Incidence of and risk factors for sexual orientation-related physical assault among young men who have sex with men.

OBJECTIVES: We sought to determine incidence of, prevalence of, and risk factors for sexual orientation-related physical assault in young men who have sex with men (MSM). METHODS: We completed a prospective open cohort study of young MSM in Vancouver, British Columbia, surveyed annually between 1995 and 2004. Correlates of sexual orientation-related physical assault before enrollment were identified with logistic regression. Risk factors for incident assaults were determined with Cox regression. RESULTS: At enrollment, 84 (16%) of 521 MSM reported ever experiencing assault related to actual or perceived sexual orientation. Incidence was 2.3 per 100 person-years; cumulative incidence at 6-year follow-up was 10.8 per 100 person-years. Increased risk of incident sexual orientation-related physical assault was observed among MSM 23 years or younger (relative hazard=3.1; 95% confidence interval [CI] = 1.6, 5.8), Canadian Aboriginal people (relative hazard = 3.0; 95% CI=1.4, 6.2), and those who previously experienced such assault (relative hazard=2.5; 95% CI=1.3, 4.8). CONCLUSIONS: These data underscore the need for increased public awareness, surveillance, and support to reduce assault against young MSM. Such efforts should be coordinated at the community level to ensure that social norms dictate that such acts are unacceptable.

Randomized clinical evaluation of self-screening for anal cancer precursors in men who have sex with men.

BACKGROUND: Self-collection of anorectal swab specimens could greatly facilitate the completion of prerequisite studies and future implementation of anal cancer screening among men who have sex with men (MSM). We therefore compared self- versus clinician- collection procedures with respect to specimen adequacy for cytological evaluation, concordance of paired cytological results, and concordance of cytological with biopsy results. METHODS: Paired self- and clinician- collected anorectal Dacron swabs for liquid-based (Thin Prep) cytological evaluation were collected in random sequence from a mostly HIV-1 seronegative cohort of young MSM in Vancouver. Slides were reviewed by one cytopathologist. Presence of any cytological abnormality (atypical squamous cells of uncertain significance, ASCUS, or above) prompted referral for high-resolution anoscopy and possible biopsy. RESULTS: Among 222 patient-clinician specimen pairs, most were adequate for cytological evaluation, though self-collected specimens were less likely to be so (83% versus 92%, McNemar's test p < 0.001). Cytological abnormalities, noted in 47 (21%) of self-collected and 47 (21%) of clinician-collected specimens (with fair agreement, kappa = 0.414) included, respectively: ASCUS (5%, 5%), and low-grade (13%, 13%) and high-grade (3%, 3%) squamous intraepithelial lesions. Among 12 men with biopsy-confirmed high-grade neoplasia, most had abnormal cytological results (including 6 patient and 9 clinician swabs) but few (2 patient and 1 clinician swab) were high-grade. CONCLUSION: Self-collection of anorectal swab specimens for cytologic screening in research and possibly clinical settings appears feasible, particularly if specimen adequacy can be further improved. The severity of biopsy-confirmed anorectal disease is seriously underestimated by cytological screening, regardless of collector.

Crystal methamphetamine and ecstasy differ in relation to unsafe sex among young gay men.

OBJECTIVE: Poly-substance use in gay social ('club') settings is common. Recent studies suggest a link between 'club' drug use and sexual risk behaviours. In this qualitative study, we compare and contrast two 'club' drugs: crystal methamphetamine and ecstasy (MDMA). METHODS: Life history interviews were conducted with 12 HIV seroconverters and 12 age-matched controls recruited from a prospective cohort study of young gay and bisexual men in Vancouver, British Columbia. Textual data concerning illicit substance use and unsafe sex were analyzed using NUDIST software. RESULTS: Most men related a substantial knowledge of and experience with crystal and ecstasy. Both drugs had attributes that enhanced gay socialization and were used in the same venues. Crystal was used to remain awake and increase energy. Ecstasy was used to induce euphoria and group connectedness. However, unlike ecstasy, crystal was associated with a distinct pattern of sexual arousal that frequently included unprotected (sometimes group) sex, was more likely to be used regularly by HIV-positive men, and was reportedly highly addictive and problematic. CONCLUSION: Crystal and ecstasy are used in the same social venues but differ markedly in relation to sexual risk behaviour.

Sexual violence among a cohort of injection drug users.

