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1.  Antiretroviral Drug Resistance and Risk Behavior Among Recently HIV-Infected Men Who Have Sex With Men 
Objectives
Examine associations among behaviors including substance use during sexual encounters, and transmitted HIV drug resistance in recently HIV-infected men who have sex with men (MSM).
Methods
Between 2002 and 2006, 117 recently HIV-infected MSM completed questionnaires regarding their 3 most recent sexual partners. Serum samples were tested for the presence of genotypic and phenotypic HIV drug resistance. Logistic regression analysis was used to assess the association of substance use, behaviors, and resistance to at least 1 class of HIV drugs.
Results
The mean age of participants was 35 years; 71% identified as white and 19% as Hispanic. Sixty (51%) reported substance use during sexual activity in the past 12 months. A total of 12.5% of 112 had genotypic drug resistance to at least 1 class of antiretroviral medications, and 14% of 117 had phenotypic drug resistance. Substances used during sexual activity associated with phenotypic drug resistance in multivariate models included any substance use (adjusted odds ratio [aOR] = 4.21, 95% confidence interval [CI]: 1.13 to 15.68), polysubstance use (aOR = 5.64, 95% CI: 1.62 to 19.60), methamphetamine (aOR = 4.00, 95% CI: 1.19 to 13.38), 3,4-methylenedioxy-N-methylamphetamine (MDMA)/Ecstasy (aOR = 7.16, 95% CI: 1.40 to 36.59), and γ-hydroxyl butyrate (GHB) (aOR = 6.98, 95% CI: 1.82 to 26.80). The genotype analysis was similar.
Conclusions
Among these recently HIV-infected MSM, methamphetamine use during sexual activity and use of other substances, such as MDMA and GHB, was associated with acquired drug-resistant virus. No other behaviors associated with acquisition of drug-resistant HIV.
doi:10.1097/QAI.0b013e3181684c3d
PMCID: PMC4153748  PMID: 18285715
HIV antiviral resistance; men who have sex with men; sexual behavior; substance use
2.  The slippery slope: Lubricant Use and Rectal Sexually Transmitted Infections: a newly identified risk 
Sexually transmitted diseases  2012;39(1):59-64.
Background
Use of lubricant products is extremely common during receptive anal intercourse (RAI) yet has not been assessed as a risk for acquisition of sexually transmitted infections (STIs).
Methods
From 2006–2008 a rectal health and behavior study was conducted in Baltimore and Los Angeles as part of the UCLA Microbicide Development Program (NIAID IPCP# #0606414). Participants completed questionnaires and rectal swabs were tested for Neisseria gonorrhoeae and Chlamydia trachomatis with the Aptima Combo 2 assay and blood was tested for syphilis (for RPR and TPHA with titer) and HIV. Of those reporting lubricant use and RAI, STI results were available for 380 participants. Univariate and multivariate regressions assessed associations of lubricant use in the past month during RAI with prevalent STIs.
Results
Consistent lubricant use during RAI in the past month was reported by 36% (137/380) of participants. Consistent past month lubricant users had a higher prevalence of STI than inconsistent users (9.5% vs. 2.9%; p=0.006). In a multivariable logistic regression model testing positive for STI was associated with consistent use of lubricant during RAI in the past month (adjusted Odds Ratio (AOR) 2.98 (95%CI 1.09, 8.15) after controlling for age, gender, study location, HIV status, and numbers of RAI partners in the past month.
Conclusions
Findings suggest some lubricant products may increase vulnerability to STIs. Because of wide use of lubricants and their potential as carrier vehicles for microbicides, further research is essential to clarify if lubricant use poses a public health risk.
doi:10.1097/OLQ.0b013e318235502b
PMCID: PMC3244680  PMID: 22183849
rectal sexually transmitted infections; lubricants; rectal health
3.  Behaviors of recently HIV-infected men who have sex with men in the year post-diagnosis: effects of drug use and partner types 
Objectives
Assess behaviors of recently HIV-infected men who have sex with men (MSM).
Methods
From 2002–2006 193 recently HIV-infected MSM in the Southern California Acute Infection and Early Disease Research Program were interviewed every 3 months. Changes in HIV status of partners, recent unprotected anal intercourse (UAI), drug use, use of antiretroviral therapy (ART), detectable viral load and partnership dynamics over one year were used to predict recent UAI in a random effect logistic regression.
