HIV testing and self-reported HIV status in South African men who have sex with men: results from a community-based survey.

OBJECTIVE: To investigate the characteristics of South African men who have sex with men (MSM) who (1) have been tested for HIV and (2) are HIV positive. METHODS: Data were collected from 1045 MSM in community surveys using questionnaires that were administered either face-to-face, by mail or on the internet. The mean age of the men was 29.9 years. The race distribution was 35.3% black, 17.0% coloured, 5.3% Indian and 41.1% white. RESULTS: The proportion of MSM tested for HIV was 69.7%; having been tested was independently associated with being older, being more open about one's homosexuality and being homosexually instead of bisexually attracted; black MSM, students and MSM living in KwaZulu-Natal were less likely to have been tested. Of the 728 MSM who had been tested, 14.1% (n = 103) reported to be HIV positive (9.9% of the total sample). Being HIV positive is independently associated with two factors: men who were positive were more likely to have a lower level of education and to know other people who had HIV/AIDS; race was not independently associated with HIV status among those who had been tested. CONCLUSIONS: The likelihood of having been tested for HIV seems to decrease with increasing social vulnerability. Racially, the distribution of HIV among MSM seems to differ from that of the general South African population, suggesting that while intertwined with the heterosexual epidemic there is also an epidemic among South African MSM with specific dynamics. These findings suggest that in-depth research is urgently needed to address the lack of understanding of HIV testing practices and HIV prevalence in South African MSM.

Same-sex sexual behavior and psychiatric disorders: findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS).

BACKGROUND: It has been suggested that homosexuality is associated with psychiatric morbidity. This study examined differences between heterosexually and homosexually active subjects in 12-month and lifetime prevalence of DSM-III-R mood, anxiety, and substance use disorders in a representative sample of the Dutch population (N = 7076; aged 18-64 years). METHODS: Data were collected in face-to-face interviews, using the Composite International Diagnostic Interview. Classification as heterosexual or homosexual was based on reported sexual behavior in the preceding year. Five thousand nine hundred ninety-eight (84.8%) of the total sample could be classified: 2.8% of 2878 men and 1.4% of 3120 women had had same-sex partners. Differences in prevalence rates were tested by logistic regression analyses, controlling for demographics. RESULTS: Psychiatric disorders were more prevalent among homosexually active people compared with heterosexually active people. Homosexual men had a higher 12-month prevalence of mood disorders (odds ratio [OR] = 2.93; 95% confidence interval [CI] = 1.54-5.57) and anxiety disorders (OR = 2.61; 95% CI = 1.44-4.74) than heterosexual men. Homosexual women had a higher 12-month prevalence of substance use disorders (OR = 4.05; 95% CI = 1.56-10.47) than heterosexual women. Lifetime prevalence rates reflect identical differences, except for mood disorders, which were more frequently observed in homosexual than in heterosexual women (OR = 2.41; 95% CI = 1.26-4.63). The proportion of persons with 1 or more diagnoses differed only between homosexual and heterosexual women (lifetime OR = 2.61; 95% CI = 1. 31-5.19). More homosexual than heterosexual persons had 2 or more disorders during their lifetimes (homosexual men: OR = 2.70; 95% CI = 1.66-4.41; homosexual women: OR = 2.09; 95% CI = 1.07-4.09). CONCLUSION: The findings support the assumption that people with same-sex sexual behavior are at greater risk for psychiatric disorders.

Sexual problems in gay men: an overview of empirical research.

This article summarizes the findings and theoretical perspectives of 19 empirical studies of sexual problems in gay men. In order to understand these problems better, various differences between male homosexual and heterosexual functioning are discussed first. The studies included differ widely in terms of the issues explored, the populations studied, and the way data have been collected. In a few studies, researchers generally have looked at the prevalence and experience of sexual problems. In other studies, researchers have focused on the etiology and treatment of specific problems, such as sexual desire disorders, sexual aversion, excitement and arousal problems, orgasm disorders, sexual pain disorders and sexual compulsivity. Overall it is surprising how little is known about these problems in gay men. This is also true, however, for same-sex sexuality in general. Suggestions are made for studies that will enable us to obtain a better understanding of sexual problems in gay men.

HIV-positive people, risk and sexual behaviour.

