Ethno-racial variations in mental health symptoms among sexually-active gay, bisexual, and other men who have sex with men in Vancouver, Canada: a longitudinal analysis.

BACKGROUND: Minority stress from racism and heterosexism may uniquely interact to impact the mental health of racialized sexual minorities. We examined variations in anxiety and depressive symptoms by reported by ethno-racial identity among gay, bisexual, and other men who have sex with men (gbMSM) in Vancouver, Canada. METHODS: We recruited gbMSM aged ≥ 16 years from February 2012 to February 2015 using respondent-driven sampling (RDS). Participants completed computer assisted self-interviews (CASI) at enrollment and every 6 months until February 2017. We examined factors associated with moderate/severe anxiety and depression scores (> 10) on the Hospital Anxiety and Depression Scale (HADS) and differences in key explanatory variables including sociodemographic, psychosocial, and substance use factors. We used multivariable mixed effects models to assess whether moderate/severe scores were associated with ethno-racial identity across all visits. RESULTS: After RDS-adjustment, of 774 participants, 79.9% of participants identified as gay. 68.6% identified as white, 9.2% as Asian, 9.8% as Indigenous, 7.3% as Latin American, and 5.1% as other ethno-racial identities. Participants contributed a median of 6 follow-up visits (Q1-Q3: 4-7). In the multivariable analysis, Asian participants had decreased odds of moderate/severe anxiety scores compared to white participants (aOR = 0.39; 95% CI: 0.18-0.86), and Latin American participants had decreased odds of moderate/severe depression scores compared to both white (aOR = 0.17; 95% CI: 0.08-0.36) and Asian (aOR = 0.07; 95% CI: 0.02-0.20) participants. CONCLUSION: Asian and Latino gbMSM reported decreased mental health symptoms compared to white participants. Asian and Latino gbMSM in Vancouver appear to manage multiple minority stressors without adversely affecting their mental health.

Attitudes of Gay, Bisexual, and Other Men Who Have Sex with Men (GBM) toward Their Use of Amphetamine-Type Stimulants and Relation to Reducing Use in Three Canadian Cities.

BACKGROUND: We explored attitudes of gay, bisexual, and other men who have sex with men (GBM) toward their amphetamine-use and associations with reduced use over time. METHODS: We recruited sexually-active GBM aged 16+ years in Montreal, Toronto, and Vancouver, Canada, from 02-2017 to 08-2019, with follow-up visits every 6-12 months until November 2020. Among participants who reported past-six-month (P6M) amphetamine-use at enrollment, we used logistic regression to identify demographic, psychological, social, mental health, other substance-use, and behavioral factors associated with reporting needing help reducing their substance-use. We used mixed-effects logistic regression to model reduced P6M amphetamine-use with perceived problematic-use as our primary explanatory variable. RESULTS: We enrolled 2,449 GBM across sites. 15.5-24.7% reported P6M amphetamine-use at enrollment and 82.6 - 85.7% reported needing no help or only a little help in reducing their substance use. Reporting needing a lot/of help or completely needing help in reducing substance-use was associated with group sex participation (AOR = 2.35, 95%CI:1.25-4.44), greater anxiety symptomatology (AOR = 2.11, 95%CI:1.16-3.83), greater financial strain (AOR = 1.35, 95%CI:1.21-1.50), and greater Escape Motive scores (AOR = 1.07, 95%CI:1.03-1.10). Reductions in P6M amphetamine-use were less likely among GBM who perceived their amphetamine-use as problematic (AOR = 0.17 95% CI 0.10 - 0.29). CONCLUSIONS: Most amphetamine-using GBM did not feel they needed help reducing their substance use, and many reported reduced amphetamine-use at subsequent visits. Those who perceived their use as problematic were less likely to reduce their use. Further interventions to assist GBM in reducing their use are needed to assist those who perceive their use as problematic.

Minority Stress, Psychological Distress, Sexual Compulsivity, and Avoidance-Based Motivations Associated with Methamphetamine Use Among Sexual Minority Men Living with HIV: Examining Direct and Indirect Associations Using Cross-Sectional Structural Equation Modeling.

