Jay P. Paul

Association of Co-Occurring Psychosocial Health Problems and Increased Vulnerability to HIV/AIDS Among Urban Men Who Have Sex With Men

OBJECTIVES We measured the extent to which a set of psychosocial health problems have an additive effect on increasing HIV risk among men who have sex with men (MSM). METHODS We conducted a cross-sectional household probability telephone sample of MSM in Chicago, Los Angeles, New York, and San Francisco. RESULTS Psychosocial health problems are highly intercorrelated among urban MSM. Greater numbers of health problems are significantly and positively associated with high-risk sexual behavior and HIV infection. CONCLUSIONS AIDS prevention among MSM has overwhelmingly focused on sexual risk alone. Other health problems among MSM not only are important in their own right, but also may interact to increase HIV risk. HIV prevention might become more effective by addressing the broader health concerns of MSM while also focusing on sexual risks.

Understanding childhood sexual abuse as a predictor of sexual risk-taking among men who have sex with men : The Urban Men's Health Study

OBJECTIVE The prevalence and characteristics of childhood sexual abuse (CSA) among men who have sex with men (MSM), and links with sexual risk are explored. A model linking CSA and sexual risk among MSM is proposed. METHOD A telephone probability sample of urban MSM (n = 2881) was recruited and interviewed between November 1996 and February 1998. The interview covered numerous health issues, including history of sexual victimization. RESULTS One-fifth reported CSA, primarily by non-family perpetrators. Initial CSA experiences are characterized by high levels of force (43% involved physical force/weapons), and penetrative sex (78%; 46% reported attempted or actual anal intercourse). Such men are more likely than nevercoerced men to engage in high risk sex (unprotected anal intercourse with a non-primary partner or with a serodiscordant male). In multivariate analyses, the effect of childhood sexual coercion on sexual risk is mediated by substance use, patterns of sexual contacts, and partner violence, but not by adult sexual revictimization or by depression. CONCLUSIONS Findings are interpreted within the context of social learning theory and prior research on sexual risk-taking. The high risk for CSA among MSM, which can predispose such men to patterns of HIV sexual risk, warrants new approaches in HIV prevention.

Gay men report high rates of unprotected anal sex with partners of unknown or discordant HIV status.

OBJECTIVE To examine patterns and factors that correlate with unprotected anal intercourse (UAI) practices among San Francisco gay men, including UAI with partners of unknown or different HIV antibody status. DESIGN A longitudinal cohort recruited for the San Francisco Young Mens Health Study in 1992; re-assessed annually. PARTICIPANTS AND METHODS A sample of 510 unmarried gay men who were 18 to 29 years at baseline were originally recruited as part of a larger population and referral-based sample. Subjects participated in four consecutive waves of data collection. RESULTS The prevalence of reported unprotected anal intercourse (UAI) increased from 37% to 50% between 1993-1994 and 1996-1997. Almost half of all men who reported UAI in 1996-1997 indicated that it occurred with a partner of unknown or discordant HIV antibody status. This high-risk practice correlated with greater numbers of male sex partners, use of nitrite inhalants, sex in commercial sex environments, perceived difficulty controlling sexual risk-taking, and negative emotional reactions following UAI. CONCLUSIONS These data on increasing rates of sexual risk-taking further confirm trends in sexual behavior previously suggested by rising rates of rectal gonorrhea in this population. Additional and sustained prevention efforts are urgently needed in light of the very high background rates of HIV infection found among gay men in San Francisco.

Differential HIV Risk in Bathhouses and Public Cruising Areas

OBJECTIVES This report investigates differences in risk behaviors among men who have sex with men (MSM) who went to gay bathhouses, public cruising areas, or both. METHODS We used a probability sample of MSM residing in 4 US cities (n = 2,881). RESULTS Men who used party drugs and had unprotected anal intercourse with nonprimary partners were more likely to go to sex venues than men who did not. Among attendees, MSM who went to public cruising areas only were least likely, and those who went to both public cruising areas and bathhouses were most likely to report risky sex in public settings. CONCLUSIONS Distinguishing between sex venues previously treated as a single construct revealed a significant association between pattern of venue use and sexual risk. Targeting HIV prevention in the bathhouses would reach the segment of men at greatest risk for HIV transmission.

Correlates of heavy substance use among young gay and bisexual men: The San Francisco Young Men's Health Study

Correlates of heavy substance use among a household-based sample of young gay and bisexual men (n=428) were identified and the odds ratio (OR) was calculated. A total of 13.6% reported frequent, heavy alcohol use and 43% reported polydrug use. Compared with men employed in professional occupations, men in service positions (OR=3.77) and sales positions (OR=2.51) were more likely to be heavy alcohol consumers. Frequent gay bar attendance and multiple sex partners were related to heavy alcohol use, as well as to polydrug use. Polydrug users were more likely to be HIV seropositive (OR=2.05) or of unknown HIV serostatus (OR=2.78). HIV serostatus was similarly related to frequent drug use. These correlates of heavier substance use among young gay and bisexual men could be used to identify and intervene early with members of this population who are at risk of substance misuse, as well as HIV/AIDS risk.

