Reinforcement value of unsafe sex as a predictor of condom use and continued HIV/AIDS risk behavior among gay and bisexual men.

The pleasure or reinforcement value of high-risk sex may be an important influence on success in risk reduction efforts. Seronegative gay and bisexual men (N?=?297) completed measures assessing their unprotected and safer sex practices, as well as measures of cognitive and skill factors and a measure assessing the subjective reinforcement value of unprotected anal intercourse. Regression analyses showed that the reinforcement value of unprotected anal intercourse accounted for variance in predicting levels of condom use above that that could be accounted for by factors such as knowledge, behavior change intentions, perceived vulnerability, condom attitudes, and sexual communication skills. Only reinforcement value of unprotected sex and substance use significantly predicted how frequently participants engaged in high-risk sex. Increased attention to the valence of sexual reinforcers will improve HIV risk reduction models and enhance AIDS prevention efforts. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Factors predicting continued high-risk behavior among gay men in small cities: Psychological, behavioral, and demographic characteristics related to unsafe sex.

Nearly 6,000 men entering gay bars in 16 small American cities were anonymously surveyed to assess their sexual behavior and to determine predictors of risky sexual practices. Excluding individuals in long-term exclusive relationships, 27% of the men reported engaging in unprotected anal intercourse in the past 2 months. Factors strongly predictive of risk included having a large number of different male partners, estimating oneself to be at greater risk, having weak intentions to use condoms at next intercourse, believing that safer sex is not an expected norm within one's peer reference group, being of younger age, and having less education. These findings indicate that HIV prevention efforts are urgently needed for gay men in smaller cities, with efforts particularly focused on young and less educated men sexually active with multiple partners. Prevention should focus on strengthening intentions to change behavior and on changing social norms to foster safer sex. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effect of HIV infection on the natural history of anal human papillomavirus infection

OBJECTIVE: To identify risk factors for the detection of prevalent and incident anal human papillomavirus (HPV) infection, and HPV persistence among HIV-seropositive and seronegative homosexual men. DESIGN: Longitudinal study of 287 HIV-seronegative and 322 HIV-seropositive men attending a community-based clinic. METHODS: Subjects underwent an interview and examination; specimens were collected for HIV serology and assessment of anal HPV and HIV DNA. RESULTS: Anal HPV DNA was detected at study entry in 91.6% of HIV-infected men, and 65.9% of men not infected with HIV. HPV detection was associated with lifetime number of sexual partners and recent receptive anal intercourse (HIV-seronegative men), decreased CD4+ lymphocyte count (HIV-seropositive men), and anal warts (all men). Among men negative for HPV at study entry, subsequent detection of HPV was associated with HIV, unprotected receptive anal intercourse, and any sexual contact since the last visit. Among men positive for HPV at study entry, subsequent detection of additional HPV types was more common among HIV-seropositive men. Becoming HPV negative during follow-up was less common among men with HIV or high HPV levels at study entry. Among those with HIV, HPV persistence was associated with presence of anal HIV DNA, but not with CD4+ lymphocyte count. CONCLUSIONS: Risk of anal HPV infection appears to increase with sexual exposure, epithelial trauma, HIV infection and immune deficiency. Incident infection may result from recent sexual exposure or reactivation of latent infection. Further studies are needed to elucidate the mechanism by which HIV DNA in the anal canal increases the risk of HPV persistence.     

Sexual relationships, sexual behavior, and HIV infection: HIV-seropositive gay and bisexual men seeking prevention services.

The authors evaluated sexual practices, sexually tempting situations, and risk avoidance coping strategies among HIV-seropositive men who have sex with men and who were seeking HIV prevention services. HIV-seropositive men who practiced unprotected anal intercourse in the previous 4 weeks reported stronger temptations to engage in high-risk sex than men who were sexually safe. Being in a positive mood and being with desirable partners were particularly tempting risk situations for seropositive men, who also possessed less coping capacity to deal with risky situations than safer men. Prevention interventions must address the needs of men infected with HIV and must remove barriers to enrolling in prevention programs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.     

