Tyrel J. Starks

Methods for the Design and Analysis of Relationship and Partner Effects on Sexual Health

Sexual intercourse involves two people and many aspects of sexual health are influenced by, if not dependent on, interpersonal processes. Yet, the majority of sexual health research involves the study of individuals. The collection and analysis of dyadic data present additional complexities compared to the study of individuals. The aim of this article was to describe methods for the study of dyadic processes related to sexual health. One-sided designs, including the PLM, involve a single individual reporting on the characteristics of multiple romantic or sexual relationships and the associations of these factors with sexual health outcomes are then estimated. This approach has been used to study how relationship factors, such as if the relationship is serious or casual, are associated with engagement in HIV risk behaviors. Such data can be collected cross-sectionally, longitudinally or through the use of diaries. Two-sided designs, including the actor–partner interdependence model, are used when data are obtained from both members of the dyad. The goal of such approaches is to disentangle intra- and inter-personal effects on outcomes (e.g., the ages of an individual and his partner may influence sexual frequency). In distinguishable datasets, there is some variable that allows the analyst to differentiate between partners within dyads, such as HIV status in a serodiscordant couple. When analyzing data from these dyads, effects can be assigned to specific types of partners. In exchangeable dyadic datasets, no variable is present that distinguishes between couple members across all dyads. Extensions of these approaches are described.

Uptake of Hiv Pre-exposure Prophylaxis (prep) in a National Cohort of Gay and Bisexual Men in the United States

Objectives: The HIV care cascade provides milestones to track the progress of HIV-positive people from seroconversion through viral suppression. We propose a Motivational pre-exposure prophylaxis (PrEP) Cascade involving 5 stages based on the Transtheoretical Model of Change. Methods: We analyzed data from 995 men in One Thousand Strong, a longitudinal study of a national panel of HIV-negative gay and bisexual men in the United States. Results: Nearly all (89%) participants were sexually active in the past 3 months and 65% met Centers for Disease Control criteria for PrEP candidacy. Of those identified as appropriate candidates, 53% were Precontemplative (stage 1; unwilling to take or believing they were inappropriate candidates for PrEP) and 23% were in Contemplation (stage 2; willing and self-identified as appropriate candidates). Only 11% were in PrEParation (stage 3; seeing PrEP as accessible and planning to initiate PrEP) and 4% were in PrEP Action (stage 4; prescribed PrEP). Although few of those who were identified as appropriate candidates were on PrEP, nearly all PrEP users (98%) reported adhering to 4 or more doses per week and most (72%) were returning for recommended quarterly medical visits, resulting in 9% of PrEP candidates reaching Maintenance and Adherence (stage 5). Conclusions: The large majority of participants were appropriate candidates for PrEP, yet fewer than 1 in 10 were using and adherent to PrEP. These findings highlight the need for interventions tailored to address the unique barriers men face at each stage of the cascade, particularly at the earliest stages where the most dramatic losses were identified.

Patterns of substance use among HIV-positive adults over 50: implications for treatment and medication adherence.

BACKGROUND The population of older adults living with HIV is increasing in the United States. Despite an increased focus on the health of HIV-positive older adults, knowledge about their substance use, a primary risk factor for HIV medication non-adherence, and the association between use, problems associated with use, and adherence behavior, is limited. METHODS Data were collected from 557 HIV-positive adults aged 50 and older in the New York City area via telephone interview. Participants reported the number of days in the past month on which they missed any doses of HIV medication as well as the number of days they used alcohol, marijuana, cocaine/crack, opiates, amyl nitrite (poppers), and other drugs. The severity of substance use associated problems was assessed using the DAST-10 and AUDIT-C. RESULTS The sample included gay/bisexual (40.4%) and heterosexual (28.1%) men as well as lesbian/bisexual (4.9%) and heterosexual (26.7%) women. Latent class analyses identified four distinct patterns of substance use: Exclusive Alcohol Use; Alcohol and Marijuana; Alcohol and Cocaine/Crack; and Multiple-Substance Use. Variability in the number of missed HIV medication days and perceptions of substance use associated problems were observed across classes, with poorest adherence reported in the Alcohol and Marijuana class, the Alcohol and Cocaine/Crack class, and the Multiple-Substance Use class. The latter two classes also reported the greatest perceived impairment from substance use. CONCLUSIONS Patterns of recent substance use were associated with varying levels of HIV medication adherence and perceived substance use impairment, indicating that substance type matters when considering the health of older adults living with HIV, and that multiple-substance use needs to be addressed by interventions aimed at improving medication adherence.

Contextualizing condom use: Intimacy Interference, stigma, and unprotected sex

Intimate relationships have received increasing attention as a context for HIV transmission. We examined the relationships among perceptions that condoms interfere with intimacy, gay-related stigma, and unprotected/protected anal intercourse. Participants included 245 single-identified men who have sex with men. Intimacy Interference was positively associated with number of unprotected anal intercourse acts, and this effect was stronger among participants who reported high levels of gay-related stigma. In contrast, Intimacy Interference was negatively associated with number of protected anal intercourse acts, and gay-related stigma was positively associated with this outcome with no evidence of interaction effects. The findings are explained in the context of rejection sensitivity theory, and implications for public health and clinical intervention are discussed.

Finding and Recruiting the Highest Risk HIV-Negative Men Who Have Sex With Men

This study compared the ability of different field and online recruitment venues to reach those at highest risk for HIV infection among HIV-negative men who have sex with men (MSM), given that some subgroups are difficult to reach, and venues vary in the demographic characteristics of the samples they yield. Compared to other venues, dating/hookup websites reached significantly higher-than-expected concentrations of White MSM aged 40 and above, including those who reported unprotected anal intercourse (UAI). Facebook was the most successful venue for the recruitment of MSM who used stimulants, including those who reported UAI. MSM who reported UAI were more likely to be recruited online. This study points to systematic variation in the samples obtained via different recruitment strategies, which should be taken into consideration when designing intervention/prevention programs targeting HIV-negative MSM.