The objective of this study was to determine the prevalence of, and factors associated with, sexual violence in childhood, adolescence and adulthood, among injection drug using men and women. The Vancouver Injection Drug User Study is a prospective cohort of injection drug users (IDU) begun in 1996. The analysis included all individuals who completed the baseline questionnaire who responded to a question about sexual assault. Multivariate modeling was used to determine and to what extent a history of sexual violence at different ages is predictive of HIV risk and other health risk behaviors. HIV prevalence was calculated as the total current number of HIV-positive individuals in the cohort. Of the 1437 eligible individuals, 36% reported a lifetime history of sexual violence; 68% of women, and 19% of men (p<0.001). After adjusting for fixed sociodemographics, these individuals were more likely to have ever been in the sex trade, to knowingly share needles/rigs with HIV-positive people, to have attempted suicide, to have ever accidentally overdosed, to binge on alcohol, and to have been diagnosed with a mental disorder/disability. The prevalence of child sexual abuse in this cohort is 21%; 33% for women, and 13% for men. The data show a dose-response relationship between age at first sexual violence and most risk behaviors examined. These relationships are further mediated by gender. The prevalence of HIV among individuals who ever experienced sexual violence was 25%, compared to 19% among those who never experienced sexual violence (p=0.006). Sexual violence, and especially child sexual abuse, is highly prevalent among this cohort, particularly among women. Child sexual abuse has worse consequences for both genders than sexual violence later in life. Nevertheless, women and men are affected differently by sexual violence at different ages, and this has significant implications for health promotion programs, and specifically HIV prevention.

Impairments, activity limitations and participation restrictions: prevalence and associations among persons living with HIV/AIDS in British Columbia.

BACKGROUND: To measure the prevalence of and associations among impairments, activity limitations and participation restrictions in persons living with HIV in British Columbia to inform support and care programs, policy and research. METHODS: A cross-sectional population-based sample of persons living with HIV in British Columbia was obtained through an anonymous survey sent to members of the British Columbia Persons With AIDS Society. The survey addressed the experience of physical and mental impairments, and the experience and level of activity limitations and participation restrictions. Associations were measured in three ways: 1) impact of types of impairment on social restriction; 2) impact of specific limitations on social restriction; and 3) independent association of overall impairments and limitations on restriction levels. Logistic regression was used to measure associations with social restriction, while ordinal logistic regression was used to measure associations with a three-category measure of restriction level. RESULTS: The survey was returned by 762 (50.5%) of the BCPWA participants. Over ninety percent of the population experienced one or more impairments, with one-third reporting over ten. Prevalence of activity limitations and participation restrictions was 80.4% and 93.2%, respectively. The presence of social restrictions was most closely associated with mental function impairments (OR: 7.0 for impairment vs. no impairment; 95% CI: 4.7 - 10.4). All limitations were associated with social restriction. Among those with 5 vs. no limitation, 95%CI: 4.9-125.0). Among those with > 200 CD4 cells/mm3, the odds of higher restriction were increased with higher limitation (OR: 2.7 for limitation score of 1-5 vs. no limitation, 95%CI: 1.4-5.1; OR: 8.6 for limitation score > 5 vs. no limitation, 95%CI: 3.9-18.8), as well as by additional number of impairments (OR:1.2 for every additional impairment; 95% CI:1.1-1.3). CONCLUSIONS: This population-based sample of people living with HIV has been experiencing extremely high rates of impairments, activity limitations and participation restrictions. Furthermore, the complex inter-relationships identified amongst the levels reveal lessons for programming, policy and research in terms of the factors that contribute most to a higher quality of life.

Non-consensual sex experienced by men who have sex with men: prevalence and association with mental health.

Little is known about the psychosocial factors associated with sexual assault experienced by males. Men (N=358), 19-35 years of age, recruited by community outreach, completed questionnaires. Eligibility criteria included: being HIV-negative and self-identifying as gay or bisexual. Lifetime prevalence rates of childhood sexual abuse, juvenile prostitution, and adult sexual assault were determined. The mental health of this population was explored including associations between sexual victimization and mental health disorders (alcohol abuse, suicidal ideation and attempts, mood disorders, and poor self-esteem). Almost 1 in 10 of the men had engaged in juvenile prostitution, 14% were forced into sexual activity before 14 years of age, and 14% were sexually victimized after the age of 14. Those exposed to non-consensual sex were 2.9 (95% CI: 1.8-4.7) times more likely to abuse alcohol than those free of victimization. Those who reported childhood sexual abuse were 3.3 (95% CI: 1.7-6.4) times more likely to have attempted suicide. Juvenile prostitution was associated with current depression (OR=6.4; 95% CI: 2.8-14.9). Health professionals have the responsibility to respond competently and sensitively to victims of sexual violence. To do this, many need to recognize the prevalence of male sexual trauma, to deconstruct their personal beliefs about same-sex sexual violence, and to learn to ask sensitive questions in their assessment interviews.

