Rodney VanDerwarker

Which HIV-infected men who have sex with men in care are engaging in risky sex and acquiring sexually transmitted infections: findings from a Boston community health centre

Objectives The primary objective was to determine the prevalence of sexually transmitted infections (STI) in a cohort of HIV-infected men who have sex with men (MSM) in their primary care setting, and to identify the demographic and behavioural characteristics of those infected with STI and the correlates of sexual transmission risk behaviour. Methods At study entry, participants (n = 398) were tested for STI and their medical charts were reviewed for STI results in the previous year. Data on demographics, substance use, sexual behaviour and HIV disease characteristics were collected through a computer-assisted self-assessment and medical record extraction. Logistic regression analyses assessed characteristics of those with recent STI and recent transmission risk behaviour. Results The sample was predominantly white (74.6%) and college educated (51.7%). On average, participants were 41.5 years old (SD 8.4) and had been HIV infected for 8.6 years (SD 6.7); 9% of the sample had an STI, with 6.4% testing positive for syphilis, 3.1% for gonorrhoea and 0.25% for chlamydia. Age and years since HIV diagnosis were significantly associated with testing positive for an STI, as was engaging in transmission risk behaviour and using methamphetamine, ketamine and inhalants. Substance use, particularly methamphetamine use, and being more recently diagnosed with HIV were each uniquely associated with transmission risk behaviour in a multivariable model. Conclusions These results underscore the need to develop more effective secondary prevention interventions for HIV-infected MSM, tailored to more recently diagnosed patients, particularly those who are younger and substance users.

Tenofovir DF plus lamivudine or emtricitabine for nonoccupational postexposure prophylaxis (NPEP) in a Boston Community Health Center.

Background:Nonoccupational postexposure prophylaxis (NPEP) has been used to decrease HIV transmission after high-risk exposures. However, suboptimal adherence in completing the recommended 28-day course has resulted in prophylaxis failures. Fenway Community Health, the largest center caring for HIV-infected and high-risk men who have sex with men (MSM) in New England, began an NPEP program in 1997, initially using zidovudine-based regimens. Methods:Two phase 4 studies, using tenofovir DF regimens combined with either lamivudine or emtricitabine, were conducted. This paper evaluates the experience of those who used tenofovir-based NPEP regimens, comparing the subjects to historical controls who used zidovudine-containing regimens. Results:Between May 2004 and March 2005, 44 individuals who presented after high-risk sexual exposure were prescribed tenofovir DF/lamivudine for NPEP. Between March 2005 and March 2006, 68 individuals with 72 high-risk experiences received tenofovir DF/emtricitabine, and were compared to122 historical controls who were prescribed 126 courses of zidovudine plus lamivudine between January 2000 and May 2004. Seventy-two percent of those who took tenofovir DF and emtricitabine, and 87.5% of the participants who took tenofovir DF and lamivudine, for NPEP completed their regimens as prescribed, whereas only 42.1% of those who took zidovudine plus lamivudine did so (P < 0.0001). Participants who took tenofovir DF-containing regimens were more likely to report diarrhea or abdominal discomfort; patients who took zidovudine-containing regimens were more likely to report nausea and vomiting, which was often severe enough to lead to product discontinuation. Conclusions:Tenofovir DF-containing regimens for NPEP are generally well tolerated with high completion rates. Tolerability and adherence compared favorably to zidovudine-containing regimens used previously. Tenofovir DF-containing regimens should be considered for PEP to enhance adherence and regimen completion.

Acceptability of an Internet-Based Partner Notification System for Sexually Transmitted Infection Exposure Among Men Who Have Sex With Men

US men who have sex with men (n=1848) completed an online questionnaire about their willingness to use Internet-based partner notification. Eighty-one percent reported that it would be important to them to receive a partner notification e-mail if they had been exposed to a sexually transmitted infection. Seventy percent reported that if infected, they would use a public health specialist to inform partners of possible exposure through Internet notification. There was broad acceptance of Internet partner notification by at-risk US men who have sex with men, including a willingness to receive or initiate a notification e-mail.