The role of sexual arousal and sexual partner characteristics in HIV+ MSM's intentions to engage in unprotected sexual intercourse.

Objective: This study investigated the effects of sexual arousal and sexual partner characteristics as determinants of HIV+ men who have sex with men's (MSM) intentions to engage in unprotected sex. Design: In a computer-based controlled experiment, 67 HIV+ MSM underwent a sexual arousal manipulation and indicated their intentions to engage in unprotected sex with hypothetical partners who differed in terms of HIV serostatus, physical attractiveness, relationship type, and preference for condom use. Main Outcome Measures: Computer-delivered questions assessed HIV+ MSM's intentions to engage in various sexual acts with each hypothetical partner. Results: As predicted, sexually aroused HIV+ MSM indicated stronger intentions to engage in unprotected sex than nonaroused HIV+ MSM; and having a partner who was attractive, HIV+, long term, or who preferred not to use condoms, also led to riskier intentions. Several significant interactions among these factors were found, which were generally consistent with predictions and with theory and research on cognitive processing and decision making. Conclusions: These findings have implications for understanding risky sexual behavior among HIV+ individuals and for the development of interventions to reduce this risk. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sexual HIV risk behaviour among men who have sex with both men and women

The aim of this study was to describe the sexual behaviour of men who had sex with both men and women in the preceding five years (behaviourally bisexual men), specifically to examine their needs in relation to HIV prevention. Anonymous telephone interviews were carried out with respondents recruited though advertisements in UK newspapers and magazines with (sexual) 'personal' or 'contact' sections. Data are reported from 745 respondents. Respondents report relatively high and approximately equal numbers of male and female sexual partners in the year preceding interview. There is a clear patterning of sexual activity by type of partner (regular or casual). A high proportion report anal intercourse with female and male partners. A third disclose their homosexual practices to regular female partners. Although self-reported HIV seroprevalence is low (less than 1%), the levels of unprotected sex with multiple sexual partners indicate substantial potential for transmission of sexually transmitted infections, including HIV. While low seroprevalence suggests that there is little overlap with existing core groups of HIV infection, the study provides information to judge the priority of targeting HIV prevention initiatives and suggests ways in which initiatives could be undertaken.     

Changes in HIV treatment beliefs and sexual risk behaviors among gay and bisexual men, 1997-2005.

Objective: Beliefs about HIV treatment effectiveness and the impact of HIV treatments on HIV transmission risks were initially related to sexual risk-taking in the late 1990s when multidrug HIV treatments first became available. This study examined changes in beliefs about the effects of HIV treatment for preventing HIV transmission and their association to sexual risk behaviors between the years 1997 and 2005. Design: Anonymous surveys were administered to a convenience sample of gay and bisexual men attending a large community event in Atlanta, Georgia in 1997 (N = 498) and again at the same community event in 2005 (N = 448). Analyses were performed for men living with HIV/AIDS and for men who have not been diagnosed with HIV/AIDS. Main Outcome Measures: Rates of unprotected anal intercourse in the previous 3 months. Results: There were significant increases in high-risk sexual practices that coincided with increased beliefs that HIV treatments can reduce the chance of transmitting HIV. However, optimistic beliefs about the health benefits of HIV treatments decreased over the 8 years and were not related to risk behaviors. Conclusions: Beliefs about how HIV treatments impact HIV infectiousness remain associated with HIV transmission risk behavior and interventions targeting at-risk as well as HIV-positive men who have sex with men must directly address these beliefs and perceptions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Risk behavior for HIV transmission among gay men surveyed in Seattle bars

Men attending four Seattle gay bars were asked to complete a self-administered questionnaire including measures of sexual behavior, perceptions of peer norms in the area of sexual safety, personal human immunodeficiency virus (HIV) risk estimate, and knowledge and use of a variety of acquired immunodeficiency syndrome (AIDS) prevention services. Twenty-nine percent of the sample reported engaging in unprotected anal intercourse at least once during the 2 months before the survey. Differences in peer norm perceptions, age, HIV risk estimate, and intent to be sexually safe in the future were found between those engaging in unprotected anal intercourse and those not reporting unprotected anal intercourse. No significant differences were found in level of education, use of AIDS prevention services, and whether or not a person had been tested for HIV. Implications for prevention programs are discussed.     