OBJECTIVE: Sexual minority men (SMM) living with HIV report significantly greater methamphetamine use compared with heterosexual and HIV-negative peers. Greater use may be related to stressors (e.g., HIV-related stigma) faced by SMM living with HIV and subsequent psychological and behavioral sequelae. We tested an integrated theoretical model comprised of pathways between stigma, discrimination, childhood sexual abuse, psychological distress, sexual compulsivity, and cognitive escape in predicting methamphetamine use among SMM living with HIV. METHODS: Among 423 SMM living with HIV, we tested a structural equation model examining factors hypothesized to be directly and indirectly associated with methamphetamine use. Analyses were adjusted for demographic covariates and sampling bias. RESULTS: The model showed good fit (CFI = 0.96, RMSEA = 0.01). Heterosexist discrimination was associated with psychological distress (ß = 0.39, p < 0.001) and psychological distress was associated with sexual compulsivity (ß = 0.33, p < 0.001). Sexual compulsivity was associated with cognitive escape (ß = 0.31, p < 0.001), which was associated with methamphetamine use (ß = 0.51, p < 0.001). Psychological distress was associated with methamphetamine use via serial indirect effects of sexual compulsivity and cognitive escape (ß = 0.05, p < 0.05). CONCLUSIONS: Heterosexist discrimination contributed to psychological distress among SMM living with HIV. Psychological distress is linked to methamphetamine use via sexual compulsivity and cognitive avoidance. Interventions seeking to reduce the likelihood that SMM living with HIV use methamphetamine should include coping strategies specific to heterosexism and related psychological distress.

Pre-exposure prophylaxis and bacterial sexually transmitted infections (STIs) among gay and bisexual men.

OBJECTIVES: While pre-exposure prophylaxis (PrEP) prevents HIV acquisition among gay, bisexual and other men who have sex with men (GBM), PrEP-using GBM may be more likely to engage in sexual behaviours associated with bacterial STIs. We examined associations between PrEP use, condomless anal sex (CAS), number of anal sex partners, oral sex and bacterial STI diagnoses among GBM living in Canada's three largest cities. METHODS: Among HIV-negative/unknown-status GBM in the baseline of the Engage cohort study, we fit a structural equation model of the associations between any PrEP use, sexual behaviours and bacterial STI diagnosis. We estimated direct and indirect paths between PrEP use and STI via CAS, number of anal sex partners and oral sex. RESULTS: The sample included 2007 HIV-negative/unknown status GBM in Montreal, Toronto and Vancouver. There was a significant direct association between PrEP use and current STI diagnosis (ß=0.181; 95% CI: 0.112 to 0.247; p<0.001), CAS (ß=0.275; 95% CI: 0.189 to 0.361; p<0.001) and number of anal sex partners (ß=0.193; 95% CI: 0.161 to 0.225; p<0.001). In the mediated model, the direct association between PrEP use and STIs was non-significant. However, the indirect paths from PrEP to CAS to STIs (ß=0.064; 95% CI: 0.025 to 0.120; p=0.008), and from PrEP to greater number of anal sex partners to CAS to STIs were significant (ß=0.059; 95% CI: 0.024 to 0.108; p=0.007). CONCLUSIONS: Our study adds to the growing awareness that PrEP use among GBM may be associated with bacterial STIs because PrEP users have more anal sex partners and are more likely to engage in CAS. The results underscore the importance of providing effective STI counselling and regular testing to PrEP users, adapting PrEP care and related STI testing to individual needs, and the need for effective prevention strategies for bacterial STIs.

Examining differential success in recruitment using respondent driven sampling (RDS) in a multi-site study of gay, bisexual and other men who have sex with men.

BACKGROUND: The Engage Study is a longitudinal biobehavioral cohort study of gay, bisexual and other men who have sex with men (GBM) in Toronto, Montreal, and Vancouver. Baseline data (2,449 participants) were collected from February 2017 - August 2019 using respondent-driven sampling (RDS). Recruitment in Montreal required fewer seeds, had a much shorter recruitment period, and recruited the largest sample. METHODS: To better understand why RDS recruitment was more successful in Montreal compared to other sites, we conducted an analysis to examine RDS recruitment characteristics for GBM in each of the three study sites, explore demographic characteristics and measures of homophily, that is, the tendency of individuals to recruit other study participants who are like themselves, and compared motivations for study participation. RESULTS: Montreal had the greatest proportion of participants over the age of 45 (29.1% in Montreal, 24.6% in Vancouver, and 21.0% in Toronto) and the highest homophily for this age group, but homophily was high across the three cities. Montreal also reported the lowest percentage of participants with an annual income greater or equal to $60,000 (7.9% in Montreal, 13.1% in Vancouver and 10.6% in Toronto), but homophily was similar across all three cities. The majority of participants indicated interest in sexual health and HIV as the main reason for participating (36.1% in Montreal, 34.7% in Vancouver, and 29.8% in Toronto). Financial interest as the main reason for participation was low (12.7% in Montreal, 10.6% in Vancouver, and 5.7% in Toronto). CONCLUSION: Taken together, although we found some differences in study demographic characteristics and homophily scores, we were unable to fully explain the different recruitment success based on the data available. Our study underlines the fact that success of RDS implementation may vary by unknown factors, and that researchers should be proactive and flexible to account for variability.

