Leo Wilton

Barebacking Among Gay and Bisexual Men in New York City: Explanations for the Emergence of Intentional Unsafe Behavior

This study was undertaken to assess the frequency with which gay and bisexual men in New York City engage in intentional unprotected anal sex, or “barebacking,” and to examine explanations about the emergence of barebacking. A total of 518 men completed a brief intercept survey. Of the 448 men who were familiar with the term “barebacking,” 204 (45.5%) reported bareback sex in the past 3 months prior to assessment. HIV seropositive men were significantly more likely than HIV seronegative men to report this behavior and reported significantly more sexual partners with which they had engaged in intentional unprotected anal intercourse. Participants reported significantly more acts of seroconcordant bareback sex (intentional unprotected anal intercourse with a partner of the same HIV status) than those of serodiscordant bareback sex. Men who reported barebacking also reported significantly more benefits associated with this behavior. The Internet and the availability of sexually oriented chat rooms, HIV treatment advances, emotional fatigue regarding HIV, and the increased popularity of “club” drugs were commonly cited as reasons for the barebacking phenomenon.

Correlates of HIV acquisition in a cohort of black men who have sex with men in the United States: HIV prevention trials network (HPTN) 061

Background Black men who have sex with men (MSM) in the United States (US) are affected by HIV at disproportionate rates compared to MSM of other race/ethnicities. Current HIV incidence estimates in this group are needed to appropriately target prevention efforts. Methods From July 2009 to October 2010, Black MSM reporting unprotected anal intercourse with a man in the past six months were enrolled and followed for one year in six US cities for a feasibility study of a multi-component intervention to reduce HIV infection. HIV incidence based on HIV seroconversion was calculated as number of events/100 person-years. Multivariate proportional hazards modeling with time-dependent covariates was used to identify correlates of HIV acquisition. Results Of 1,553 Black MSM enrolled, 1,164 were HIV-uninfected at baseline and included in follow-up. Overall annual HIV incidence was 3.0% (95% confidence interval (CI): 2.0, 4.4%) and 5.9% among men ≤30 years old (95% CI: 3.6, 9.1%). Men ≤30 years old reported significantly higher levels of sexual risk and were more likely to have a sexually transmitted infection diagnosed during follow-up. Younger men also were more likely to not have a usual place for health care, not have visited a health care provider recently, and to have unmet health care needs. In multivariate analysis, age ≤30 years (hazard ratio (HR): 3.4; 95% CI: 1.4, 8.3) and unprotected receptive anal intercourse with HIV-positive or unknown status partners (HR: 4.1; 95% CI: 1.9, 9.1) were significantly associated with HIV acquisition. Conclusion In the largest cohort of prospectively-followed Black MSM in the US, HIV incidence was high, particularly among young men. Targeted, tailored and culturally appropriate HIV prevention strategies incorporating behavioral, social and biomedical based interventions are urgently needed to lower these rates.

Concomitant Socioeconomic, Behavioral, and Biological Factors Associated with the Disproportionate HIV Infection Burden among Black Men Who Have Sex with Men in 6 U.S. Cities

Background American Black men who have sex with men (MSM) are disproportionately affected by HIV, but the factors associated with this concentrated epidemic are not fully understood. Methods Black MSM were enrolled in 6 US cities to evaluate a multi-component prevention intervention, with the current analysis focusing on the correlates of being newly diagnosed with HIV compared to being HIV-uninfected or previously diagnosed with HIV. Results HPTN 061 enrolled 1553 Black MSM whose median age was 40; 30% self-identified exclusively as gay or homosexual, 29% exclusively as bisexual, and 3% as transgender. About 1/6th (16.2%) were previously diagnosed with HIV (PD); of 1263 participants without a prior HIV diagnosis 7.6% were newly diagnosed (ND). Compared to PD, ND Black MSM were younger (p<0.001); less likely to be living with a primary partner (p<0.001); more likely to be diagnosed with syphilis (p<0.001), rectal gonorrhea (p = 0.011) or chlamydia (p = 0.020). Compared to HIV-uninfected Black MSM, ND were more likely to report unprotected receptive anal intercourse (URAI) with a male partner in the last 6 months (p<0.001); and to be diagnosed with syphilis (p<0.001), rectal gonorrhea (p = 0.004), and urethral (p = 0.025) or rectal chlamydia (p<0.001). They were less likely to report female (p = 0.002) or transgender partners (p = 0.018). Multivariate logistic regression analyses found that ND Black MSM were significantly more likely than HIV-uninfected peers to be unemployed; have STIs, and engage in URAI. Almost half the men in each group were poor, had depressive symptoms, and expressed internalized homophobia. Conclusions ND HIV-infected Black MSM were more likely to be unemployed, have bacterial STIs and engage in URAI than other Black MSM. Culturally-tailored programs that address economic disenfranchisement, increase engagement in care, screen for STIs, in conjunction with safer sex prevention interventions, may help to decrease further transmission in this heavily affected community.

