Screening for depressive symptoms in an online sample of men who have sex with men.

Depression is a debilitating disorder and relatively high rates have been reported in studies of men who have sex with men (MSM). This study was undertaken to assess the utility of screening for, and characteristics associated with, depressive symptoms in an online survey of MSM. In 2003-2004, an online cross-sectional study was conducted among 2,964 MSM from the US and Canada. Using the two-item Patient Health Questionnaire (PHQ-2), 18% of the study participants screened positive for depressive symptoms within the past three months. Characteristics associated with a positive PHQ-2 screen for depressive symptoms in multivariate analysis included: having less than a high school or college degree; being single (not having a primary male partner) or being married to a woman; being HIV-positive; and not having recent sex. Additionally, among men who screened positive on the PHQ-2, predictors of not having treatment from a mental health provider in the past year were: low education; being black/African American/Canadian or Hispanic; and having no primary care provider. The Internet is a viable medium to reach and screen men at-risk for depression. Future work is needed for online outreach and connection to offline assessment as well as intervention.

Characteristics of HIV antiretroviral treatments, access and adherence in an ethnically diverse sample of men who have sex with men.

Data regarding HIV antiretroviral treatment regimens, access to treatment and medical care, and adherence to medications were collected as part of the Seropositive Urban Men's Study, a formative study of HIV-positive men who have sex with men. Participants (N = 456) were recruited from AIDS service organizations, mainstream gay venues and public/commercial sex environments. The sample was 94% gay or bisexually-identified; 29% were African American, 24% Latino and 30% white. The majority (71%) indicated being on antiretroviral treatment, and most were taking a protease inhibitor/nucleoside reverse transcriptase inhibitor combination. African American men in New York City were less likely to be on treatment. Among those on treatment (n = 322), 51% reported at least one day in which they had missed a dose of their medication and the mean number of days in which a dose was missed (in the past 30 days) was 1.72. Multivariate analyses indicated that avoidant coping, frequency of drinking alcohol and difficulty in communicating with sex partners about HIV were related to days of missed doses, suggesting the need or desire to escape from the reality of life with HIV as a potential explanation for poor adherence.

Awareness and use of untested barrier methods by HIV-seropositive gay and bisexual men.

Little is known about HIV-seropositive men's awareness and use of untested barrier methods during anal intercourse. A sample of 240 HIV-seropositive men (69.2% men of color) completed a self-administered survey that included items on nonoxynol-9 (N-9), female condoms, and the simultaneous use of two male condoms (double bagging). Most participants (79.6%) had heard of N-9 being used to prevent HIV transmission during anal intercourse. Of these, 20.0% rated N-9 as more effective than condoms, and 14.6% had used N-9 instead of condoms. Fewer men (35.4%) were aware of female condoms being used during anal intercourse. Overall, few respondents (5.4%) had used female condoms; 53.8% of whom rated the device as more pleasurable than male condoms. Most men (69.6%) had heard of double bagging, and 35.2% had engaged in this practice. Of these, 45.1% rated the practice as less pleasurable than using a single condom. Few associations were observed between participant characteristics and the awareness or use of these barrier methods. The widespread use of these untested methods emphasizes the urgent need to further educate HIV-seropositive men about the potential risks of N-9 use and to test the effectiveness of other strategies that may serve as alternatives to male condom use.

Are we headed for a resurgence of the HIV epidemic among men who have sex with men?

HIV remains a critical health issue for men who have sex with men (MSM). In the United States, an estimated 365,000 to 535,000 MSM are living with HIV, and 42% of new HIV infections occur in this population. Recent data on sexually transmitted diseases and on sexual behavior indicate the potential for a resurgence in HIV infections among MSM. Outbreaks of gonorrhea and syphilis have been reported in a growing number of cities, and several studies have observed an increase in unprotected anal intercourse among MSM. These increases in HIV risk behavior may be attributed to several factors that have affected the sexual practices of MSM, including changes in beliefs regarding the severity of HIV disease. These emerging data have implications for surveillance and intervention research activities and indicate a need to reevaluate, refocus, and reinvigorate HIV prevention efforts for MSM. Our recommendations for addressing the HIV prevention needs of MSM include the need to consider HIV-related issues within the broader context of the physical, mental, and sexual health of MSM.

