Sara Nelson Glick

Persistence of racial differences in attitudes toward homosexuality in the United States.

Background:Stigma may mediate some of the observed disparity in HIV infection rates between black and white men who have sex with men (MSM). Methods:We used data from the General Social Survey to describe race-specific trends in the US populations attitude toward homosexuality, reporting of male same-sex sexual behavior, and behaviors that might mediate the relationship between stigma and HIV transmission among MSM. Results:The proportion of blacks who indicated that homosexuality was “always wrong” was 72.3% in 2008, largely unchanged since the 1970s. In contrast, among white respondents, this figure declined from 70.8% in 1973 to 51.6% in 2008 with most change occurring since the early 1990s. Participants who knew a gay person were less likely to have negative attitudes toward homosexuality (relative risk, 0.60; 95% confidence interval, 0.52 to 0.69). Among MSM, twice as many black MSM reported that homosexuality is “always wrong” compared with white MSM (57.1% versus 26.8%, P = 0.003). MSM with unfavorable attitudes toward homosexuality were less likely to report ever testing for HIV compared with MSM with more favorable attitudes (relative risk, 0.50; 95% confidence interval, 0.31 to 0.78). Conclusions:US attitudes toward homosexuality are characterized by persistent racial differences, which may help explain disparities in HIV infection rates between black and white MSM.

A comparison of sexual behavior patterns among men who have sex with men and heterosexual men and women

Objective:Men who have sex with men (MSM) have higher rates of HIV and other sexually transmitted infections than women and heterosexual men. This elevated risk persists across age groups and reflects biological and behavioral factors; yet, there have been few direct comparisons of sexual behavior patterns between these populations. Methods:We compared sexual behavior patterns of MSM and male and female heterosexuals aged 18–39 using 4 population-based random digit dialing surveys. A 1996–1998 survey in 4 US cities and 2 Seattle surveys (2003 and 2006) provided estimates for MSM; a 2003–2004 Seattle survey provided data about heterosexual men and women. Results:Sexual debut occurred earlier among MSM than heterosexuals. MSM reported longer cumulative lifetime periods of new partner acquisition than heterosexuals and a more gradual decline in new partnership formation with age. Among MSM, 86% of 18- to 24-year-olds and 72% of 35- to 39-year-olds formed a new partnership during the previous year, compared with 56% of heterosexual men and 34% of women at 18–24 years, and 21% and 10%, respectively, at 35–39 years. MSM were also more likely to choose partners >5 years older and were 2–3 times as likely as heterosexuals to report recent concurrent partnerships. MSM reported more consistent condom use during anal sex than heterosexuals reported during vaginal sex. Conclusions:MSM have longer periods of partnership acquisition, a higher prevalence of partnership concurrency, and more age disassortative mixing than heterosexuals. These factors likely help to explain higher HIV/sexually transmitted infections rates among MSM, despite higher levels of condom use.

Understanding structural barriers to accessing HIV testing and prevention services among black men who have sex with men (BMSM) in the United States

Structural-level factors have contributed to the substantial disproportionate rates of HIV among Black men who have sex with men (BMSM) in the United States. Despite insufficient HIV testing patterns, however, there is a void in research investigating the relationship between structural factors and access to HIV testing and prevention services among BMSM. Building on previous scholarly work and incorporating a dynamic social systems conceptual framework, we conducted a comprehensive review of the literature on structural barriers to HIV testing and prevention services among BMSM across four domains: healthcare, stigma and discrimination, incarceration, and poverty. We found that BMSM experience inadequate access to culturally competent services, stigma and discrimination that impede access to services, a deficiency of services in correctional institutions, and limited services in areas where BMSM live. Structural interventions that eliminate barriers to HIV testing and prevention services and provide BMSM with core skills to navigate complex systems are needed.

Infrequent HIV testing and late HIV diagnosis are common among a cohort of black men who have sex with men in 6 US cities.