Masculinity, Body Image, and Sexual Behavior in HIV-Seropositive Gay Men: A Two-Phase Formative Behavioral Investigation Using the Internet

The purpose of this study was to understand the synergistic relationships between conceptions of masculinity, body image, and sexual behavior in HIV-positive gay men. The data were drawn from a two-phase formative behavioral mixed methodologies investigation with the use of the Internet. Findings demonstrated that conceptions of masculinity were intimately linked to body image and sexual adventurism, such that men defined their masculinity by their physical appearance and sexual behavior. Further, the data support high levels of risk taking, including steroid use and intentional unprotected anal intercourse (barebacking), which correlated with the participants’ conception of physical masculinity. Clinical implications suggest that it is critical to examine the interaction that occurs between the individual’s gay, masculine, and HIV-positive identities as these appear to be overlapping realities that have an impact on the decisions and behaviors in which these men engage.

An Exploratory Study of Contextual and Situational Factors Related to Methamphetamine Use among Gay and Bisexual Men in New York City

This exploratory investigation describes methamphetamine use among a convenience sample of gay and bisexual men in New York City. A total of 49 participants reported using methamphetamine, on average, 12 days over the past three months, and 63.1% of the participants reported use with the majority of their sexual encounters. Poly-substance use was high in this sample of methamphetamine users. Methamphetamine use was more frequent among those men who reported using the drug in bathhouses and bars, and frequency of use was associated with a need to escape unpleasant emotions and physical discomfort, avoid social conflict, and enjoy pleasant times with others. The data suggest a contextual understanding of methamphetamine use in New York City that is similar to that of gay communities of the western United States.

Barebacking identity among HIV-positive gay and bisexual men: Demographic, psychological, and behavioral correlates

Objectives:To determine the correlates associated with barebacking identity among HIV-positive gay and bisexual men. Design:An analysis of data from the baseline quantitative assessment of a randomized controlled intervention study of 1168 HIV-positive gay and bisexual men from New York City and San Francisco. Methods:Participants were actively and passively recruited from mainstream gay venues, AIDS service organizations, and public and commercial sex environments. Participants completed a computerized quantitative questionnaire assessing their identity as a barebacker, sexual behavior, demographic factors, psychosocial states, perceptions of health risks, and substance use. Results:Men of color were less likely to identify themselves as barebackers. Men who did identify themselves as barebackers were slightly younger. They were more likely to miss a dose of medication; report drug use (non-injection and injection); exhibit higher levels of sexual compulsivity and lower personal responsibility for safer sex; and report higher rates of unprotected insertive anal intercourse, unprotected receptive anal intercourse, and unprotected insertive oral intercourse with all partners, regardless of their HIV serostatus. Conclusion:Barebacking and its corresponding behaviors pose immediate public health risks for HIV-positive gay and bisexual men. Further work is needed to understand this phenomenon more fully in relation to the psychological, sociological, biomedical, and cultural realities.

