Retrospective reports of developmental stressors, syndemics, and their association with sexual risk outcomes among gay men.

Gay and bisexual men (GBM) continue to have a disproportionately higher HIV incidence than any other group in Canada and the United States. This study examined how multiple co-occurring psychosocial problems, also known as a syndemic, contribute to high-risk sexual behavior among GBM. It also examined the impact of early life adversity on high-risk sexual behavior as mediated by syndemic severity. A sample of 239 GBM completed self-report questionnaires at baseline and 6-month follow-up. Syndemic variables included depression, polysubstance use, and intimate partner violence. Early life adversity variables measured retrospectively included physical and verbal bullying by peers and physical and sexual abuse by adults. A Cochran-Armitage trend test revealed a proportionate increase between number of syndemic problems and engagement in high-risk sex (p < .0001), thereby supporting syndemic theory. All early life adversity variables were positively correlated with number of syndemic problems. A bootstrap mediation analysis revealed indirect effects of two types of early life adversity on high-risk sex via syndemic severity: verbal bullying by peers and physical abuse by adults. There was also an overall effect of physical bullying by peers on high-risk sexual behavior, but no specific direct or indirect effects were observed. Consistent with syndemic theory, results provide evidence that certain types of early life adversity impact high-risk sex later in life via syndemic problems. Behavioral interventions to reduce sexual risk among GBM should address anti-gay discrimination experienced before adulthood as well as adult psychological problems.

Drug use prior to incarceration and associated socio-behavioural factors among males in a provincial correctional facility in Ontario, Canada.

OBJECTIVES: To describe the prevalence of drug use in males in a provincial detention centre during the year before incarceration and to examine the association between socio-demographic and behavioural factors and drug use. METHODS: In 2009, 500 adult males completed a survey after admission to a provincial detention centre in Ontario. Past-year prevalence rates were calculated for the use of opioids, cocaine, crack and methamphetamine, and by route of administration. Bivariate logistic regression was used to examine associations between drug use and socio-demographic and behavioural factors. RESULTS: More than 56% of participants reported use of opioids, cocaine, crack or methamphetamine in the previous year. Risk factors for blood-borne and sexually transmitted infections were commonly reported for the previous year: 12.2% had injected drugs, 78.0% had had unprotected sex, and 48.0% had had more than one sexual partner. In unadjusted analyses, participants who were older than 24 years were more likely to have used any drugs and to have injected drugs in the previous year. CONCLUSIONS: This study provides the first Canadian data in the past decade on drug use by recently incarcerated adults. We found that drug use and behaviours that increase the risk of transmission of sexually transmitted and blood-borne infections remain very common in this population. Incarceration provides an opportunity to provide services and links to programs for people who use drugs, which could decrease drug-related harms to individuals and society.

Individual and jurisdictional factors associated with voluntary HIV testing in Canada: Results of a national survey, 2011.

OBJECTIVE: HIV testing remains a central strategy for HIV prevention for its ability to link those who test positive to treatment and support. In Canada, national guidelines have recently changed as part of standard primary care to recommend voluntary HIV testing for those aged 16-64 years. Using results from a nationally representative survey, we examined individual and jurisdictional factors associated with voluntary testing. METHODS: A total of 2,139 participants were sampled using a regionally stratified, two-stage recruitment process. English or French interviews (by phone or online) were conducted during May 2011. Voluntary testing was defined as testing at least once for reasons other than blood donation, insurance purposes, immigration screening or research participation. Weighted logistic regression analysis (including socio-demographic, sexual activity, HIV/AIDS knowledge and jurisdictional factors of HIV prevalence and anonymous testing availability) were conducted for the overall sample, and stratified by sex. RESULTS: Twenty-nine percent (29%) of survey participants reported at least one lifetime voluntary HIV test. For the full-sample model, the following were associated with increased odds of testing: age <60 years, female sex, sexual minority status, perceived HIV knowledge, casual sex partner in previous year, and living in a higher-prevalence jurisdiction. For men, the strongest factor related to testing was sexual minority status (OR = 5.15, p < 0.001); for women, it was having a casual sex partner in the previous year (OR = 2.57, p = 0.001). For both men and women, residing in a jurisdiction with lower HIV prevalence decreased odds of testing. DISCUSSION: Sex differences should be considered when designing interventions to increase testing uptake. Jurisdictional factors, including HIV prevalence and testing modality, should be investigated further.

A systematic review of the relationships between intimate partner violence and HIV/AIDS.