Results
Over a year significantly fewer partners in the past month were reported (mean 8.81 to 5.84; p<.0001). Percentage of recent UAI with HIV-status unknown last partners decreased from enrollment to 9 months (49% to 27%) and rebounded at 12 months to 71%. In multivariable models controlling for ART use, recent UAI was significantly associated with: baseline methamphetamine use (AOR 7.65, 95% CI 1.87, 31.30), methamphetamine use at follow-up (AOR 14.4, 95% CI 2.02, 103.0), HIV-uninfected partner at follow-up (AOR 0.14, 95% CI 0.06, 0.33) and partners with unknown HIV status at follow-up (AOR 0.33, 95% CI 0.11, 0.94). HIV viral load did not influence rate of UAI.
Conclusions
Transmission behaviors of these recently HIV-infected MSM decreased and serosorting increased after diagnosis; recent UAI with serostatus unknown or negative partners rebounded after nine months, identifying critical timepoints for interventions targeting recently HIV-infected individuals. There was no evidence in this cohort that the viral load of these recently infected men guided their decisions about protected or unprotected anal intercourse.
doi:10.1097/QAI.0b013e3181ff9750
PMCID: PMC3023009  PMID: 21119524
recent HIV infection; post HIVdiagnosis behaviors; HIV positive MSM risk behavior; HIV and substance use
4.  Epidemiology, Sexual Risk Behavior, and HIV Prevention Practices of Men who Have Sex with Men Using GRINDR in Los Angeles, California 
Young men who have sex with men (YMSM) are at alarming risk for HIV acquisition, demonstrating the highest rates of incident infection of any age-risk group. GRINDR is a global positioning service-based social networking application popular with YMSM for sexual partnering. To assess the characteristics of YMSM who use GRINDR, we conducted a computer-assisted self-interview-based survey of 375 YMSM using GRINDR in metropolitan Los Angeles, recruited using the GRINDR platform. The median age was 25 (interquartile range, 22–27) years old, 42.4 % caucasian, 6.4 % African American, 33.6 % Latino, and 14.1 % Asian/Pacific Islander. Participants reported high rates of sexual partnering and unprotected anal intercourse (UAI). The majority (70 %) of those reporting unprotected anal intercourse reported low perception of HIV-acquisition risk. Of the participants, 83.1 % reported HIV testing within the past 12 months; 4.3 % had never been HIV tested. Of the participants, 4.5 % reported HIV-positive serostatus; 51.7 % indicated that they would be interested in participating in a future HIV prevention trial. Latinos were more likely than either caucasians or African Americans to endorse trial participation interest (odds ratio, 1.9; 95 % confidence interval [1.1–3.3]). HIV-positive test results were associated with increased number of anal sex partners in the past 3 months (adjusted odds ratio (AOR), 1.53 [0.97–2.40]), inconsistent inquiry about partners’ serostatus (AOR, 3.63 [1.37–9.64]), reporting the purpose for GRINDR use including “friendship” (AOR, 0.17 [0.03–1.06), and meeting a sexual partner in a bookstore in the past 3 months (AOR, 33.84 [0.99–1152]). Men recruited via GRINDR were high risk for HIV acquisition or transmission and interested in clinical trial participation, suggesting potential for this method to be used for recruitment of YMSM to HIV prevention trials.
doi:10.1007/s11524-012-9766-7
PMCID: PMC3732683  PMID: 22983721
Sexual risk behavior; HIV prevention; Education; Study recruitment
5.  Risk Behaviors by Type of Concurrency among Young People in Three US STD Clinics 
Sexual health  2012;9(3):280-287.
Background
Concurrent sexual partnerships can increase sexually transmitted diseases (STD) transmission on a population level. However, different concurrency types may be associated with differential risk for transmission. To investigate this, we describe the prevalence and correlates of four specific concurrency types.
Methods
Between 2001 and 2004, 1098 young adults attending 3 STD clinics were interviewed and tested for STDs. Characteristics associated with concurrency types were identified using logistic regression.
Results
Approximately one-third of respondents reported reactive (34%), transitional (36%), compensatory (32%), and experimental (26%) concurrency. Among men, reactive concurrency was associated with not identifying as heterosexual, drug use, and having sex the same day as meeting a partner. Among women, reactive concurrency was associated with African American race and having >3 lifetime partners. Transitional concurrency was associated with >3 lifetime partners for men and women. Among men, compensatory was associated with African American race; whereas, among women there were no associations with compensatory concurrency. Among men, experimental concurrency was associated with >3 lifetime partners and having sex the same day as meeting a partner. Among women, experimental concurrency was associated with not identifying as heterosexual, drug use, and having sex the same day as meeting a partner.
Conclusions
All concurrency types were common in this population and each was associated with a set of demographic and risk factors. Reactive and experimental concurrency types were associated with other high-risk behaviors, such as drug use.
doi:10.1071/SH11047
PMCID: PMC4077433  PMID: 22697146
6.  Acceptability of Potential Rectal Microbicide Delivery Systems for HIV Prevention: A Randomized Crossover Trial 
AIDS and behavior  2013;17(3):1002-1015.
