Linda A. Valleroy

Unrecognized HIV infection, risk behaviors, and perceptions of risk among young men who have sex with men: opportunities for advancing HIV prevention in the third decade of HIV/AIDS.

This study evaluated the magnitude and distribution of unrecognized HIV infection among young men who have sex with men (MSM) and of those with unrecognized infection, the prevalence and correlates of unprotected anal intercourse (UAI), perceived low risk for infection, and delayed HIV testing. MSM aged 15-29 years were approached, interviewed, counseled, and tested for HIV at 263 randomly sampled venues in 6 US cities from 1994-2000. Of 5649 MSM participants, 573 (10%) tested positive for HIV. Of these, 91% of black, 69% of Hispanic, and 60% of white MSM (77% overall) were unaware of their infection. The 439 MSM with unrecognized infection reported a total of 2253 male sex partners in the previous 6 months; 51% had UAI; 59% perceived that they were at low risk for being infected; and 55% had not tested in the previous year. The HIV epidemic among MSM in the United States continues unabated, in part, because many young HIV-infected MSM are unaware of their infection and unknowingly expose their partners to HIV. To advance HIV prevention in the third decade of HIV/AIDS, prevention programs must reduce unrecognized infection among young MSM by increasing the demand for and availability of HIV testing services.

Regional Patterns and Correlates of Substance Use Among Young Men Who Have Sex With Men in 7 US Urban Areas

OBJECTIVES We sought to characterize substance use patterns in young men who have sex with men (MSM) in 7 US urban areas and sociodemographic characteristics and history associated with such use. METHODS We examined data collected from 1994 through 1998 in a venue-based, cross-sectional survey. RESULTS Among the 3492 participants, 66% reported use of illicit drugs; 28%, use of 3 or more drugs; 29%, frequent drug use (once a week or more); and 4%, injection drug use. These practices were more common among participants who were White, self-identified as bisexual or heterosexual, had run away, or had experienced forced sex. CONCLUSIONS Effective drug prevention and treatment programs addressing local drug-use patterns and associated factors are urgently needed for young MSM, a population with a high rate of illicit drug use.

Associations between substance use and sexual risk among very young men who have sex with men.

Objective: To determine if an association exists in young men who have sex with men (MSM) between being under the influence of alcohol or drugs during sex and participation in sexual behaviors which increase the risk of human immunodeficiency virus (HIV). Study Design: A total of 3492 young MSM were interviewed through the Young Men’s Survey, an anonymous, cross-sectional, multisite, venue-based survey conducted from 1994 through 1998 at 194 public venues frequented by MSM aged 15 to 22 years in 7 US cities. Results: The majority of young MSM reported both receptive and insertive anal intercourse, and of these, approximately half reported not using condoms. Report of unprotected receptive anal intercourse at least once in the prior 6 months was associated with being under the influence of alcohol (adjusted odds ratio [AOR] = 1.5; 95% confidence interval [CI] = 1.2–1.8), cocaine (AOR = 1.6; 95% CI = 1.1–2.2), amphetamines (AOR = 1.5; 95% CI = 1.1–2.0) or marijuana during sex (AOR = 1.3; 95% CI = 1.1–1.6). Report of unprotected insertive anal intercourse at least once in the prior 6 months was associated with being under the influence of alcohol (AOR = 1.2; 95% CI = 1.0–1.5), cocaine (AOR = 1.5; 95% CI = 1.1–2.0) or amphetamines (AOR = 1.9; 95% CI = 1.4–2.6). Conclusions: HIV prevention strategies for young MSM need to incorporate substance use risk reduction.

Very young gay and bisexual men are at risk for HIV infection: the San Francisco Bay Area Young Men's Survey II.

Objectives: To compare HIV seroprevalence and sexual risk behavior among very young gay and bisexual men (aged 15‐17 years) and their older counterparts (aged 18‐22 years). To examine drug‐use patterns and correlates of sexual risk behavior in both of these age groups. Design and Methods: An interviewer‐administered cross‐sectional survey of 719 gay and bisexual males between 15 and 22 years old was conducted through a venuebased sampling design. Blood specimens were collected and tested for HIV antibodies, hepatitis B, and syphilis. Interviews assessed sexual and drug‐use behavior as well as psychosocial variables believed to be related to sexual risk‐taking, including self‐acceptance of gay or bisexual identity, perceptions of peer norms concerning safer sex, and perceptions of the ability to practice safer sex (safer sex self‐efficacy). Results: Of the 719 participants, 100 (16.2%) were aged between 15 and 17 years. HIV seroprevalence was somewhat lower among those aged 15 to 17 years (2.0%) compared with those aged 18 to 22 years (6.8%). Overall, the prevalence of hepatitis‐B core antibody was significantly lower in the younger age group (5.0%) than in the older group (14.1%). The men aged 15 to 17 years used alcohol, ecstasy, and heroin less frequently than those aged 18 to 22 years. The age groups did not differ in the proportion of men who reported any unprotected anal intercourse in the previous 6 months (31.2%). In both age groups, use of amphetamines, ecstasy, and amyl nitrate was associated with unprotected anal intercourse. Self‐acceptance of gay or bisexual identity was related to less sexual risk for those aged 15 to 17 years. In both age groups, greater safer sex self‐efficacy was linked to less HIV sexual risk‐taking. In the younger group, perceptions of peer norms that support safer sex were related to less risk behavior. Conclusions: Very young gay and bisexual men engage in unprotected anal sex at rates comparable with those for their somewhat older counterparts, raising serious concern over their risk of acquiring HIV infection. To prevent seroconversions, interventions must target those <18 years of age, and prevention programs should address the use of certain drugs in relation to sex and sexual risk‐taking. To be most effective, programs should develop innovative communication strategies to take into account lack of self‐acceptance of gay or bisexual identity and low self‐efficacy for practicing safer sex.