Sorting through chickens and eggs: A longitudinal examination of the associations between attitudes, norms, and sexual risk behavior.

Objective: Health behavior theories posit that health-relevant attitudes, beliefs, and behavioral skills drive subsequent actions people take to protect themselves from health threats. Within the realm of HIV-related sexual risk behavior, much of the research in support of this notion is cross-sectional, rather than longitudinal, particularly in studies of gay and bisexual men. Other psychological theories (e.g., self-perception or cognitive dissonance theories) suggest that the opposite could be true—that health-relevant attitudes and beliefs might change as a function of previous risk or precautionary behavior. Appreciating the complex nature of these associations is essential for modifying theory and developing appropriate interventions. Design: Using longitudinal data from gay and bisexual men (n = 1465), we used structural equation modeling to examine three possibilities—that perceived norms and attitudes about sexual risk would be (a) related to unprotected anal intercourse cross-sectionally, (b) related to unprotected anal intercourse at a subsequent time point, and/or (c) predicted from previous instances of unprotected anal intercourse. Results: Safe-sex norms and attitudes were related to unprotected anal intercourse cross-sectionally, but did not predict unprotected sex longitudinally. Rather, perceived norms and attitudes changed as a function of previous risk behavior. Conclusions: These results raise the possibility that modified theoretical models might be necessary to adequately describe sexual risk behavior among gay and bisexual men. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Close relationships and elevated HIV risk behavior: Evidence and possible underlying psychological processes.

A review of research on AIDS preventive behavior indicates that minority and nonminority heterosexual adolescents and adults, gay men, injection drug users, and commercial sex workers are all less likely to practice safer sex with close relationship partners, compared with partners they perceive to be "casual" sexual partners. Because many individuals in close relationships have engaged in HIV risk behavior over extended periods of time and are unaware of their actual HIV status, practicing unprotected sexual intercourse with a committed relationship partner who is not tested for HIV appears to be a major and unrecognized source of HIV risk. This article reviews the evidence for higher levels of HIV risk behavior in close relationships and then presents relevant conceptual and empirical work to explore the psychological processes that may underlie risky sexual behavior in close relationships, using as a framework the information-motivation-behavioral skills model of preventive behavior. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prevalence of high-risk sex among HIV-positive gay and bisexual men: a longitudinal analysis

INTRODUCTION: This longitudinal study examined the prevalence and demographic correlates of unprotected insertive and receptive anal intercourse among HIV-positive gay and bisexual men who were aware of their serostatus. METHODS: Participants (n = 395), sampled randomly at two HIV outpatient clinics in Los Angeles, completed two waves of self-administered questionnaires (separated by approximately 7-9 months) that measured sexual behaviors in the previous 60 days. RESULTS: The cross-sectional prevalence of unprotected insertive anal intercourse was 11.2% at time 1 and 7.1% at time 2. Longitudinal analysis indicated that nearly 15% of the participants had engaged in that high-risk behavior either at time 1 or time 2 and approximately 4% had engaged in the behavior at each time period. Similar rates of unprotected receptive anal intercourse were observed. These high-risk activities were more prevalent with seropositive and unknown serostatus partners than with seronegative partners. The rate of anal intercourse risk behaviors was higher among asymptomatic men and among those who were exclusively gay. CONCLUSION: The findings demonstrate considerable differences in the prevalence of stable and occasional high-risk sexual behaviors among HIV-positive gay and bisexual men. Simple cross-sectional analyses cannot capture the stability or variation in behavior across time and, thus, may generate misleading conclusions about disease transmission, especially if the partner's HIV serostatus is not considered in the analysis. The findings indicate a need for focused safer-sex interventions for seropositive men. The HIV outpatient clinic is an ideal setting for such interventions.     

HIV sexual risk behavior following bereavement in gay men.