BACKGROUND: Intimate partner violence (IPV) is a significant health problem that has been associated with HIV infection in numerous studies. We aimed to systematically review the literature on relationships between IPV and HIV in order to describe the prevalence of IPV in people with HIV, the prevalence of HIV in people experiencing IPV, the association between IPV and HIV, and evidence regarding mechanisms of risk and interventions. METHODS: Data sources were 10 electronic databases and reference lists. Studies were included if they reported data on the relationship between IPV and HIV. All records were independently reviewed by two authors at the stages of title and abstract review and full text review. Any abstract considered eligible by either reviewer was reviewed in full, and any disagreement regarding eligibility of full texts or data extracted was resolved by discussion. RESULTS: 101 articles were included. Experiencing IPV and HIV infection were associated in unadjusted analyses in most studies, as well as in adjusted analyses in many studies. The findings of qualitative and quantitative studies assessing potential mechanisms linking IPV and HIV were variable. Few interventions have been assessed, but two identified in this review were promising in terms of preventing IPV, though not HIV infection. CONCLUSIONS: Experiencing IPV and HIV infection tend to be associated in unadjusted analyses, suggesting that IPV screening and linkage with relevant programs and services may be valuable. It is unclear whether there is a causal association between experiencing IPV and HIV infection. Research should focus on defining parameters of IPV which are relevant to HIV infection, including type of IPV and period of exposure and risk, on assessing potential mechanisms, and on developing and assessing interventions which build on the strengths of existing studies.

Intimate partner violence is associated with incident HIV infection in women in Uganda.

OBJECTIVES: To quantify the association between intimate partner violence (IPV) and incident HIV infection in women in the Rakai Community Cohort Study between 2000 and 2009. DESIGN AND METHODS: Data were from the Rakai Community Cohort Study annual surveys between 2000 and 2009. Longitudinal data analysis was used to estimate the adjusted incidence rate ratio (IRR) of incident HIV associated with IPV in sexually active women aged 15-49 years, using a multivariable Poisson regression model with random effects. The population attributable fraction was calculated. Putative mediators were assessed using Baron and Kenny's criteria and the Sobel-Goodman test. RESULTS: Women who had ever experienced IPV had an adjusted IRR of incident HIV infection of 1.55 (95% CI 1.25-1.94, P = 0.000), compared with women who had never experienced IPV. Risk of HIV infection tended to be greater for longer duration of IPV exposure and for women exposed to more severe and more frequent IPV. The adjusted population attributable fraction of incident HIV attributable to IPV was 22.2% (95% CI 12.5-30.4). There was no evidence that either condom use or number of sex partners in the past year mediated the relationship between IPV and HIV. CONCLUSION: IPV is associated with incident HIV infection in a population-based cohort in Uganda, although the adjusted population attributable fraction is modest. The prevention of IPV should be a public health priority, and could contribute to HIV prevention.

Risk factors for intimate partner violence in women in the Rakai Community Cohort Study, Uganda, from 2000 to 2009.

BACKGROUND: Intimate partner violence (IPV) is a significant public health problem. There is a lack of data on IPV risk factors from longitudinal studies and from low and middle income countries. Identifying risk factors is needed to inform the design of appropriate IPV interventions. METHODS: Data were from the Rakai Community Cohort Study annual surveys between 2000 and 2009. Female participants who had at least one sexual partner during this period and had data on IPV over the study period were included in analyses (N = 15081). Factors from childhood and early adulthood as well as contemporary factors were considered in separate models. Logistic regression was used to assess early risk factors for IPV during the study period. Longitudinal data analysis was used to assess contemporary risk factors in the past year for IPV in the current year, using a population-averaged multivariable logistic regression model. RESULTS: Risk factors for IPV from childhood and early adulthood included sexual abuse in childhood or adolescence, earlier age at first sex, lower levels of education, and forced first sex. Contemporary risk factors included younger age, being married, relationships of shorter duration, having a partner who is the same age or younger, alcohol use before sex by women and by their partners, and thinking that violence is acceptable. HIV infection and pregnancy were not associated with an increased odds of IPV. CONCLUSIONS: Using longitudinal data, this study identified a number of risk factors for IPV. These findings are useful for the development of prevention strategies to prevent and mitigate IPV in women.

The impact of stressful life events on unprotected anal intercourse among gay and bisexual men.

