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BackgroundSelf-reported data are widely used in substance-use research, yet few studies have assessed the validity of self-reported methamphetamine use compared to biological assays.ObjectivesWe sought to assess the validity and correlates of validity of self-reported methamphetamine use compared to urine toxicology (UTOX).MethodsUsing a sample of methamphetamine-dependent individuals enrolled in a randomized controlled pharmacotherapy trial in the United States (n = 327 visits among 90 participants), we calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the kappa coefficient of self-reported methamphetamine use in the past 3days compared to UTOX, as well as the NPV of self-reported methamphetamine use over an extended recall period of 1month. We used multivariable logistic regression models to assess correlates of concordance between self-reported methamphetamine use and UTOX.ResultsThe sensitivity of self-reported methamphetamine use in the past 3days was 86.7% (95% confidence intervals (95%CI): 81.4%-91.4%), the specificity was 85.3% (77.7-91.3), the PPV was 91.5% (86.9-94.8), and the NPV was 78.0% (69.4-86.1), compared to UTOX (kappa = 0.71). The NPV over the extended recall period was 70.6% (48.0-85.7). In multivariable analyses, validity of self-reported methamphetamine use was higher for older participants but lower during follow-up compared to baseline and when polysubstance use or depressive symptoms were reported. Conclusions/Importance: Our sample of methamphetamine-dependent adults reported recent methamphetamine use with high validity compared to UTOX. Validity increased with age but decreased when participants reported depressive symptoms or polysubstance use as well as later in the study timeline and during longer recall periods.

Background and aims Methamphetamine use is increasingly prevalent and associated with HIV transmission. Early-phase human studies suggested naltrexone reduced amphetamine use among dependent individuals. We tested if extended-release naltrexone (XRNTX) reduces methamphetamine use and associated sexual risk behaviors among high-risk methamphetamine-dependent men who have sex with men (MSM). Design Double-blind, placebo-controlled, randomized trial of XRTNX versus placebo over 12 weeks from 2012 to 2015. Setting San Francisco Department of Public Health, California, USA. Participants One hundred community-recruited, sexually-active, actively-using methamphetamine-dependent MSM. Mean age was 43.2 years; 96% were male, 3% transfemale, and 1% transmale; 55.0% were white, 19.0% African American, and 18.0% Latino. Interventions XRNTX 380 mg (n = 50) or matched placebo (n = 50) administered by gluteal injection at 4-week intervals. Measurements Regression estimated average level and change in level of positive urines during the period 2-12 weeks (primary outcomes) and sexual risk behaviors (secondary outcome). Findings Ninety per cent of visits were completed. By intent-to-treat, participants assigned to XRNTX had similar differences during 2-12 weeks in methamphetamine-positive urines as participants assigned to placebo [incidence rate ratio (IRR) = 0.95, 95% confidence interval (CI) = 0.76-1.20; Bayes factor 0.05). There were no serious adverse events related to study drug and no differences in frequency of adverse events by treatment arm. Conclusions Notwithstanding very high medication adherence for this study, extended-release naltrexone does not appear to reduce methamphetamine use or sexual risk behaviors among methamphetamine-dependent men who have sex with men compared with placebo.

