Patrick A. Wilson

Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: a meta-analysis

BACKGROUND We did a meta-analysis to assess factors associated with disparities in HIV infection in black men who have sex with men (MSM) in Canada, the UK, and the USA. METHODS We searched Embase, Medline, Google Scholar, and online conference proceedings from Jan 1, 1981, to Dec 31, 2011, for racial comparative studies with quantitative outcomes associated with HIV risk or HIV infection. Key words and Medical Subject Headings (US National Library of Medicine) relevant to race were cross-referenced with citations pertinent to homosexuality in Canada, the UK, and the USA. Data were aggregated across studies for every outcome of interest to estimate overall effect sizes, which were converted into summary ORs for 106,148 black MSM relative to 581,577 other MSM. FINDINGS We analysed seven studies from Canada, 13 from the UK, and 174 from the USA. In every country, black MSM were as likely to engage similarly in serodiscordant unprotected sex as other MSM. Black MSM in Canada and the USA were less likely than other MSM to have a history of substance use (odds ratio, OR, 0·53, 95% CI 0·38-0·75, for Canada and 0·67, 0·50-0·92, for the USA). Black MSM in the UK (1·86, 1·58-2·18) and the USA (3·00, 2·06-4·40) were more likely to be HIV positive than were other MSM, but HIV-positive black MSM in each country were less likely (22% in the UK and 60% in the USA) to initiate combination antiretroviral therapy (cART) than other HIV-positive MSM. US HIV-positive black MSM were also less likely to have health insurance, have a high CD4 count, adhere to cART, or be virally suppressed than were other US HIV-positive MSM. Notably, despite a two-fold greater odds of having any structural barrier that increases HIV risk (eg, unemployment, low income, previous incarceration, or less education) compared with other US MSM, US black MSM were more likely to report any preventive behaviour against HIV infection (1·39, 1·23-1·57). For outcomes associated with HIV infection, disparities were greatest for US black MSM versus other MSM for structural barriers, sex partner demographics (eg, age, race), and HIV care outcomes, whereas disparities were least for sexual risk outcomes. INTERPRETATION Similar racial disparities in HIV and sexually transmitted infections and cART initiation are seen in MSM in the UK and the USA. Elimination of disparities in HIV infection in black MSM cannot be accomplished without addressing structural barriers or differences in HIV clinical care access and outcomes. FUNDING None.

Effects of a coping intervention on transmission risk behavior among people living with HIV/AIDS and a history of childhood sexual abuse

Objectives:To examine the effect of a 15-session coping group intervention compared with a 15-session therapeutic support group intervention among HIV-positive men and women with a history of childhood sexual abuse (CSA) on sexual transmission risk behavior. Design:A randomized controlled behavioral intervention trial with 12-month follow-up. Methods:A diverse sample of 247 HIV-positive men and women with histories of CSA was randomized to 1 of 2 time-matched group intervention conditions. Sexual behavior was assessed at baseline; immediately after the intervention; and at 4-, 8-, and 12-month follow-up periods (5 assessments). Changes in frequency of unprotected anal and vaginal intercourse by intervention condition were examined using generalized linear mixed models for all partners, and specifically for HIV-negative or serostatus unknown partners. Results:Participants in the HIV and trauma coping intervention condition decreased their frequency of unprotected sexual intercourse more than participants in the support intervention condition for all partners (P < 0.001; d = 0.38, 0.32, and 0.38 at the 4-, 8-, and 12-month follow-up periods, respectively) and for HIV-negative and serostatus unknown partners (P < 0.001; d = 0.48, 0.39, and 0.04 at the 4-, 8-, and 12-month follow-up periods, respectively). Conclusion:A group intervention to address coping with HIV and CSA can be effective in reducing transmission risk behavior among HIV-positive men and women with histories of sexual trauma.

Race-Based Sexual Stereotyping and Sexual Partnering Among Men Who Use the Internet to Identify Other Men for Bareback Sex

This qualitative study used sexual scripting theory to explore sexual stereotyping and sexual partnering practices among a racially diverse sample of men who use the Internet to engage in “bareback” sex with other men. The sample included 81 (73%) HIV-negative and 30 (27%) HIV-positive men who were recruited on Web sites where men seek other men to have bareback sex. Participants completed a semi-structured interview that included topics on their racial identification, their sexual experiences tied to race, and their experiences having sex with men of different racial groups. The findings suggested that a variety of race-based sexual stereotypes were used by participants. Sexual stereotyping appeared to directly and indirectly affect the sexual partnering decisions of participants. Sexual scripts may reinforce and facilitate race-based sexual stereotyping, and this behavior may structure sexual networks.