Prevalence of activity limitation among persons living with HIV/AIDS in British Columbia.

BACKGROUND: As antiretrovirals increase the life expectancy of persons living with HIV, quality of life issues become more important. Little research has examined the types and levels of activity limitations among HIV-positive populations. The objective of this report is to compare the levels of limitations among HIV-positive persons to the general population. METHODS: The BC Persons With AIDS (BCPWA) Society consists of approximately 3,500 HIV-positive members. A recent survey conducted among BCPWA members included a section assessing activity limitations. Prevalence of limitations in this group was compared to the general population of BC using the National Population Health Survey (NPHS) to calculate standardized prevalence ratios (SPR). RESULTS: Compared to the general BC population, BCPWA members were more likely to be male, aged over 30 years, not to have graduated from high school, unemployed, living alone and having a household income less than $10,000 per year. The SPR for activity limitations among male participants applying the rates of limitation among the general population of BC was 9.4 (8.4-10.6). The SPR for women was 9.9 (7.2-11.1). Using an NPHS rate restricted to individuals who reported a chronic condition, the SPR for males was 6.0 (5.9-6.5) and for females was 7.0 (5.8-8.2). INTERPRETATION: Limitations on activity are prevalent, even when comparing those with high CD4 counts and restricting the standard to those with chronic conditions. These findings suggest that implementation of programs offering support with everyday tasks would be of value in this population.

Association between childhood physical abuse, unprotected receptive anal intercourse and HIV infection among young men who have sex with men in Vancouver, Canada.

INTRODUCTION: The association between childhood sexual abuse and HIV risk among men who have sex with men (MSM) is well established. However, no studies have examined the potential impact of other forms of childhood maltreatment on HIV incidence in this population. METHODS: We explored the impact of child physical abuse (CPA) on HIV seroconversion in a cohort of gay/bisexual men aged 15 to 30 in Vancouver, Canada. Cox proportional hazard models were used, controlling for confounders. RESULTS: Among 287 participants, 211 (73.5%) reported experiencing CPA before the age of 17, and 42 (14.6%) reporting URAI in the past year. After a median of 6.6 years follow-up, 16 (5.8%) participants HIV-seroconverted. In multivariate analysis, CPA was significantly associated with HIV seroconversion (adjusted hazard ratio [AHR] = 4.89, 95% confidence interval (CI): 1.65-14.48), after controlling for potential confounders. CONCLUSION: Our study uncovered a link between childhood physical violence and HIV incidence. Results highlight an urgent need for screening of young gay and bisexual men for histories of violence, and social and structural supports to prevent HIV transmission in this population.

'It's like the treasure': beliefs associated with semen among young HIV-positive and HIV-negative gay men.

This paper examines cultural and social meanings associated with semen, along with related issues of unprotected receptive anal intercourse, HIV seroconversion, treatment optimism and viraemia. The findings are derived from qualitative interviews conducted with 12 HIV-positive young gay men and 12 HIV-negative counterparts who participated in a prospective cohort study in Vancouver, Canada. Focussing on the narratives of young gay men, the analysis reveals a diverse range of knowledge, values and functions of semen, especially in relation to its exchange. Beliefs about semen appeared to differ by HIV serostatus and were linked with intimacy, identity and pleasure, particularly among the HIV-positive men. Against dominant representations of semen in relation to issues of loss, anxiety and infertility, this unique study sheds much needed light on its role within the cultural construction of sexuality among gay men. As such, these narratives are of direct importance to primary and secondary HIV prevention, including condom promotion and the development of rectal microbicides.

Sexual violence among two populations of men at high risk of HIV infection.