Getting the message: HIV information sources of women who have sex with injecting drug users -- a two-site study.

PIP: A field interview was conducted among 325 female sex partners (FSPs) of male injecting drug users (IDUs) in New York City and Long Beach, California, to assess FSPs¿ source of HIV information; attitudes and beliefs regarding the disease and condom use; and risk behaviors. Findings revealed that the subjects, whose only current risk was sexual contact with a drug-injecting partner, were mostly Latino women (62%) or African American women (29%) in their early to mid 30s. One-third had a history with injecting drug use and one in six had previously traded sex for money or drugs. Most of them were presently at-risk for HIV infection; and reported little or no condom use during sexual contact with a male IDU partner. In comparison with FSPs in Long Beach, FSPs in New York: were more knowledgeable about HIV transmission; perceived themselves as being at-risk for exposure to HIV from having unprotected vaginal intercourse with their main partners; have positive attitudes toward condom use; perceived social pressure in using condoms with their main partners; and were more exposed to HIV information from mass media, small media and interpersonal resources. The study generally indicated that FSPs in Long Beach and New York are reachable and reported attitudes and knowledge that support the use of condoms with their main partners.^ieng

HIV prevention case management: current practice and future directions.

Prevention case management (PCM) for HIV is an intervention developed in the early 1990s by combining individual HIV risk-reduction interventions and case management. To learn about the practice of PCM, staff from the Centers for Disease Control and Prevention (CDC) interviewed staff at the 25 community-based organizations directly funded by CDC to conduct PCM and visited seven of these agencies. Most of the programs (80 percent) served HIV-seropositive and HIV-seronegative people. Results indicated considerable variation in the structure of PCM programs, the types of services, and the populations served.

HIV serostatus disclosure among gay and bisexual men in four American cities: general patterns and relation to sexual practices.

The present study examined patterns of serostatus disclosure among previously untested HIV-seropositive and HIV-seronegative gay and bisexual men recruited from four American cities (n = 701). Six months after learning their HIV serostatus, 97% of study participants had disclosed their test results to at least one other individual. Consistent with earlier studies, test results were most frequently shared with friends and the respondent's primary partner. HIV serostatus was disclosed less frequently to family members, co-workers, and non-primary sex partners. Compared with HIV-seronegative men, HIV-seropositive men were more likely to have disclosed their status to a health care provider and less likely to have shared this information with family members. Of seropositive men, 11% did not disclose their serostatus to their primary partner and 66% did not disclose to a non-primary sex partner. Of HIV-seropositive men with one or more non-primary partners, 16% of those who did not disclose their serostatus reported inconsistent condom use during anal intercourse with these partners. No significant differences in self-reported sexual practices were observed for HIV-seropositive disclosers versus non-disclosers. Compared with HIV-seronegative men who did not disclose, seronegative men who shared information about their serostatus were more likely to have had receptive anal intercourse with their primary partner (p < 0.05) and to have engaged in mutual masturbation (p < 0.005), receptive oral sex (p < 0.005) and insertive anal intercourse (p < 0.05) with non-primary partners. No significant differences were observed between disclosers and non-disclosers with regard to condom use. Implications of the findings for future research and HIV prevention programmes are discussed.

Sex hustling, injection drug use, and non-gay identification by men who have sex with men. Associations with high-risk sexual behaviors and condom use.

OBJECTIVE: To explore differences in demographic characteristies, risk practices, and preventive behaviors among subgroups of men who have sex with men (MSM), including gay- and non-gay-identified MSM, MSM who inject drugs, and those engaging in sex hustling. DESIGN: A secondary analysis of cross-sectional data collected through interviewer-administered questionnaires in a purposive sample of MSM. SETTING: Gay bars, bath houses, adult video arcades, and out-door crusing areas in Denver and Long Beach. PARTICIPANTS: Men who reported oral or anal sex with another man in the past year with oversampling of non-gay-identified MSM. RESULTS: Of 1,290 MSM, 417 (32%) did not gay-identify, 86 (7%) were drug injectors, and 117 (9%) were hustlers. Of drug-injecting MSM, 55% reported sex hustling and 40% of hustlers reported injection drug use. Hustling was associated with higher number of partners, more frequent anal sex with men and women, and less frequent condom use during anal sex with occasional male partners. Hustlers and drug-injecting MSM used condoms less consistently during vaginal intercourse with female partners than did other MSM. CONCLUSIONS: Among MSM, subgroups at particularly high risk for HIV can be identified. Although these subgroups may be relatively small, they may be important epidemiologic links to the larger MSM and heterosexual communities and warrant focused behavioral interventions to prevent the further spread of HIV.