High prevalence of HIV infection among young men who have sex with men in New York City.

ObjectiveTo determine the prevalence of HIV infection and risk behaviors among young men who have sex with men (MSM) aged 15–22 years in New York City. DesignAn anonymous cross-sectional survey. MethodsThe 1998 Young Mens Survey in New York City (YMS–NYC), was a multistage probability survey of 541 MSM aged 15–22 years who attend public venues. After identification of venues and their associated high attendance time periods, random samples of venues and time periods were selected on a monthly basis. At each sampling event, potential participants were approached to determine eligibility. Eligible and willing men were interviewed, counselled and had a blood specimen drawn. ResultsBetween December 1997 and September 1998, 115 sampling events were conducted. Of 612 men enrolled, 541 reported ever having had sex with a male partner. The HIV seroprevalence among the 541 MSM sampled was 12.1%. The HIV seroprevalence was 18.4% among African-Americans, 16.7% among persons of mixed race, 8.8% among Latino individuals and 3.1% among white men. HIV seroprevalence was 5.0% among 15–18 year olds and 16.4% among 19–22 year olds. A total of 65.5% of MSM were susceptible to hepatitis B virus infection (HBV). Almost half (46.1%) of the men reported unprotected anal sex in the previous 6 months and 16.3% reported ever having had an STD. Multiple regression analyses found that being older, of mixed race, black or ever having had an STD was associated with being HIV antibody positive. ConclusionThese data identify a large subgroup of MSM in need of effective HIV and HBV primary and secondary prevention programs.

Repeat HIV testing, risk behaviors, and HIV seroconversion among young men who have sex with men: a call to monitor and improve the practice of prevention.

&NA; Objectives: We compared recent risk behaviors and HIV seroconversion among young men who have sex with men (MSM) who were first‐time, infrequent, and repeat HIV testers. Methods: Male adolescents and young men aged 15 to 22 years were randomly sampled, interviewed, counseled, and tested for HIV at 194 gay‐identified venues in seven U.S. cities from 1994 through 1998. Analyses were restricted to MSM who reported having never tested or last tested HIV‐negative. Results: Of 3430 participants, 36% tested for the first time, 39% had tested infrequently (one or two times), and 26% had tested repeatedly (≥ three times). Compared with first‐time testers, repeat testers were more likely to report recent risk behaviors and to acquire HIV (7% versus 4%). Over 75% of repeat testers who seroconverted acquired HIV within 1 year of their last test. Compared with repeat testers, first‐time testers reported similar use of health care but delayed testing for nearly 2 additional years after initiating risk. Conclusions: Many young MSM soon acquire HIV after repeated use of HIV counseling and testing services. Providers must strengthen practices to identify, counsel, and test young MSM and provide enhanced behavioral interventions for those with persistent risks.

HIV infection in disadvantaged out-of-school youth: prevalence for U.S. Job Corps entrants, 1990 through 1996.

To describe HIV infection prevalence and prevalence trends for disadvantaged out-of-school youth in the United States, we analyzed the HIV prevalence for and demographic characteristics of youth, aged 16 through 21 years, who entered the U.S. Job Corps from January 1990 through December 1996. Job Corps is a federally funded jobs training program for socially and economically disadvantaged out-of-school youth. All 357,443 entrants residing at Job Corps centers during their training were tested for HIV infection; 822 (2.3 per 1000) were HIV-positive. HIV prevalence was higher for women than for men (2.8 per 1000 versus 2.0 per 1000; relative risk [RR]=1.4; 95% confidence interval [CI]=1.2-1.6). Among racial/ethnic groups, prevalence was highest for African Americans (3.8 per 1000). Prevalence was higher for African American women (4.9 per 1000) than for any other gender and racial/ethnic group. From 1990 through 1996, standardized HIV prevalence-stratified by age, race/ethnicity, home region, population of home metropolitan statistical area, and year of entry--declined for women and for men: for women, from 4.1 per 1000 in 1990 to 2.1 per 1000 in 1996 (p=.001); and for men, from 2.8 per 1000 in 1990 to 1.4 per 1000 in 1996 (p=.001). These data suggest that HIV prevalence for disadvantaged out-of-school youth declined from 1990 through 1996. However, considering their youth, prevalence was still high, particularly for women and African Americans, most notably African American women. These data support the need for ongoing HIV prevention programs targeting such youth.