Importance Methamphetamine use is increasingly prevalent and associated with HIV transmission. A previous phase 2a study of mirtazapine demonstrated reductions in methamphetamine use and sexual risk behaviors among men who have sex with men. Objective To determine the efficacy of mirtazapine for treatment of methamphetamine use disorder and reduction in HIV risk behaviors. Design, Setting, and Participants This double-blind randomized clinical trial of mirtazapine vs placebo took place from August 2013 to September 2017 in an outpatient research clinic in San Francisco, California. Participants were community-recruited adults who were sexually active; cisgender men, transgender men, and transgender women who (1) had sex with men, (2) had methamphetamine use disorder, and (3) were actively using methamphetamine were eligible. Participants were randomized to receive the study drug or placebo for 24 weeks, with 12 more weeks of follow-up. Data analysis took place from February to June 2018. Exposures Mirtazapine, 30 mg, or matched placebo orally once daily for 24 weeks, with background counseling. Main Outcomes and Measures Positive urine test results for methamphetamine over 12, 24, and 36 weeks (primary outcomes) and sexual risk behaviors (secondary outcomes). Sleep, methamphetamine craving, dependence severity, and adverse events were assessed. Results Of 241 persons assessed, 120 were enrolled (5 transgender women and 115 cisgender men). The mean (SD) age was 43.3 (9.8) years; 61 (50.8%) were white, 31 (25.8%) were African American, and 15 (12.5%) were Latinx. A mean (SD) of 66% (47%) of visits were completed overall. By week 12, the rate of methamphetamine-positive urine test results significantly declined among participants randomized to mirtazapine vs placebo (risk ratio [RR], 0.67 [95% CI, 0.51-0.87]). Mirtazapine resulted in reductions in positive urine test results at 24 weeks (RR, 0.75 [95% CI, 0.56-1.00]) and 36 weeks (RR, 0.73 [95% CI, 0.57-0.96]) vs placebo. Mean (SD) medication adherence by WisePill dispenser was 38.5% (27.0%) in the mirtazapine group vs 39.5% (26.2%) in the placebo group (P = .77) over 2 to 12 weeks and 28.1% (23.4%) vs 38.5% (27.0%) (P = .59) over 13 to 24 weeks. Changes in sexual risk behaviors were not significantly different by study arm at 12 weeks, but those assigned to receive mirtazapine had fewer sexual partners (RR, 0.52 [95% CI, 0.27-0.97];P = .04), fewer episodes of condomless anal sex with partners who were serodiscordant (RR, 0.47 [95% CI, 0.23-0.97];P = .04), and fewer episodes of condomless receptive anal sex with partners who were serodiscordant (RR, 0.37 [95% CI, 0.14-0.93];P = .04) at week 24. Participants assigned to mirtazapine had net reductions in depressive symptoms (Center for Epidemiologic Studies Depression Scale score, 6.2 [95% CI, 1.3-11.1] points lower;P = .01) and insomnia severity (Athens score, 1.4 [95% CI, 0.1-2.7] points lower;P = .04) at week 24. There were no serious adverse events associated with the study drug. Conclusions and Relevance In this expanded replication trial, adding mirtazapine to substance use counseling reduced methamphetamine use and some HIV risk behaviors among cisgender men and transgender women who have sex with men, with benefits extending after treatment despite suboptimal medication adherence. Trial Registration ClinicalTrials.gov identifier:NCT01888835

IMPORTANCE: Diagnosis of human immunodeficiency virus (HIV) infection, linkage and retention in care, and adherence to antiretroviral therapy are steps in the care continuum enabling consistent viral suppression for people living with HIV, extending longevity and preventing further transmission. While incarcerated, people living with HIV receive antiretroviral therapy and achieve viral suppression more consistently than after they are released. No interventions have shown sustained viral suppression after jail release. OBJECTIVE: To test the effect on viral suppression in released inmates of the manualized LINK LA (Linking Inmates to Care in Los Angeles) peer navigation intervention compared with standard transitional case management controls. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial conducted from December 2012 through October 2016 with people living with HIV being released from Los Angeles (LA) County Jail. All participants were (1) 18 years or older; (2) either men or transgender women diagnosed with HIV; (3) English speaking; (4) selected for the transitional case management program prior to enrollment; (5) residing in LA County; and (6) eligible for antiretroviral therapy. MAIN OUTCOMES AND MEASURES: Change in HIV viral suppression (

Objectives Trichomoniasis (TV) is associated with an increased risk of acquisition of sexually transmitted diseases (STDs) and HIV. The purpose of this study is to evaluate factors associated with incidence TV among female STD clinic attendees in the USA. Methods Data were collected from women participating in a randomised controlled trial evaluating brief risk reduction counselling at the time of HIV testing to reduce sexually transmitted infections (STIs) incidence in STD clinics. Participants recruited from STD clinics underwent STI testing at baseline and 6-month follow-up. TV testing was performed using Nucleic Acid Amplification Test. Results 1704 participants completed study assessments. Prevalence of TV was 14.6%, chlamydia 8.6%, gonorrhoea 3.0%, herpes simplex virus 2 44.7% and HIV 0.4%. Cumulative 6-month incidence of TV was 7.5%. Almost 50% of the incident TV cases had TV at baseline and had received treatment. Factors associated with incidence of TV were having chlamydia, TV and HIV at baseline: TV relative risk (RR)=3.37 (95% CI 2.35 to 4.83, p Conclusions Prevalent and incident TV is common among STD clinic attendees; and baseline TV is the main risk factor for incident TV, suggesting high rates of reinfection or treatment failures. This supports the importance of rescreening women after treatment for TV, evaluating current treatment regimens and programmes to ensure treatment of sexual partners. Clinical trial number NCT01154296.

