for CDU. CONCLUSION: Prevalence estimates varied considerably due to differences in the definition used and population assessed. Standardised definitions and studies with representative national samples of MSM are required to improve our understanding of the extent of Chemsex and its associated risks. Longitudinal event-level data for SDU and Chemsex are needed to monitor impact of interventions.

The new MTV generation: Using methamphetamine, Truvada™, and Viagra™ to enhance sex and stay safe.

INTRODUCTION: Gay and bisexual men (GBM) often use illicit drugs to enhance sexual pleasure, commonly referred to as 'chemsex' or 'party n play'. In particular, the use of methamphetamine and Viagra™, and other erectile dysfunction medications, both together and separately are strongly predictive of subsequent HIV infection. Truvada™, as pre-exposure prophylaxis (PrEP), virtually eliminates HIV transmission during condomless anal intercourse (CLAI). HIV-negative GBM in intensive sex partying networks may be adding PrEP to their drug regimen to actively reduce the possibility of HIV transmission during chemsex. AIM: We describe the prevalence and context of concurrent use of methamphetamine, Truvada™ (or its generic formulations), and Viagra™ or other erectile dysfunction medication (collectively, MTV). METHOD: The Following Lives Undergoing Change study is an online prospective observational study of licit and illicit drug use among Australian GBM. Between January and July 2017, 1831 GBM provided details about their use of MTV. Binary logistic multiple regression analysis were used to estimate adjusted odds ratios (aOR) and associated 95% confidence intervals (95%CI). RESULTS: Concurrent MTV use was reported by 6.0% of participants; 3.1% used methamphetamine and Viagra™ or other erectile dysfunction medication ('MV only') and 11.2% used Truvada™ as PrEP ('T only'). In multivariate analysis, compared to use of 'MV only', MTV was independently associated with CLAI with casual partners (aOR = 6.78;95%CI = 1.42-32.34) and 'fuckbuddies' (aOR = 3.47;95%CI = 1.41-8.56) in the previous six months. Compared to use of 'T only', MTV was independently associated with being older (aOR = 3.95;95%CI = 1.55-10.03) and engaging in group sex (aOR = 3.31;95%CI = 1.82-6.00). Greater social engagement with other gay men (aOR = 1.44;95%CI = 1.18-1.76) and having more sexual partners (aOR = 2.30;95%CI = 1.10-4.82) were independently associated with use of MTV compared to use of 'MV only' or 'T only'. CONCLUSION: GBM in intensive sex partying networks are increasingly adding PrEP alongside other drugs they use to enhance sexual experiences. Interventions that promote the use of PrEP during chemsex could mitigate HIV risk.

Nurse-Led HIV PEP Program Used by Men at High Risk for HIV Seroconversion.

We trialed a nurse-led HIV postexposure prophylaxis (PEP) program in two sexually transmitted infection clinics in Ottawa, Canada. From September 5, 2013 to September 4, 2015, 112 persons sought PEP: 103 were male, of whom 84 were men who have sex with men (MSM). Seventy-two patients (59 MSM) initiated PEP; 11 were diagnosed with HIV: 6 diagnoses occurred during initial assessment (all MSM; 1 also shared injection equipment); 5 MSM were diagnosed with HIV within 1 year of seeking PEP. This level of positivity indicated that, when access is facilitated, individuals at high risk of HIV seek PEP. However, the 8.5% of MSM who seroconverted within a year of taking PEP demonstrated that this group remained at risk and needed additional prevention services. Delivery of PEP should include provision of medication, as well as an opportunity to address individual-level HIV risk strategies and population-level syndemic conditions that contribute to ongoing HIV transmission among MSM.

Surveillance of sexualised drug use - the challenges and the opportunities.