Recent HIV testing among young men who have sex with men: correlates, contexts, and HIV seroconversion.

Objectives: We evaluated the correlates and contexts of HIV testing within the past year, subsequent risk reduction, and HIV seroconversion among young men who have sex with men (MSM). Methods: Young men aged 23 to 29 years were approached, interviewed, counseled, and tested for HIV at 181 randomly sampled MSM-identified venues in six U.S. cities from 1998 through 2000. Analyses were restricted to 2,797 MSM who reported never testing HIV-positive. Results: Of the 2,797 MSM, 1,281 (46%) either never previously tested or had not tested in the past year (never/remote testers); 1,516 (54%) had tested in the past year (recent testers); and 271 (10%) tested HIV-positive as part of the study. Of 1,885 recent sex partners reported by HIV-infected participants, 68% were partners of never/remote testers. Of recent testers, 50% tested anonymously, 51% tested because of specific risks, 59% were counseled, 47% reported reducing their risks after testing, and 8% tested HIV-positive (percent HIV-infected by race: blacks, 24%; Hispanics, 6%; whites, 4%; Asians, 1%). Conclusion: Nearly half of young MSM participants had not tested in the past year and HIV-infected never/remote testers accounted for approximately two thirds of recent partners potentially exposed to HIV. Of those who had tested recently, many MSM, especially those who are black, had already acquired HIV. To reduce HIV transmission and facilitate early diagnosis and entry into care, increased HIV testing among young at-risk MSM in the United States, especially those who are black, is needed.

Perceptions of Lifetime Risk and Actual Risk for Acquiring HIV Among Young Men Who Have Sex with Men

Among young men who have sex with men (MSM) surveyed in six US cities, we evaluated the magnitude and correlates of perceived lifetime risk for acquiring HIV, and missed opportunities to increase risk perception by providers of health-care and HIV-testing services. Overall, approximately one quarter of young MSM perceived themselves at moderate/high risk for acquiring HIV. Adjusting for demographic, prior testing, and behavioral characteristics, moderate/high perceived risk had the strongest association with unrecognized HIV infection. However, half of the 267 young MSM with unrecognized infection perceived themselves at low lifetime risk for acquiring HIV, and many young MSM with low-risk perception reported considerable risk behaviors. Providers of health-care and HIV-testing services missed opportunities to assess risks and recommend testing for young MSM. To increase HIV testing, prevention providers should intensify efforts to assess, and to increase when needed, perceptions of lifetime risks for acquiring HIV among young MSM.

HIV incidence in the United States, 1978-1999

Context: HIV incidence measurements, which reflect recent or current transmission, are valuable for monitoring the epidemic and evaluating prevention programs. Objectives: To summarize HIV incidence patterns and trends in U.S. population groups. Data Sources: Publications in English from 1980 through mid‐2000. Study Selection and Statistical Methods: We searched the literature for reports of HIV incidence in the United States. Locally weighted scatterplot smoothing was used to generate smooth curves to estimate trends in incidence. Spearman rank correlation was used to estimate the correlation coefficient between prevalence and incidence. Data Synthesis: In 74 eligible reports, HIV incidence varied widely (0.002‐19.8 per 100 person‐years [py]) depending on risk group. Among men who have sex with men (MSM), HIV incidence peaked in the early 1980s (5‐20/100 py) and then declined but remained high during the 1990s (2‐4/100 py). Among injection drug users (IDUs), incidence decreased since the mid‐1980s but differed by geographic area; in the 1990s, incidence remained high in the East (1‐3/100 py) but was lower in the West (<0.5/100 py). Throughout the late 1980s and 1990s, incidence was low and stable in broader populations (blood donors: <0.01/100 py; military personnel: 0.01‐0.07/100 py). The correlation between HIV incidence and prevalence was strong in populations with a prevalence less than 1% (r = 0.94, p < .0001), moderate in populations with a prevalence from 1% to less than 10% (r = 0.57, p < .0001), and weak in populations with a prevalence at least 10% (r = 0.23, p = .09). Conclusions: HIV prevention in the United States should continue to focus on MSM and IDUs. HIV incidence measurements should be considered for monitoring HIV transmission in MSM, IDUs, and other populations in which seroprevalence is high.