We assessed the acceptability of three of over-the-counter products representative of potential rectal microbicide (RM) delivery systems. From 2009 to 2010, 117 HIV-uninfected males (79 %) and females (21 %) who engage in receptive anal intercourse participated in a 6-week randomized crossover acceptability trial. Participants received each of three products (enema, lubricant-filled applicator, suppository) every 2 weeks in a randomized sequence. CASI and T-ACASI scales assessed product acceptability via Likert responses. Factor analysis was used to identify underlying factors measured by each scale. Random effects models were fit to examine age and gender effects on product acceptability. Three underlying factors were identified: Satisfaction with Product Use, Sexual Pleasure, and Ease of Product Use. For acceptability, the applicator ranked highest; however, differences between product acceptability scores were greatest among females and younger participants. These findings indicate that RM delivery systems impact their acceptability and should be considered early in RM development to enhance potential use.
doi:10.1007/s10461-012-0358-z
PMCID: PMC3594349  PMID: 23114512
Anorectal products; Receptive anal intercourse; HIV prevention
7.  Intimate Partner Violence and Anal Intercourse among Young Adult Heterosexual Relationships 
Context
The prevalence of intimate partner violence and anal intercourse is high in young adult relationships, but few have looked the intersection of the two. This paper considers this association within multiple intimate partner violence contexts.
Methods
Using wave 3 of the National Longitudinal Study of Adolescent Health, an analysis was completed on the association of physical and sexual intimate partner violence and anal intercourse in relationships reported by young women. This wave was collected from 2001–2002 when the women were between 18 and 28 years old. A hierarchical random effects model was used to control for the clustered survey design and multiple relationships reported per participant. This analysis included 10,462 relationships reported by 6,280 women.
Results
In multivariate analysis, relationships where women perpetrated physical violence (AOR 1.9) and relationships that were reciprocally physically violent (AOR 1.7) were more likely to include anal intercourse than non-abusive relationships. Among those that included anal intercourse, relationships where the woman was a victim of physical violence (AOR 0.2) were less likely to have ever used a condom during anal intercourse. There was no association between sexual violence and condom use.
Conclusion
These analyses demonstrate that women in violent relationships may be at increased risk of sexually transmitted infections due to unprotected anal intercourse. More information on the context surrounding anal intercourse and intimate partner violence is needed in order to understand the nuances of this association.
doi:10.1363/4500613
PMCID: PMC3843245  PMID: 23489852
8.  Prevalence and types of rectal douches used for anal intercourse: results from an international survey 
Background
Rectal products used with anal intercourse (AI) may facilitate transmission of STIs/HIV. However, there is limited data on rectal douching behavior in populations practicing AI. We examined the content, types of products, rectal douching practices and risk behaviors among those reporting AI.
Methods
From August 2011 to May 2012, 1,725 women and men reporting receptive AI in the past 3 months completed an internet-based survey on rectal douching practices. The survey was available in English, French, German, Mandarin, Portuguese, Russian, Spanish, and Thai and included questions on sexual behaviors associated with AI including rectal douching. Differences by rectal douching practices were evaluated using chi-square methods and associations between reported douching practices and other factors including age and reported STI history were evaluated using logistic regression analysis.
Results
Respondents represented 112 countries, were mostly male (88%), and from North America (55%) or Europe (22%). Among the 1,339 respondents (66%) who reported rectal douching, most (83%) reported always/almost always douching before receptive AI. The majority of rectal douchers reported using non-commercial/homemade products (93%), with water being the most commonly used product (82%). Commercial products were used by 31%, with the most common product being saline-based (56%). Rectal douching varied by demographic and risk behaviors. The prevalence of rectal douching was higher among men (70% vs. 32%; p-value < .01), those reporting substance-use with sex (74% vs. 46%; p-value < .01), and those reporting an STI in the past year (69% vs. 57% p-value < .01) or ever testing HIV-positive (72% vs. 53%; p-value < .01). In multivariable analysis, adjusting for age, gender, region, condom and lubricant use, substance use, and HIV-status, douchers had a 74% increased odds of reporting STI in the past year as compared to non-douchers [adjusted odds ratio (AOR) = 1.74; 95% CI 1.01-3.00].