We investigated the hypothesis that gay and bisexual men experiencing stressful life events are more likely to engage in risky sexual behavior. Data were from a cohort study of 155 HIV-positive and 207 HIV-negative men in Ontario, Canada (1998-2007). We quantified the relation between stressful life events and unprotected anal intercourse with a non-regular partner. In the past 6 months, 19% reported unprotected intercourse (HIV+: 28%; HIV-: 13%) and 58% reported one or more stressful life events (HIV+: 64%; HIV-: 55%). Among HIV-negative men, the odds of unprotected intercourse increased by 1.15 for each additional event (95%CI 1.06, 1.24). Among HIV-positive men, those who reported the event "problems due to alcohol or drugs" were 1.80 (95%CI 1.27, 2.56) times more likely to report unprotected intercourse. Interventions to assist men to cope with stress may help to prevent population spread of HIV and improve overall health.

Prevalence and predictors of urethral chlamydia and gonorrhea infection in male inmates in an Ontario correctional facility.

OBJECTIVES: To determine the prevalence of urethral chlamydia and gonorrhea in males in a correctional facility in Ontario, Canada, and to explore risk factors for infection. METHODS: Between June and December, 2009, 500 adult males who had been newly admitted at a correctional facility in southern Ontario completed a survey of risk factors and provided a urine sample for testing. Those who tested positive were treated and their names were provided to the local public health unit for follow-up including contact tracing. Prevalence and 95% confidence intervals were calculated for infection with chlamydia and gonorrhea, respectively, and a multivariable model was used to look at risk factors for infection. RESULTS: The study population reported high levels of sexual risk behaviours and drug use. The overall chlamydia prevalence was 2.9% (95% CI 1.6-4.8) and the overall gonorrhea prevalence was 0.6% (95% CI 0.1-1.8). Rates were particularly high for chlamydia in younger males, at 16% (95% CI 4.5-36) in 18-19 year olds and 3.7% (95% CI 1.0-9.3) in 20-24 year olds, and for gonorrhea in males aged 20-24 at 1.9% (95% CI 0.2-6.6). A multivariable logistic regression model revealed that though not statistically significant, younger age was associated with infection. CONCLUSION: The relatively high prevalence of chlamydia and gonorrhea found in this study suggests that primary and secondary prevention programs should be instituted for males in correctional facilities, in particular among younger inmates. Further research is required to ensure internal and external generalizability of these results, as well as to determine the cost-effectiveness of potential interventions.

Stress and increased HIV infection risk among gay and bisexual men.

OBJECTIVE: Our principal objective was to determine whether psychosocial stress raises the risk of HIV infection among gay and bisexual men. If so, we also aimed to evaluate the evidence for the underlying mechanism, specifically whether stress has an intermediate effect on sexual risk behaviour or an independent, cofactor effect. METHODS: Participants were recruited through the provincial HIV diagnostic laboratory, physicians and community organizations in Ontario, Canada, 1998-2006. Confirmed recent seroconverters (n = 123 cases) were asked about stressful life events and behaviour during the likely period of infection (median 8, range 3-33 months). HIV-negative controls (n = 240) were asked about an equivalent time period. We used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Cases reported more stressful life events (median = 3, 33% 5 or more) than controls (median = 2, 20% 5 or more). Compared to men who reported no events, risk of HIV infection increased with the number of events, to a 2.5-fold increase in risk among men reporting 5 or more (95% CI 1.3, 4.7). The association weakened when adjusted for sexual risk behaviour (OR = 1.7, 95% CI 0.82, 3.6) and when restricted to men who engaged in unprotected receptive anal sex with an HIV-positive or status unknown partner (OR = 1.3, 95% CI 0.50, 3.6). CONCLUSIONS: Gay and bisexual men experiencing stressful life events were at increased risk of HIV infection. This effect was mediated by sexual risk behaviour. We recommend that coping strategies in response to stress be considered in prevention research and health policy.

Late presentation for human immunodeficiency virus care in the United States and Canada.