Patterns of Event-Level Concurrent Substance Use During Sex Among Gay, Bisexual, and Other Men Who Have Sex with Men in Metro Vancouver.

This study identified patterns of sexualized substance use among gay, bisexual, and other men who have sex with men (gbMSM) and examined associated risk factors for sexually transmitted and blood borne infections (STBBI). Data were from a longitudinal cohort recruited using respondent-driven sampling between Feb-2017 and Feb-2019. Participants reported on events with up to five of their most recent sexual partners. Latent class analysis examined patterns of concurrent substance use 2 h prior to or during sex. Multinomial regression identified demographic, partner-level, and event-level factors associated across 11,877 sexual events reported by 757 participants. Most combinations of substance use were rare, but most drugs were frequently combined with other drugs when they were used prior to or during a sexual event. Six latent classes of concurrent event-level substance use were identified. The referent class (58.8% of events) was characterized by limited use of any drugs. The Common Drug Use class (12.1%) was characterized by use of alcohol, cannabis, and poppers and the Licit Drug Use class (21.6%) was characterized by use of alcohol alone. The Party 'N' Play (PnP) class (2.3%) was characterized by use of crystal methamphetamine GHB, Poppers, and Erectile Drugs; The Multi-use (3.5%) class was characterized by the PnP substances plus alcohol and ecstasy; and the Cannabis + class was characterized by use of Cannabis, Erectile Drugs, and Ecstasy. Relative to the referent class, all other classes were associated with events with more behavioural and network risk factors for STBBIs-highlighting the need for harm reduction interventions for gbMSM who use these drugs.

Examining Associations Between Resilience and PrEP Use Among HIV-negative GBM in Toronto, Montreal and Vancouver.

This study evaluated the association between resilience and PrEP use among a population-based sample of Canadian gay, bisexual, and other men who have sex with men (GBM). Sexually active GBM aged ≥ 16 years old were recruited via respondent-driven sampling (RDS) in Toronto, Montreal, and Vancouver from 02/2017 to 07/2019. We conducted a pooled cross-sectional analysis of HIV-negative/unknown GBM who met clinical eligibility for PrEP. We performed multivariable RDS-II-weighted logistic regression to assess the association between scores on the Connor-Davidson Resilience-2 Scale and PrEP. Mediation analyses with weighted logistic and linear regression were used to assess whether the relationship between minority stressors and PrEP use was mediated by resilience. Of 1167 PrEP-eligible GBM, 317 (27%) indicated they took PrEP in the past six months. Our multivariable model found higher resilience scores were associated with greater odds of PrEP use in the past six months (aOR = 1.13, 95%CI = 1.00, 1.28). We found that resilience reduced the effect of the association between heterosexist discrimination and PrEP use. Resilience also mediated the relationship between internalized homonegativity and PrEP use and mediated the effect of the association between LGBI acceptance concern and PrEP use. Overall, PrEP-eligible GBM with higher resilience scores had a greater odds of PrEP use in the past six months. We also found mixed results for the mediating role of resilience between minority stress and PrEP use. These findings underline the continued importance of strength-based factors in HIV prevention.

Treatment interruptions and community connectedness among gbMSM living with HIV in Metro Vancouver, Canada.

HIV treatment interruptions are a major public health concern that demonstrate a lack of engagement in care and is detrimental to the health of people living with HIV. Community connectedness have demonstrated a protective effect for psychosocial health but are not well understood for HIV treatment outcomes. We explored associations between community connectedness and treatment interruptions among gay, bisexual and other men who have sex with men (gbMSM) living with HIV in Vancouver, British Columbia. We analyzed survey data from the Momentum Health Study and identified treatment interruptions through data linkages with the provincial HIV Drug Treatment Program as episodes lasting more than 60 days beyond an expected antiretroviral therapy refill date from February 2012 to July 2019. We built a mixed-effects logistic regression model, adjusting for confounders. Of 213 gbMSM living with HIV, 54 experienced treatment interruption (25.4%) over a median five-year follow-up. Multivariable results found the number gbMSM who spoken to in the past month (aOR = 0.995; 95% CI = 0.991, 1.000 (per 100-unit increase)) and attending a gay community meeting more than once per month (aOR = 0.32; 95% CI = 0.11, 0.89) were associated with lower odds of treatment interruptions. These results highlight the importance of social connections in facilitating effective HIV care.