PIP: With HIV incidence rates as high as 0.7-2.4% per year, men who have sex with men (MSM) accounted for half of all AIDS cases and 43% of non-AIDS HIV cases among men reported to the US Centers for Disease Control and Prevention in 1996. Subgroups of MSM who are at particular risk of HIV infection, such as MSM who inject drugs, MSM who have sex in exchange for money or drugs (hustlers), and non-gay-identified MSM, may be less likely to be reached by HIV/AIDS prevention messages targeted at the broader MSM community. Sex behavior-related data were collected from 1290 MSM recruited in Denver and Long Beach from gay bars and bath houses, adult video arcades, and outdoor cruising areas between September 1993 and June 1994. The 531 MSM sampled in Denver and 759 in Long Beach reported having had sex with a man during the preceding year. 417 (32%) were non-gay-identified, 86 (7%) had injected drugs in the past 6 months, and 117 (9%) had exchanged sex for drugs or money. 10% of non-gay-identified men identified themselves as being straight. Of drug-injecting MSM and hustlers, 19% and 13%, respectively, were straight-identified. Detailed information on HIV testing and serostatus, number of partners, and sex practices, including condom use, was available for the 482 men who had reported anal or oral sex with a man or who had injected drugs in the past 30 days. 55% of drug-injecting MSM reported sex hustling and 40% of hustlers reported IV drug use. Hustling was associated with a higher number of sex partners, more frequent anal sex with men and women, and less frequent condom use during anal sex with occasional male partners. Hustlers and drug-injecting MSM used condoms less consistently during vaginal intercourse with female partners than did other MSM.

Impact of a longitudinal community HIV intervention targeting injecting drug users' stage of change for condom and bleach use.

PURPOSE: To evaluate the impact of the Long Beach AIDS Community Demonstration Project, a community-based HIV-prevention intervention incorporating principles from the Transtheoretical model in its design and evaluation. DESIGN: Repeated cross-sectional sampling with matched intervention and comparison communities. SETTING: Neighborhoods in Long Beach, California, having a high prevalence of drug abuse and prostitution. SUBJECTS: 3081 injecting drug users who were sexually active and/or shared injection equipment. INTERVENTION: Trained peer volunteers distributed fliers featuring role model stories targeted to the population's stage of change. Fliers were packaged with bleaching kits and/or condoms. MEASURES: Primary outcome measures were exposure to the intervention, condom carrying, and stage of change for disinfecting injection equipment with bleach and for using condoms with main and other partners. RESULTS: Toward the end of the study, 77% of injection drug users in the intervention area reported being exposed to the intervention. In the intervention area, rates of condom carrying increased from 10 to 27% (p < .001), and there was an increase from 2.32 to 3.11 in mean stage of change for using condoms with other partners, while stage of change decreased in the comparison area (p < .01). Mean stage of change for using condoms with a main partner also increased in the intervention area, but the difference was not significant after controlling for change in the comparison area. Subjects with recent project exposure had higher stage-of-change scores for using condoms with a main partner (p < .05) and other partners (p < .01) and for cleaning injection equipment with bleach (p < .05). CONCLUSIONS: The results demonstrate the effectiveness of the AIDS Community Demonstration Project intervention for reaching injecting drug users in the community and for motivating the adoption of risk-reducing practices.