For a long time, the sexual behaviour of HIV-infected persons did not receive any serious attention for a variety of reasons. Initially, diagnosis of HIV-infection appeared to imply a death sentence. In this context, the sex life of those infected seemed a secondary issue making prevention focused on sexual behaviour hard to imagine. Furthermore, the conviction that stigmatisation should be avoided also precluded an interest in the sexual behaviour of HIV-infected persons. From an epidemiological perspective and in the context of the developments in the medical treatment of AIDS it is important to address the sexuality of HIV-infected people. The scarce research done until now shows that there are various ways in which an HIV-infection affects people's sexuality. It seems that the sexuality of HIV-infected people can be compromised by their infection, inducing various sexual problems. Research also shows that there are HIV-infected people who do engage in unprotected sex, just as there are HIV-negative people or people with unknown serostatus who do so. Studies into the determinants of unsafe sex in HIV-infected people suggest that to some extent the same determinants are operative as among people in general. These include intention and self-efficacy regarding safe sex. Recreational drug use also affects safe sex regardless of serostatus. However, safe sex as well as sex in general is different for seropositive persons than for people who are seronegative or have an unknown serostatus. Among seropositive people, sex is also related to dilemma's involving disclosing their serostatus to potential sex partners, and their motivation to protect their partners as well as themselves against surinfection and STD. Furthermore, having to cope with a serious disease induces negative mood states (particularly depression) and may compromise sexual functioning. Comprehensive prevention aimed at HIV infected persons should address these various issues and should be an integrated part of general HIV-prevention.

Reaching homosexual men for HIV surveillance through a gay magazine.

HIV surveillance in homosexual men is poor in most countries, as this risk group is difficult to sample. The aim of this study is to test the feasibility of reaching homosexual men for national HIV surveillance using gay community media. In 1989, a questionnaire on general gay issues, with a section on AIDS, was included in a widely sold gay magazine in the Netherlands. Among 17,700 sold copies, 1134 responses were obtained from males (6%). Of these, 669 men (59%) gave their address, of which in turn 84% responded to a questionnaire on risk behaviour in 1990. In 1991/1992, the 669 men were asked to participate in an HIV serosurvey, in which eventually 308 participated with a blood test (46%) and 147 without (total 68%). Participation in the serosurvey with blood test was associated with reporting multiple partners in 1989. Twenty participants were infected (6.5%). In logistic regression analysis, risk factors for infection were recent unprotected receptive anal intercourse with multiple partners (odds ratio (OR): 10.7; 95% confidence interval (CI): (2.18-52.2); one partner 1.17 (0.31-4.48); none 1) and living in Amsterdam (OR: 3.92; 95% CI: (0.99-15.5); urbanised western Netherlands 2.15 (0.57-8.03); elsewhere 1), while a high educational level was protective (OR: 0.29 (0.08-0.96); middle 0.41 (0.11-1.54); low 1). Among those who participated in 1991/1992, risk behaviour increased between 1989 and 1991/1992 (reporting multiple casual partners rose from 55% to 64%; reporting inconsistent condom use with receptive anal sex from 58% to 71%). Using a predictive model which included self-reported serostatus in 1989, the HIV prevalence rate in 1991/1992 among all male responders to the 1989 questionnaire was estimated to be 5.3% (95% CI: 3.1 7.7%). In conclusion, unless initial response is improved, recruitment through a gay magazine may not allow reliable estimates of HIV prevalence in homosexual men. However, it can be useful at the national level for monitoring changes in prevalence and risk behaviour over time, geographical differences and risk factors for infection.

Avoidance as a predictor of the biological course of HIV infection over a 7-year period in gay men.

The present study prospectively investigated the relation between avoidance coping and active cognitive and behavioral coping and the progression of HIV infection over 7 years in 181 gay men. Findings revealed that for a number of medical and behavioral factors, (a) avoidance coping predicted a lower rate of decline in CD4 cells, (b) the proportional hazard (PH) attributable to avoidance of developing a syncytium-inducing HIV variant was 0.72 (95% confidence interval [CI]: 0.53 - 0.99, p < .05), and (c) the PH attributable to avoidance of dropping below 200 CD4 cells/microl was 0.66 (95% CI: 0.50 - 0.89, p < .01). Avoidance coping was not related to the development of AIDS-defining clinical symptoms. Active cognitive and behavioral coping was not related to the outcome measures.

Homosexual encounters in different venues.

We aim to provide empirical data regarding the role of various sex-on-premises venues for gay men in the spread of HIV infection and homosexual activity with casual partners at different (public) venues was assessed. A questionnaire was filled out by participants in a cohort study in Amsterdam, The Netherlands. Questions were asked regarding sex in private homes, baths, cruising areas, darkrooms, cinemas, and hotel rooms. The majority of the 410 men who had sex with casual partners had done so in private homes (67.8%). However, cruising areas, baths and darkrooms were also highly frequented. Three general 'scenes' of venues frequented could be distinguished, and characteristics of men frequenting different types of venues were found to differ. Men who reported unprotected anal sex did so for only one type of venue. Private homes were the locations where most men engaged in high-risk behaviours. However, the number of partners practising unprotected anogenital sex was highest in (semi) public venues.