Common roots: a contextual review of HIV epidemics in black men who have sex with men across the African diaspora

Pooled estimates from across the African diaspora show that black men who have sex with men (MSM) are 15 times more likely to be HIV positive compared with general populations and 8·5 times more likely compared with black populations. Disparities in the prevalence of HIV infection are greater in African and Caribbean countries that criminalise homosexual activity than in those that do not criminalise such behaviour. With the exception of US and African epidemiological studies, most studies of black MSM mainly focus on outcomes associated with HIV behavioural risk rather than on prevalence, incidence, or undiagnosed infection. Nevertheless, black MSM across the African diaspora share common experiences such as discrimination, cultural norms valuing masculinity, concerns about confidentiality during HIV testing or treatment, low access to HIV drugs, threats of violence or incarceration, and few targeted HIV prevention resources.

Situational predictors of sexual risk episodes among men with HIV who have sex with men

Background: Men with HIV who have sex with men (MSM) represent the largest group of people living with HIV/AIDS in the United States. It is important to understand the sexual risk-taking behaviours that may be linked to the transmission of HIV and other sexually transmitted infections in this population. Models of HIV risk that focus solely on personal factors have been demonstrated to be ineffective at explaining risk behaviour. Rather, in order to fully understand sexual risk-taking, it is important to examine the factors linked to high-risk sexual situations and not solely the factors linked to potentially high-risk people. Methods: A diverse sample of 100 MSM with HIV completed a 6-week internet-based sex diary that collected detailed information on recent sexual encounters. In total, information on over 250 sexual episodes was collected and analysed. Generalised linear mixed models were used to examine situational predictors of risk episodes. Results: Analyses revealed that drug use by self and sex partners (examined individually and together) were positively related to risk episodes. Likewise, having a sex partner met online and having a sexual encounter in a sex party or bathhouse setting was linked to risk episodes. Sexual episodes that involved a sex-partner who was perceived as sexually desirable and those involving communication about HIV and/or condom use with partners each were negatively related to risk. Conclusions: Situational factors play an important role in explaining sexual risk-taking among MSM with HIV. Researchers should place a greater focus on drug use and characteristics of sex partners and settings in which sexual behaviours occur as situational predictors of risk in order to comprehensively understand sexual risk-taking in this population.

Substance Use and Sexual Risk Behavior in HIV-Positive Men Who Have Sex With Men: An Episode-Level Analysis

Men who have sex with men (MSM) make up nearly half of all people living with HIV in the United States. The prevalence of the epidemic in this population makes it vitally important to understand the transmission of the infection and to develop methods to prevent its spread. The current study uses longitudinal diary methods to examine relationships between substance use and unprotected anal intercourse in a sample of 158 HIV-positive, mostly ethnic minority MSM. Results indicate that both general substance use and use of specific drugs (i.e., inhalants, cocaine, crack, and club drugs) have a substantial impact on the sexual risk behavior of this population.

Sexual Stigma, Criminalization, Investment, and Access to HIV Services Among Men Who Have Sex with Men Worldwide

Abstract Globally, HIV disproportionately affects men who have sex with men (MSM). This study explored associations between access to HIV services and (1) individual-level perceived sexual stigma; (2) country-level criminalization of homosexuality; and (3) country-level investment in HIV services for MSM. 3,340 MSM completed an online survey assessing access to HIV services. MSM from over 115 countries were categorized according to criminalization of homosexuality policy and investment in HIV services targeting MSM. Lower access to condoms, lubricants, and HIV testing were each associated with greater perceived sexual stigma, existence of homosexuality criminalization policies, and less investment in HIV services. Lower access to HIV treatment was associated with greater perceived sexual stigma and criminalization. Criminalization of homosexuality and low investment in HIV services were both associated with greater perceived sexual stigma. Efforts to prevent and treat HIV among MSM should be coupled with structural interventions to reduce stigma, overturn homosexuality criminalization policies, and increase investment in MSM-specific HIV services.ResumenGlobalmente, el VIH afecta desproporcionadamente a los HSH. Este estudio exploró las asociaciones entre el acceso a servicios para el VIH y (1) la percepción del estigma sexual a nivel individual; (2) la criminalización de la homosexualidad en cada país; y (3) el nivel de inversión financiera por país en servicios para el VIH dirigidos a HSH. Un total de 3,340 HSH completaron una encuesta a través del internet sobre el acceso a servicios para el VIH. HSH de más de 115 países fueron clasificados según las legislaciones sobre la criminalización de la homosexualidad y el nivel de inversión en servicios para el VIH dirigido a HSH. Un menor acceso a condones, lubricantes y pruebas del VIH fueron asociados con una mayor percepción del estigma sexual, la existencia de legislación sobre la criminalización de la homosexualidad y menos inversión en servicios para el VIH. Menos acceso a tratamientos para el VIH, fue asociado con una mayor percepción de estigma sexual y la criminalización de la homosexualidad. A su vez, la criminalización de la homosexualidad y la baja inversión en servicios para el VIH, fueron asociados con una mayor percepción del estigma sexual. Los esfuerzos para prevenir y tratar el VIH entre HSH necesitan ser ligados a intervenciones estructurales para reducir el estigma, reformar legislaciones de criminalización de la homosexualidad y aumentar las inversiones en los servicios para el VIH específicamente diseñados para HSH.

