Mary Lou Miller

Increasing incidence of HIV infections among young gay and biseuxal men in Vancouver

Since the beginning of the HIV epidemic in north America, the majority of HIV infections have occurred among men who engage in sexual relations with other men. As the HIV epidemic enters its third decade, gay and bisexual men continue to have among the highest rates of HIV infection. Previous studies have highlighted the decline in the incidence of HIV and risk behaviour among gay and bisexual men. However, several studies have suggested that young gay and bisexual men continue to engage in unprotected sexual behaviours and are at continued risk of HIV infection. Recent reports in the media and research literature have indicated an increase in the incidence of HIV among gay and bisexual individuals in many of the worlds major cities. The purpose of this study was to determine trends in HIV incidence using data from a prospective cohort of young gay and bisexual men.

An Interactive CD-ROM for Nutrition Screening and Counseling

OBJECTIVES The goal of this project was to develop an interactive CD-ROM for nutrition screening and counseling, designed to produce dietary behavior change in fat and fruit and vegetable intake. METHODS The design was based on principles of relevance to the learner, readiness for change, feedback, individualization, facilitation of skills, and goal setting. It was tested in community settings such as libraries, senior centers, and Women, Infants, and Children clinics. RESULTS Nearly 80% of the respondents (n = 284), including numerous low-income persons, reported learning something new about nutrition and health or their own dietary habits. More than 50% of those recontacted 2 to 4 weeks later had put some of their dietary goals into practice. CONCLUSIONS This program is useful for dietary screening, feedback, skill building, and motivation in settings in which in-person counseling by nutrition professionals is not feasible.

Risk factors associated with HIV infection among young gay and bisexual men in Canada

Objective: To assess risk factors associated with HIV prevalence and incidence among gay and bisexual men in two prospective Canadian cohorts. Methods: The Vanguard Project and the Omega Cohort are prospective cohort studies of gay and bisexual men ongoing in Vancouver and Montreal, respectively. For this analysis, baseline sociodemographic characteristics, sexual behavior, and substance use data from these two cohorts were combined. Assessment of risk factors for HIV seroprevalence and seroconversion were carried out using univariate and multivariate analysis. Results: This analysis was based on 1373 gay and bisexual men aged 16 to 30 years. Men who were HIV‐seropositive at baseline (n = 48) were more likely to report living in unstable housing, to have had less than a high school education, and to have been unemployed than those who were HIV‐negative (n = 1325). HIV‐positive men were also more likely to report having engaged in sexual risk behavior, including having had consensual sex at a younger age, having had at least 6 partners during the previous year, ever having been involved in the sex trade, and having engaged in unprotected receptive anal intercourse. With respect to substance use, HIV‐positive men were more likely to report the use of crack, cocaine, heroin, and marijuana and to use injection drugs. Similarly, men who seroconverted during the course of the studies (n = 26) were more likely to report having less than a high school education and having lived in unstable housing at baseline. Compared with HIV‐negative men, men who seroconverted were more likely to report ever having been involved in the sex trade and engaging in unprotected receptive anal intercourse. Reports of cocaine use and injection drug use were also significantly higher for men who seroconverted compared with HIV‐negative men. Conclusions: Our data indicate that HIV‐positive gay and bisexual men are more likely to be living in unstable conditions and to report more risky sexual and substance use behaviors than HIV‐negative men.

Sexual violence among two populations of men at high risk of HIV infection

Abstract This study sought to compare the prevalence of, and relationship between, age at first experience of sexual violence and HIV and other health risk behaviors in two populations of men at high risk of HIV infection. Data were drawn from two cohorts: Vanguard, a prospective study of young men who have sex with men (MSM), and VIDUS, the Vancouver Injection Drug Users Study. Controlling for fixed sociodemographics, multivariate logistic regression was used to assess the relationship between age at first sexual violence (vs. never experiencing it) and several health risk behaviors. There were 140/498 (28%) MSM from Vanguard and 173/932 (19%) injection drug users (IDU) from VIDUS who reported having experienced sexual violence. Among VIDUS men, 130/852 (15%) IDU-only and 43/80 (54%) who were both IDU and MSM reported a history of sexual violence. The prevalence of child sexual abuse was 13% in Vanguard MSM, and 11% among VIDUS IDU-only, but 26% among VIDUS MSM/IDU. The median age of onset was significantly lower among VIDUS IDU-only compared to the two other groups. Experiencing sexual violence first in childhood was strongly related to ever being in the sex trade in both IDU and MSM. MSM in Vanguard who experienced sexual violence in childhood were more likely to have attempted suicide, and have a diagnosed mood disorder. Non-MSM IDU in VIDUS who experienced sexual violence in childhood were more likely to have a diagnosed mental illness, to binge on alcohol, and to have ever accidentally overdosed. In conclusion, men who have ever had sex with men appear to have a higher lifetime prevalence of sexual violence, compared to non-MSM injection drug users. Sexual violence is differentially associated with different health risk behaviors, depending on the age at first occurrence and the primary HIV risk factor (i.e. MSM vs. IDU).