Introduction and Aims Alcohol and substance use can have negative health consequences among both human immunodeficiency virus (HIV)-positive and -negative individuals, and are associated with behaviors that facilitate HIV transmission and acquisition. The relationship of substance use and HIV is well documented among key populations at risk for HIV. However, although transwomen (male-to-female transgender) are disproportionately impacted by HIV, this overlap remains understudied in this population. We sought to evaluate the association between HIV, alcohol and substance use among transwomen. Design and Methods We conducted a secondary data analysis of Respondent Driven Sampling study which collected information on self-reported alcohol and substance use among 314 transwomen. We used multivariable logistic regression to assess relationship between HIV infection and classes and patterns of alcohol and substance use. Results We found that 58% of transwomen used alcohol, and 43.3% used substances. The most common substances used were: marijuana (29%), methamphetamine (20.1%), crack cocaine (13.4%), and ‘club drugs’ (13.1%). Transwomen who reported any methamphetamine use [adjusted odds ratio (AOR) 3.02 (95% confidence interval (CI) = 1.51–6.02)], methamphetamine use before or during anal intercourse [AOR 3.27 (95% CI = 1.58–6.77)], and at least weekly methamphetamine use [AOR 3.89 (95% CI = 1.64–9.23)] had significantly greater odds of testing positive for HIV. Discussion and Conclusions Transfemales have high prevalence of alcohol and substance use; those tested positive for HIV used significantly more methamphetamine in general, and in conjunction with sex. Given the disproportionate prevalence of HIV and substance use in this population, interventions aimed at addressing both substance use and HIV risk among transwomen are urgently needed. [Santos G-M, Rapues J, Wilson EC, Macias O, Packer T, Colfax G, Raymond HF. Alcohol and substance use among transgender women in San Francisco: Prevalence and association with human immunodeficiency virus infection. Drug Alcohol Rev 2014;33:287–295]

OBJECTIVE To evaluate for changes in sexual behaviors associated with daily pill use among men who have sex with men (MSM) participating in a preexposure prophylaxis trial. DESIGN Randomized, double-blind, placebo-controlled trial. Participants were randomized 1:1:1:1 to receive tenofovir disoproxil fumarate or placebo at enrollment or after a 9-month delay and followed for 24 months. METHODS Four hundred HIV-negative MSM reporting anal sex with a man in the past 12 months and meeting other eligibility criteria enrolled in San Francisco, Atlanta, and Boston. Sexual risk was assessed at baseline and quarterly visits using Audio Computer-Assisted Self-Interview. The association of pill taking with sexual behavior was evaluated using logistic and negative-binomial regressions for repeated measures. RESULTS Overall indices of behavioral risk declined or remained stable during follow-up. Mean number of partners and proportion reporting unprotected anal sex declined during follow-up (P < 0.05), and mean unprotected anal sex episodes remained stable. During the initial 9 months, changes in risk practices were similar in the group that began pills immediately vs. those in the delayed arm. These indices of risk did not differ significantly after initiation of pill use in the delayed arm or continuation of study medication in the immediate arm. Use of poppers, amphetamines, and sexual performance-enhancing drugs were independently associated with one or more indices of sexual risk. CONCLUSIONS There was no evidence of risk compensation among HIV-uninfected MSM in this clinical trial. Monitoring for risk compensation should continue now that preexposure prophylaxis has been shown to be efficacious in MSM and other populations and will be provided in open-label trials and other contexts.

Objectives. We evaluated the use of respondent-driven sampling (RDS) among a high-risk population of transfemales. We also obtained up-to-date epidemiological data on HIV infection and related correlates among this population. Methods. We evaluated the utility of RDS in recruiting a sample of 314 transfemales in San Francisco, California, from August to December 2010 by examining patterns of recruitment and assessing network sizes and equilibrium. We used RDS weights to conduct bivariate and multivariate analyses of correlates of HIV infection. Results. The sample had moderate homophily and reached equilibrium at the eighth wave of recruitment. Weighted HIV prevalence among transfemales was 39.5%. Being a transfemale of color, using injection drugs, and having low educational attainment were independently associated with HIV infection and having a high number of sexual partners and identifying as female were not. Conclusions. RDS performed well and allowed for analyses that are generalizable to the population from which the sample was drawn. Transfemales in San Francisco are disproportionately affected by HIV compared with all other groups except men who have sex with men who also inject drugs.

Aims To test aripiprazole for efficacy in decreasing use in methamphetamine-dependent adults, compared to placebo. Design Participants were randomized to receive 12 weeks of aripiprazole or placebo, with a 3-month follow-up and a platform of weekly 30-minute substance abuse counseling. Setting The trial was conducted from January 2009 to March 2012 at the San Francisco Department of Public Health. Participants Ninety actively using, methamphetamine-dependent, sexually active adults were recruited from community venues. Measurements The primary outcome was regression estimated reductions in weekly methamphetamine-positive urines. Secondary outcomes were study medication adherence [by self-report and medication event monitoring systems (MEMS)], sexual risk behavior and abstinence from methamphetamine. Findings Participant mean age was 38.7 years, 87.8% were male, 50.0% white, 18.9% African American, and 16.7% Latino. Eighty-three per cent of follow-up visits and final visits were completed. By intent-to-treat, participants assigned to aripiprazole had similar reductions in methamphetamine-positive urines as participants assigned to placebo [risk ratio (RR) 0.88, 95% confidence interval (CI): 0.66–1.19, P = 0.41]. Urine positivity declined from 73% (33 of 45 participants) to 45% (18 of 40) in the placebo arm and from 77% (34 of 44) to 44% (20 of 35) in the aripiprazole arm. Adherence by MEMS and self-report was 42 and 74%, respectively, with no significant difference between arms (MEMS P = 0.31; self-report P = 0.17). Most sexual risk behaviors declined similarly among participants in both arms (all P > 0.05). There were no serious adverse events related to study drug, although participants randomized to aripiprazole reported more akathisia, fatigue and drowsiness (P