PIP: The impact of the Long Beach (California, US) AIDS Community Demonstration Project, a community-based HIV prevention intervention based on the principles of the transtheoretical model of behavioral change, was tested in selected areas with high concentrations of intravenous drug users and prostitutes. Enrolled in repeated cross-sectional samples with matched intervention and comparison communities were 3081 injecting drug users who were sexually active and/or shared injection equipment. In the intervention areas (n = 1497), trained peer volunteers distributed fliers featuring role model stories targeted to the population's stage of change as well as bleaching kits and/or condoms. By the last data collection wave, 77% of injecting drug users in the intervention area had been exposed to the project. Rates of condom carrying increased from 10% to 27% in this group and there was an increase from 2.32 to 3.11 in mean stage of change for using condoms with partners other than a main partner; the increase in stage of change for using condoms with a main partner was not significant. In contrast, condom use in the nonintervention area remained stable at about 8% and the stage of change for condom use with main and other partners decreased. Subjects with recent project exposure had higher stage-of-change scores for using condoms with a main partner and other partners and for cleaning injecting equipment with bleach. Overall, these findings support the utility of community-based approaches to changing behaviors that are related to a risk of HIV infection.

The effects of HIV counseling and testing on risk-related practices and help-seeking behavior.

In an earlier review of the behavioral effects of HIV counseling and testing (HIV CT), Higgins and colleagues (1991) found that the evidence regarding the ability of HIV CT to influence HIV-risk related practices was largely inconclusive. This article reviews 35 domestic and international studies published since that time to reassess the scientific data regarding the ability of HIV CT to motivate changes in risk-related practices and to promote help-seeking behavior. The studies identified for this review were grouped into four categories according to subject population: (1) men who have sex with men, (2) injection and other drug users, (3) women and heterosexual couples, and (4) mixed samples recruited from sexually transmitted disease (STD) clinics and other settings. Findings from the studies reviewed were generally mixed--many provided at least some evidence supporting the ability of HIV CT to motivate risk-reducing and help-seeking behavior, but others did not. The pattern of results varied substantially across, and within, study populations and were often limited by considerable methodological weaknesses.

Bleaching injection equipment: influencing factors among IDUs who share.

This study investigates factors influencing needle-bleaching intentions and behavior among IDUs who share injection equipment. Analysis of 443 interviews conducted with IDUs who share revealed that intention to bleach and frequency of bleaching were positively associated with attitudes, social norms, perceived behavioral control, and perceived risk of unsafe sharing. Intention was related (positively) to exposure to AIDS-prevention information, whereas frequency of bleaching was associated (negatively) with frequency of intoxication. Exposure to AIDS information may be more effective in creating intention to bleach needles than in stimulating behavior, and noninjection drug use may inhibit bleaching behavior.

Sources of HIV information among injecting drug users: association with gender, ethnicity, and risk behaviour. AIDS Community Demonstration Projects.

Sources of HIV information were examined for 774 male and female injecting drug users (IDUs). The majority (80.7%) had received HIV information from one or more sources in the prior 3 months. The most frequently mentioned sources were television (39.9%) and friends or family (22.2%). There were few differences in source of HIV information with regard to gender, ethnicity, or age. Differences were more frequently observed between cities. The relationship of information source and subject characteristics with HIV knowledge, perceived risk, drug-related and sexual practices was examined using logistic regression. For men, exposure to mass media sources (OR = 1.48) and small media materials (OR = 2.03) were related to HIV knowledge. Small media and interpersonal information were related to HIV testing for men (OR = 1.95 and 1.85, respectively) and women (OR = 2.25 and 2.54). Interpersonal sources of information were also associated with increased sharing of injection equipment (OR = 2.04) and bleach use (OR = 2.23) among female IDUs. Significant differences in HIV knowledge and risk-related practices were also observed for ethnicity, city, men who have sex with men, and women who had traded sex for money or drugs. Implications for targeting HIV prevention efforts for IDUs are discussed.

Sources of AIDS information among low-risk and at-risk populations in five U.S. cities. AIDS Community Demonstration Projects.