Examining the secondary impacts of the COVID-19 pandemic on syndemic production and PrEP use among gay, bisexual and other men who have sex with men (GBM) in Vancouver, Canada.

BACKGROUND: The secondary impacts of the COVID-19 pandemic may disproportionately affect gay, bisexual, and other men who have sex with men (GBM), particularly related to HIV prevention and treatment outcomes. We applied syndemic theory to examine PrEP disruptions during the during the height of the COVID-19 pandemic in Vancouver, Canada. METHODS: Sexually-active GBM, aged 16 + years, were enrolled through respondent-driven sampling (RDS) from February 2017 to August 2019. Participants completed a Computer-Assisted Self-Interview every six months and data were linked to the BC PrEP Program (program responsible for publicly funded PrEP in the province) to directly measure PrEP disruptions. The analysis period for this study was from March 2018-April 2021. We used univariable generalized linear mixed models to examine (1) six-month trends for syndemic conditions: the prevalence of moderate/severe depressive or anxiety symptoms, polysubstance use, harmful alcohol consumption, intimate partner violence, and (2) six-month trends for PrEP interruptions among HIV-negative/unknown GBM. We also applied 3-level mixed-effects logistic regression with RDS clustering to examine whether syndemic factors were associated with PrEP interruptions. RESULTS: Our study included 766 participants, with 593 participants who had at least one follow-up visit. The proportion of respondents with abnormal depressive symptoms increased over the study period (OR = 1.35; 95%CI = 1.17, 1.56), but we found decreased prevalence for polysubstance use (OR = 0.89; 95%CI = 0.82, 0.97) and binge drinking (OR = 0.74; 95%CI = 0.67, 0.81). We also found an increase in PrEP interruptions (OR = 2.33; 95%CI = 1.85, 2.94). GBM with moderate/severe depressive symptoms had higher odds (aOR = 4.80; 95%CI = 1.43, 16.16) of PrEP interruptions, while GBM with experiences of IPV had lower odds (aOR = 0.38; 95%CI = 0.15, 0.95) of PrEP interruptions. GBM who met clinical eligibility for PrEP had lower odds of experiencing PrEP interruptions (aOR = 0.25; 95%CI = 0.11, 0.60). CONCLUSION: There were increasing PrEP interruptions since March 2020. However, those most at risk for HIV were less likely to have interruptions. Additional mental health services and targeted follow-up for PrEP continuation may help to mitigate the impacts of the COVID-19 pandemic on GBM.

Longitudinal uptake of the human papillomavirus vaccine among gay, bisexual and other men who have sex with men in British Columbia, Canada 2012-2019.

OBJECTIVES: In 2015, a publicly funded human papillomavirus (HPV) vaccination programme was implemented for gay, bisexual and other men who have sex with men (gbMSM) up to age 26 years in British Columbia, Canada. We assessed trends and correlates of HPV vaccine uptake from 2012 to 2019 in a cohort of gbMSM in Vancouver. METHODS: We recruited sexually active gbMSM aged ≥16 years using respondent-driven sampling from February 2012 to February 2015 and followed them until July 2019. We evaluated self-reported HPV vaccine trends using mixed-effects logistic regression and identified factors associated with uptake using multivariable mixed-effects Poisson regression. RESULTS: A total of 719 participants were recruited and completed the baseline visit, of whom 549 were unvaccinated with at least one follow-up visit. The median age was 33 years and 23% were living with HIV. HPV vaccination increased from 4% in 2012 to 28% in 2019 (p<0.001) among gbMSM >26 years, and from 9% in 2012 to 20% in 2017 (p<0.001) among gbMSM ≤26 years. Vaccination uptake increased after September 2015, following vaccination policy expansion (adjusted rate ratio (aRR)=1.82, 95% CI 1.06 to 3.12). In multivariable models, increased vaccination was associated with age ≤26 years vs ≥45 years (aRR=3.90; 95% CI 1.75 to 8.70), age 27-44 vs ≥45 years (aRR=2.86; 95% CI 1.46 to 5.62), involvement in gay community sports teams (aRR=2.31; 95% CI 1.15 to 4.64) and other groups (aRR=1.71; 95% CI 1.04 to 2.79), awareness of HIV-postexposure prophylaxis (aRR=5.50; 95% CI 1.31 to 23.09), recent sexually transmitted infection testing (aRR=2.72; 95% CI 1.60 to 4.60) and recent sex-work (aRR=2.59; 95% CI 1.08 to 6.19). CONCLUSIONS: Although we observed increases in HPV vaccination uptake from 2012, by 2019 HPV vaccination still remained below 30% among gbMSM in Vancouver, BC. Additional interventions are needed to increase vaccine uptake.