The role men who have sex with men and women (MSMW) play in heterosexual HIV transmission is not well understood. We analyzed baseline data from Project MIX, a behavioral intervention study of substance-using men who have sex with men (MSM), and identified correlates of unprotected vaginal intercourse, anal intercourse, or both with women (UVAI). Approximately 10 % (n = 194) of the men reported vaginal sex, anal sex, or both with a woman; of these substance-using MSMW, 66 % (129) reported UVAI. Among substance-using MSMW, multivariate analyses found unemployment relative to full/part-time employment (OR = 2.28; 95 % CI 1.01, 5.17), having a primary female partner relative to no primary female partner (OR = 3.44; CI 1.4, 8.46), and higher levels of treatment optimism (OR = 1.73; 95 % CI 1.18, 2.54) increased odds of UVAI. Strong feelings of connection to a same-race gay community (OR = 0.71; 95 % CI 0.56, 0.91) and Viagra use (OR = 0.31; 95 % CI 0.10, 0.95) decreased odds of UVAI. This work suggests that although the proportion of substance-using MSM who also have sex with women is low, these men engage in unprotected sex with women, particularly with primary female partners. This work highlights the need for further research with the substance using MSMW population to inform HIV prevention interventions specifically for MSMW.

Objectives The authors explored whether respondent-driven sampling (RDS) can generate a more diverse sample of black men who have sex with men (MSM) than time-location sampling (TLS) by comparing sample characteristics accrued by each method in two independent studies. Methods The first study exclusively recruited black MSM through RDS (N=256), while the second recruited MSM through TLS including a subsample of black MSM (N=69). Crude and adjusted point estimates and 95% CIs were calculated for socio-demographic and behavioural characteristics, HIV prevalence and prevalence of unrecognised infections, and were compared using the Z-test. Results The samples differed significantly regarding all socio-demographic and some behavioural characteristics. Compared with TLS, RDS estimated higher proportions of older, less educated, poorer, currently homeless and self-identified bisexual black MSM. Participants in RDS were less likely to have a main partner, had fewer male partners, were more likely to have a female partner and have both male and female partners, and reported greater methamphetamine, crack and heroin use. Prevalence of HIV and unrecognised infections were slightly higher among RDS participants. Conclusions The RDS sample comprised black MSM who were more diverse with respect to socio-demographic characteristics and may also be at higher risk for HIV. Thus, RDS has advantages in reaching higher risk black MSM who are most hidden from intervention research and service delivery. Future studies of black MSM using RDS could use steering strategies to recruit younger participants and other subgroups of greatest interest to public health and prevention.

Seroadaptive behaviors have been widely described as preventive strategies among men who have sex with men (MSM) and other populations worldwide. However, causal links between intentions to adopt seroadaptive behaviors and subsequent behavior have not been established. We conducted a longitudinal study of 732 MSM in San Francisco to assess consistency and adherence to multiple seroadaptive behaviors, abstinence and condom use, whether prior intentions predict future seroadaptive behaviors and the likelihood that observed behavioral patterns are the result of chance. Pure serosorting (i.e., having only HIV-negative partners) among HIV-negative MSM and seropositioning (i.e., assuming the receptive position during unprotected anal sex) among HIV-positive MSM were more common, more successfully adhered to and more strongly associated with prior intentions than consistent condom use. Seroconcordant partnerships occurred significantly more often than expected by chance, reducing the prevalence of serodiscordant partnerships. Having no sex was intended by the fewest MSM, yet half of HIV-positive MSM who abstained from sex at baseline also did so at 12 month follow-up. Nonetheless, no preventive strategy was consistently used by more than one-third of MSM overall and none was adhered to by more than half from baseline to follow-up. The effectiveness of seroadaptive strategies should be improved and used as efficacy endpoints in trials of behavioral prevention interventions.