Sexualised drug use (SDU), the use of drugs in a sexual context, has emerged as a marker of high-risk sexual activity and poor sexual health among gay, bisexual and other men who have sex with men, however, there are no robust estimates of the prevalence of SDU. The primary sources of surveillance data on SDU should include both sexual health and drug treatment services. The challenges to achieving comprehensive, timely and valid SDU surveillance include establishing case definitions, selecting appropriate surveillance settings, and normalising the monitoring of SDU at clinical services. In this commentary we propose a means to address these challenges and discuss other sources of SDU data from ad hoc population surveys and sentinel systems. We also present case studies of SDU surveillance development in England and Switzerland. The patterns of SDU will be affected by a rapidly changing drug market and, as a result, surveillance systems must continuously adapt to ensure that they are fit for purpose and can provide data to guide policy.

Typology of drug use in United Kingdom men who have sex with men and associations with socio-sexual characteristics.

BACKGROUND: Analysis of specific drug use patterns in men who have sex with men (MSM) is important in targeting HIV prevention and harm reduction interventions and in developing a fuller picture of drug use in context beyond consideration of use of specific drugs in isolation. OBJECTIVES: We sought to develop a typology of recent drug use in MSM, and to explore how distribution of MSM across the classes in this typology differs by socio-sexual characteristics. METHODS: We examined last-year drug use reported by 16,814 MSM as part of a cross-sectional, internet-based survey of MSM living in the UK for which data were collected in late summer 2014. We tested models with between two and six classes for types of specific drug use, and related socio-sexual covariates to the classes in the best model using multinomial regression. RESULTS: Our five-class model described a range of drug use patterns, including minimal users, low-threshold users, old-skool users, chemsex-plus users and diverse users. MSM identifying as gay were more likely to not be minimal users. HIV-positive MSM were more likely to be chemsex-plus users than HIV-negative MSM. Number and type of non-steady partners, ethnicity and education were each related to class membership, though trends were complex. CONCLUSIONS: Findings from associations between correlates and latent classes suggest avenues for service development beyond current attention to opiates or chemsex drugs. Our findings draw attention to heterogeneity in drug use patterns in MSM beyond what current discourse on chemsex drugs would suggest.

Implications of survey labels and categorisations for understanding drug use in the context of sex among gay and bisexual men in Melbourne, Australia.

BACKGROUND: Reliably measuring drug use by gay, bisexual and other men who have sex with men (GBM) in the context of sex can inform sexual health service responses. We report changing drug use patterns among GBM testing for HIV at a community-based service in Melbourne in response to behavioural survey modifications. METHODS: Surveys were completed by GBM prior to all HIV tests. Survey one asked about use of "party drugs for the purpose of sex" and survey two asked about specific drug use (alcohol, amyl nitrate, methamphetamine, cocaine, ecstasy, GHB, Viagra®/Cialis®) before or during sex. Differences in drug use prevalence and demographic and sexual risk correlates are reported. RESULTS: Reported drug use increased from 16.9% in survey one to 54.0% in survey two. Among GBM completing both surveys, 45% who reported no drug use in survey one reported drug use in survey two. Drug use was associated with high HIV risk behaviours across both surveys. CONCLUSION: Survey modification improved ascertainment of drug use in the context of sex among GBM. Continued monitoring of drug use in this setting will improve our understanding the relationship between use of specific drugs and sexual health and help inform client focused health promotion.

Daily associations between alcohol and sexual behavior in young adults.

We tested within-person effects of alcohol on sexual behavior among young adults in a longitudinal burst design (N = 213, 6,487 days) using data collected from a previously published parent study. We differentiated effects of alcohol on likelihood of sexual activity versus use of protection against sexually transmitted diseases (STDs) or pregnancy on intercourse occasions by testing a multilevel multinomial model with 4 outcomes (no sex, oral sex without intercourse, protected intercourse, and unprotected intercourse). At the within-person level, effects of alcohol were hypothesized to be conditional upon level of intoxication (i.e., curvilinear effect). We also tested effects of four between-person moderators: gender, typical length of relationship with sexual partners, and two facets of self-control (effortful control and reactivity). Consistent with our hypothesis, low-level intoxication was associated with increased likelihood of engaging in oral sex or protected intercourse (relative to no sex) but was not related to likelihood of unprotected intercourse. The effect of intoxication on unprotected versus protected intercourse was an accelerating curve, significantly increasing likelihood of unprotected intercourse at high levels of intoxication. Between-person factors moderated associations between intoxication and sexual behavior. Effects of intoxication on both protected and unprotected intercourse were diminished for individuals with more familiar sexual partners. Effortful control exhibited a protective effect, reducing the effects of intoxication on likelihood of unprotected intercourse. Hypothesized effects of reactivity were not supported. Intoxication was a stronger predictor of oral sex and protected intercourse (but not unprotected intercourse) for women relative to men. Results highlight the inherent complexities of the alcohol-sexual behavior nexus. (PsycINFO Database Record