HIV incidence and related risks among gay, bisexual, and other men who have sex with men in Montreal, Toronto, and Vancouver: Informing blood donor selection criteria in Canada.

BACKGROUND: An individualized behavior-based selection approach has potential to allow for a more equitable blood donor eligibility process. We collected biological and behavioral data from urban gay, bisexual, and other men who have sex with men (GBM) to inform the use of this approach in Canada. STUDY DESIGN AND METHODS: Engage is a closed prospective cohort of sexually active GBM, aged 16+ years, recruited via respondent-driven-sampling (RDS) in Montreal, Toronto, and Vancouver, Canada. Participants completed a questionnaire on behaviors (past 6 months) and tested for HIV and sexually transmitted and blood-borne infections at each visit. Rate ratios for HIV infection and predictive values for blood donation eligibility criteria were estimated by RDS-adjusted Poisson regression. RESULTS: Data on 2008 (study visits 2017-02 to 2021-08) HIV-negative participants were used. The HIV incidence rate for the three cities was 0.4|100 person-years [95%CI:0.3, 0.6]. HIV seroconversion was associated with age <30 years: adjusted rate ratio (aRR) 9.1 [95%CI:3.2, 26.2], 6-10 and >10 anal sex partners versus 1-6 aRR: 5.3 [2.1,13.5] and 8.4 [3.4, 20.9], and use of crystal methamphetamine during sex: 4.2 [1.5, 11.6]. Applying the combined selection criteria: drug injection, ≥2 anal sex partners, and a new anal sex partner, detected all participants who seroconverted (100% sensitivity, 100% negative predictive value), and would defer 63% of study participants from donating. CONCLUSION: Using three screening questions regarding drug injection and sexual behaviors in the past 6 months would correctly identify potential GBM donors at high risk of having recently contracted HIV. Doing so would reduce the proportion of deferred sexually active GBM by one-third.

Undetectable or Unknown? A Longitudinal Event-Level Analysis of Disclosure of HIV Serostatus and Undetectability Among Gay, Bisexual, and Other Men Who have Sex with Men (gbMSM) in Metro Vancouver.

We examined temporal trends and factors associated with reporting partner's serostatus and viral load among a sample of gay, bisexual and other men who have sex with men (gbMSM) in Vancouver, Canada. Participants were recruited using respondent-driven sampling and we collected prospective cohort data from 09/2014 to 02/2017 using a computer-assisted questionnaire and nurse-administered STI/HIV testing. Our study included 481 participants reporting on 3780 sexual events. Among HIV-negative/unknown gbMSM we found a trend towards decreased proportions of sexual events reporting an unknown HIV-status partner (42-19%; p = < 0.001) and found increased proportions among gbMSM living with HIV (11-27%; p = 0.043). More participants living with HIV reported sex with undetectable partners, compared to HIV-negative/unknown participants (14.8% versus 5%). Our multivariable model found that compared with unknown status partners, undetectable partners were older, were from longer sexual relationships and were more likely to engage in condomless anal sex. Findings indicate that HIV-negative gbMSM seem more aware of the serostatus of their partners over time, but knowledge of partners' viral load over time was not significant. Further research should assess the degree to which new campaigns such as Undetectable = Untransmittable (U = U) are associated with discussions about HIV disclosure and viral load status.

Variations in Sexual Behaviors by Use of Specific Substances Among Vancouver Gay, Bisexual, and Other Men Who Have Sex with Men: An Event-Level Analysis.