Men who have sex with men (MSM) remain disproportionately infected with HIV. MSM accounted for 53% of the 56,300 new HIV infections in the US in 2006, despite representing only 4% of the national male population [1, 2]. This high HIV disease burden coincides with high prevalence of non-injection substance use and alcohol consumption among US MSM. A national MSM sample found a 42% previous year prevalence for any non-injection substance use [3]. The recently released United States National HIV/AIDS strategy highlights the need to address substance use among MSM as a critical component of reducing HIV incidence in the United States [4]. To advance this goal, it is imperative to: (1) redress the knowledge gaps on patterns of non-injection substance use among substance using MSM (SUMSM); (2) improve upon existing interventions; (3) develop effective, scalable interventions for the spectrum of users; and (4) determine how to best identify and address the structural and cultural factors that may contribute to non-injection substance use in the MSM population. Non-injection substance use may increase susceptibility to HIV infection in multiple ways [5, 6]. Many epidemiological studies document the association between these substances and sexual risk behaviors [7–24]. These sexual risks are paralleled by high rates of incident and prevalent HIV cases and sexually transmitted infections among SUMSM. Most notably, methamphetamine, cocaine, poppers, and alcohol use have each been associated with an increased risk for HIV and other STD infections [9, 12, 24–30]. The contribution of polysubstance use may also be considerable [9, 28, 31]. Patterns of Substance Use among MSM Drug use among MSM is not an all or nothing phenomenon. There needs to be more emphasis on addressing the specific patterns of non-injection substance use among SUMSM, and what implications these patterns have for intervention approaches. Most SUMSM are not drug-dependent, but rather use episodically (i.e., using substances less than weekly). National HIV Behavioral Surveillance (NHBS) data show that 69–86% of SUMSM report less than weekly substance use [32–35]. Episodic binge drinking is also common among high-risk MSM [36, 37]. Importantly, episodic patterns are associated with high-risk sexual behaviors, suggesting that while perhaps less concerning from a drug-dependence perspective, they may nonetheless contribute substantially to HIV transmission rates among SUMSM [24, 38]. Polysubstance use patterns (i.e., taking more than one substance concurrently, or periodically over a period of time) are often the norm among SUMSM. For example, exclusive of alcohol use, 93% of non-injection methamphetamine using MSM in the San Francisco NHBS sample reported polysubstance use during the prior 12 months before interview; similarly, 94% of cocaine and 90% of poppers users reported using other substances [39]. In a sample of HIV-positive methamphetamine using MSM, 95% of respondents were polysubstance users [40]. Similar findings were reported among samples of MSM club drug users and African American MSM [41–43]. Among various MSM samples, 11–44% of participants reported recent use of three or more substances [44–48]. We need to better understand how to address the wide spectrum of non-injection substance use patterns among MSM. At one extreme are the substance-dependent MSM for whom risk behavior and substance use morbidity may be especially high. Yet, there is also the larger population of MSM whose substance use is infrequent, but for whom it is associated with harmful use and HIV risk. It is unclear where on the substance use spectrum interventions should be invested to have the maximum effectiveness. There is also little understanding as to why, with overall substance use being so prevalent among MSM, only a small proportion develops dependence. Similarly, there is a paucity of understanding as to why some MSM do not use substances, and what factors confer protective effects or relative resiliency with regard to substance use [49]. Finally, how substance use patterns vary across the life trajectories of MSM and how those variations coincide with major life milestones (e.g., sexual debut, coming out, dating, aging, etc.), remains largely unexplored.

Black men who have sex with men (MSM) are disproportionately affected by HIV infection. Black MSM in San Francisco may have higher rates of unrecognized HIV infections. Increased HIV testing among Black MSM may reduce the numbers of unrecognized infections, inform more men of their status and thus reduce the potential for ongoing transmissions. Social network HIV testing programs have focused on asking HIV-positive and/or high-risk negative men to recruit their social or sexual contacts. We used a network approach to deliver HIV testing to Black MSM in San Francisco and collected risk assessment data. Participants were asked to recruit any of their social contacts who were also Black MSM. Recruitment by risk level and HIV status was heterogeneous. HIV infection among this population is associated with older age, having a high school education or higher and currently being homeless. Fully 23% of HIV positive Black MSM are unaware of their infection. Only a third of unrecognized infections were recruited by a known HIV-positive participant. Linkage to care was a challenge and underscores the need for comprehensive systems and support to link Black MSM to care and treatment.

"Seroadaptation" comprises sexual behaviors to reduce the risk of HIV acquisition and transmission based on knowing one's own and one's sexual partners' serostatus. We measured the prevalence of seroadaptive behaviors among men who have sex with men (MSM) recruited through time-location sampling (TLS) across three perspectives: by individuals (N = 1207 MSM), among sexual dyads (N = 3746 partnerships), and for sexual episodes (N = 63,789 episodes) in the preceding six months. Seroadaptation was more common than 100% condom use when considering the consistent behavioral pattern of individuals (adopted by 39.1% vs. 25.0% of men, respectively). Among sexual dyads 100% condom use was more common than seroadaptation (33.1% vs. 26.4%, respectively). Considering episodes of sex, not having anal intercourse (65.0%) and condom use (16.0%) were the most common risk reduction behaviors. Sex of highest acquisition and transmission risks (unprotected anal intercourse with a HIV serodiscordant or unknown status partner in the riskier position) occurred in only 1.6% of sexual episodes. In aggregate, MSM achieve a high level of sexual harm reduction through multiple strategies. Detailed measures of seroadaptive behaviors are needed to effectively target HIV risk and gauge the potential of serosorting and related sexual harm reduction strategies on the HIV epidemic.