BACKGROUND. Initiatives to improve early detection and access to human immunodeficiency virus (HIV) services have increased over time. We assessed the immune status of patients at initial presentation for HIV care from 1997 to 2007 in 13 US and Canadian clinical cohorts. METHODS. We analyzed data from 44,491 HIV-infected patients enrolled in the North American-AIDS Cohort Collaboration on Research and Design. We identified first presentation for HIV care as the time of first CD4(+) T lymphocyte (CD4) count and excluded patients who prior to this date had HIV RNA measurements, evidence of antiretroviral exposure, or a history of AIDS-defining illness. Trends in mean CD4 count (measured as cells/mm(3)) and 95% confidence intervals were determined using linear regression adjusted for age, sex, race/ethnicity, HIV transmission risk, and cohort. RESULTS. Median age at first presentation for HIV care increased over time (range, 40-43 years; P < .01), whereas the percentage of patients with injection drug use HIV transmission risk decreased (from 26% to 14%; P < .01) and heterosexual transmission risk increased (from 16% to 23%; P < .01). Median CD4 count at presentation increased from 256 cells/mm(3) (interquartile range, 96-455 cells/mm(3)) to 317 cells/mm(3) (interquartile range, 135-517 cells/mm(3)) from 1997 to 2007 (P < .01). The percentage of patients with a CD4 count > or = 350 cells/mm(3) at first presentation also increased from 1997 to 2007 (from 38% to 46%; P < .01). The estimated adjusted mean CD4 count increased at a rate of 6 cells/mm(3) per year (95% confidence interval, 5-7 cells/mm(3) per year). CONCLUSION. CD4 count at first presentation for HIV care has increased annually over the past 11 years but has remained <350 cells/mm(3), which suggests the urgent need for earlier HIV diagnosis and treatment.

Trends in multidrug treatment failure and subsequent mortality among antiretroviral therapy-experienced patients with HIV infection in North America.

BACKGROUND: Although combination antiretroviral therapy continues to evolve, with potentially more effective options emerging each year, the ability of therapy to prevent multiple regimen failure and mortality in clinical practice remains poorly defined. METHODS: Sixteen cohorts representing over 60 sites contributed data on all individuals who initiated combination antiretroviral therapy. We identified those individuals who experienced virologic failure (defined as a human immunodeficiency virus [HIV] RNA level >1000 copies/mL), received modified therapy, and subsequently had a second episode of virologic failure. Multivariate Cox regression was used to assess factors associated with time to second regimen failure and the time to death after the onset of second regimen failure. RESULTS: Of the 42,790 individuals who received therapy, 7159 experienced a second virologic failure. The risk of second virologic failure decreased from 1996 (56 cases per 100 person-years) through 2005 (16 cases per 100 person-years; P < .001). The cumulative mortality after onset of second virologic failure was 26% at 5 years and decreased over time. A history of AIDS, a lower CD4(+) T cell count, and a higher plasma HIV RNA level were each independently associated with mortality. Similar trends were observed when analysis was limited to the subset of previously treatment-naive patients CONCLUSIONS: Although the rates of multiple regimen failure have decreased dramatically over the past decade, mortality rates for those who have experienced failure of at least 2 regimens have remained high. Plasma HIV RNA levels, CD4(+) T cell counts at time of treatment failure, and a history of AIDS remain independent risk factors for death, which emphasizes that these factors remain important targets for those in need of more-aggressive therapeutic interventions.

Effect of early versus deferred antiretroviral therapy for HIV on survival.

BACKGROUND: The optimal time for the initiation of antiretroviral therapy for asymptomatic patients with human immunodeficiency virus (HIV) infection is uncertain. METHODS: We conducted two parallel analyses involving a total of 17,517 asymptomatic patients with HIV infection in the United States and Canada who received medical care during the period from 1996 through 2005. None of the patients had undergone previous antiretroviral therapy. In each group, we stratified the patients according to the CD4+ count (351 to 500 cells per cubic millimeter or >500 cells per cubic millimeter) at the initiation of antiretroviral therapy. In each group, we compared the relative risk of death for patients who initiated therapy when the CD4+ count was above each of the two thresholds of interest (early-therapy group) with that of patients who deferred therapy until the CD4+ count fell below these thresholds (deferred-therapy group). RESULTS: In the first analysis, which involved 8362 patients, 2084 (25%) initiated therapy at a CD4+ count of 351 to 500 cells per cubic millimeter, and 6278 (75%) deferred therapy. After adjustment for calendar year, cohort of patients, and demographic and clinical characteristics, among patients in the deferred-therapy group there was an increase in the risk of death of 69%, as compared with that in the early-therapy group (relative risk in the deferred-therapy group, 1.69; 95% confidence interval [CI], 1.26 to 2.26; P<0.001). In the second analysis involving 9155 patients, 2220 (24%) initiated therapy at a CD4+ count of more than 500 cells per cubic millimeter and 6935 (76%) deferred therapy. Among patients in the deferred-therapy group, there was an increase in the risk of death of 94% (relative risk, 1.94; 95% CI, 1.37 to 2.79; P<0.001). CONCLUSIONS: The early initiation of antiretroviral therapy before the CD4+ count fell below two prespecified thresholds significantly improved survival, as compared with deferred therapy.

