Overall, one in five Massachusetts MSM reported having engaged in specific sexual behaviors in the prior 12 months with intent to reduce their HIV risk. Contrary to our hypotheses and prior research on drug use,7–10,12
abstaining from drug use during sex was not significantly associated with risk reduction among the current sample. However, MSM who did not use alcohol during sex and those who were not depressed were more likely to engage in less risky sexual behaviors, consistent with prior studies.10,13–15,23
These findings suggest that HIV prevention interventions with MSM would benefit from addressing “syndemics”24,25
associated with sexual risk taking. In particular, alcohol use, depression, and sexual risk behavior may be interacting health conditions that additively increase negative health consequences (i.e., HIV transmission) among some MSM.26
HIV prevention interventions for MSM may benefit from incorporating screening and/or treatment for alcohol use or depression, thus allowing some MSM to respond more effectively to behavioral change approaches to HIV prevention.27
With respect to contextual variables, risk reducers were less likely to have met sex partners in the prior 12 months at public cruising areas and via the Internet. This finding is consistent with prior research showing that MSM frequenting specific gay venues are more likely to engage in high risk sexual behaviors28,29
and more often use substances during sex30,31
compared to those who do not. Findings from the current study suggest that in addition to addressing psychosocial issues, effective HIV prevention interventions should consider ways to engage the MSM at greatest risk for HIV acquisition and transmission in their risky environments.
The data presented here should be interpreted cautiously. First, as a cross-sectional study, data are subject to the limitations of a study design that descriptively measures exposure and disease status at the same point in time, not allowing for inferences about causality to be made. Second, this convenience sample could be confounded by possible sampling biases (e.g., recruiting a sample less representative of the population), resulting in limited generalizability. Moreover, small sample size poses a significant limitation with respect to statistical power, particularly in multivariable logistic regression analyses. Last, because approximately half of the participants were patients recruited at FCH, a community health center specializing in LGBT health care, the sample may be more gay-identified or “out” with a higher prevalence of HIV infection/STD history than the greater Boston area MSM population.
Limitations notwithstanding, the current analysis found that certain psychosocial and behavioral factors were associated with decreased sexual risk behaviors among MSM. Identifying and understanding factors associated with risk reduction behaviors may be important to consider in designing effective sexual health prevention interventions for the riskiest subpopulations of MSM.
It has been suggested that challenges of maintaining MSM's interest in prevention efforts may be exacerbated by a failure of some HIV prevention programs to update risk reduction messages.32,33
Understanding alternative sexual practices which MSM engage in may help to reinvigorate HIV prevention efforts aimed at making sex not only safer, but also to tailor prevention messages to help MSM feel that sex can remain exciting, gratifying, and intimate. Educating MSM about alternate, safer-sex behaviors besides condom use may normalize a range of sexual practices and desires between men that pose less HIV risk than unprotected anal sex.