Event-level studies measure substance use and sexual behaviors happening during a specific sexual encounter, ensuring that both variables are temporally paired. This study explored the event-level associations between a range of sexual behaviors (masturbation, anal sex, oral sex, rimming, fisting, sex toys, and group sex) and five sexualized substances (poppers, methamphetamine, GHB, ecstasy/MDMA, and ketamine) used during 11,582 sexual events reported by 762 gay, bisexual, and other men who have sex with men (GBMSM) in Vancouver, Canada. Data were obtained from a prospective cohort of GBMSM who self-reported their behaviors via computer-based questionnaires on their last sexual encounter with up to five of their most recent partners in the past six months. These clustered data were analyzed with multivariable generalized linear mixed models. Participants reported popper use in 16.1% of sexual encounters, methamphetamine in 8.6%, gamma-hydroxybutyrate (GHB) in 4.1%, ecstasy/3,4-methylenedioxymethamphetamine (MDMA) in 3.3%, and ketamine in 1.5%. Condomless receptive anal sex (25.0% of events) was associated with increased odds of using poppers, methamphetamine, GHB, and ecstasy/MDMA. Group sex (13.1% of events) and sharing sex toys (2.0% of events) were more likely with the use of all five substances. Receiving money/drugs/goods in exchange for sex (2.5% of events) was associated with increased odds of poppers, methamphetamine, GHB, and ecstasy/MDMA use. GBMSM living with HIV (29.9% of participants) had higher odds of using poppers, methamphetamine, and GHB, but lower odds of using ecstasy/MDMA. In conclusion, these event-level results suggest public health strategies are needed to address the possible negative impacts of sexualized substance use among GBMSM.

Factors Associated with Productive Recruiting in a Respondent-Driven Sample of Men who Have Sex with Men in Vancouver, Canada.

Respondent-driven sampling (RDS) has become a preferred sampling strategy for HIV research and surveillance in many global settings. Methodological investigation into the validity of RDS-generated samples has helped improve theoretical components of design. However, the operational challenges of implementing RDS remain underreported. We sought to identify factors independently associated with productive recruiting in an urban RDS-generated sample of gay, bisexual, and other men who have sex with men (MSM). Data were collected from the Momentum Health Study, a cohort of MSM recruited by RDS in Vancouver, Canada. Eligible men were given up to six RDS coupons to recruit their peers. The primary outcome was a count variable of each participant's number of eligible recruits. Multivariable Poisson regression identified independent predictors of productive recruitment. In total, 719 individuals comprised this analysis, of which 119 were seeds. The distribution of eligible recruits was right skewed, with 391 (54.4 %) having never recruited another participant and only eight participants (1.1 %) having recruited five. Significant, independent predictors of recruiting one additional participant included network size per ten unit increase (adjusted risk ratio [aRR] 1.03), being of Aboriginal race/ethnicity compared with White (aRR 1.51), being HIV-positive (aRR 1.31), being sexually active with only males (aRR 2.48), being single compared with common law/married (aRR 1.37), having recently read gay newspapers (aRR 1.58), having recently sought sex partners online (aRR 1.33) and being out to a male parent (aRR 1.30). This analysis demonstrates the importance of social network size in RDS adjustment, but also identifies other socio-demographic and behavioral variables that increased RDS coupon return, which may help researchers better operationalize the implementation of RDS.

Event-Level Analysis of Anal Sex Roles and Sex Drug Use Among Gay and Bisexual Men in Vancouver, British Columbia, Canada.

This study analyzed event-level partnership data from a computer-assisted survey of 719 gay and bisexual men (GBM) enrolled in the Momentum Health Study to delineate potential linkages between anal sex roles and the so-called "sex drugs," i.e., erectile dysfunction drugs (EDD), poppers, and crystal methamphetamine. Univariable and multivariable analyses using generalized linear mixed models with logit link function with sexual encounters (n = 2514) as the unit of analysis tested four hypotheses: (1) EDD are significantly associated with insertive anal sex roles, (2) poppers are significantly associated with receptive anal sex, (3) both poppers and EDD are significantly associated with anal sexual versatility, and (4) crystal methamphetamine is significantly associated with all anal sex roles. Data for survey respondents and their sexual partners allowed testing these hypotheses for both anal sex partners in the same encounter. Multivariable results supported the first three hypotheses. Crystal methamphetamine was significantly associated with all anal sex roles in the univariable models, but not significant in any multivariable ones. Other multivariable significant variables included attending group sex events, venue where first met, and self-described sexual orientation. Results indicate that GBM sex-drug use behavior features rational decision-making strategies linked to anal sex roles. They also suggest that more research on anal sex roles, particularly versatility, is needed, and that sexual behavior research can benefit from partnership analysis.