Men who have sex with men (MSM) continue to be disproportionately affected by human immunodeficiency virus (HIV) infection. While the MSM population does better than other HIV infection risk groups with regard to linkage to and retention in care, little is known about engagement in care outcomes for important subpopulations of MSM. There is also a dearth of research on engagement in care strategies specific to the MSM population. Key MSM subpopulations in the United States on which to focus future research efforts include racial/ethnic minority, young, and substance-using MSM. Health care systems navigation may offer a promising engagement in care strategy for MSM and should be further evaluated. As is the case for HIV-infected populations in general, future research should also focus on identifying the best metrics for measuring engagement in care.

Clinician-delivered prevention interventions offer an opportunity to integrate risk-reduction counseling as a routine part of medical care. The HIV Intervention for Providers study, a randomized controlled trial, developed and tested a medical provider HIV prevention training intervention in 4 northern California HIV care clinics. Providers were assigned to either the intervention or control condition (usual care). The intervention arm received a 4-hour training on assessing sexual risk behavior with HIV-positive patients and delivering risk-reduction-oriented prevention messages to patients who reported risk behaviors with HIV-uninfected or unknown-status partners. To compare the efficacy of the intervention versus control on transmission risk behavior, 386 patients of the randomized providers were enrolled. Over six-months of follow-up, patients whose providers were assigned the intervention reported a relative increase in provider-patient discussions of safer sex (OR = 1.49; 95% CI = 1.06 to 2.09), assessment of sexual activity (OR = 1.60; 95% CI = 1.05 to 2.45), and a significant decrease in the number of sexual partners (OR = 0.49, 95% CI = 0.26 to 0.92). These findings show that a brief intervention to train HIV providers to identify risk and provide a prevention message results in increased prevention conversations and significantly reduced the mean number of sexual partners reported by HIV-positive patients.

This study compared HIV-related attitudes and intentions by respondent HIV-status in a large sample of substance-using men who have sex with men (MSM) in the United States. Attitudes and intentions included self-efficacy for safer sex; difficulty communicating with sex partners about safer sex; intent to use condoms consistently and to not use substances before sex in the next 3 months; and less concern for HIV given effective antiviral treatments. Differences were found for behavior during the most recent anal sex encounter by HIV-status, including (a) insertive and (b) receptive anal sex risk behavior, and (c) substance use before or during the encounter. Self-efficacy for safer sex was associated with less risk behavior among HIV-negative men but not among HIV-positive men, suggesting that self-efficacy for safer sex continues to be a relevant issue to address in counseling uninfected MSM. HIV-positive men who reported less concern for HIV given treatments were more likely to report receptive risk behavior, as were HIV-negative men who reported difficulty communicating about safer sex. Implications are discussed for potentially heightened client desire and therapeutic opportunity to reduce future substance use during sex for clients who report recent substance use during sex. Keywords: HIV; sexual risk; substance use; MSM; cognitive domain HIV infection continues to be a concern in the United States and around the world, with estimated annual new infections at approximately 56,300 (Hall et al., 2008) and 2.7 million (Joint United Nations Programme on HIV/AIDS, 2009), respectively. Men who have sex with men (MSM) continue to be the dominant risk group of new infections in America (Hall et al., 2008), accounting for 53% of all new US infections, and MSM are at heightened risk for infection, compared to heterosexuals, even in low- and middle-income countries (Baral, Sifakis, Cleghorn, & Beyrer, 2007). Although effective medical treatments have existed since the mid-1990s, in the absence of an effective vaccine, behavioral prevention counseling continues to be key to decreasing the spread of HIV infection. Most behavioral interventions, whether for affective disorders or health behaviors, view the therapeutic process in terms of the client's cognitive framework for understanding his own behavior and behavior change (Beck, 1995). This has also been the case for the general area of preventive health behavior. Behaviors ranging from smoking cessation to radon screening have been examined in terms of perceived personal vulnerability to negative outcomes (Weinstein, 1989), self-efficacy expectancies for engaging in precautionary behavior (Bandura, 1991), outcome expectancies about the effectiveness of behavioral change, health beliefs, and related cognitive processes (Harvey & Lawson, 2009; Weinstein, 1993). Similarly, a variety of health promotion programs have incorporated basic attitude models, which focus on the development or change of behavioral intentions. Intentions are seen as a stable cognitive set toward a behavioral domain, derived from beliefs about a behavior and its outcomes, affective value for the behavior or outcome, and perceived norms of others (Ajzen, 2001; Fishbein & Middlestadt, 1989). Since the first HIV/AIDS cases were identified, understanding and reducing risk behavior- particularly sexual risk behavior-has been a primary focus of researchers and practitioners. Consistent with other areas of health promotion, HIV prevention has emphasized cognitive processes such as perceptions, beliefs, attitudes, and behavioral intentions (e.g., The Health Belief Model [Bakker, Buunk, Siero, & Van den Eijnden, 1997; Janz & Becker, 1984]; The Theory of Reasoned Action [Ajzen & Fishbein, 1980; Fishbein & Middlestadt, 1989]; and Social Cognitive Theory [Bandura, 1986; Forsyth, Carey, & Fuqua, 1997]). Specific counseling or behavioral program components based on these social-cognitive approaches have included (1) simple knowledge about HIV or HIV transmission, (2) self-efficacy for safer sex, (3) perceived difficulty communicating with partners about safer sex, (4) perceived severity of HIV given that effective medical treatments exist, and (5) intentions to engage in safer sex in the future. …