Sources of HIV information were examined for 4,329 residents in five inner-city neighborhoods. Half of the respondents were female; 58% were African American, 21% Hispanic, and 21% White. Forty-nine percent of participants reported one or more practices contributing to HIV risk: injection drug use (35%), sexual contact with an injection drug user (31%), prostitution (27%), or for men, anal sex with a male partner (5% of males). Most had received HIV information in the prior three months through mass or small media sources (78%), and 47% had spoken with someone about HIV. Television was the most frequently mentioned media source (48% of all respondents), while friends and family were the most frequently cited interpersonal source (20%). Exposure to specific mass and small media sources was related to gender, ethnicity, and risk status. Women and individuals at-risk of HIV infection were most likely to have talked with someone about HIV in the past three months. African Americans, however, were less likely to have discussed HIV. Differences associated with gender, ethnicity, and risk status were also observed for interpersonal information sources. Implications for future HIV education efforts are discussed.

Increasing the use of bleach and condoms among injecting drug users in Denver: outcomes of a targeted, community-level HIV prevention program.

OBJECTIVE: To evaluate the impact of an HIV risk-reduction program among injecting drug users (IDU) in Denver, Colorado. DESIGN: A targeted, community-level intervention study with multiple, time-phased, cross-sectional measurements assessing HIV high-risk behaviors among IDU in intervention and comparison sites. SETTING: Neighborhoods with high IDU prevalence in Denver, Colorado (intervention site) and Long Beach, California (non-intervention comparison site). PARTICIPANTS: Street-recruited IDU who had injected drugs in the previous 30 days and shared injection equipment in the previous 60 days to evaluate the use of bleach to clean injection equipment; or had sexual intercourse in the previous 30 days, to evaluate condom use. INTERVENTION: A prevention program in which peer volunteers were recruited and trained to distribute and discuss intervention kits that included condoms, bleach bottles and role model stories. MAIN OUTCOME MEASURES: Multiple cross-sectional surveys were conducted in the intervention and comparison sites to assess the impact of the intervention on the consistent use of bleach before sharing injection equipment and the consistent use of condoms for vaginal intercourse with steady and occasional partners. RESULTS: Between February 1991 and December 1993, 1997 IDU were interviewed, 890 at the intervention site and 1107 at the comparison site. In contrast to the comparison site, subjects from the intervention site reported significant increases in consistent use of bleach [odds ratio (OR), 2.6; 95% confidence interval (CI), 1.3-5.1; P < 0.001], and consistent use of condoms with occasional partners (OR, 13.6; 95% CI, 3.2-58.0; P < 0.001). CONCLUSION: This targeted, peer-based intervention was associated with significant HIV risk reduction among IDU in Denver and may be useful in other communities at risk for HIV infection.

Condom use with main and other sex partners among high-risk women: intervention outcomes and correlates of reduced risk.

PIP: As part of the Acquired Immunodeficiency Syndrome (AIDS) Community Demonstration Projects program, a community-level HIV prevention program was implemented among high-risk women (female sex workers and intravenous drug users or their sex partners) from Long Beach, California, US, during 1991-94. The intervention, based on health behavior theory and formative research, included publications portraying the experiences of local role models moving through the stages of behavioral change, distribution of role-model stories by peer volunteers, and environmental facilitation through distribution of condoms and bleach. The program was evaluated through anonymous street interviews in control and intervention communities. 71% of at-risk women interviewed in the intervention area but only 2.2% of controls were reached by the project. An increase of about one-third of a behavioral stage occurred in the intervention group, but the increase was significant (p 0.01) only for condom use with non-main partners. When exposed vs. nonexposed women in the intervention area were compared, significant increases in condom use were recorded for exposed women with both main (p 0.05) and non-main partners (p 0.001); the mean behavioral stage gains were one-quarter and one-half a stage, respectively. Increased condom use with both types of partners was significantly associated with perceived condom use by peers, prior experience with condoms, sex work, self-efficacy, perceived behavior control, attitudes, and perceived risk. Likely to be at relatively earlier stages of change were women who smoked crack cocaine, African-Americans, and those with a jail/prison history.^ieng

Men's disclosure of HIV test results to male primary sex partners.