Substance use, sexual behaviour and prevention strategies of Vancouver gay and bisexual men who recently attended group sex events.

Group sex events are an epidemiologically important part of some gay and bisexual men's sexual culture in Canada. Associated with condomless anal intercourse and polysubstance use, such events have been cited as disproportionally contributing to HIV infection rates. We analysed questionnaire data from the Momentum Health Study in Vancouver, Canada, to understand substance use, sexual behaviour, psychosocial variables (Sexual Sensation Seeking, Sexual Escape Motivation, Treatment Optimism) and HIV prevention strategies (sero-sorting, strategic positioning, avoiding anal sex, disclosure, treatment as prevention) of men attending such events, which were defined as group (n ≥ 4 partners) sex parties, blackout events and darkrooms. Analysis by multivariable logistic regression compared men attending group sex events within the past six months (n = 180) with non-attendees (n = 539). Results showed that attendees reported: (1) significantly higher use of sex drugs and alcohol consumption, (2) higher scores on the Sexual Sensation Scale, more anal sex partners, greater odds of any condomless anal sex with sero-discordant partners and greater odds of reporting fisting and sex toy use and (3) different prevention practices that varied by HIV-serostatus. Findings are interpreted in light of the importance of pleasure, sociality and HIV/STI prevention strategies associated with group sex events. Findings contribute to the development of appropriate education and intervention for attendees.

Including Online-Recruited Seeds: A Respondent-Driven Sample of Men Who Have Sex With Men.

BACKGROUND: Technology has changed the way men who have sex with men (MSM) seek sex and socialize, which may impact the implementation of respondent-driven sampling (RDS) among this population. Initial participants (also known as seeds) are a critical consideration in RDS because they begin the recruitment chains. However, little information is available on how the online-recruited seeds may effect RDS implementation. OBJECTIVE: The objectives of this study were to compare (1) online-recruited versus offline-recruited seeds and (2) subsequent recruitment chains of online-recruited versus offline-recruited seeds. METHODS: Between 2012 and 2014, we recruited MSM using RDS in Vancouver, Canada. RDS weights were used with logistic regression to address each objective. RESULTS: A total of 119 seeds were used, 85 of whom were online-recruited seeds, to recruit an additional 600 MSM. Compared with offline-recruited seeds, online-recruited seeds were less likely to be HIV-positive (OR 0.34, 95% CI 0.13-0.88), to have attended a gay community group (AOR 0.33, 95% CI 0.12-0.90), and to feel gay community involvement was "very important" (AOR 0.16, 95% CI 0.03-0.93). Online-recruited seeds were more likely to ask a sexual partner's HIV status always versus <50% of the time (AOR 5.21, 95% CI 1.17-23.23), to have watched the Pride parade (AOR 6.30, 95% CI 1.69-23.45), and to have sought sex online (AOR 4.29, 95% CI 1.53-12-12.05). Further, compared with recruitment chains started by offline-recruited seeds, recruits from chains started by online-recruited seeds (283/600, 47.2%) were less likely to be HIV-positive (AOR 0.25, 95% CI 0.16-0.40), to report "versatile" versus "bottom" sexual position preference (AOR 0.56, 95% CI 0.35-0.88), and to be in a relationship lasting >1 year (AOR 1.65, 95% CI 1.06-2.56). Recruits of online seeds were more likely to be out as gay for longer (eg, 11-21 vs 1-4 years, AOR 2.22, 95% CI 1.27-3.88) and have fewer Facebook friends (eg, 201-500 vs >500, AOR 1.69, 95% CI 1.02-2.80). CONCLUSIONS: Online-recruited seeds were more prevalent, recruited fewer participants, but were different from those recruited offline. This may therefore help create a more diverse overall sample. Our work has shown the value of geosocial networking apps for aiding RDS recruitment efforts, especially when faced with slow participation uptake by other means. Understanding the degree to which networks interact will be an important next step in confirming the efficacy of online RDS recruitment strategies.

Problematic alcohol use among gay, bisexual, and other men who have sex with men in Canada: the role of proximal stressors and anxiety.