Conclusion
Given that rectal douching before receptive AI is common and because rectal douching was associated with other sexual risk behaviors the contribution of this practice to the transmission and acquisition of STIs including HIV may be important.
doi:10.1186/1471-2334-14-95
PMCID: PMC4015843  PMID: 24555695
Rectal health; Rectal douching; Enema use; Anal intercourse
9.  Effect of Computer-Assisted Interviewing on Self-Reported Sexual Behavior Data in a Microbicide Clinical Trial 
AIDS and behavior  2013;17(2):790-800.
In a microbicide safety and effectiveness trial (HPTN 035) in Malawi, 585 women completed the same questionnaire through a face-to-face interview (FTFI) and an audio computer-assisted self-interview (ACASI). Concordance between FTFI and ACASI responses ranged from 72.0 % for frequency of sex in the past week to 95.2 % for anal intercourse (AI) in the past 3 months. Reported gel and condom use at last sex act were marginally lower with ACASI than FTFI (73.5 % vs. 77.2 %, p = 0.11 and 60.9 % vs. 65.5 %, p = 0.05, respectively). More women reported AI with ACASI than FTFI (5.0 % vs. 0.2 %, p < 0.001). Analyses of consistency of responses within ACASI revealed that 15.0 % of participants in the condom-only arm and 28.7 % in the gel arm provided at least one discrepant answer regarding total sex acts and sex acts where condom and gel were used (19.2 % reported one inconsistent answer, 8.1 % reported two inconsistent answers, and 1.4 % reported three inconsistent answers). While ACASI may provide more accurate assessments of sensitive behaviors in HIV prevention trials, it also results in a high level of internally inconsistent responses.
doi:10.1007/s10461-012-0302-2
PMCID: PMC3550005  PMID: 23054034
ACASI interviewing; Microbicides; Sexual behavior reporting
10.  Anal Human Papillomavirus Infection in a Street Based Sample of Drug Using HIV-Positive Men 
HIV facilitates an increase in human papillomavirus (HPV) associated conditions. HIV-positive men living in a substance use context in Los Angeles were recruited using Respondent Driven Sampling, completed a questionnaire and had biological samples including an anal HPV swab taken. 316 evaluable men were enrolled in the study. The prevalence of all HPV, high-risk (HR) infection, and multiple type infection was highest for men who have sex with men (MSM) (93.9%, 64.6%, 29.7% respectively). When all HPV and HR-HPV prevalence in all men was stratified by age, the youngest group had 100% and 68.2% prevalence respectively with similarly high rates maintained up to 49 years. The individual’s use of alcohol, marijuana, cocaine, methamphetamine or heroin was not significantly associated with anal HPV isolation. In this marginalized population, high anal HPV and HR-HPV prevalence rates over a wide age range may increase the individual’s risk for anal dysplasia and anal cancer.
doi:10.1258/ijsa.2011.011169
PMCID: PMC3899933  PMID: 22581874
human papillomavirus (HPV); substance use; anal; HIV; men who have sex with men (MSM)
11.  Intimate Partner Violence and Sexually Transmitted Infections among Young Adult Women 
Sexually transmitted diseases  2012;39(5):10.1097/OLQ.0b013e3182478fa5.
Background
Intimate partner violence (IPV) is common among young adult relationships, and is associated with significant morbidity, including sexually transmitted infections (STI). This study measured the association between IPV victimization and perpetration and prevalent STIs and STI-risk behaviors among a sample of young women.
Methods
This analysis uses wave 3 of the National Longitudinal Study of Adolescent Health and was restricted to the 3,548 women who reported on a sexual relationship that occurred in the previous three months and agreed to STI testing. A multivariate random effects model was used to determine associations between STI and STI-risk behaviors and IPV.
Results
The IPV prevalence over the past year was 32%: 3% victim-only, 12% perpetrator-only, and 17% reciprocal. The STI prevalence was 7.1%. Overall, 17% of participants reported partner concurrency and 32% reported condom use at last vaginal intercourse. In multivariate analysis, victim-only and reciprocal IPV were associated with not reporting condom use at last vaginal intercourse. Perpetrator-only, victim-only, and reciprocal IPV were associated with partner concurrency. Victim-only IPV was associated with a higher likelihood of having a prevalent STI (OR: 2.1; 95% CI: 1.0-4.2).
Conclusions
This analysis adds to the growing body of literature that suggests that female IPV victims have a higher STI prevalence, as well as a higher prevalence of STI-risk behaviors, compared to women in non-violent relationships. Women in violent relationships should be considered for STI screening in clinics and IPV issues should be addressed in STI prevention messages given its impact on risk for STI acquisition.
doi:10.1097/OLQ.0b013e3182478fa5
PMCID: PMC3856434  PMID: 22504601
intimate partner violence; sexually transmitted infections; STI-risk behaviors
12.  Seroadaptation in a Sample of Very Poor Los Angeles Area Men Who Have Sex with Men 
AIDS and behavior  2013;17(5):1862-1872.
