Zohar Mor

Men Who Have Sex With Men, Risk Behavior, and HIV Infection: Integrative Analysis of Clinical, Epidemiological, and Laboratory Databases

BACKGROUND Centralized data collection and analytic tools facilitate tracing HIV transmission trends at the patient-population level with increasing resolution, complementing behavioral studies while avoiding sampling biases. By several measures, the rate of HIV infection among men who have sex with men (MSM) in Israel increased in the past several years more rapidly than was expected. We describe features of the data that connect this increase to behavioral changes. METHODS We retrospectively analyzed data from the national HIV reference laboratory and the national HIV and sexually transmitted infections registries. We examined changes in selected epidemiologic and clinical parameters and in the pattern of drug-resistant virus transmission among MSM in Israel. In particular, virus isolates from 296 MSM (23.8% of all MSM who received a diagnosis) were genotyped, drug-resistance conferring mutations were characterized, and phylogenetic trees were constructed. RESULTS Compared with earlier years, during 2007-2009 MSM were more often infected with drug-resistant virus before treatment initiation, were coinfected with syphilis, and received a diagnosis during acute retroviral syndrome. Phylogenetic analysis suggested frequent transmission of drug-resistant HIV by drug-treated individuals to >1 partner. Secondary transmission of resistant virus by drug-naive patients is also consistent with the phylogenetic patterns. In addition, non-B HIV subtypes began to appear among MSM. CONCLUSIONS Together, our findings suggest that the sexual behavior of MSM, both HIV-infected and uninfected, has become riskier, contributing to the number of those seeking early clarification of status, to syphilis comorbidity, and to the spread of drug resistance. These findings call for action by public health planners and community-based organizations aimed at increasing awareness of the risks, bringing a change in attitude and establishing safe sex norms.

Pre-immigration screening process and pulmonary tuberculosis among Ethiopian migrants in Israel.

More than 75,000 displaced Ethiopians have moved to Israel. Tuberculosis (TB) incidence in Ethiopia is 44 times higher than in Israel (344 versus 8 cases per 100,000 inhabitants, respectively). The aims of the present retrospective cohort study were to evaluate the pre-immigration screening process initiated in 2001 on pulmonary TB (PTB) morbidity and to assess its cost-effectiveness. Ethiopian immigrants who were screened before departure (study group) were compared with those who were screened after arrival (comparison group). Between 1998 and 2005, 24,051 Ethiopian immigrants arrived in Israel. PTB was diagnosed in 332 (1.4%) immigrants, an incidence density of 325 patients per 100,000 person-yrs. PTB cumulative incidence was lower in the study group than in the comparison group: 711 compared with 1,746 patients per 100,000 immigrants, respectively (rate ratio 0.4). PTB was detected significantly earlier in the study group than in the comparison group: 193 versus 487 days after entry, respectively. Disease incidence declined significantly during the first 2 yrs following immigration. A 5-yr predictive model indicated that 98 individuals would be free of PTB, saving US

Knowledge, attitudes, sexual practices and STI/HIV prevalence in male sex workers and other men who have sex in Tel Aviv, Israel: a cross-sectional study

91,055 on annual treatment cost, due to screening. The pre-immigration screening process reduced pulmonary tuberculosis incidence in subsequent years following immigration. Pulmonary tuberculosis was diagnosed earlier in the screened group than in the comparison group and the process was found to be both cost-beneficial and cost-effective.

Thirty years of HIV in Israel: current epidemiology and future challenges

Objective To explore knowledge, attitudes and sexual practices of male sex workers (MSW) in Tel Aviv in comparison with men who have sex with men (MSM) classified by their risk behaviours and to outline attributes related to sexually transmitted infections (STI)/HIV prevalence. Methods MSW were recruited for this cross-sectional study from designated street venues and gay-dating internet site. MSM were recruited from gay-related venues and divided into high-risk MSM (HRMSM) if they performed unprotected anal intercourse in the last 6 months with an HIV-discordant/unknown partner and to low-risk MSM (LRMSM). Each participant completed a questionnaire and was tested for STI/HIV. Results Of 87 MSW and 635 MSM approached, 53 (60.9%) and 235 (37.0%) participated, respectively. Street-MSW (N=32) had more female sex partners and were more drug dependent than internet-MSW (N=21). No differences were found in their knowledge regarding STI/HIV transmission, practices and STI/HIV burden. Compared with HRMSM, MSW had different demographic attributes and demonstrated more realistic perception regarding the risk to getting STI/HIV, while no differences were found in their knowledge and sexual practices. STI burden among MSW, HRMSM (N=119) and LRMSM (N=116) were 28.3%, 23.5% and 10.3% (p=0.009) and HIV burden among MSW, HRMSM and LRMSM were 5.6%, 9.2% and 0%, (p=0.001), respectively. Multivariate models evaluating attributes associated with HIV/STI diagnosis did not find sex work to be significant if the variable used was MSW versus HRMSM, regardless of the adjustments performed. However, when MSW versus LRMSM was used in the model, sex work was associated with STI/HIV diagnosis. Conclusions Street-MSW and internet-MSW, similar to all MSW and HRMSM, had comparable sexual practices and had no difference in their STI/HIV prevalence.

