Richard J. Wolitski

Greater Risk for HIV Infection of Black Men Who Have Sex With Men: A Critical Literature Review

HIV rates are disproportionately higher for Black men who have sex with men (MSM) than for other MSM. We reviewed the literature to examine 12 hypotheses that might explain this disparity. We found that high rates of HIV infection for Black MSM were partly attributable to a high prevalence of sexually transmitted diseases that facilitate HIV transmission and to undetected or late diagnosis of HIV infection; they were not attributable to a higher frequency of risky sexual behavior, nongay identity, or sexual nondisclosure, or to reported use of alcohol or illicit substances. Evidence was insufficient to evaluate the remaining hypotheses.Future studies must address these hypotheses to provide additional explanations for the greater prevalence of HIV infection among Black MSM.

Do prevention interventions reduce HIV risk behaviours among people living with HIV: a meta-analytic review of controlled trials

Objective:To conduct a meta-analytic review of HIV interventions for people living with HIV (PLWH) to determine their overall efficacy in reducing HIV risk behaviours and identify intervention characteristics associated with efficacy. Methods:Comprehensive searches included electronic databases from 1988 to 2004, hand searches of journals, reference lists of articles, and contacts with researchers. Twelve trials met the stringent selection criteria: randomization or assignment with minimal bias, use of statistical analysis, and assessment of HIV-related behavioural or biologic outcomes at least 3 months after the intervention. Random-effects models were used to aggregate data. Results:Interventions significantly reduced unprotected sex [odds ratio (OR), 0.57; 95% confidence interval (CI) 0.40–0.82] and decreased acquisition of sexually transmitted diseases (OR, 0.20; 95% CI, 0.05–0.73). Non-significant intervention effects were observed for needle sharing (OR, 0.47, 95% CI, 0.13–1.71). As a whole, interventions with the following characteristics significantly reduced sexual risk behaviours: (1) based on behavioural theory; (2) designed to change specifically HIV transmission risk behaviours; (3) delivered by health-care providers or counsellors; (4) delivered to individuals; (5) delivered in an intensive manner; (6) delivered in settings where PLWH receive routine services or medical care; (7) provided skills building, or (8) addressed a myriad of issues related to mental health, medication adherence, and HIV risk behaviour. Conclusion:Interventions targeting PWLH are efficacious in reducing unprotected sex and acquisition of sexually transmitted diseases. Efficacious strategies identified in this review should be incorporated into community HIV prevention efforts and further evaluated for effectiveness.

Sexual harm reduction practices of HIV-seropositive gay and bisexual men : serosorting, strategic positioning, and withdrawal before ejaculation

Objective:This study assessed unprotected anal and oral sex behaviors of HIV-positive gay and bisexual men in New York City and San Francisco with their main and non-main sexual partners. Here we focus on the use of three harm reduction strategies (serosorting, strategic positioning, and withdrawal before ejaculation) in order to decrease transmission risk. Method:The data from a baseline assessment of 1168 HIV-positive gay and bisexual men in the two cities were utilized. Men were recruited from a variety of community-based venues, through advertising and other techniques. Results:City differences were identified, with more men in San Francisco reporting sexual risk behaviors across all partner types compared with men in New York City. Serosorting was identified, with men reporting significantly more oral and anal sex acts with other HIV-positive partners than with HIV-negative partners. However, men also reported more unprotected sex with partners of unknown status compared with their other partners. Some evidence of strategic positioning was identified, although differences were noted across cities and across different types of partners. Men in both cities reported more acts of oral sex without ejaculation than with ejaculation, but the use of withdrawal as a harm reduction strategy for anal sex was more common among men from San Francisco. Conclusion:Overall, evidence for harm reduction was identified; however, significant differences across the two cities were found. The complicated nature of the sexual practices of gay and bisexual men are discussed, and the findings have important implications for prevention efforts and future research studies.

Health status, health care use, medication use, and medication adherence among homeless and housed people living with HIV/AIDS.