Data from 635 very poor men who have sex with men (MSM) were used to identify seroadaptation with 1,102 male partners reported between 2005-2007 in Los Angeles as part of the Sexual Acquisition and Transmission of HIV Cooperative Agreement Program. The mean age of the sample was 41.7 years; 53% had experienced homelessness in the past year. Condoms were reported in 51% of sexual events involving anal intercourse. HIV seroconcordance was reported in 41% of sexual partnerships among HIV-positive participants. HIV-positive men were more likely to have oral-only or unprotected receptive anal intercourse and less likely to have unprotected insertive anal intercourse with HIV-negative or unknown partners compared to HIV-positive partners. Even in the face of poverty, HIV-positive MSM report mitigating risks of HIV-transmission though seroadaptation in the context of modest rates of condom use.
doi:10.1007/s10461-012-0213-2
PMCID: PMC3479326  PMID: 22644067
serosorting; seropositioning; oral-only sex; poverty
13.  The Cumulative Effects of Medication Use, Drug Use, and Smoking on Erectile Dysfunction Among Men Who Have Sex With Men 
The Journal of Sexual Medicine  2012;9(4):1106-1113.
Introduction
Erectile dysfunction (ED) is highly prevalent among Human Immunodeficiency Virus-seropositive (HIV+) men who have sex with men (MSM). There is a need for additional research to determine the correlates of HIV+ and HIV-seronegative (HIV−) MSM, especially regarding non-antiretroviral medication use.
Aims
This study examined the prevalence of ED and the socio-demographic, medical conditions, medication use, and substance use correlates of ED among HIV+ and HIV− MSM.
Methods
A modified version of the International Index of Erectile Function (IIEF) for MSM was self-administered by participants enrolled in the Multicenter AIDS Cohort Study (MACS), an ongoing prospective study of the natural and treated histories of HIV infection among MSM in the United States. The study sample included 1,340 participants, including 612 HIV+ and 728 HIV− men. Poisson regression with robust error variance was used to estimate prevalence ratios of ED in multivariable models in combined (HIV+/−) and separate analyses.
Main outcome measure
ED was determined by the summed scores of a modified version of the IIEF validated among MSM.
Results
Twenty-one percent of HIV+ MSM and 16% of HIV− MSM reported ED. Being >55 years of age, Black race, cumulative pack-years of smoking, cumulative antihypertensive use, and cumulative antidepressant use had significant positive associations with the prevalence of ED in the total sample. Among HIV+ men, duration of antihypertensive use and antidepressant use were significantly associated with increasing prevalence of ED. Among HIV− men, being >55 years of age, Black race, and cigarette smoking duration were associated with increased prevalence of ED.
Conclusion
Predictors of ED may differ by HIV status.. Although smoking cessation and effective medication management may be important as possible treatment strategies for ED among all MSM, there may be a burden on sexual functioning produced by non-HIV medications for HIV+ men.
doi:10.1111/j.1743-6109.2011.02648.x
PMCID: PMC3319271  PMID: 22321450
14.  Predictors of Unrecognized HIV Infection Among Poor and Ethnic Men Who Have Sex with Men in Los Angeles 
AIDS and behavior  2011;15(3):643-649.
This study evaluates associations between unrecognized HIV infection and demographic factors, internalized homonegativity, drug use, and sexual behaviors among HIV positive men who have sex with men (MSM). We analyzed data from 347 HIV positive participants from the Los Angeles site for NIDA’s Sexual Acquisition and Transmission of HIV-Cooperative Agreement Program. Participants were HIV positive MSM and MSM/W and predominantly African American (36.0%) or Latino (38.7%), and unemployed (82.8%). Results from a multivariate logistic regression suggest that, compared to HIV positive participants who correctly reported their HIV positive status, being African-American (OR: 9.81, CI: 1.2–77.9) or Latino (OR: 10.92, CI: 1.3–88.4) rather than White, MSM/W rather than MSM (OR: 3.24, CI: 1.09–9.62), and having higher homonegativity scores (OR: 1.22, CI: 1.02–1.4) is associated with unrecognized HIV infection, controlling for age, education, and homelessness. Findings provide some immediate evidence to help craft HIV prevention interventions.
doi:10.1007/s10461-009-9653-8
PMCID: PMC3029495  PMID: 20043200
Unrecognized HIV; HIV testing; Homonegativity; Stigma; Awareness of HIV status
15.  The Relative Role of Perceived Partner Risks in Promoting Condom Use in a Three-City Sample of High-Risk, Low-Income Women 
AIDS and Behavior  2010;15(7):1347-1358.