Syndemic conditions associated with increased HIV risk in a global sample of men who have sex with men

Objective We evaluated the relationship among syndemic conditions (defined as a cluster of interconnected psychosocial health conditions), sexual behaviours and self-reported HIV infection in a global sample of men who have sex with men (MSM). Methods We used generalised estimating equations logistic regression models with robust SEs to assess the relationships among cumulative number of syndemic conditions—including depression, substance use, violence, sexual stigma and homelessness—and unprotected anal intercourse (UAI) and HIV infection, while accounting for clustering within-country in a global cross-sectional survey of 3934 MSM across 151 countries. Results We observed parallel, significant dose–response associations between the number of syndemic conditions and UAI, as well as number of syndemic conditions and HIV infection. Compared with participants without syndemics, the adjusted OR (aOR) for UAI among those with 1, 2 and 3 or more syndemic conditions were 1.44 (Bonferroni-adjusted 95% CI 1.23 to 1.68), 1.89 (1.51 to 2.36) and 2.03 (1.43 to 2.89), respectively. Compared with participants without syndemics, the aOR for HIV infection among those with 1, 2 and 3 or more syndemic conditions were 1.67 (1.24 to 2.26), 2.02 (1.44 to 2.85) and 2.35 (1.31 to 4.21), respectively. Conclusions This analysis provides evidence of intertwining syndemics that may operate synergistically to increase HIV risk among MSM globally. To curb HIV effectively and advance the health of MSM, multiple conditions must be addressed concurrently using multi-level approaches that target both individual and structural risk factors.

Reductions in alcohol and cocaine use following a group coping intervention for HIV-positive adults with childhood sexual abuse histories.

AIMS Few interventions exist to reduce alcohol and non-injection drug use among people living with HIV/AIDS. This study tested the effects of a coping group intervention for HIV-positive adults with childhood sexual abuse histories on alcohol, cocaine and marijuana use. DESIGN Participants were assigned randomly to the experimental coping group or a time-matched comparison support group. Both interventions were delivered in a group format over 15 weekly 90-minute sessions. SETTING AND PARTICIPANTS A diverse sample of 247 HIV-positive men and women with childhood sexual abuse were recruited from AIDS service organizations and community health centers in New York City. MEASUREMENTS Substance use was assessed pre- and post-intervention and every 4 months during a 12-month follow-up period. Using an intent-to-treat analysis, longitudinal changes in substance use by condition were assessed using generalized estimating equations. FINDINGS At baseline, 42% of participants drank alcohol, 26% used cocaine and 26% used marijuana. Relative to participants in the support group, those in the coping group had greater reductions in quantity of alcohol use (Wald χ²(₄)=10.77, P = 0.029) and any cocaine use (Wald χ²(₄) = 9.81, P = 0.044) overtime. CONCLUSIONS Many HIV patients, particularly those with childhood sexual abuse histories, continue to abuse substances. This group intervention that addressed coping with HIV and sexual trauma was effective in reducing alcohol and cocaine use, with effects sustained at 12-month follow-up. Integrating mental health treatment into HIV prevention may improve outcomes.

Access to Basic HIV-Related Services and PrEP Acceptability among Men Who Have Sex with Men Worldwide:: Barriers, Facilitators, and Implications for Combination Prevention

Introduction. Men who have sex with men (MSM) are disproportionately impacted by HIV globally. Easily accessible combination HIV prevention strategies, tailored to the needs of MSM, are needed to effectively address the AIDS pandemic. Methods and Materials. We conducted a cross-sectional study among MSM (n = 3748) from 145 countries from April to August 2012. Using multivariable random effects models, we examined factors associated with acceptability of preexposure prophylaxis (PrEP) and access to condoms, lubricants, HIV testing, and HIV treatment. Results. Condoms and lubricants were accessible to 35% and 22% of all respondents, respectively. HIV testing was accessible to 35% of HIV-negative respondents. Forty-three percent of all HIV-positive respondents reported that antiretroviral therapy was easily accessible. Homophobia, outness, and service provider stigma were significantly associated with reduced access to services. Conversely, community engagement, connection to gay community, and comfort with service providers were associated with increased access. PrEP acceptability was associated with lower PrEP-related stigma, less knowledge about PrEP, less outness, higher service provider stigma, and having experienced violence for being MSM. Conclusions. Ensuring HIV service access among MSM will be critical in maximizing the potential effectiveness of combination approaches, especially given the interdependence of both basic and newer interventions like PrEP. Barriers and facilitators of HIV service access for MSM should be better understood and addressed.