BACKGROUND: Gay, bisexual, and other men who have sex with men (GBM) report high rates of problematic alcohol use, anxiety, and depression. This may, in part, be due to stressors related to their sexual identity (i.e., minority stressors). However, few studies have examined both distal and proximal stressors, as well as the specific psychological mechanisms by which these stressors may be related to alcohol use outcomes, in a representative sample of GBM. We explored the relationship between distal and proximal stressors and alcohol use outcomes, as well as the role of anxiety and depression as potential mediators of these relationships. METHODS: We analyzed the baseline data of 2,449 GBM from Engage, a cohort study of sexually active GBM recruited using respondent-driven sampling (RDS) in Montreal, Toronto, and Vancouver from February 2017 to August 2019. Using structural equation modeling, we examined the associations between distal minority stressors (i.e., experiences of heterosexist harassment, rejection, and discrimination), proximal minority stressors (i.e., internalized homonegativity, concerns about acceptance, concealment, and lack of affirmation), anxiety and depression, and alcohol consumption and alcohol use problems. RDS-adjusted analyses controlled for age, income, sexual orientation, ethnicity, recruitment city, and HIV serostatus. RESULTS: There were positive direct associations between distal stress and proximal stress, anxiety, and depression, but not alcohol use outcomes. Proximal stress had a positive direct association with anxiety, depression, and alcohol use problems, but not alcohol consumption. Anxiety was positively associated with alcohol consumption and alcohol use problems. Depression was negatively associated with alcohol consumption but not alcohol use problems. Regarding indirect effects, distal stress was associated with alcohol use outcomes via proximal stress and anxiety, but not via depression. CONCLUSIONS: We found support for a minority stress model as it relates to alcohol use outcomes among GBM. Findings suggest that proximal minority stress and anxiety differentially impact the problematic alcohol use among GBM who experience heterosexist discrimination. Clinical providers should consider incorporating the treatment of proximal minority stressors and anxiety into existing alcohol interventions for GBM.

Factors associated with improvements in symptoms of anxiety and depression among gay, bisexual and other men who have sex with men (gbMSM) in Vancouver, Canada: A prospective cohort study.

BACKGROUND: Depression and anxiety are commonly experienced among gay, bisexual and other men-who-have-sex-with-men (gbMSM). We explored factors associated with improvements in mental health symptoms among gbMSM with abnormal depression and anxiety scores over a period of four years, in Vancouver, Canada. METHODS: Sexually active gbMSM ≥16 years of age were recruited using respondent-driven sampling from February 2012 to February 2015. Participants completed a computer-assisted questionnaire which included the Hospital Anxiety and Depression Scale (HADS), and psychometric scales to measure loneliness, self-esteem and social connectedness, every 6 months until July 2019. Generalized linear mixed models were used to assess factors associated with normal/borderline HADS scores (<11) following a previous abnormal score (≥11) for each of anxiety and depression subscales. RESULTS: We recruited 694 participants, of whom 580 had at least one follow-up visit. Across all visits, 43.6 % of participants ever had abnormal anxiety scores and 16.2 % ever had abnormal depression scores. Among those with abnormal anxiety scores, 34.9 % of follow-up visits demonstrated reductions in anxiety scores. Among those with abnormal depression scores 51.0 % of follow-up visits demonstrated reductions in depression scores. Reductions in anxiety scores were associated with increased self-esteem, decreased loneliness and the number of gbMSM seen/spoken to in the previous month. Reductions in depression scores were associated with increased self-esteem, decreased loneliness and having a regular partner. CONCLUSION: Improvements in mental health symptoms were frequently observed. Social connectedness was related with improved anxiety and depression symptoms. Interventions to improve social connectedness may help to improve mental health for gbMSM.

Hosts as Gatekeepers for North American Gay and Bisexual Men's Private Group Sex Parties.

Gay and bisexual men's (GBM) group sex parties are considered HIV risk environments due to their association with concurrent sexual partners, condomless anal sex, and polysubstance use. The possibility of group sex party hosts acting as gatekeepers to minimize risks has been suggested, but remains understudied. We analyzed qualitative data from 20 in-depth interviews with North American GBM who recently attended private group sex parties to determine if hosts' actions constitute harm reduction strategies. Results showed hosts acting as gatekeepers before parties by establishing and disseminating themes and rules, screening applicants, and selecting guests. During parties hosts enforced rules and rejected uninvited guests. By their actions, hosts established a more controlled environment compared to public sex-on-premises bathhouses, and facilitated boundary play, the paradoxical behavior of simultaneously desiring risk and safety, previously noted for GBM circuit parties. Results suggest initiating education programs focusing on private group sex party hosts as gatekeepers.