HIV and STD Status Among MSM and Attitudes About Internet Partner Notification for STD Exposure

Objectives: This study assessed the acceptability and perceived utility of Internet-based partner notification (PN) of sexually transmitted disease (STD) exposure for men who have sex with men (MSM) by human immunodeficiency virus (HIV) serostatus. Study Design: We recruited 1848 US MSM via a banner advertisement posted on an MSM website for meeting sexual partners between October and November 2005. Results: Even though there was broad acceptance of a PN e-mail across HIV serostatus groups, HIV-infected men rated the importance of each component (e.g., information about where to get tested/treated, additional education regarding the STD exposed to, a mechanism for verifying the authenticity of the PN e-mail) lower than HIV-uninfected or status-unknown participants (all Ps <0.01). Additionally, HIV-infected participants were less likely to use the services offered within a PN e-mail (if they were to receive an e-mail notifying them of possible STD exposure in the future), and were less likely to inform their partners of possible STD exposure via an Internet notification system in the future (all Ps <0.01). A similar trend emerged about men who reported not having a previous STD compared with those who did. Men who reported no previous STD found Internet PN more acceptable. Conclusions: Overall, this study documents broad acceptance of Internet PN by at-risk MSM, regardless of HIV serostatus, including a willingness to receive or initiate PN-related e-mail. If public health officials consider using Internet notification services, they may need to anticipate and address concerns of HIV-infected MSM, and will need to use a culturally-sensitive, social marketing campaign to ensure that those who may benefit from these services are willing to use this modality for PN. Internet PN should be considered as a tool to decrease rising STD and HIV rates among MSM who use the Internet to meet sexual partners.

Asymptomatic gonorrhea and chlamydial infections detected by nucleic acid amplification tests among Boston area men who have sex with men.

Background: The purpose of this project was to determine the prevalence of asymptomatic sexually transmitted diseases (STDs) among men who have sex with men (MSM) in the Boston area who had been sexually active (oral and/or anal sex) with another male within the past year. Methods: Over a 1-month period (March 2007), asymptomatic MSM in care at a Boston community health center (n = 114) were screened for gonorrhea and chlamydia using the BD ProbeTec technique. Deidentified medical record data were analyzed and linked to prevalence monitoring results. Results: Eleven percent of the sample tested positive for one of the 2 STDs (gonorrhea or chlamydia) from at least one mucosal site. Individuals who were infected with an STD were considerably more likely to have a prior history of one or more STD infections when compared with those without an STD history (OR = 3.69; P <0.02). There were no significant differences observed in psychosocial and other behavioral risk factors between patients with or without an STD. Conclusions: Screening asymptomatic MSM using nucleic acid amplification tests (NAATs) revealed a substantial STD burden that might not have been diagnosed using traditional assays. These data are critical for the design of effective public health interventions for this population.

Polysubstance Use and HIV/STD Risk Behavior among Massachusetts Men Who Have Sex with Men Accessing Department of Public Health Mobile Van Services: Implications for Intervention Development

Polysubstance use has been posited to be a significant contributor to excess burden of HIV disease among men who have sex with men (MSM). The current study investigated polysubstance use and sexual risk among men who utilize Massachusetts Department of Public Health (MDPH) van services (such as HIV, chlamydia, gonorrhea, or syphilis testing; Hepatitis A and B vaccinations) at venues targeting MSM. Participants (n = 214) completed a one-time, cross-sectional survey via an audio computer-assisted self-interview (ACASI) in English or Spanish between June 2007 and September 2007. Fifteen percent of the overall sample did not know their HIV status; 11% reported polysubstance use (concurrent use of three or more: poppers, ecstasy, GHB, cocaine, crystal methamphetamine, Viagra) during sex in the 12 months prior to study enrollment. Polysubstance users were more likely to be HIV infected (odds ratio [OR] = 4.62; p = 0.03) and to have a history of one or more sexually transmitted diseases (STDs; OR = 4.74; p = 0.03) relative to participants who did not report polysubstance use during sex. After controlling for covariates of age, race/ethnicity, education level, insurance status, sexual orientation, STD history, HIV status, and depression, multivariable logistic regression analyses revealed that polysubstance users were 9 times more likely to have reported unprotected anal (insertive or receptive) sex in the 12 months prior to study enrollment (adjusted OR = 9.53; p = 0.007) compared to nonpolysubstance-using MSM. Polysubstance users lacked access to care (21% were uninsured) and the overwhelming majority (96%) were first time users of mobile health van services. Accessible outreach services for MSM such as mobile van services need to include drug screening and interventions that triage men into treatment programs; year-round availability of van services is warranted.