Objective:US guidelines recommend at least annual HIV testing for those at risk. This analysis assessed frequency and correlates of infrequent HIV testing and late diagnosis among black men who have sex with men (BMSM). Methods:HIV testing history was collected at enrollment from participants in HPTN 061, an HIV prevention trial for at-risk US BMSM. Two definitions of late HIV diagnosis were assessed: CD4 cell count <200 cells per cubic millimeter or <350 cells per cubic millimeter at diagnosis. Results:HPTN 061 enrolled 1553 BMSM. HIV testing questions were completed at enrollment by 1284 (98.7%) of 1301 participants with no previous HIV diagnosis; 272 (21.2%) reported no HIV test in previous 12 months (infrequent testing); 155 of whom (12.1% of the 1284 with testing data) reported never testing. Infrequent HIV testing was associated with: not seeing a medical provider in the previous 6 months (relative risk [RR]: 1.08, 95% confidence interval [CI]: 1.03 to 1.13), being unemployed (RR: 1.04, CI: 1.01 to 1.07), and having high internalized HIV stigma (RR: 1.03, CI: 1.0 to 1.05). New HIV diagnoses were more likely among infrequent testers compared with men tested in the previous year (18.4% vs. 4.4%; odds ratio: 4.8, 95% CI: 3.2 to 7.4). Among men with newly diagnosed HIV, 33 (39.3%) had a CD4 cell count <350 cells per cubic millimeter including 17 (20.2%) with CD4 <200 cells per cubic millimeter. Conclusions:Infrequent HIV testing, undiagnosed infection, and late diagnosis were common among BMSM in this study. New HIV diagnoses were more common among infrequent testers, underscoring the need for additional HIV testing and prevention efforts among US BMSM.

The use of web-based diaries in sexual risk behaviour research: a systematic review

Background An increasing number of studies have used the diary method, which provides quantitative event-level data about sexual encounters. Diaries are an attractive tool for sexual behaviour research, yet little is known about the range of uses, methodological issues and best practices associated with this technology. Objectives To conduct a systematic review of the literature regarding the use of web-based diaries in sexual risk behaviour studies. Design Systematic review. Data sources Five bibliographical databases, supplemented by references from previous reviews. Methods Eligible studies were published in English before August 2013, used the internet to transmit data from collection device to study staff, and measured behaviours affecting HIV or sexually transmitted infection transmission risk. The primary author conducted an initial screen to eliminate irrelevant articles. Both authors conducted full-text reviews to determine final articles. We abstracted data on diary methodology, validity and reactivity (behaviour change caused by diary completion). Results Twenty-three articles representing 15 studies were identified. Most diaries were collected daily for 1 month via websites, and completion was generally high (>80%). Compensation varied by study and was not associated with completion. Studies comparing diary with retrospective survey data demonstrated evidence of over-reporting on retrospective tools, except for the least frequent behaviours. Most studies that assessed reactivity as a result of diary completion demonstrated some change in behaviour associated with frequent monitoring. Conclusions Web-based diaries are an effective means of studying sexual risk behaviour. More uniform reporting and further research on the extent of reactivity are needed.

Brief Report: Increasing Acceptance of Homosexuality in the United States Across Racial and Ethnic Subgroups.

Abstract:After recent civil rights expansions for sexual minorities in the United States, we updated previous findings on population-level attitudes toward homosexuality measured in the General Social Survey. In 2014, 40.1% of respondents reported that homosexuality was “always wrong” compared with 54.8% in 2008 (P < 0.001). Although black and Hispanic respondents consistently reported more negative attitudes regarding homosexuality than white respondents throughout 2008 to 2014, the percentage declined among all racial/ethnic groups. Among MSM, more positive attitudes were associated with HIV testing. Research shows a potential association between homophobia and HIV risk; thus, these population-level changes may promote better health among MSM.

Sexually Transmitted Infections Among HIV-Infected Adults in HIV Care Programs in Kenya: A National Sample of HIV Clinics

Background Identifying sexually transmitted infections (STI) in HIV-infected individuals has potential to benefit individual and public health. There are few guidelines regarding routine STI screening in sub-Saharan African HIV programs. We determined sexual risk behavior and prevalence and correlates of STI in a national survey of large HIV treatment programs in Kenya. Methods A mobile screening team visited 39 (95%) of the 42 largest HIV care programs in Kenya and enrolled participants using population-proportionate systematic sampling. Participants provided behavioral and clinical data. Genital and blood specimens were tested for trichomoniasis, gonorrhea, chlamydia, syphilis, and CD4 T-lymphocyte counts. Results Among 1661 adults, 41% reported no sexual partners in the past 3 months. Among those who reported sex in the past 3 months, 63% of women reported condom use during this encounter compared with 77% of men (P < 0.001). Trichomoniasis was the most common STI in women (10.9%) and men (2.8%); prevalences of gonorrhea, chlamydia, and syphilis were low (<1%–2%). Among women, younger age (adjusted odds ratio [OR], 0.96 per year; 95% confidence interval [CI], 0.94–0.98) and primary school education or lower level (adjusted OR, 2.16; 95% CI, 1.37–3.40) were independently associated with trichomoniasis, whereas CD4 count, cotrimoxazole use, and reported condom use were not. Reported condom use at last sex was associated with reporting that the clinic provided condoms among both women (OR, 1.7; 95% CI, 1.17–2.35) and men (OR, 2.4; 95% CI, 1.18–4.82). Conclusions Women attending Kenyan HIV care programs had a 10.9% prevalence of trichomoniasis, suggesting that screening for this infection may be useful. Condom provision at clinics may enhance secondary HIV prevention efforts.