Objective: To determine whether actively using, methamphetamine (meth)-dependent men who have sex with men (MSM) could be enrolled and retained in a pharmacologic intervention trial, and the degree to which participants would adhere to study procedures, including medication adherence. Study design: Phase II randomized, double-blind trial of bupropion vs. placebo. Methods: Thirty meth-dependent, sexually active MSM were randomized to receive daily bupropion XL 300 mg or placebo for 12 weeks. Participants received weekly substance use counseling, provided weekly urine specimens, and completed monthly audio-computer assisted self-interview (ACASI) behavioral risk assessments. Adherence was measured by medication event monitoring systems (MEMS) caps (the number of distinct MEMS cap openings divided by the number of expected doses) and self-report. Results: Ninety percent completed the trial: 89% of monthly ACASIs were completed, 81% of study visits were attended, and 81% of urine samples were collected. Adherence by MEMS cap was 60% and by self-report was 81% and did not differ significantly by treatment assignment. The median number of positive urine samples was 5.5 out of a possible 11 (50%). Participants in both arms reported similar declines in the median number of sex partners (P = 0.52). No serious adverse events occurred and there were no significant differences in adverse events by treatment assignment (P = 0.11). Conclusions: It is feasible to enroll and retain actively using, meth-dependent MSM in a pharmacologic intervention. Bupropion was well tolerated. Study participation and retention rates were high, however, study drug medication adherence was only moderate. Findings support a larger trial with improved adherence support to evaluate the efficacy of bupropion and other pharmacologic interventions for meth dependence in this population.

Men who have sex with men (MSM) show high rates of HIV infection, and higher rates of depression than non-MSM. We examined the association between depression and sexual risk among "high risk" MSM. Evidence has been mixed regarding the link between depression and risky sex, although researchers have rarely considered the role of psychosocial vulnerabilities such as self-efficacy for sexual safety or "escape" coping styles. In a national sample (N = 1,540) of HIV-positive and HIV-negative MSM who reported unprotected sex and drug use with sex partners, we found evidence that depression is related to HIV transmission risk. Self-efficacy for sexual safety and cognitive escape mediated the link between depression and risk behavior, suggesting that psychosocial vulnerability plays an important role in the association of depression with sexual risk. These findings may help us construct more accurate theories regarding depression and sexual behavior, and may inform the design of sexual safety interventions.

Objective: Human papillomavirus (HPV) is a common sexually transmitted agent that causes anogenital cancer and precancer lesions that have an inflammatory infiltrate, may be friable and bleed. Our aim was to determine the association between anal HPV infection and HIV acquisition. Design: A prospective cohort study. Methods: We recruited 1409 HIV-negative men who have sex with men from a community-based setting in Boston, Denver, New York and San Francisco. We used Cox proportional hazards regression modeling and assessed the independent association of HPV infection with the rate of acquisition of HIV infection. Results: Of 1409 participants contributing 4375 person-years of follow-up, 51 HIVseroconverted. The median number of HPV types in HPV-infected HIV-seroconverters was 2 (interquartile range 1‐3) at the time of HIV seroconversion. After adjustment for sexual activity, substance use, occurrence of other sexually transmitted infections and demographic variables, there was evidence (P ¼0.002) for the effect of infection with at least two HPV types (hazard ratio 3.5, 95% confidence interval 1.2‐10.6) in HIV seroconversion. Conclusion: Anal HPV infection is independently associated with HIV acquisition. Studies that incorporate high-resolution anoscopy to more accurately identify HPVassociated disease are needed to determine the relationship between HPV-associated disease and HIV seroconversion. 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins AIDS 2009, 23:000‐000