High-risk behaviour in steady and in casual relationships among men who have sex with men in Israel

Objective The HIV/AIDS burden in Israel is increasing. This study aims to describe the nationwide-HIV epidemiology in the last 30 years and highlight areas of concern in HIV/AIDS control. Design Descriptive study. Setting The National HIV/AIDS Registry in Israel. Participants All individuals who were reported with HIV/AIDS in Israel. Primary outcome measures Classification of HIV/AIDS cases by risk groups, calculation of annual trend analysis and estimation of HIV transmission rates by dividing the annual HIV/AIDS-incidence by the prevalence, while the number of newly diagnosed HIV/AIDS cases reported was a proxy of the incidence. Results From 1981 to 2010, 6579 HIV/AIDS cases were reported in an upward trend from 3.6 new HIV diagnoses/100 000 population in 1986 to 5.6 in 2010. Immigrants from countries of generalised epidemic (ICGE) comprised 2717 (41.3%) of all cases: 2089 (76.9%) were Israeli citizens and 628 (23%) were non-Israeli citizens, mostly migrant workers. The majority (N=2040) of ICGE Israeli citizens were born in Ethiopia. Only 796 (12.1%) of all HIV/AIDS cases were heterosexuals who were non-ICGE and not injecting drug users (IDUs). IDU comprised 13.4% (N=882) of all cases. Men who have sex with men (MSM) accounted for 33.2% (N=1403) of all men reported, while the annual number of MSM reported with HIV/AIDS has quadrupled between 2000 and 2010. It is estimated that the HIV point prevalences in 2010 for Ethiopian-born Israeli citizens, IDU and MSM aged 16–45 were 1805, 1492 and 3150, respectively. The crude estimated transmission rates among Israeli citizens, excluding the Ethiopian-born, was 10.5, while among Ethiopian-born Israeli citizens, IDU and MSM the rates were 3.6, 6.3 and 13.2, respectively. Conclusions The HIV/AIDS burden in Israel is low among heterosexuals and higher in risk-groups. Among these risk groups, the highest HIV transmission rate was in MSM, followed by IDU and ICGE. Culturally sensitive and focused prevention interventions should be tailored exclusively for each of the vulnerable risk groups.

Individual and Community Resilience Factors Among Lesbian, Gay, Bisexual, Queer and Questioning Youth and Adults in Israel

Objective To explore the differences in sexual risk behaviour between men who have sex with men (MSM) with steady partners versus casual partner(s) in the gay community. Methods This online cross-sectional convenience-sampling study assessed MSM practices, their knowledge and their motivation regarding safe sex. Participants not knowing their HIV status or who performed insertive or receptive unprotected anal intercourse (UAI) or with a sex partner whose HIV status was unknown or discordant were considered ‘at-risk’. Results Of all 2569 participants who completed the questionnaire, 907/2569 (35.3%) had a steady partner, and 896/2569 (34.9%) had a casual partner(s) in the past 6 months. 262/907 (28.9%) with steady partners and 248/896 (27.7%) with casual partners demonstrated at-risk sexual behaviour. Of all participants with steady partners, 108/907 (11.9%) performed UAI with their partner without undergoing mutual HIV testing. Of all participants with steady partners, 476/907 (52.5%) had a concurrent casual partner, and 144/476 (30.3%) performed UAI with both the steady and the casual partner. Of all participants with steady partners, 775/907 (85.4%) negotiated the possibility of sex outside their relationship with their main partner. The length of the steady relationship correlated with the number of concurrent casual partners. Conclusions At-risk sexual behaviour was associated with insufficient negotiation skills, difficulties in condom use and a general risk-taking profile. Health educators should encourage MSM with steady partners to perform HIV testing before practising UAI, to improve their negotiation skills during the contact and to support open discussions with regard to sexual contact besides the steady relationship, as it may not be monogamous.

Gym exercising patterns, lifestyle and high-risk sexual behaviour in men who have sex with men and in heterosexual men

Drawing on resilience theories, this study examined the individual and community factors of Israeli lesbians, gays, bisexuals, queers, and questioning (LGBQs) that contribute to positive mental health and the degree to which individual and community protective factors mitigate the adverse effect of risk factors for poor mental health. Differences in resilience factors between LGBQ youth and adults were explored. Data were collected on 890 LGBQ youth and adults. Findings emphasize the role of community-level resilience factors in the lives of LGBQs, and that these support systems differ slightly between the two age groups. Among youth, family support was both a strong predictor for well-being and a protective factor for mental distress. Although family support was found as a resilience factor among adults as well, other community-level factors (friends’ support, LGBT connectedness and having steady partner) were found as protective factors for poorer mental health. These findings suggest for efforts on fostering familial support for LGBQ youth and a multi-level system that offers support at the familial, peer, relationship and community levels for both LGBQ youth and adults.