OBJECTIVES We sought to compare health status, health care use, HIV anti-retroviral medication use, and HIV medication adherence among homeless and housed people with HIV/AIDS. METHODS Data were obtained from a cross-sectional, multisite behavioral survey of adults (N=7925) recently reported to be HIV positive. RESULTS At the time interviews were conducted, 304 respondents (4%) were homeless. Self-ratings of mental, physical, and overall health revealed that the health status of homeless respondents was poorer than that of housed respondents. Also, homeless respondents were more likely to be uninsured, to have visited an emergency department, and to have been admitted to a hospital. Homeless respondents had lower CD4 counts, were less likely to have taken HIV anti-retroviral medications, and were less adherent to their medication regimen. Homeless respondents needed more HIV social and medical services, but nearly all respondents in both groups had received needed services. Housing status remained a significant predictor of health and medication outcomes after we controlled for potential confounding variables. CONCLUSIONS Homeless people with HIV/AIDS are at increased risk of negative health outcomes, and housing is a potentially important mechanism for improving the health of this vulnerable group.

Meta-analysis of cognitive-behavioral interventions on HIV-positive persons' mental health and immune functioning

OBJECTIVE To evaluate the efficacy of cognitive-behavioral interventions (CBIs) for improving the mental health and immune functioning of people living with HIV (PLWH). DESIGN Comprehensive searches of electronic databases from 1988 to 2005, hand searches of journals, reference lists of articles, and contacts with researchers. Meta-analytic approaches were used in synthesizing findings. MAIN OUTCOME MEASURES Intervention effects on symptoms of depression, anxiety, and anger, stress, and CD4 cell counts were assessed. RESULTS Data from 15 controlled trials were analyzed. Significant intervention effects were observed for improving symptoms of depression (d = 0.33), anxiety (d = 0.30), anger (d = 1.00), and stress (d = 0.43). There is limited evidence suggesting intervention effects on CD4 cell counts (d = 0.08). The aggregated effect size estimates for depression and anxiety were statistically significant in trials that provided stress management skills training and had more than 10 intervention sessions. CONCLUSION CBIs are efficacious in improving various psychological states of PLWH. Future research should examine the relationship among interventions, psychological states, medication adherence, and immune functions, and identify other relevant factors associated with intervention effects.

A comparison of on-line and off-line sexual risk in men who have sex with men: an event-based on-line survey.

Objective:To assess whether men who have sex with men (MSM) are more likely to report unprotected anal intercourse (UAI) with partners met on-line compared with those met off-line. Methods:A total of 6122 individuals consented to participate in an anonymous behavioral survey on-line. This event-based analysis is limited to the 1683 men from the United States and Canada who had sex in the 3 months before the study and reported that their last sexual encounter included a new or casual male partner or partners. Prevalence and predictors of UAI were analyzed separately for the 386 men reporting more than 1 partner (multiple) and the 1297 men reporting only 1 (single) partner in their last encounter. Results:Of the 1683 MSM recruited on-line, 51% met their partner(s) in their last sexual encounter on-line and 23% reported UAI. No difference in risk for UAI was found for partners met on-line versus off-line in the bivariate or multivariate analyses. In a multivariate analysis of men with multiple-partner encounters, UAI was significantly associated with being HIV-seropositive (adjusted odds ratio [OR] = 2.87; P = 0.02) in a model that included age; education; whether partners were met on-line or off-line; and use of crystal methamphetamine, sildenafil, or alcohol before sex. Using the same model, significant predictors of UAI in men reporting a single-partner encounter were use of crystal methamphetamine (adjusted OR = 5.67; P = 0.001) and no college degree (adjusted OR = 1.63; P = 0.01). Conclusions:MSM recruited on-line who reported a new or casual sex partner(s) in the prior 3 months are at considerable risk of HIV or other sexually transmitted infections, but they are equally likely to report UAI whether sex partners were met on-line or off-line. The Internet may be an ideal venue for reaching high-risk MSM.