A Decline in HIV Testing Among Persons Who Inject Drugs in the Seattle Area, 2004–2015

Background: Promoting HIV testing is a key component of the public health response to HIV. Assessing HIV testing frequency among persons who inject drugs (PWID) monitors the status of these efforts and can identify unmet needs and opportunities to more effectively promote testing. Methods: Data were combined from 4 Seattle-area surveys of PWID from the National HIV Behavioral Surveillance (NHBS) program (2005–2015) and 6 surveys of Needle Exchange clients (2004–2015). Results: The proportion of PWID reporting an HIV test in the previous 12 months declined from 64% in 2005% to 47% in 2015 in the NHBS surveys and from 72% to 58% in the Needle Exchange surveys. These declines persisted in multivariate analyses controlling for differences in the study populations in age, race, sex, area of residence, education, current homelessness, drug most frequently injected, daily injection frequency, and combined male-to-male sex and amphetamine injection status. The proportion of NHBS participants reporting not knowing the HIV status of their last injection partner increased from 38% to 45%. The proportion not knowing the HIV status of their last sex partner increased from 27% to 38%. Conclusions: A decrease in HIV testing was found in 2 independent Seattle-area study populations. This was complemented by increases in the proportions not knowing the HIV status of their last sex and last injection partners. Research is needed to ascertain if such declines are observed elsewhere, the reasons for the decline, and appropriate means to effectively attain optimal HIV testing frequency among PWID.

O16.3 Controlling Chlamydia: Population Modeling to Assess Promising Interventions

Background Chlamydia is an important public health problem associated with neonatal sequelae, pelvic inflammatory disease, infertility, and ectopic pregnancy. Methods Using a population model with 2 genders and ages 15–44 years in 5-year groups, but only heterosexual contacts, we evaluated the impact of actual and hypothetical interventions on chlamydia in the U.S. Parameters were obtained from the literature or estimated from the National Health and Social Life Survey and Seattle Sex Survey. The model was calibrated by adjusting gender-specific probabilities of infection on contact. We calculated the basic reproduction number (R0), defined as the average number of secondary infections per infectious person in a wholly-susceptible population without interventions. We also calculated the age- and gender-specific equilibrium prevalence and contributions to R0. And we assessed the impact of interventions by comparing reproduction numbers with and without them. To assess the feasibility of opportunistic screening, we analysed Market Scan, a commercial health insurance database, to determine the proportion of people seeking medical care. Results Treating symptomatic men and women who seek care and screening 38% of women aged 15–24 years during annual examinations more than halve the reproduction number. The equilibrium age- and gender-specific prevalence of infection match those observed in the National Health and Nutrition Examination Survey. Men cause more secondary infections than women (contributing twice as much to R0 in some age groups), and people aged 25–29 years cause as many as those aged 20–24. Analysis of the Market Scan database indicates that insured men seek care often enough for screening to have substantial impact. Screening women reduces the reproduction number by 3%; screening a similar proportion of young men would reduce it another 4%. Conclusions Our modelling suggests that screening men as well as women and extending the upper age to 29 years may affect chlamydia transmission or sequelae.

HIV Among MSM and Heterosexual Women in the United States: An Ecologic Analysis

Background: Phylogenetic studies show links between heterosexual women and men who have sex with men (MSM) that are more numerous than from heterosexual men to women suggesting that HIV infections among heterosexual women may stem from MSM. Poor communities have been associated with high rates of HIV among heterosexual women. Our analysis investigates potential transmission of HIV between MSM and female heterosexuals. Methods: National HIV Behavioral Surveillance data describe transmission risk behaviors of MSM, and HIV case reporting data describe the percentages of cases that are attributed to transmission risk categories. We examined correlations between the percentages of men who were MSM who also have sex with women and female heterosexual cases. We also examined census data to characterize each city in terms of poverty level and race/ethnicity makeup. Results: There was a high correlation (0.93) between the percentage of reported living HIV cases attributed to male heterosexual contact and female heterosexual contact and a moderate nonsignificant correlation (0.49) between the percentage of MSM who were men who have sex with men and women (MSMW) in National HIV Behavioral Surveillance and the percentage of reported cases that were attributed to female heterosexual contact suggesting some potential overlap. Cities with high levels of poverty and African American/Black residents had higher levels of MSMW and higher levels of heterosexual female cases. Conclusions: Addressing HIV in cities with high levels of MSMW may have the dual effect of improving the health of MSM populations that have a high burden of HIV and to improve the health of their larger communities.