We examined the effect of women’s perceptions of sexual partner risks on condom use. Women from three US cities (n = 1,967) were recruited to provide data on HIV risks. In univariate models, increased odds of condom use were associated with perceiving that partners had concurrent partners and being unaware of partners': (a) HIV status, (b) bisexuality, (c) concurrency; and/or (d) injection drug use. In multivariate models, neither being unaware of the four partner risk factors nor perceiving a partner as being high risk was associated with condom use. Contextual factors associated with decreased odds of condom use were having sex with a main partner, homelessness in the past year, alcohol use during sex, and crack use in the past 30 days. Awareness of a partner’s risks may not be sufficient for increasing condom use. Contextual factors, sex with a main partner in particular, decrease condom use despite awareness of partner risk factors.
doi:10.1007/s10461-010-9840-7
PMCID: PMC3180610  PMID: 20976538
Perceptions of partner HIV risk behaviors; Condom use; HIV transmission to women; Crack; Alcohol
16.  Understanding the Psychosocial Needs of HIV-Infected Children and Families: A Qualitative Study 
Objective
This study aims to engage children living with HIV/AIDS and their caregivers in a qualitative assessment to address psychosocial needs pertaining to this population. The purpose is to identify unique situations and concerns they experienced in dealing with the disease and ongoing treatment process.
Material and Method
Individual in-depth interviews using a semi-structured interview guide were employed.
Results
Thirty-four children (12 boys and 22 girls) aged 8–16 and thirty-five primary caretakers (6 males and 29 females) aged 21–66 participated in this study. Results identified some of the common concerns and challenges shared among this population, including impact of the illness on loved ones, disclosure, adherence, behavioural problems, discrimination, treatment affordability, and financial constraints. Certain issues that emerged as important themes specific to this population include unwarranted concerns about certain aspects of the illness, misinterpretation of the nonverbal clues within families, future child guardianship and placement planning, treatment availability during transitional period, and the challenge of maintaining the confidentiality of the diagnosis.
Conclusion
The needs and suggestions of the target groups provided the framework for improving the current services such as the provision of private sessions with children separated from their caregivers (especially for older children and adolescents), disclosure intervention, behavioral screening, life skills building, and empowerment mobilization. Thus, the information gained can be used to facilitate the holistic and humanized health care provision for children living with HIV/AIDS.
PMCID: PMC2942078  PMID: 19253500
HIV/AIDS; Children; Families
17.  Pre-exposure Prophylaxis State of the Science: Empirical Analogies for Research and Implementation 
Current HIV/AIDS Reports  2010;7(4):201-209.
Pre-exposure prophylaxis (PrEP) has the potential to become a powerful biomedical approach to HIV prevention; however, its success depends on behavioral and social factors that may determine its appropriate use. This article is designed to facilitate interdisciplinary empirical analogies relevant to PrEP implementation, reviewing behavioral and social science findings that may provide lessons critical to the success of PrEP as a biomedical–behavioral prevention strategy. As we prepare for the dissemination of new biomedical approaches to HIV prevention, integrating the state of the science across disciplines may result in innovative strategies for implementation that can enhance their success.
doi:10.1007/s11904-010-0057-1
PMCID: PMC2938422  PMID: 20809218
HIV; Pre-exposure prophylaxis (PrEP); Adherence; Risk reduction; Decision-sciences; Risk analysis; Health communication
18.  Predictors of Unrecognized HIV Infection Among Poor and Ethnic Men Who Have Sex with Men in Los Angeles 
AIDS and Behavior  2009;15(3):643-649.
This study evaluates associations between unrecognized HIV infection and demographic factors, internalized homonegativity, drug use, and sexual behaviors among HIV positive men who have sex with men (MSM). We analyzed data from 347 HIV positive participants from the Los Angeles site for NIDA’s Sexual Acquisition and Transmission of HIV-Cooperative Agreement Program. Participants were HIV positive MSM and MSM/W and predominantly African American (36.0%) or Latino (38.7%), and unemployed (82.8%). Results from a multivariate logistic regression suggest that, compared to HIV positive participants who correctly reported their HIV positive status, being African-American (OR: 9.81, CI: 1.2–77.9) or Latino (OR: 10.92, CI: 1.3–88.4) rather than White, MSM/W rather than MSM (OR: 3.24, CI: 1.09–9.62), and having higher homonegativity scores (OR: 1.22, CI: 1.02–1.4) is associated with unrecognized HIV infection, controlling for age, education, and homelessness. Findings provide some immediate evidence to help craft HIV prevention interventions.