Self-Identification as “Down Low” Among Men Who Have Sex with Men (MSM) from 12 US Cities

Men who have sex with men (MSM) who are on the “down low” (DL) have been the subject of considerable media attention, but few data on this population exist. This exploratory study (N=455) compared MSM who considered themselves to be on the DL with MSM who did not (non-DL MSM). 20% self-identified as DL. Blacks and Hispanics were more likely than Whites to self identify as DL. MSM who did not identify as gay were more likely than gay-identified MSM to describe themselves as DL. DL-identified MSM were less likely to have had seven or more male partners in the prior 30 days, but were more likely to have had a female sex partner and to have had unprotected vaginal sex. DL-identified MSM were less likely to have ever been tested for HIV than were non-DL MSM. Prevention agencies should expand existing programs for MSM to include specific efforts to reach DL MSM.

Sex hustling, injection drug use, and non-gay identification by men who have sex with men: Associations with high-risk sexual behaviors and condom use

Objective: To explore differences in demographic characteristics, risk practices, and preventive behaviors among subgroups of men who have sex with men (MSM), including gay‐ and non‐gay‐identified MSM, MSM who inject drugs, and those engaging in sex hustling. Design: A secondary analysis of cross‐sectional data collected through interviewer‐administered questionnaires in a purposive sample of MSM. Setting: Gay bars, bath houses, adult video arcades, and outdoor cruising areas in Denver and Long Beach. Participants: Men who reported oral or anal sex with another man in the past year with oversampling of non‐gay‐identified MSM. Results: Of 1,290 MSM, 417 (32%) did not gay‐identify, 86 (7%) were drug injectors, and 117 (9%) were hustlers. Of drug‐injecting MSM, 55% reported sex hustling and 40% of hustlers reported injection drug use. Hustling was associated with higher number of partners, more frequent anal sex with men and women, and less frequent condom use during anal sex with occasional male partners. Hustlers and drug‐injecting MSM used condoms less consistently during vaginal intercourse with female partners than did other MSM. Conclusions: Among MSM, subgroups at particularly high risk for HIV can be identified. Although these subgroups may be relatively small, they may be important epidemiologic links to the larger MSM and heterosexual communities and warrant focused behavioral interventions to prevent the further spread of HIV.

HIV serostatus disclosure among gay and bisexual men in four American cities: general patterns and relation to sexual practices.

The present study examined patterns of serostatus disclosure among previously untested HIV-seropositive and HIV-seronegative gay and bisexual men recruited from four American cities (n = 701). Six months after learning their HIV serostatus, 97% of study participants had disclosed their test results to at least one other individual. Consistent with earlier studies, test results were most frequently shared with friends and the respondents primary partner. HIV serostatus was disclosed less frequently to family members, co-workers, and non-primary sex partners. Compared with HIV-seronegative men, HIV-seropositive men were more likely to have disclosed their status to a health care provider and less likely to have shared this information with family members. Of seropositive men, 11% did not disclose their serostatus to their primary partner and 66% did not disclose to a non-primary sex partner. Of HIV-seropositive men with one or more non-primary partners, 16% of those who did not disclose their serostatus reported inconsistent condom use during anal intercourse with these partners. No significant differences in self-reported sexual practices were observed for HIV-seropositive disclosers versus non-disclosers. Compared with HIV-seronegative men who did not disclose, seronegative men who shared information about their serostatus were more likely to have had receptive anal intercourse with their primary partner (p < 0.05) and to have engaged in mutual masturbation (p < 0.005), receptive oral sex (p < 0.005) and insertive anal intercourse (p < 0.05) with non-primary partners. No significant differences were observed between disclosers and non-disclosers with regard to condom use. Implications of the findings for future research and HIV prevention programmes are discussed.

Sexual Health, HIV, and Sexually Transmitted Infections among Gay, Bisexual, and Other Men Who Have Sex with Men in the United States

The sexual health of gay, bisexual, and other men who have sex with men (MSM) in the United States is not getting better despite considerable social, political and human rights advances. Instead of improving, HIV and sexually transmitted infections (STIs) remain disproportionately high among MSM and have been increasing for almost two decades. The disproportionate and worsening burden of HIV and other STIs among MSM requires an urgent re-assessment of what we have been doing as a nation to reduce these infections, how we have been doing it, and the scale of our efforts. A sexual health approach has the potential to improve our understanding of MSM’s sexual behavior and relationships, reduce HIV and STI incidence, and improve the health and well-being of MSM.