Differences in perception of risk for HIV infection with steady and non-steady partners among homosexual men.

In this study it was assessed whether homosexual men who practiced unprotected anogenital intercourse with steady and non-steady partners subjectively perceived their behaviors to be risky. Data were collected from 165 homosexual participants in an ongoing cohort study who reported unprotected anal sex. A variety of psychological factors which could possibly explain why some men were at risk but did not perceive their behavior as such, were investigated. This study showed that the majority of men who engaged in sexual risk behaviors within their primary relationship did not subjectively appraise their behavior as risky. The factors found to explain this discrepancy were not having had sex with a partner known to be HIV infected or to have AIDS (for couples of unknown serostatus) and not having had friends or relatives who were ill or had died (for seronegative couples). Homosexual men who had unprotected anal sex with casual partners generally were aware of the risk involved in their behavior.

Psychosocial group intervention and the rate of decline of immunological parameters in asymptomatic HIV-infected homosexual men.

The aim of the study was to determine changes in the rate of decline of immunological parameters after psychosocial group intervention. Subjects were 26 asymptomatic HIV-infected homosexual men who participated in a cognitive-behavioral group therapy (CBT; n = 14), or an experiential group therapy program (ET; n = 12), both of 15 weeks duration. The outcome measures were changes in the decline of CD4 cell counts, and T cell proliferative responses to anti-CD3 monoclonal antibodies from preintervention to 24 months postintervention. No differences in the rate of decline of CD4 cells or T cell responses between the CBT and ET condition were found, and there were no significant changes in CD4 cell count from pre- to postintervention. However, those subjects who showed larger decreases in distress showed a smaller decline in CD4 cell counts. While the rate of decline in T cell responses was significantly less after both interventions, a similar positive change in T cell responses was found in a comparison group of 149 HIV-infected men with similar demographic, psychosocial and immunological characteristics who did not participate in one of the interventions. We conclude that the psychosocial intervention programs tested here did not cause changes in CD4 cell decline or T cell responses and that decreases in distress were related to increases in CD4 cell counts.

Behavioral risk-reduction strategies to prevent HIV infection among homosexual men: a grounded theory approach.

To be able to design effective health education interventions for homosexual men, it is necessary to understand determinants of safe and unsafe sex from the perspective of those involved. In this qualitative study, therefore, an open approach was taken to allow for this perspective. Interviews were conducted with 50 randomly selected HIV-antibody negative participants in the Amsterdam Cohort Study. Detailed questions were asked about sexual interactions and behaviors with steady and nonsteady partners. Whether or not homosexual men consciously protected themselves from HIV infection and which strategy they adopted was found to depend on three major factors: 1) motivation and intention, 2) significance of anal sex, and 3) risk perception within specific relationships. From a theoretical perspective results indicate that, next to the centrality of individual motivation as postulated in both the Theory of Reasoned Action and the Theory of Planned Behavior, symbolic meaning inherent in sexual acts, as well as type of relationship are important determinants of protective sexual behaviors that have to be taken into account to understand adequately why homosexual men engage in safe or unsafe sex. Some strategies employed by homosexual men carry uncertainties that continue to put them at increased risk for HIV infection. Health education interventions can be designed to address these issues.

Increase in safe sex among the young and non-monogamous: knowledge, attitudes and behavior regarding safe sex and condom use in The Netherlands from 1987 to 1993.

In 1987, the Dutch STD Foundation started several safe sex campaigns targeting the general population. These campaigns have been accompanied by surveys which were conducted every 6 months. Questions were asked about knowledge, attitudes and behavior. The number of people who regard condom use as being a safe sex practice increased over the years, as did the number of people who know that condoms protect against STDs and AIDs. Surprisingly, no accompanying changes in attitudes occurred. Nevertheless, the number of people saying they have done something to prevent HIV infection increased significantly among the young and non-monogamous. Also, specifically in these groups, both actual and intentional condom use increased remarkably. Although it is encouraging that those towards whom the campaigns were particularly directed, show the largest changes, there are also signs that these behavioral changes are levelling off.

Cognitive-behavioral and experiential group psychotherapy for HIV-infected homosexual men: a comparative study.