Substance Use and Cognitive Function as Drivers of Condomless Anal Sex Among HIV-Positive Gay, Bisexual, and Other Men Who Have Sex with Men Aged 50 and Older: The Gold Studies.

PURPOSE: Substance use has been linked to the sexual transmission of HIV among gay, bisexual, and other men who have sex with men (MSM) across the lifespan. Among older, HIV-positive, MSM populations, cognitive dysfunction associated with age and HIV disease progression also may play a role in sexual risk-taking. People aged 50 years and older represent a growing proportion of the overall HIV-positive population. This study aimed to explore relationships between substance use and cognitive function, and their impact on condomless anal sex (CAS) among HIV-positive gay, bisexual, and other MSM aged 50 years and older. METHODS: Data from a cross-sectional study of HIV-positive MSM, aged 50 and older (N = 169) were gathered using a computer-assisted survey, researcher-administered behavioral and neurocognitive measures. RESULTS: More than 50% of the men used substances and had one or more cognitive impairments. However, only 25% were at higher risk for dementia (i.e., two or more cognitive impairments). Multivariable modeling indicated that use of alcohol to intoxication and date of HIV diagnosis were the strongest predictors of CAS in both a model that included dementia risk and a model that included impaired executive function risk. Current illicit substance use was a significant predictor of CAS only in the model that included dementia risk. Those with better cognitive and executive function had higher odds of CAS. However, only executive function was a significant cognitive predictor of CAS. CONCLUSION: Further research is needed to clarify the impact of cognitive function and substance use on sexual risk behaviors as these HIV-positive men achieve normal life expectancies, while continuing to use substances and engage in CAS. Furthermore, addiction treatment remains a critical need for this group even as they transition into later adulthood.

The Role of Alcohol Expectancies in Sexual Risk Behaviors Among Adolescents and Young Adults in the Democratic Republic of the Congo.

PURPOSE: Considering the increased risk of HIV among alcohol users, we explored the role of individual alcohol expectancies in risk behaviors among youth in the Democratic Republic of the Congo. METHODS: We surveyed 1,396 adolescents (ages 15-19) and young adults (ages 20-24) on alcohol and sexual behaviors in May, 2010. We assessed expectancies of alcohol use (1) leading to sex or positive sexual experiences; (2) diminishing one's ability to resist unwanted sex; and (3) diminishing one's ability to use or negotiate use of condoms. Adjusted logistic regression models assessed the association between alcohol use and alcohol expectancies with unprotected sex and multiple sex partners (MSP). RESULTS: Participants reporting alcohol use (36.8%) were more likely to have engaged in unprotected sex and MSP than nondrinkers (adjusted odds ratio [AOR]: 2.87, 95% confidence interval [CI]: 2.29-3.60; AOR: 3.73 95% CI: 2.94-4.72, respectively). Among alcohol users, after adjusting for drinking quantity, moderate expectancies of alcohol leading to positive sexual experiences were significantly associated with MSP among adolescent boys (AOR: 4.20, 95% CI: 1.49-11.86) and girls (AOR: 3.97, 95% CI: 1.36-11.60), whereas high expectancies were significant among young adult men (AOR: 2.70, 95% CI: 1.19-6.10). Among adolescent girls who used alcohol, adjusted odds of unprotected sex were elevated among those with expectancies of diminished ability to refuse unwanted sex (AOR: 5.13, 95% CI: 1.41-16.64) or to negotiate condom use (AOR: 16.22; 2.08-126.8). CONCLUSIONS: HIV prevention efforts for youth should acknowledge the role of alcohol expectancies in sexual risk behaviors and tailor programs to address different roles of expectancies in males and females.