The present study followed a group of 100 gay men up to 1 year before and 1 year after losing a partner to AIDS (University of California, San Francisco Coping Project). Following bereavement, participants were at increased risk for engaging in unprotected anal intercourse: at 4 to 6 months for HIV-negative men and at 8 to 12 months for HIV-positive men. Sociodemographic variables, HIV serostatus, substance use, depression, prebereavement relationship quality, and social support did not explain sexual risk-taking in this sample. However; men who engaged in unprotected anal intercourse were twice as likely to be involved in a new primary relationship as those who did not. The authors concluded that risk varies over time by HIV status and may involve engagement in new relationships. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of disengagement coping with HIV risk on unprotected sex among HIV-negative gay men in New York City.

Objective: This study examined how disengagement coping with HIV risk mediated the association between internalized homophobia and unprotected anal intercourse (UAI) and how sexual encounters in public venues (public sex) and drug use moderated the association between disengagement coping and UAI among HIV-negative gay men. Disengagement coping included fatalistic beliefs about maintaining HIV-negative seronegative serostatus (fatalism), optimistic attitudes toward medical seriousness of HIV infection and reduced concern about HIV risk due to highly active anti-retroviral therapies (optimism), and negative affective states associated with sexual risk (anxiety). Design: A survey was conducted among 285 HIV-negative gay men at an HIV prevention counseling program in New York City. Main Outcome Measures: Sexual risk was defined as having had UAI with nonprimary partners in the past 6 months. Results: In addition to the positive association between internalized homophobia, disengagement coping, and UAI, fatalism mediated the association between internalized homophobia and UAI; and optimism mediated the association between anxiety and UAI. A significant moderation effect of public sex was found between fatalism and UAI. Conclusions: The findings highlight the importance of understanding disengagement coping as it affects sexual risk practices among HIV-negative gay men in the continuing epidemic. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sexual risk behavior and risk factors for HIV-1 seroconversion in homosexual men participating in the Tricontinental Seroconverter Study, 1982-1994

Trends in sexual behavior associated with incident infection with human immunodeficiency virus (HIV) type 1 are described and a case-control study was conducted to examine risk factors for HIV seroconversion in homosexual men who became infected with HIV between 1982 and 1994 from four geographic sites: Amsterdam, the Netherlands; San Francisco, California; Vancouver, Canada; and Sydney, Australia. Changes in sexual behaviors were evaluated from cohort visits in the preseroconversion, seroconversion, and postseroconversion intervals and were further examined over three time periods: 1982-1984, 1985-1987, and 1988-1994. In a case-control study, sexual behaviors, substance use, and presence of sexually transmitted disease were compared between 345 HIV-positive cases and 345 seronegative controls matched by visit date and site. Receptive anal intercourse was the sexual behavior most highly associated with seroconversion. The odds ratio (OR) per receptive anal intercourse partner increase was 1.05 (95% confidence interval (CI) 1.02-1.09). To more carefully examine risk associated with receptive oral intercourse, analyses were done in a subgroup of men who reported no or one receptive anal intercourse partner. The risk (OR) associated with receptive oral intercourse partner increase was 1.05 (95% CI 1.0-1.11). In multivariate conditional logistic regression analyses, presence of sexually transmitted disease (OR = 3.39, 95% CI 1.95-5.91) and amphetamine use (OR = 2.55, 95% CI 1.26-5.15) were independently associated with seroconversion. Although the prevalence of major risk factors has decreased over time, the associations of these behaviors and HIV infection persist, suggesting that these risk behaviors remain important avenues for public health interventions.     

Internalized heterosexism among HIV-positive, gay-identified men: Implications for HIV prevention and care.