The knowledge of being infected with the human immunodeficiency virus type 1 (HIV-1) brings about psychological distress and social problems including anxiety, depression, and social isolation. Participating in psychosocial intervention programs can help to reduce these problems. To date, however, very little is known about the efficacy of different intervention strategies. We implemented a study with a randomized experimental design to investigate the effectiveness of a cognitive-behavioral group psychotherapy (CBT) and an experiential group psychotherapy (ET) program for 39 asymptomatic HIV-infected homosexual men. Both therapies consisted of 17 sessions over a 15-week period. The major finding of this study was that psychosocial intervention, independent of the therapeutic orientation, decreased distress significantly, as compared with a waiting-list control group (WCG). There were no significant changes in the intervention groups as compared with the WCG in coping styles, social support, and emotional expression. Finally, CBT and ET did not differ in their effects on psychological distress or on the other psychosocial variables measured in this study.

[HIV infection and unsafe sexual behavior among young homosexual men in Amsterdam, 1992]. / HIV-infectie en riskant seksueel gedrag onder jonge homoseksuele mannen te Amsterdam, 1992.

OBJECTIVE: To determine the prevalence of sexual behaviour with the risk of HIV transmission among young homosexual men in Amsterdam. DESIGN: Point prevalence study. SETTING: Amsterdam. METHODS: Participants were recruited through advertisements and in gay bars and a STD clinic in the period October 1991-1992. A questionnaire regarding sexual behaviour was completed, and blood samples were drawn to test for presence of serological markers of HIV infection, hepatitis B and syphilis. RESULTS: Enrolled in the study were 154 men (mean age: 25 years). The prevalence of antibodies against HIV was 5% and that of hepatitis B 22%. Receptive anogenital intercourse with steady partners in the previous six months was reported by 60% (74% sometimes without a condom), with non-steady partners by 41% (40% without a condom). The figures for insertive anogenital intercourse were: steady partners: 45% (74%); non-steady partners: 49% (41%). Overall 43% (66/153) reported at least one unprotected anogenital contact in the previous six months. The presence of HIV antibodies was correlated with the number of partners with whom anogenital sexual intercourse was practised. CONCLUSION: The HIV prevalence (5%) was relatively low. Considering the high prevalence of unsafe sexual behaviour further spread of HIV infection among young homosexual men is to be expected.

Increase in unprotected anogenital intercourse among homosexual men.

Results are presented from two sources, data of which indicate an increase in high-risk sexual behaviors for human immunodeficiency virus infection among homosexual men. The number of cases of gonorrhea among homosexual and bisexual visitors to municipal sexually transmitted disease clinics in Amsterdam, The Netherlands, is increasing. An increase was also observed in unprotected anogenital intercourse among homosexual participants in the Amsterdam cohort. These findings indicate that a rebound in the behavior change process among homosexual men is occurring. Furthermore, longitudinal behavioral data show that lapse and relapse into unsafe sex are prevalent in the Amsterdam cohort.

Why do homosexual men relapse into unsafe sex? Predictors of resumption of unprotected anogenital intercourse with casual partners.

OBJECTIVE: To assess predictors of relapse into unprotected anogenital intercourse with casual partners among homosexual men in Amsterdam, The Netherlands. DESIGN: A prospective study ongoing since October 1984. METHODS: Self-reported data on sexual behaviour were obtained at 12 semi-annual intervals. Participants who reported unprotected anogenital intercourse with casual partners at wave 12 but not at wave 11 were considered to have relapsed into unsafe sex (n = 47). Men who did not report unprotected anogenital intercourse at wave 11 or at wave 12 were considered to have maintained behaviour change (n = 197). RESULTS: Relapse into unsafe sex with casual partners occurred more frequently among men with a less positive attitude towards condom use, lower personal efficacy with respect to using condoms with casual partners, a weaker intention to avoid anogenital intercourse with casual partners and those who were not involved in a primary relationship. Intention to avoid anogenital intercourse with casual partners was related to an individual's attitude, normative beliefs and personal efficacy with respect to avoiding anogenital intercourse. CONCLUSIONS: In order to improve motivation it is important to support homosexual men in their personal decision-making process, which may be more resolute when the outcome is in accordance with individual preferences. Therefore, health education should be community-based and sensitive to individual needs.