Characterization of an emerging heterosexual HIV epidemic in Russia.

BACKGROUND: The Russian Federation is currently experiencing one of the fastest growing HIV epidemics worldwide. The objective was to identify sexual risk factors for recent heterosexually-acquired HIV infections. METHODS: A case-control study of recent HIV infection was conducted in the regions of Altaiskiy Krai, Krasnoyarskiy Krai, Saratov Oblast, and Tverskaya Oblast. Data from 166 participants who did not report recent injection drug use were analyzed (19 male cases, 22 male controls, 67 female cases, 58 female controls). Independent risk factors for HIV infection are reported as adjusted odds ratios (AOR) with 95% confidence intervals (CI). RESULTS: Risk factors were unprotected sex with an HIV-positive/status unknown regular partner (among women only: AOR 5.4, 95% CI 2.1-13); a regular sexual partner who was an injection drug user (AOR 3.6, 95% CI 1.5-8.5); 5 or more sexual partners (among men only: AOR 2.7, 95% CI 0.66-11); unprotected sex with a partner who had a diagnosed sexually transmitted infection (STI) or signs/symptoms of an STI (AOR 6.4, 95% CI 1.1-38); and undiagnosed signs/symptoms of an STI (AOR 3.4, 95% CI 1.5-7.6). CONCLUSIONS: These data provide evidence of bridging between the injecting and noninjecting populations. Concomitant STI seem to have a major role in fueling the Russian HIV epidemic.

Prior opiate injection and incarceration history predict injection drug use among inmates.

AIMS: To describe injection drug use among inmates, and to identify correlates of drug injection while incarcerated. DESIGN: Cross-sectional survey. SETTING: Six provincial correctional centres in Ontario, Canada. PARTICIPANTS: Face-to-face interviews were conducted with a random sample of 439 adult males and 158 females. MEASUREMENTS: Inmates were asked about drug use in their lifetime, outside the year prior to their current incarceration, and while incarcerated in the past year. Among the 32% (189 / 597) with a prior history of drug injection, independent correlates of injection while incarcerated in the past year were identified using multiple logistic regression. FINDINGS: Among all inmates while incarcerated in the past year, 45% (269 /597) used drugs and 19% (113 / 596) used non-cannabis drugs. Among those with a prior history of injecting, 11% (20 / 189) injected while incarcerated in the past year. Rates of injection with used needles were the same pre-incarceration as they were while incarcerated (32%). Independent correlates of drug injection while incarcerated were injection of heroin (OR = 6.4) or other opiates (OR = 7.9) and not injected with used needles (OR = 0.20) outside in the year prior to incarceration, and ever being incarcerated in a federal prison (OR = 5.3). CONCLUSIONS: The possibility of transmission of human immunodeficiency virus (HIV), hepatitis C (HCV) or other blood-borne diseases exists in Ontario correctional centres. In this setting, drug injection while incarcerated is primarily related to opiate use prior to incarceration. The correlation between injecting and extensive incarceration history suggests missed opportunities to improve inmates' health.

Voluntary HIV testing among inmates: sociodemographic, behavioral risk, and attitudinal correlates.

We sought to determine the prevalence and correlates of self-reported HIV testing among inmates in correctional centers in Ontario, Canada. A cross-sectional survey was conducted with a stratified random sample of 597 male and female adult inmates. The participation rate was 89%. Descriptive statistics and multiple logistic regression were used to analyze HIV testing. Fifty-eight percent had ever been tested, and 21% had voluntarily tested while incarcerated in the past year. Having ever been tested was more common among those at risk for HIV through injection drug use (IDU) or sexual behavior. Testing while incarcerated in the past year was independently associated with being single (OR = 2.6), frequent IDU (OR = 4.0), not having casual sex partners prior to incarceration (OR = 0.53), a history of hepatitis (OR = 2.4), previous HIV testing (OR = 3.7), a close relationship with an HIV-positive person in the outside community (OR = 1.7), knowing an HIV-positive person inside (OR = 2.7), a perceived chance of being infected during incarceration (OR = 2.2), and support of mandatory testing (OR = 2.0). The predominant motivations for testing while incarcerated were IDU or fears of infection inside, possibly through contact with blood, during fights, or even by casual contact. Voluntary HIV testing in prison should be encouraged, and inmates should receive appropriate counseling and information to allow realistic assessment of risk.