Sexual Risk Profile of Young Men in Vancouver, British Columbia, Who Have Sex with Men and Inject Drugs

We compared sexual risk behaviors of men who have sex with men and inject drugs (MSM/IDU) with those of other men who have sex with men (MSM). Of 910 MSM surveyed, 106 (12%) injected drugs in the previous year. MSM/IDU were younger than MSM and more likely to be HIV-seropositive, Aboriginal, economically disadvantaged, engaged in the trade of sex for money or drugs, and to report having female sexual partners. MSM/IDU reported more casual sexual partners and in multivariate analyses were twice as likely to report unprotected receptive anal intercourse with casual partners. These results, combined with those from previous analyses, suggest that the higher risk for HIV seroconversion among MSM/IDU in this cohort is attributable mainly to sexual rather than injection-related exposures. Controlled assessments are needed to identify optimal sexual risk reduction strategies for MSM/IDU.

Randomized clinical evaluation of self-screening for anal cancer precursors in men who have sex with men

Background Self-collection of anorectal swab specimens could greatly facilitate the completion of prerequisite studies and future implementation of anal cancer screening among men who have sex with men (MSM). We therefore compared self- versus clinician- collection procedures with respect to specimen adequacy for cytological evaluation, concordance of paired cytological results, and concordance of cytological with biopsy results. Methods Paired self- and clinician- collected anorectal Dacron® swabs for liquid-based (Thin Prep®) cytological evaluation were collected in random sequence from a mostly HIV-1 seronegative cohort of young MSM in Vancouver. Slides were reviewed by one cytopathologist. Presence of any cytological abnormality (atypical squamous cells of uncertain significance, ASCUS, or above) prompted referral for high-resolution anoscopy and possible biopsy. Results Among 222 patient-clinician specimen pairs, most were adequate for cytological evaluation, though self-collected specimens were less likely to be so (83% versus 92%, McNemars test p < 0.001). Cytological abnormalities, noted in 47 (21%) of self-collected and 47 (21%) of clinician-collected specimens (with fair agreement, kappa = 0.414) included, respectively: ASCUS (5%, 5%), and low-grade (13%, 13%) and high-grade (3%, 3%) squamous intraepithelial lesions. Among 12 men with biopsy-confirmed high-grade neoplasia, most had abnormal cytological results (including 6 patient and 9 clinician swabs) but few (2 patient and 1 clinician swab) were high-grade. Conclusion Self-collection of anorectal swab specimens for cytologic screening in research and possibly clinical settings appears feasible, particularly if specimen adequacy can be further improved. The severity of biopsy-confirmed anorectal disease is seriously underestimated by cytological screening, regardless of collector.

Comparison of sexual behaviors, unprotected sex, and substance use between two independent cohorts of gay and bisexual men.