Alcohol Increases Delay and Probability Discounting of Condom-Protected Sex: A Novel Vector for Alcohol-Related HIV Transmission.

BACKGROUND: Alcohol use, especially at binge levels, is associated with sexual HIV risk behavior, but the mechanisms through which alcohol increases sexual risk taking are not well-examined. Delay discounting, that is, devaluation of future consequences as a function of delay to their occurrence, has been implicated in a variety of problem behaviors, including risky sexual behavior. Probability discounting is studied with a similar framework as delay discounting, but is a distinct process in which a consequence is devalued because it is uncertain or probabilistic. METHODS: Twenty-three, nondependent alcohol users (13 male, 10 female; mean age = 25.3 years old) orally consumed alcohol (1 g/kg) or placebo in 2 separate experimental sessions. During sessions, participants completed tasks examining delay and probability discounting of hypothetical condom-protected sex (Sexual Delay Discounting Task, Sexual Probability Discounting Task) and of hypothetical and real money. RESULTS: Alcohol decreased the likelihood that participants would wait to have condom-protected sex versus having immediate, unprotected sex. Alcohol also decreased the likelihood that participants would use an immediately available condom given a specified level of sexually transmitted infection (STI) risk. Alcohol did not affect delay discounting of money, but it did increase participants' preferences for larger, probabilistic monetary rewards over smaller, certain rewards. CONCLUSIONS: Acute, binge-level alcohol intoxication may increase sexual HIV risk by decreasing willingness to delay sex in order to acquire a condom in situations where one is not immediately available, and by decreasing sensitivity to perceived risk of STI contraction. These findings suggest that delay and probability discounting are critical, but heretofore unrecognized, processes that may mediate the relations between alcohol use and HIV risk.

Actor-Partner Effects of Male Couples Substance Use with Sex and Engagement in Condomless Anal Sex.

Few studies have examined actor-partner effects about male couples' substance use with sex. Dyadic data from 361 male couples were used to examine these effects regarding engagement in condomless anal sex (CAS) by type of partner and substance. Couples with one or both partners reported using marijuana, amyl nitrates, party drugs, and/or stimulants with sex in their relationship was positively associated with them having had CAS. Actor-partner effects for stimulant use with sex with the main partner were associated with CAS with a casual MSM partner. Only an actor effect for stimulant use with sex with a casual MSM partner was associated with CAS with that partner type, and an actor effect for marijuana use with sex for both partner types was associated with CAS with both partner types. These findings illuminate the need for further inquiry about male couples' substance use with sex for HIV prevention.

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.

Drug use moderates associations between location of sex and unprotected anal intercourse in men who have sex with men: nested cross-sectional study of dyadic encounters with new partners.

OBJECTIVES: This nested cross-sectional study of dyadic sexual encounters with new male partners reported by men living in England who have sex with men tested moderation between drug use and location of sex in associations with unprotected anal intercourse (UAI). METHODS: Data were drawn from two waves of a longitudinal monthly internet survey of men living in England who have sex with men conducted in 2011. Using generalised estimating equations and logit link, we tested the relationship with UAI of any respondent drug use before sex, specific respondent drug use before sex, location of sex (distinguishing private, sex-on-premises venue and cruising locations) and location-drug use interactions. RESULTS: Any respondent drug use (OR 1.57, 95% CI 1.31 to 1.88) was associated with increased odds of UAI. Relative to encounters in private locations, encounters in sex-on-premises venues (0.69, 95% CI 0.52 to 0.91), but not cruising locations, were associated with decreased odds of UAI. Any respondent drug use, respondent use of poppers and respondent use of alcohol were each associated with increased UAI in sex-on-premises venues. DISCUSSION: This analysis presents evidence of moderation between drug use and location of sex in associations with UAI. Though this analysis used a large sample, it relied on community-recruited respondents. Our findings may reflect either 'totalising' effects of drug use across venues or site-specific use of drugs as a mechanism for cognitive escape. Additional qualitative research is necessary to understand these findings in context.