Profiles of Executive Functioning: Associations with Substance Dependence and Risky Sexual Behavior

The present investigations applied a theoretical perspective regarding the impact of executive functioning (EF) on sexual risk among substance users, using a methodological approach designed to examine whether EF subtypes differentially predict behavior patterns. Participants included 104 substance-using HIV-negative gay and bisexual men. Participants completed 5 neuropsychological assessment tasks selected to tap discrete EF components, and these data were linked to data on substance dependence and behavioral reports of substance use and sexual risk in the past 30 days. Cluster analysis identified 3 EF subtypes: (a) high performing (good performance across all measures); (b) low performing (poor performance across all measures); and (c) poor IGT performance (impairment on the Iowa Gambling Task [IGT] and its variant, but good performance on all other tasks). The 3 subtypes did not differ in amount of substance use, but the low-performing subtype was associated with greater rates of substance dependence. The low-performing subtype reported the highest rates of sexual behavior and risk, while the poor-IGT-performance subtype reported the lowest rates of sexual risk taking. Global associations between substance use and sexual risk were strongest among the low-performing subtype, but event-level associations appeared strongest among individuals in the high-performing subtype. These data suggest complex associations between EF and sexual risk among substance users, and suggest that the relationship between substance use and sexual risk may vary by EF subtypes.

Rules about casual sex partners, relationship satisfaction, and HIV risk in partnered gay and bisexual men.

The authors used latent class analysis to investigate rules guiding nonmonogamy in partnered gay and bisexual men. Data are from a 2010 survey (N = 463) from which those in relationships (n = 191) were analyzed. More than half (56%) were nonmonogamous, and these men responded to 13 rules about sex outside of their relationship. The safe anonymous sex group (34%) included men who indicated that they must use condoms for anal sex and not have sex with people they know. The communication mandate group (19%) included men who indicated that they must talk about outside partners before sex occurs, disclose their relationship status to outside partners, and use condoms for anal sex. The play together group (9%) included men who indicated that they must play with others as a couple, not have anal sex with outside partners, and not spend the night with outside partners. Those in the no salient rule group (37%) were individuals who did not endorse a clear set of rules. These 4 groups (and compared with monogamous men) differed in age, agreement formality and flexibility, relationship satisfaction, and whether anal sex recently occurred with casual partners. This study provides a novel approach for understanding nonmonogamous same-sex relationships and highlights their complexity.

Syndemic factors associated with HIV risk for gay and bisexual men: comparing latent class and latent factor modeling.

Abstract Syndemics theory has been proposed as a framework for understanding the role of multiple risk factors driving the HIV epidemic among gay and bisexual men. Previous studies have examined five syndemic indicators (polydrug use, depression, childhood sexual abuse, sexual compulsivity, and intimate partner violence). Many of these studies have utilized sum scores, the total number of syndemic factors endorsed, to quantify syndemic stress. This approach assumes a unidimensional latent factor and equivalence of factor loadings. It also overlooks the possibility that patterns, or classes, of syndemic factor endorsement may be present. The current study utilized survey data from 669 gay and bisexual men to test assumptions of unidimensionality and factor loading equivalence and to examine the utility of identifying latent classes of syndemic stress. Analysis supported operationalizing syndemics as a unidimensional latent factor. Assumptions of loading equality were not supported. Meaningful profiles of syndemic stress were not evident in latent class analysis results.

The Psychological Cost of Anticipating HIV Stigma for HIV-Negative Gay and Bisexual Men

Much research has examined the impact of HIV-associated stigma on HIV-positive individuals, but little work has explored its impact on HIV-negative persons. However, many gay and bisexual men may imagine the stigma they would experience upon seroconverting, and this anticipated stigma may be associated with negative mental health. Such concerns may be exacerbated among men who identify with the receptive role during anal sex, because of greater risk for infection. This study examined the association between anticipated HIV stigma and negative affect among 683 HIV-negative gay and bisexual men living in New York City. Anticipated HIV stigma predicted negative affect over and above internalized homonegativity. Sexual role identity was associated directly with anticipated stigma and indirectly with negative affect. Results suggest that anticipated HIV stigma may be an important mental health issue for gay and bisexual men. Public health messaging discussing sexual positioning should be sensitive to the potential for exacerbating anticipated HIV stigma among bottom-identified men.

RELATIVE EFFICIENCY OF FIELD AND ONLINE STRATEGIES IN THE RECRUITMENT OF HIV-POSITIVE MEN WHO HAVE SEX WITH MEN

Efforts to reach HIV-positive men who have sex with men (MSM) and link them to care must be expanded; however, finding and recruiting them remains a challenge. We compared the efficiency of three recruitment sources in reaching self-identified HIV-positive MSM with various characteristics. Relative to recruitment online and at clubs and bars, AIDS Service Organizations (ASOs) were significantly more efficient in reaching HIV-positive MSM in general. This was also true for those with specific characteristics of interest such as substance/stimulant use, and HIV-positive MSM who were racial/ethnic minorities. Both ASOs and online recruitment were more efficient than clubs and bars in reaching HIV-positive MSM not taking HIV medication. This was also the case for White HIV-positive MSM in general, and White HIV-positive MSM who used substances and stimulants. Online recruitment was also more efficient than clubs and bars in reaching HIV-positive MSM who were young across the board.