We evaluated disclosure of human immunodeficiency virus (HIV) antibody status to a main sex partner and the impact on the relationship in men who have sex with men and who are enrolled in the Acquired Immunodeficiency Syndrome (AIDS) Community Demonstration Projects cohorts. Eighty-nine percent of both seronegative and seropositive men disclosed the results to their main sex partner. Seventy percent of the seronegative men and 82% of the seropositive men who did so reported that the relationship remained "as strong as ever" after 6 months. Most men who did not disclose their test results to their main partner reported being "single" after 6 months.

An experiential program to reduce AIDS risk among female sex partners of injection-drug users.

This article describes the development and implementation of an acquired immune deficiency syndrome (AIDS) intervention program for female sex partners of male injection-drug users. Four psychoeducational workshops were designed to motivate personal risk reduction, provide participants with necessary cognitive and behavioral skills, and enhance participants' perceived ability to enact positive changes in their lives. The development of the workshop modules was guided by traditional theories of health behavior change and social learning. Also included in the intervention are referral and advocacy services, personal risk reduction counseling, and human immunodeficiency virus (HIV) antibody testing. Preliminary results indicate that the program has made a significant impact on the AIDS risk of participants--91 percent of women who completed the program reported that they had made positive changes in their lives to reduce their risk of HIV infection.

PIP: Preliminary results of a psychoeducational program for the female sex partners of intravenous drug users suggest that this approach can motivate women to make behavioral changes that reduce their risk of human immunodeficiency virus (HIV) infection. Sexual contact with an intravenous drug user was identified, in 1991, as the primary risk factor in 4484 cases of acquired immunodeficiency syndrome (AIDS) in the US. The program was developed and implemented, on a pilot basis, by health and mental health professionals in Long Beach, California. Program components included risk reduction counseling, HIV antibody testing, referral for social and medical services, free condoms and bleach for cleaning needles, and participation in a series of 4 interactive workshops. By the end of the 3rd workshop session, participants are expected to make a personal commitment to reducing their risk of HIV infection, set specific short-term risk reduction goals, and articulate a plan for achieving them. In the 4th session, women practice partner negotiation skills and identify positive sources of social support. To date, 84 women have attended at least 1 workshop and 69 have completed all 4 sessions. The majority of participants were Black and Hispanic women on public assistance; although recruitment was limited to women who were not intravenous drug users, 40% were regular crack cocaine users. Interviews conducted with 53 participants immediately after the last workshop revealed numerous indicators of attitudinal and behavioral change. 91% indicated that the program had induced them to make changes in their life to reduce their HIV risk. All but 1 women had spoken with her male partner about stopping or reducing his drug use and 68% of women who had not used condoms before entering the program adopted condom use. 45% reported they had asked their male partner to mover out of the household and 15% had either moved out themselves or successfully evicted their partner due to his refusal to negotiate HIV risk reduction behaviors. Participants continue to receive case management services and have former informal support networks.

AIDS and competing health concerns of blacks, Hispanics, and whites.

Blacks, Hispanics, and whites were interviewed in a door-to-door survey assessing personal concern about AIDS relative to other health threats and willingness to attend in-home AIDS education programs. The survey consisted of three parts: (1) an open-ended inquiry regarding which health problems individuals wanted to learn more about, (2) ratings of concern about AIDS and nine other common health threats, and (3) assessment of willingness to participate in future neighborhood-based AIDS education programs. Usable data were obtained from 453 respondents. Sixty-seven health threats were mentioned in response to the open-ended inquiry; AIDS was mentioned by 50.7%, followed by cancer (19.9%). AIDS was mentioned more frequently by blacks (63.9%) than by Hispanics (42.5%) or whites (45.7%), X2(3) = 32.07, p less than .002. Participants also reported higher levels of concern about AIDS than any other health problem with the exception of cancer. Concern about AIDS was greater among blacks (M = 2.68) than among Hispanics (M = 2.33) or whites (M = 2.36), F(2,351) = 5.06, p less than .01. Differences as a function of ethnicity, gender, and/or age were observed with respect to concern about heart disease, high blood pressure, diabetes, drug abuse, colds and flu, and herpes. In general, blacks and Hispanics expressed more interest in participating in AIDS education programs than did whites. Concern about AIDS and other health threats was not consistently related to either disease prevalence or severity.