PIP: The objective was to assess predictors of relapse into unprotected anogenital intercourse with casual partners among homosexual men in Amsterdam, The Netherlands. In the period 1984-91 1103 predominantly white, well-educated, homosexual men participated in the study. 340 participants were HIV-antibody-positive, and 763 men were HIV-antibody-seronegative. Self-reported data on sexual behavior were obtained at 12 semi-annual intervals. Mean age of the participants at wave 12 was 41.2 years, and participants had been homosexually active for an average of 23.2 years, Participants were categorized according to sexual behavior in waves 11 and 12, the interval in which an increase in unprotected anogenital intercourse with casual partners was observed. Participants who reported unprotected anogenital intercourse with casual partners at wave 12, but not at wave 11, were considered to have relapsed into unsafe sex (n=47). Men who did not report unprotected anogenital intercourse at wave 11 or at wave 12 were considered to have maintained a behavior change (n=197). Possible predictors of relapse into unprotected anogenital intercourse with casual partners included a large number of variables assessed from wave 9 up to wave 12. Bivariate relations between outcome measure and predictors were first assessed. Significant variables were entered in a multivariate logistic regression analysis. 4 variables were multivariately reacted to maintenance of safer sex behaviors versus relapse into unprotected anogenital intercourse with casual partners. The relationships found indicated that relapse was more likely to occur among participants who had less intention to avoid unprotected anal sex with casual partners (odds ratio (OR) 3.75), were less convinced that they can use condoms with casual sex partners (OR 3.54), had a less favorable attitude towards the use of condoms (OR 3.2), and were not involved in a primary relationship

Estimation of the magnitude of the HIV epidemic among homosexual men: utilization of survey data in predictive models.

A group of 709 randomly selected males aged 18-55 years living in the city of Amsterdam, the Netherlands, were questioned about sexual lifestyle and related behavior. A substantial proportion (10%) of these men appeared to be homo- or bisexual. Of these homo- and bisexual men, 16.5% were predicted to be HIV seropositive, using their behavioral information in logistic regression models derived from a second study among 506 homo- or bisexual volunteers who were questioned and tested for HIV antibodies as well. Generalizing the results of the sample, the magnitude of the homo- and bisexual population in Amsterdam is estimated to be 21,500 (95% confidence interval: 17,000-26,000) of whom 3500 are HIV seropositive. This is in agreement with estimations on the basis of AIDS surveillance data. The study shows that in the absence of serological data it is possible to estimate HIV prevalence, given that the relation between the presence of HIV antibodies and sexual activity or indicators for sexual activity is known. Since serological data are lacking in many occasions, this method may be of help to estimate HIV prevalence in other geographic locations and risk groups.

[Increase in unsafe sex behavior among homosexual men in Amsterdam]. / Toename van onveilig seksueel gedrag onder homoseksuele mannen in Amsterdam.

Since 1984 a decrease in the prevalence of unprotected anogenital intercourse among homosexual men was observed in a longitudinal cohort study in Amsterdam. Two years ago, there was a strong indication that this trend was reversed, as the number of cases of gonorrhoea among homo- and bisexual visitors of the municipal STD clinic in Amsterdam started to increase again. In addition, recent analysis of behavioural data reported by participants in the cohort showed an increase in the percentage of men who had unprotected insertive or receptive anogenital intercourse (p < 0.05). Between the second half of 1990 and the second half of 1991, the percentage of men reporting unprotected insertive or receptive anogenital contact with a steady partner remained constant: 24.6% versus 27.7%. However, a serious increase occurred in the percentage of men having unprotected anogenital intercourse with casual partners (an increase from 13.1% to 24.0%; p < 0.01). Findings regarding the age distribution among homo- and bisexual men diagnosed with gonorrhoea indicate that the increase in unprotected anogenital contact was strongest among men under the age of thirty.

Orogenital sex and the transmission of HIV among homosexual men.

OBJECTIVE: To investigate the possibility of orogenital transmission of HIV. DESIGN: Cohort study on HIV infection among homosexual men. SETTING: The Municipal Health Service, Amsterdam, The Netherlands. PATIENTS, PARTICIPANTS: Homosexual men for whom the date of HIV seroconversion was known (n = 102) were included in our study. MAIN OUTCOME MEASURES: Data on the sexual behaviour of our subjects in the 6-9 months preceding HIV seroconversion were collected. In order to identify those men who consistently denied practising receptive anogenital intercourse, information was retrieved from written questionnaires and from face-to-face interviews. RESULTS: Receptive anogenital intercourse in the 6-9 months before seroconversion was denied by 20 seroconverters in their written questionnaires. However, in face-to-face interviews, 11 men later reported this sexual practice. CONCLUSIONS: Orogenital transmission of HIV appears to occur, but its frequency may be overestimated because of reluctance to report the practice of receptive anogenital intercourse.