This study sought to compare the prevalence of, and relationship between, age at first experience of sexual violence and HIV and other health risk behaviors in two populations of men at high risk of HIV infection. Data were drawn from two cohorts: Vanguard, a prospective study of young men who have sex with men (MSM), and VIDUS, the Vancouver Injection Drug Users Study. Controlling for fixed sociodemographics, multivariate logistic regression was used to assess the relationship between age at first sexual violence (vs. never experiencing it) and several health risk behaviors. There were 140/498 (28%) MSM from Vanguard and 173/932 (19%) injection drug users (IDU) from VIDUS who reported having experienced sexual violence. Among VIDUS men, 130/852 (15%) IDU-only and 43/80 (54%) who were both IDU and MSM reported a history of sexual violence. The prevalence of child sexual abuse was 13% in Vanguard MSM, and 11% among VIDUS IDU-only, but 26% among VIDUS MSM/IDU. The median age of onset was significantly lower among VIDUS IDU-only compared to the two other groups. Experiencing sexual violence first in childhood was strongly related to ever being in the sex trade in both IDU and MSM. MSM in Vanguard who experienced sexual violence in childhood were more likely to have attempted suicide, and have a diagnosed mood disorder. Non-MSM IDU in VIDUS who experienced sexual violence in childhood were more likely to have a diagnosed mental illness, to binge on alcohol, and to have ever accidentally overdosed. In conclusion, men who have ever had sex with men appear to have a higher lifetime prevalence of sexual violence, compared to non-MSM injection drug users. Sexual violence is differentially associated with different health risk behaviors, depending on the age at first occurrence and the primary HIV risk factor (i.e. MSM vs. IDU).

Illustrated instructions for self-collection of anorectal swab specimens and their adequacy for cytological examination.

BACKGROUND: Self-collection of anorectal swab specimens would facilitate screening for anal cancer precursors and sexually transmitted rectal infections among men who have sex with men (MSM). However, pictorial guides for self-collection were not previously available. GOALS: Develop and field test a set of illustrated self-collection instructions. DESIGN: Cross-sectional study of community-recruited MSM who were naïve with regard to collection of specimens for anal cytology. RESULTS: Among 222 self- and clinician-collected swab pairs provided by mostly human immunodeficiency virus (HIV)-1 seronegative MSM (median age, 31.5 years), most specimens were adequate for cytologic evaluation, though self-collected swabs were less likely to be so (83% versus 92%, P = <0.001). The illustrated instructions were reportedly essential, but having used them, men rated their understanding of the self-collection procedure as very high. CONCLUSIONS: Provided with illustrated instructions, most MSM who are naïve to the technique can self-collect anorectal swab specimens that are suitable for screening.

Similar sexual behaviors with casual partners among gay men with and without a regular partner.

OBJECTIVES: We hypothesized that men in a relationship would engage in less risky sexual activity with their casual partners compared to men with only casual partners. STUDY: Cross-sectional data were collected between 1999 and 2003 in a study of young human immunodeficiency virus-seronegative gay men in Vancouver, British Columbia. We assessed the substance use and sexual behaviors of 156 men and compared those having casual partners in addition to 1 regular partner for the duration of the previous year (n = 43) to those reporting only casual partners during the previous year (n = 113). RESULTS: Men with just 1 regular partner were not significantly different from men without a regular partner with regard to sexual behaviors reportedly engaged in with casual partners, self-reported sexually transmitted infections diagnosed within the previous year, or demographic characteristics. Only previous use of poppers and higher frequencies of marijuana use were found among men without a regular partner. CONCLUSIONS: In our cohort, young gay men in a relationship do not appear less likely to engage in risky sex with casual partners than men with casual partners only.

Unprotected anal intercourse associated with recreational drug use among young men who have sex with men depends on partner type and intercourse role.

OBJECTIVE: The objective of this study was to measure associations of unprotected anal intercourse (UAI) and substance use by sexual partner (regular vs. casual) and role [insertive (I) vs. receptive (R)]. GOAL: The goal of this study was to identify determinants of the association of specific drugs and UAI. STUDY: We conducted a prospective study of young men who have sex with men (MSM), 1997-2002. Odds ratios (ORs) for association of substance use and UAI during the previous year were adjusted for age and calendar year. RESULTS: UAI was significantly associated with sexual situation-specific use of marijuana (OR, 1.43), crystal methamphetamine (OR, 1.75), ecstasy (OR, 1.88), and ketamine (OR, 2.17); global use associations were similar. Situation-specific associations with alcohol (OR, 1.93) and gamma-hydroxybutyrate (GHB; OR, 1.98) were not seen with global measures. GHB and ketamine were specifically associated with IUAI with regular partners, and methamphetamine with RUAI with casual partners. CONCLUSION: Type of drug use measure, partner, and role are important determinants of the association of specific substances and UAI.