Differential HIV Risk Behavior among Men who have Sex with Men Seeking Health-Related Mobile Van Services at Diverse Gay-Specific Venues

Distinguishing between gay venues may provide important information to better understand patterns of environmental influence and HIV/STI behavioral risk among MSM. Massachusetts MSM accessing State Health Department mobile van services (n = 214) at Gay Pride events, bars/clubs, and private safer sex parties completed a one-time, cross-sectional survey via ACASI. In the past 12 months, private safer sex party attendees reported a higher mean number of anonymous partners, were more likely to report meeting sex partners via the Internet, and were more likely to report sex while drunk; in logistic regression analyses, they were less likely to report both unprotected insertive and receptive anal sex in the past year relative to men from other venues. Private safer sex parties may represent a strategy used by some MSM to reduce HIV/STI risk. Differentiating risk behavior by venue type provides valuable information with which to effectively target interventions to reach MSM at greatest risk.

Sex Parties among Urban MSM: An Emerging Culture and HIV Risk Environment

Private sex parties are an emerging risk environment for HIV among men who have sex with men (MSM). In 2009, 103 participants who reported attending at least one sex party in Massachusetts in the prior 12 months completed an in-depth, interviewer-administered quantitative assessment. Multivariable logistic regression analyses were conducted to examine associations with having engaged in one or more serodiscordant unprotected anal sex (SDUAS) acts at the most recent sex party attended. Nearly one-third (32%) of the sample reported engaging in SDUAS at the most recent sex party attended. Adjusting for age, race/ethnicity, and educational attainment, variables associated with an increased odds of engaging in SDUAS at the most recent sex party were: total number of unprotected anal receptive sex acts at sex parties in the past 12 months, self-perception of being at-risk for transmitting or acquiring HIV, and sexual sensation seeking. Examined in the same model, if condoms were provided/available at the most recent sex party attended, participants were at a decreased odds of engaging in SDUAS at that sex party. The majority (80%) expressed an interest in HIV prevention activities for MSM who attend sex parties. HIV prevention interventions are needed to reach MSM who attend sex parties and should take into account individual and contextual factors that may contribute to sexual risk. Environmental factors in the sex party setting, in particular the presence and availability of condoms, may potentially mitigate individual-level factors such as unprotected anal sex.

“It's a Quick Way to Get What You Want”: A Formative Exploration of HIV Risk Among Urban Massachusetts Men Who Have Sex with Men Who Attend Sex Parties

Community-based studies with men who have sex with men (MSM) suggest that between 8% and 25% of MSM have met recent male sexual partners at private sex parties. Little is known about HIV sexual risk behaviors of MSM who attend sex parties and whether risk reduction interventions can be delivered in this setting. In 2008, 40 MSM who reported attending and/or hosting sex parties in Massachusetts in the past 12 months completed a qualitative interview and quantitative assessment. Participants reported attending a mean number of 10 sex parties in Massachusetts in the past 12 months. A significant percentage (43%) reported also hosting sex parties. Participants had made sexual partner connections across multiple venues, including public cruising areas, bars/clubs, and the Internet. At the most recent sex party attended, the majority had used alcohol (58%) and/or drugs (50%), and one quarter (25%) put themselves at risk of acquiring or transmitting HIV or other sexually transmitted infections (STIs) by having unprotected anal sex with a mean number of three serodiscordant male sex partners. Although many participants perceived that communicating about sexual health in the sex party context would “ruin the mood,” the majority (80%) considered some form of HIV prevention at sex parties to be appropriate and necessary, as well as acceptable. Nonintrusive prevention and education activities were especially endorsed (i.e., condoms, lubricants, and coupons for free HIV/STI testing). The majority of participants (75%) expressed some interest in “safer sex” parties. MSM attending sex parties appear to be a subpopulation at high risk for HIV and STI acquisition and transmission. Risk reduction interventions responsive to the needs of MSM who attend sex parties are warranted.

“40 & Forward”: Preliminary Evaluation of a Group Intervention to Improve Mental Health Outcomes and Address HIV Sexual Risk Behaviors Among Older Gay and Bisexual Men

We examined the initial efficacy of “40 & Forward,” a manualized group intervention developed to reduce HIV sexual risk for gay and bisexual men age 40 and older who self-report problems with depression, isolation/loneliness, and social anxiety. A retrospective evaluation of program data from 84 participants (mean age = 51; 26% HIV infected) across four groups compared within-person change in mental health and sexual risk outcomes between baseline and post-intervention assessments. Participants who completed the intervention demonstrated statistically significant reductions across all mental health outcomes, including depressive symptoms, social anxiety symptoms, loneliness, and fear of negative evaluation, as well as increased condom use self-efficacy. Current findings offer a promising approach for additional research and intervention development with this population of aging sexual minority men.