Suicide Attempts Among Gay and Bisexual Men: Lifetime Prevalence and Antecedents

OBJECTIVES We examined lifetime prevalence of suicide attempts and psychosocial correlates in a large population-based sample of men who have sex with men (MSM). METHODS A telephone probability sample of US urban MSM (n = 2881) were interviewed between November 1996 and February 1998. RESULTS Twenty-one percent had made a suicide plan; 12% had attempted suicide (almost half of those 12% were multiple attempters). Most who attempted suicide made their first attempt before age 25. Although prevalence of parasuicide (i.e., attempted suicide) has remained constant across birth cohorts, mean age at initial attempts has declined. CONCLUSIONS MSM are at elevated risk for suicide attempts, with such risk clustered earlier in life. Some risk factors were specific to being gay or bisexual in a hostile environment.

Cigarette smoking among gay and bisexual men.

OBJECTIVES This study measured the prevalence of cigarette smoking among gay men and identified associations with smoking. METHODS Household-based (n = 696) and bar-based (n = 1897) sampling procedures yielded 2593 gay male participants from Portland, Ore, and Tucson, Ariz, in the spring of 1992. RESULTS Forty-eight percent of the combined sample reported current smoking, a rate far above prevalence estimates for men in Arizona (z = 14.11, P < .001) or Oregon (z = 24.24, P < .001). Significant associations with smoking included heavy drinking, frequent gay bar attendance, greater AIDS-related losses, HIV seropositivity, lower health rating than members of same age cohort, lower educational attainment, and lower income. CONCLUSIONS Rates of cigarette smoking are very high among gay men. Tobacco prevention and cessation campaigns should be designed to reach the gay male community.

Actual versus perceived HIV status, sexual behaviors and predictors of unprotected sex among young gay and bisexual men who identify as HIV-negative, HIV-positive and untested.

Objectives:To compare the prevalence and predictors of HIV sexual risk behavior among young gay and bisexual men who perceived themselves to be HIV-negative, HIV-positive, or who were untested. Design:Population-based sample of young gay and bisexual men. Methods:Using multi-stage probability sampling, 408 gay and bisexual men aged 18–29 years in San Francisco were recruited and interviewed, and blood samples for HIV-testing from 364 participants were obtained. Results:HIV prevalence was 18.7%, although 25% of the men who were HIV-positive did not know it. Thirty-seven per cent reported engaging in unprotected anal intercourse during the past year, including 59% of the men who knew they were HIV-positive, 35% of the men who perceived themselves HIV-negative and 28% of the untested men. Logistic regressions found similar predictors of unprotected intercourse for HIV-negatives and HIV-positives, including sexual impulsivity, substance use, sexual enjoyment and communication problems. Conclusions:The high rates of unprotected intercourse, particularly among the HIV-positive men, attest to the urgent need for HIV-prevention interventions for young gay and bisexual men. The findings suggest that many of the important variables to target in interventions are similar for both HIV-positive and HIV-negative men.

Decisions to get HIV tested and to accept antiretroviral therapies among gay/bisexual men : implications for secondary prevention efforts

The objective of this study was to report prevalence rates of adherence by HIV-seropositive individuals to medical recommendations for the treatment of HIV infection, a behavioral pattern referred to as AIDS secondary prevention. We report cross-sectional data (n = 2,593) from two household-based and two bar-based samples of gay/bisexual men, gathered in 1992 in Tucson, Arizona, and Portland, Oregon. The main outcome variables were prevalence of HIV antibody testing and adherence to recommended secondary prevention behaviors to prevent onset of AIDS symptoms. Approximately one-third of the gay/bisexual men in these samples do not know their current HIV status. Of the gay/bisexual men who do know that they are HIV-seropositive, approximately three-fourths adhere to each of the secondary prevention recommendations, as appropriate to their stage of disease progression. In a multivariate logistic model, three variables distinguished between HIV-seropositive men who did and did not adhere: perceived antiviral treatment norms (OR = 1.4, CI = 1.1-1.7), perceived efficacy of secondary prevention treatments (OR = 1.4, CI = 1.1-1.7), and quality of the relationship with ones health-care provider (OR = 2.5, CI = 1.6-4.0). These findings indicate that efforts to support AIDS secondary prevention behaviors can occur not only through health education to change the perceptions of at-risk communities about the options available to delay the onset of opportunistic infections among HIV-seropositive individuals but also by enhancing effective doctor/patient communication.

Childhood Sexual Abuse and HIV Risk-Taking Behavior Among Gay and Bisexual Men

We explored the prevalence of childhood sexual abuse among adult gay and bisexual men and measured the association between childhood sexual abuse and high-risk sexual behavior in adulthood. Two separate population-based samples of gay and bisexual men (n = 1,941) residing in Portland and Tucson were surveyed. Over one quarter reported a history of childhood sexual abuse (sexual behavior with someone at least 5 years older prior to age 13, or with someone at least 10 years older when between ages 13 and 15). Men who were abused were more likely to engage in sexual risk behavior than men who were not abused (e.g., unprotected anal intercourse with non-primary partners in the previous 12 months: 21.4% vs. 15.0%, p < .001). Perception of having been coerced was associated with greater sexual risk. Furthermore, childhood sexual abuse and level of coercion were associated with reported levels of HIV infection among gay and bisexual men. It is recommended that existing programs for those at risk for HIV be modified to deal with these issues, and that efforts to bring about behavior change will require approaches that go beyond simply increasing knowledge and awareness.