ObjectiveTo compare demographic characteristics, sexual practices, unprotected receptive and insertive anal intercourse, substance use and rates of HIV-1 seroconversion between two prospective cohorts of HIV-negative men who have sex with men. DesignComparative analysis of two independent cohorts. MethodsBetween May 1995 and April 1996, 235 HIV-negative Vanguard Project (VP) participants were enrolled and between January and December 1985, 263 HIV-negative participants in the Vancouver Lymphadenopathy AIDS Study (VLAS) completed a follow-up visit. The VP participants were compared with VLAS participants with respect to self-reported demographic variables, sexual behaviors, unprotected sex, substance use and rates of HIV-1 seroconversion during follow-up. ResultsIn comparison with the VLAS participants the VP participants were younger (median age, 26 versus 34 years; P  < 0.001), more likely to be non-Caucasian (75 versus 97%; P  < 0.001), and were less likely to have attended university/college (35 versus 46%; P  = 0.014). The VP participants reported a higher mean number of male sex partners in the previous year (15 versus 12; P  = 0.026) and a higher mean number of regular partners (1.7 versus 0.6; P  < 0.001). The VP participants were more likely to report engaging in receptive (92 versus 60%; P  < 0.001) and insertive (90 versus 69%; P  < 0.001) anal intercourse with regular partners and receptive anal intercourse with casual partners (62 versus 38%; P  < 0.001). The VLAS participants were more likely to report never using condoms during insertive and receptive anal intercourse with both regular and casual partners. The VP participants were less likely to report using nitrite inhalants (34 versus 43%; P  = 0.033), but more likely to report the use of cocaine (30 versus 8%; P  < 0.001), LSD (21 versus 3%; P  < 0.001), amphetamine (11 versus 1%; P  < 0.001), heroin (3 versus 0%; P  = 0.010) and methyldiamphetamine (17 versus 10%; P  = 0.034). The VLAS participants were nine times more likely to report high-risk sexual behavior, after controlling for differences in age, ethnicity, substance use, and method of recruitment between cohort members. After adjustment for differences in demographics, sexual behaviors, and level of substance use, the risk ratio for seroconversion among VLAS participants remained significantly elevated compared with VP participants. ConclusionThese data provide evidence that men who have sex with men who were enrolled in the VP were more sexually active than their VLAS counterparts were 10 years ago as measured by self-reported numbers of regular and casual partners and frequency of anal intercourse with these partners. However, condom use appears to be significantly higher among VP participants, which has contributed to a lower rate of HIV-1 infection.

‘It's like the treasure’: beliefs associated with semen among young HIV‐positive and HIV‐negative gay men

This paper examines cultural and social meanings associated with semen, along with related issues of unprotected receptive anal intercourse, HIV seroconversion, treatment optimism and viraemia. The findings are derived from qualitative interviews conducted with 12 HIV‐positive young gay men and 12 HIV‐negative counterparts who participated in a prospective cohort study in Vancouver, Canada. Focussing on the narratives of young gay men, the analysis reveals a diverse range of knowledge, values and functions of semen, especially in relation to its exchange. Beliefs about semen appeared to differ by HIV serostatus and were linked with intimacy, identity and pleasure, particularly among the HIV‐positive men. Against dominant representations of semen in relation to issues of loss, anxiety and infertility, this unique study sheds much needed light on its role within the cultural construction of sexuality among gay men. As such, these narratives are of direct importance to primary and secondary HIV prevention, including condom promotion and the development of rectal microbicides.

Incidence of and Risk Factors for Sexual Orientation-Related Physical Assault Among Young Men Who Have Sex With Men

OBJECTIVES We sought to determine incidence of, prevalence of, and risk factors for sexual orientation-related physical assault in young men who have sex with men (MSM). METHODS We completed a prospective open cohort study of young MSM in Vancouver, British Columbia, surveyed annually between 1995 and 2004. Correlates of sexual orientation-related physical assault before enrollment were identified with logistic regression. Risk factors for incident assaults were determined with Cox regression. RESULTS At enrollment, 84 (16%) of 521 MSM reported ever experiencing assault related to actual or perceived sexual orientation. Incidence was 2.3 per 100 person-years; cumulative incidence at 6-year follow-up was 10.8 per 100 person-years. Increased risk of incident sexual orientation-related physical assault was observed among MSM 23 years or younger (relative hazard=3.1; 95% confidence interval [CI] = 1.6, 5.8), Canadian Aboriginal people (relative hazard = 3.0; 95% CI=1.4, 6.2), and those who previously experienced such assault (relative hazard=2.5; 95% CI=1.3, 4.8). CONCLUSIONS These data underscore the need for increased public awareness, surveillance, and support to reduce assault against young MSM. Such efforts should be coordinated at the community level to ensure that social norms dictate that such acts are unacceptable.

Illustrated instructions for self-collection of anorectal swab specimens and their adequacy for cytological examination.

Background: Self-collection of anorectal swab specimens would facilitate screening for anal cancer precursors and sexually transmitted rectal infections among men who have sex with men (MSM). However, pictorial guides for self-collection were not previously available. Goals: Develop and field test a set of illustrated self-collection instructions. Design: Cross-sectional study of community-recruited MSM who were naïve with regard to collection of specimens for anal cytology. Results: Among 222 self- and clinician-collected swab pairs provided by mostly human immunodeficiency virus (HIV)-1 seronegative MSM (median age, 31.5 years), most specimens were adequate for cytologic evaluation, though self-collected swabs were less likely to be so (83% versus 92%, P = <0.001). The illustrated instructions were reportedly essential, but having used them, men rated their understanding of the self-collection procedure as very high. Conclusions: Provided with illustrated instructions, most MSM who are naïve to the technique can self-collect anorectal swab specimens that are suitable for screening.