doi:10.1007/s10461-009-9653-8
PMCID: PMC3029495  PMID: 20043200
Unrecognized HIV; HIV testing; Homonegativity; Stigma; Awareness of HIV status
19.  Homonegativity, Substance Use, Sexual Risk Behaviors, and HIV Status in Poor and Ethnic Men Who Have Sex with Men in Los Angeles 
This study evaluates associations between internalized homonegativity and demographic factors, drug use behaviors, sexual risk behaviors, and HIV status among men who have sex with men (MSM) and with men and women (MSM/W). Participants were recruited in Los Angeles County using respondent-driven sampling (RDS) and completed the Internalized Homonegativity Inventory (IHNI) and questionnaires on demographic and behavioral factors. Biological samples were tested for HIV and for recent cocaine, methamphetamine, and heroin use. The 722 MSM and MSM/W participants were predominantly African American (44%) and Hispanic (28%), unemployed (82%), homeless (50%), and HIV positive (48%) who used drugs in the past 6 months (79.5%). Total and Personal Homonegativity, Gay Affirmation, and Morality of Homosexuality IHNI scores were significantly higher for African American men than for other ethnicities, for MSM/W than for MSM, for recent cocaine users than for recent methamphetamine users, and for HIV-seronegative men than for HIV-seropositive men. Linear regression showed the Gay Affirmation scale significantly and inversely correlated with the number of sexual partners when controlling for effects of ethnicity/race and sexual identification, particularly for men who self-identified as straight. Highest IHNI scores were observed in a small group of MSM/W (n = 62) who never tested for HIV. Of these, 26% tested HIV positive. Findings describe ways in which internalized homophobia is a barrier to HIV testing and associated HIV infection and signal distinctions among participants in this sample that can inform targeted HIV prevention efforts aimed at increasing HIV testing.
doi:10.1007/s11524-009-9372-5
PMCID: PMC2705491  PMID: 19526346
Homophobia; Homonegativity; Drug abuse; Gay men; Bisexual men; HIV
20.  Bridging Sexual Boundaries: Men Who Have Sex with Men and Women in a Street-Based Sample in Los Angeles 
The purpose of the study was to determine the potential contribution of bisexual men to the spread of HIV in Los Angeles. We compare the characteristics and behaviors of men who have sex with men and women (MSMW) to men who have sex with only women (MSW) and men who have sex with only men (MSM) in Los Angeles. Men (N = 1,125) who participated in one of the two waves of data collection from 2005 to 2007 at the Los Angeles site for NIDA’s Sexual Acquisition and Transmission of HIV—Cooperative Agreement Program were recruited using Respondent Driven Sampling. Participants completed Audio Computer Assisted Self Interviews and received oral HIV rapid testing with confirmatory blood test by Western Blot and provided urine specimens for detection of recent powder cocaine, crack cocaine, methamphetamine, or heroin use. MSM, MSW, or MSMW were defined by the gender of whom they reported sex with in the past 6 months. Chi-square tests and ANOVAs were used to test independence between these groups and demographic characteristics, substance use, and sexual behaviors. We fit generalized linear random intercept models to predict sexual risk behaviors at the partner level. Men were mostly of low income, unemployed, and minority, with many being homeless; 66% had been to jail or prison, 29% had ever injected drugs, and 25% had used methamphetamine in the past 30 days. The sample had high HIV prevalence: 12% of MSMW, 65% of MSM, and 4% of MSW. MSMW were behaviorally between MSW and MSM, except that more MSMW practiced sex for trade (both receiving and giving), and more MSMW had partners who are drug users than MSW. Generalized linear random intercept models included a partner-level predictor with four partner groups: MSM, MSMW-male partners, MSMW-female partners, and MSW. The following were significantly associated with unprotected anal intercourse (UAI): MSW (AOR 0.15, 95% CI 0.08, 0.27), MSMW-female partners (AOR 0.4, 95% CI 0.27, 0.61), HIV-positive partners (AOR 2.03, 95% CI 1.31, 3.13), and being homeless (AOR 1.37, 95% CI 1.01, 1.86). The factors associated with giving money or drugs for sex were MSMW-female partners (AOR 1.70, 95% CI 1.09, 2.65), unknown HIV status partners (AOR 1.72, 95% CI 1.29, 2.30), being older (AOR 1.02, 95% CI 1.00, 1.04), history of incarceration (AOR 1.64, 95% CI 1.17, 2.29), and being homeless (AOR 1.73, 95% CI 1.27, 2.36). The following were associated with receiving money or drugs for sex: MSW (AOR 0.53, 95% CI 0.32, 0.89), African American (AOR 2.42, 95% CI 1.56, 3.76), Hispanic (AOR 1.85, 95% CI 1.12, 3.05), history of incarceration (AOR 1.44, 95% CI 1.04, 2.01), history of injecting drugs (AOR 1.57, 95% CI 1.13, 2.19), and had been recently homeless (AOR 2.14, 95% CI 1.57, 2.94). While overall HIV-positive MSM had more UAI with partners of any HIV status than MSMW with either partner gender, among HIV-positive MSMW, more had UAI with HIV-negative and HIV status unknown female partners than male partners. Findings highlight the interconnectedness of sexual and drug networks in this sample of men—as most have partners who use drugs and they use drugs themselves. We find a concentration of risk that occurs particularly among impoverished minorities—where many men use drugs, trade sex, and have sex with either gender. Findings also suggest an embedded core group of drug-using MSMW who may not so much contribute to spreading the HIV epidemic to the general population, but driven by their pressing need for drugs and money, concentrate the epidemic among men and women like themselves who have few resources.