Internalized heterosexism (IH), or the internalization of societal antihomosexual attitudes, has been consistently linked to depression and low self-esteem among gay men, and it has been inconclusively associated with substance use and sexual risk in gay and bisexual men. Using structural equation modeling, the authors tested a model framed in social action theory (C. K. Ewart, 1991, 2004) in which IH is associated with HIV transmission risk and poor adherence to HIV antiretroviral therapy (ART) through the mechanisms of negative affect and stimulant use. Data from a sample of 465 gay-identified men interviewed as part of an HIV risk reduction behavioral trial were used to test the fit of the model. Results support the hypothesized model in which IH was associated with unprotected receptive (but not insertive) anal intercourse with HIV-negative or unknown HIV status partners, and with ART nonadherence indirectly via increased negative affect and more regular stimulant use. The model accounted for 15% of the variance in unprotected receptive anal intercourse and 17% of the variance in ART nonadherence. Findings support the potential utility of addressing IH in HIV prevention and treatment with HIV-positive gay men. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relationships among HIV risk beliefs, attitudes, and behaviors in sexually active, seronegative gay men

Safer-sex guidelines established during the early days of the HIV/AIDS epidemic have undergone very little revision despite some controversy. Although these guidelines have been widely disseminated in the gay community, many gay men continue to engage in behaviors that are believed to put them at high risk for transmission of HIV. This suggests either that they have not accepted safer-sex guidelines as accurate or that other factors override personal implementation of the guidelines. The study examined seronegative gay men's beliefs about the accuracy of safer sex guidelines and the men's participation in behaviors risky for transmitting HIV. The greatest disagreement between the men's beliefs and behaviors centered on the risk of oral intercourse; this suggests a need for clarification of the safer sex message about this behavior. The findings of this study support the need to reformulate safer-sex guidelines. When unprotected oral and anal sex are classified at the same level of risk, those who engage in unprotected oral sex may proceed to unprotected anal sex with less reservation.     

AIDS treatment advances and behavioral prevention setbacks: Preliminary assessment of reduced perceived threat of HIV–AIDS.

Recent advances in AIDS treatment have brought renewed optimism for prolonging the lives of those infected with HIV. This article examined beliefs about how new treatments may reduce HIV transmission risk among 298 HIV-negative gay and bisexual men attending a gay pride festival. Results from an anonymous survey showed that men who practiced unprotected anal intercourse as the receptive partner (UAR intercourse) were younger, less well educated, and more likely to believe that it is safe to have UAR intercourse with an HIV-positive man who has an undetectable viral load and that new treatments for HIV relieve their worries about unsafe sex. As HIV treatments continue to advance, new challenges for HIV prevention will likely emerge. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Enhancing motivation to reduce the risk of HIV infection for economically disadvantaged urban women

This research evaluated a motivation-based HIV risk reduction intervention for economically disadvantaged urban women. Participants completed a survey that assessed HIV-related knowledge, risk perceptions, behavioral intentions, sexual communication, substance use, and risk behavior. A total of 102 at-risk women (76% African American) were randomly assigned to either the risk reduction intervention or to a waiting list. Women were reassessed at 3 and 12 weeks. Results indicated that treated women increased their knowledge and risk awareness, strengthened their intentions to adopt safer sexual practices, communicated their intentions with partners, reduced substance use proximal to sexual activities, and engaged in fewer acts of unprotected vaginal intercourse. These effects were observed immediately, and most were maintained at follow-up.     

HIV prevention with male prostitutes and patrons of hustler bars: replication of an HIV preventive intervention

The core objectives of this study were to document the process by which a community-based organization replicated and adapted an experimentally developed intervention to its own use and to explore the effectiveness of that HIV prevention program for male prostitutes and other patrons in New York City "hustler" bars. The intervention model employed was based on previous research with gay men (Kelly, St. Lawrence, Diaz, et al., 1991; Kelly, St. Lawrence, Stevenson, et al., 1992) and inspired by diffusion of innovation theory (Rogers, 1995). The effects of the current intervention were assessed on a sample of 1,741 male prostitutes and bar patrons. Analyses indicated significant reductions in paid, unprotected sexual intercourse and oral sex following the intervention. Analyses further indicated that the data were partially consistent with the program's model, which specified that norms were the putative mediator of behavior change in the intervention. Also, the intervention's effects varied by bar and by participants' race/ethnicity. Data support the utility of the intervention model for an urban sample of men at high risk for HIV infection. The importance of exploring the mechanisms that underlie the intervention is discussed.