Understanding structural barriers to accessing HIV testing and prevention services among black men who have sex with men (BMSM) in the United States

Structural-level factors have contributed to the substantial disproportionate rates of HIV among Black men who have sex with men (BMSM) in the United States. Despite insufficient HIV testing patterns, however, there is a void in research investigating the relationship between structural factors and access to HIV testing and prevention services among BMSM. Building on previous scholarly work and incorporating a dynamic social systems conceptual framework, we conducted a comprehensive review of the literature on structural barriers to HIV testing and prevention services among BMSM across four domains: healthcare, stigma and discrimination, incarceration, and poverty. We found that BMSM experience inadequate access to culturally competent services, stigma and discrimination that impede access to services, a deficiency of services in correctional institutions, and limited services in areas where BMSM live. Structural interventions that eliminate barriers to HIV testing and prevention services and provide BMSM with core skills to navigate complex systems are needed.

The physical, emotional and interpersonal impact of HAART : Exploring the realities of HIV seropositive individuals on combination therapy

The purpose of this qualitative study was to understand the impact of HAART on the lives of HIV seropositive men and women. The data demonstrate that the demands of these treatments are substantial, but that renewed health and hope for the future due to the implementation of HAART often overshadows the stress of the treatments on the physical, emotional and social well-being of the individuals. Practitioners should be keenly aware of the struggles faced by those on HAART, and provide multidimensional support to assure maximum effectiveness of these treatments in light of the realities of their clients’ lives.

Infrequent HIV testing and late HIV diagnosis are common among a cohort of black men who have sex with men in 6 US cities.

Objective:US guidelines recommend at least annual HIV testing for those at risk. This analysis assessed frequency and correlates of infrequent HIV testing and late diagnosis among black men who have sex with men (BMSM). Methods:HIV testing history was collected at enrollment from participants in HPTN 061, an HIV prevention trial for at-risk US BMSM. Two definitions of late HIV diagnosis were assessed: CD4 cell count <200 cells per cubic millimeter or <350 cells per cubic millimeter at diagnosis. Results:HPTN 061 enrolled 1553 BMSM. HIV testing questions were completed at enrollment by 1284 (98.7%) of 1301 participants with no previous HIV diagnosis; 272 (21.2%) reported no HIV test in previous 12 months (infrequent testing); 155 of whom (12.1% of the 1284 with testing data) reported never testing. Infrequent HIV testing was associated with: not seeing a medical provider in the previous 6 months (relative risk [RR]: 1.08, 95% confidence interval [CI]: 1.03 to 1.13), being unemployed (RR: 1.04, CI: 1.01 to 1.07), and having high internalized HIV stigma (RR: 1.03, CI: 1.0 to 1.05). New HIV diagnoses were more likely among infrequent testers compared with men tested in the previous year (18.4% vs. 4.4%; odds ratio: 4.8, 95% CI: 3.2 to 7.4). Among men with newly diagnosed HIV, 33 (39.3%) had a CD4 cell count <350 cells per cubic millimeter including 17 (20.2%) with CD4 <200 cells per cubic millimeter. Conclusions:Infrequent HIV testing, undiagnosed infection, and late diagnosis were common among BMSM in this study. New HIV diagnoses were more common among infrequent testers, underscoring the need for additional HIV testing and prevention efforts among US BMSM.

English language proficiency and lifetime mental health service utilization in a national representative sample of Asian Americans in the USA

BACKGROUND US Department of Health and Human Services reported that the lack of English language proficiency and the shortage of providers who possessed appropriate language skills were identified as major barriers to mental health service use for approximately half of the population of Asians and Pacific Islanders. The aim of this study was to examine the predictors of lifetime mental health service use in relation to English language proficiency among Asian Americans. METHODS Data from 2095 Asian participants from the National Latino and Asian American Study were analyzed using logistic regression. RESULTS Respondents with better English language proficiency and with a mental health diagnosis were more inclined to use mental health services. Participants who were born in the USA, who were widowed, separated or divorced, who sought comfort from religion, who reported worse physical and mental health self-ratings were more likely to use mental health services. The lack of health insurance coverage was not a significant predictor. CONCLUSIONS The public health implications for behavioral health include the need to educate health-care providers working with Asian Americans regarding the benefits derived from seeking services and making interpreter services available in a culturally sensitive environment.