Childhood tuberculosis in Israel: epidemiological trends and treatment outcomes, 1999–2010

Objective Lifestyle may be associated with risk behaviours. This study compares gym exercise and sexual risk behaviour between men who have sex with men (MSM) and heterosexual men. The research was based on the assumption that men who become muscular and physically attractive increase their number of sex partners and consequently their risk of HIV or other sexually transmitted infections (STIs). Setting Five gyms in central Tel Aviv, Israel. Participants In 2012, a sample of 182 (48%) MSM and 197 (52%) heterosexual men who train in gyms completed anonymous questionnaires regarding their training, health and sexual behaviours. Outcomes Participants in this cross-sectional study who exercised more than the median number of anaerobic training hours were defined as performing intensive anaerobic training (IAT), and those who had performed more than one act of unprotected anal/vaginal intercourse in the preceding 6 months with a partner whose HIV status was unknown were defined as high risk. Results MSM showed a stronger desire to become muscular than heterosexual men, were more likely to perform IAT, and used protein powders or anabolic steroids. They reported that improving their body shape and increasing their self-confidence were their main reasons for training, whereas heterosexual men indicated weight loss and health improvement as the main reasons for training. MSM engaged in riskier sexual behaviour than heterosexual men. Of all the high-risk men, 61.9% (N=70) performed IAT, while 38.1% (N=43) performed moderate anaerobic training (p<0.01). The association between IAT and sexual risk was stronger in MSM than in heterosexual men (p<0.01 vs p=0.05, respectively). The interaction between MSM and IAT in high-risk participants was multiplicative. Conclusions MSM practised more IAT than heterosexual men, and their interaction between IAT and sexual risk was multiplicative. The MSM community could benefit from a holistic approach to sexual health and its association with body image and IAT. The gym MSM culture demonstrates how internal dynamics and social norms are possible factors driving MSM to high-risk behaviour for HIV/STI. Study registration The study was approved by the Wolfson Hospital Review Board, Holon, Israel (WOMC-0058-09).

Seeking sex online: social and sexual risk factors among adolescent and young gay and bisexual men

Childhood tuberculosis (TB) poses a high risk for morbidity and death. This study describes the characteristics of childhood TB in Israel and examines treatment outcomes. Data sources were the National TB Registry and the National Civil Census. Between 1999 and 2010, 416 children (aged <18 years) had TB, averaging 1.5 per 100 000 children (range 0.6–3.2), demonstrating a declining trend. The average proportion of all TB cases reported annually that were in children was 8.4% (range 5.4–11.8%). Most (n=320, 79%) of the childhood TB cases were pulmonary. TB rates were highest for the 0–4-year age group and lowest for the 10–14-year age group. Of all childhood TB cases, 236 (56.7%) were born in countries with high prevalence of TB: 214 were Israeli citizens who were Ethiopian-born and 22 were non-Israeli citizens. The overall childhood TB incidence in 2010 was 1.05 cases per 100 000 children. The incidence of TB for Israeli-born children, children whose parents were Ethiopian-born and children of migrant workers was 0.55 per 100 000, 7.5 per 100 000 and 50–100 per 100 000, respectively. Cultures were taken from 60% of all childhood TB cases. Most children (97.8%) achieved treatment success, while three children (0.7%) died. Overall, rates of childhood TB rates in Israel are decreasing. However, children of parents born in countries with a high prevalence of TB are still at high risk of developing TB. Bacteriological confirmation should be encouraged to improve control of childhood TB.

A Population-Structured HIV Epidemic in Israel: Roles of Risk and Ethnicity.

UNLABELLED Background With the increased use of the Internet to seek sex, research has documented its associated sexual risk behaviours, especially among gay and bisexual men. Only a few studies to date have been conducted among adolescent and young men, and these have focussed on behavioural components to do with seeking sex online, without considering the role of same-sex identity formation processes. The current study aimed to identify behavioural and identity formation variables associated with seeking sex online among adolescents and youth. METHODS A web sampling of young Israeli gay and bisexual men aged 12-30 years (n=445) was used to assess their seeking sex online characteristics, mental health, sexual risk behaviours, substance use, same-sex disclosure and acceptance and coping resources. RESULTS Nearly half of the sample used the Internet to seek sex, which was correlated with substance use and sexual risk behaviour. Young adults seek for sex online more commonly than adolescents. Higher numbers of: sexual partners, level of outness, levels of friends support and stronger connectedness to the gay community predicted seeking sex online. Seeking sex online was found to be more of predictor for sexual risk behaviour than any other predictor. CONCLUSIONS Seeking sex online is influenced by the gay sub-culture climate and peer group relationships, rather than by social stressor variables related to sexual orientation formation processes, or by the subjects general mental health condition. These results underscore the possible risks pertaining to seeking sex among gay and bisexual men and the possible use for this venue to convey safe-sex messages to adolescents and young adults.