doi:10.1007/s11524-009-9370-7
PMCID: PMC2705489  PMID: 19543837
Sexual bridging; MSMW; HIV risk behavior; HIV transmission risks
21.  Simultaneous Recruitment of Drug Users and Men Who Have Sex with Men in the United States and Russia Using Respondent-Driven Sampling: Sampling Methods and Implications 
The Sexual Acquisition and Transmission of HIV Cooperative Agreement Program (SATHCAP) examined the role of drug use in the sexual transmission of the human immunodeficiency virus (HIV) from traditional high-risk groups, such as men who have sex with men (MSM) and drug users (DU), to lower risk groups in three US cities and in St. Petersburg, Russia. SATHCAP employed respondent-driven sampling (RDS) and a dual high-risk group sampling approach that relied on peer recruitment for a combined, overlapping sample of MSM and DU. The goal of the sampling approach was to recruit an RDS sample of MSM, DU, and individuals who were both MSM and DU (MSM/DU), as well as a sample of sex partners of MSM, DU, and MSM/DU and sex partners of sex partners. The approach efficiently yielded a sample of 8,355 participants, including sex partners, across all four sites. At the US sites—Los Angeles, Chicago, and Raleigh–Durham—the sample consisted of older (mean age = 41 years), primarily black MSM and DU (both injecting and non-injecting); in St. Petersburg, the sample consisted of primarily younger (mean age = 28 years) MSM and DU (injecting). The US sites recruited a large proportion of men who have sex with men and with women, an important group with high potential for establishing a generalized HIV epidemic involving women. The advantage of using the dual high-risk group approach and RDS was, for the most part, the large, efficiently recruited samples of MSM, DU, and MSM/DU. The disadvantages were a recruitment bias by race/ethnicity and income status (at the US sites) and under-enrollment of MSM samples because of short recruitment chains (at the Russian site).
doi:10.1007/s11524-009-9365-4
PMCID: PMC2705484  PMID: 19472058
Respondent-driven sampling; HIV; MSM; MSMW; DU; IDU; SATHCAP
22.  Transmission of STIs/HIV at the partnership level: Beyond individual-level analyses 
Mathematical modeling of transmission dynamics of sexually transmitted infections (STIs) and HIV has considerably advanced HIV research by highlighting the importance of certain types of partnerships in epidemic spread. Notably, concurrent partnerships, defined as a sexual partnership in which one or more of the partnership members have other sexual partners while continuing sexual activity with the original partner, have been shown to play a fundamental role in potentiating the spread of STIs and HIV. Risk behaviors such as concurrency and sex without condoms as well as STI/HIV prevalence vary with physical, social, and emotional factors within partnerships. The efficiency of STI/HIV transmission appears to vary across types of concurrent partnerships according to the differing dynamics within them. Previous research on partnership dynamics has improved our understanding of the multidimensional aspects of sexual partnering, but little is understood of how these aspects of sexual partnering interact and increase risks for HIV, nor how types of partnerships, partnership dynamics, and concurrency work together to affect both the behavior of condom use and the biological transmission of disease. In this article, we discuss the need to extend our understanding of concurrency to include partnerships among men who have sex with men (MSM) and to differentiate between types of partnerships and to develop interventions to modify risk within partnerships. We also introduce a conceptual framework that reflects how individual and partner characteristics influence partnership dynamics that in turn influence risk behaviors, such as concurrency and not using condoms, and associated risks for STIs and HIV.
doi:10.1093/jurban/jtg079
PMCID: PMC3456259  PMID: 14713668
Concurrency; Partnerships; STI/HIV; Sexual transmission dynamics; Bridging behaviors

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