This study explored the relationship between gay identity-related factors (gay community involvement, gay bar attendance, gay identity importance, and self-homophobia) and unprotected anal sex (UA) in the past 3 months among men who have sex with men (MSM) of three different race/ethnicity groups. Four hundred eighty-three MSM (mean age 34) were recruited in the San Francisco Bay Area (33% African American, 34% Latino and 33% White). Compared with White MSM, African American and Latino MSM were less likely to identify as gay, and to attend gay bars/clubs, and more likely to report self-homophobia. Just over one third of the sample reported UA (did not vary by race). Gay community involvement was associated with receptive UA with all partners (adjusted odds ratio [AOR = 1.30, 95% Confidence Interval (CI) = 1.06-1.60). Gay bar attendance was associated with insertive UA with all partners (AOR = 1.20, 95% CI = 1.01-1.43) and with HIV-discordant partners (AOR = 1.35, 95% CI = 1.08-1.69). Implications for prevention include addressing community norms and encouraging alternatives to bars as settings in which to meet and socialize with other MSM.

Objectives: To evaluate trends in the HIV epidemic among men who have sex with men (MSM) in San Francisco and the implications for HIV prevention. Methods: An ecological approach assessed temporal trends in sexual risk behaviour, sexually transmitted infections (STI), HIV incidence and prevalence from multiple data sources between 1998 and 2007. Results: By 2007, there were over 13 000 HIV-infected MSM living in San Francisco. No consistent upward or downward temporal trends were found in HIV incidence, newly reported HIV cases, AIDS deaths, proportion of AIDS cases using antiretroviral therapy, rectal gonorrhoea or primary and secondary syphilis cases among MSM during the study period. Trends in indicators of sexual risk behaviour among MSM were mixed. Overall, unprotected anal intercourse (UAI) increased in community-based surveys. Among HIV-positive MSM, no significant trends were noted for UAI. Among HIV-negative MSM, UAI with unknown serostatus partners decreased but increased with potentially discordant serostatus partners. Among MSM seeking HIV testing, increases were noted in insertive UAI at anonymous testing sites and at the STI clinic, in receptive UAI at anonymous test sites and in receptive UAI with a known HIV-positive partner at the STI clinic. Conclusions: Temporal trends in multiple biological and behavioural indicators over the past decade describe a hyperendemic state of HIV infection among MSM in San Francisco, whereby prevalence has stabilised at a very high level. In the absence of new, effective prevention strategies this state will persist.

Objectives We investigated the prevalence of HIV-positive patients discussing alcohol use with their HIV primary care providers and factors associated with these discussions. Methods We recruited 1225 adult participants from 10 HIV care clinics in three large US cities from May 2004 to 2005. Multivariate logistic regression analysis was used to assess the associations between self-reported rates of discussion of alcohol use with HIV primary care providers in the past 12 months and the CAGE screening measure of problem drinking and sociodemographic variables. Results Thirty-five percent of participants reported discussion of alcohol use with their primary care providers. The odds of reporting discussion of alcohol were three times greater for problem drinkers than for non-drinkers, but only 52% of problem drinkers reported such a discussion in the prior 12 months. Sociodemographic factors associated with discussion of alcohol use (after controlling for problem drinking) were being younger than 40, male, being non-white Hispanic (compared with being Hispanic), being in poorer health, and having a better patient–provider relationship. Conclusions Efforts are needed to increase the focus on alcohol use in the HIV primary care setting, especially with problem drinkers. Interventions addressing provider training or brief interventions that address alcohol use by HIV-positive patients in the HIV primary care setting should be considered as possible approaches to address this issue.

Objectives Sexually transmitted infections (STIs) are significant public health and financial burdens in the United States. This manuscript examines the relationship between substance use and prevalent and incident STIs in HIV-negative adult patients at STI clinics. Methods A secondary analysis of Project AWARE was performed based on 5012 patients from 9 STI clinics. STIs were assessed by laboratory assay and substance use by self-report. Patterns of substance use were assessed using latent class analysis. The relationship of latent class to STI rates was investigated using Poisson regression by population groups at high risk for STIs defined by participant’s and partner’s gender. Results Drug use patterns differed by risk group and substance use was related to STI rates with the relationships varying by risk behavior group. Substance use treatment participation was associated with increased STI rates. Conclusions Substance use focused interventions may be useful in STI clinics to reduce morbidity associated with substance use. Conversely, gender-specific sexual health interventions may be useful in substance use treatment.

Factors associated with HIV transmission risk may differ between subgroups of persons living with HIV/AIDS (PLWHA). This study examined such factors in a sample of PLWHA recruited in 3 US metropolitan areas. Sexually active participants were categorized as gay or bisexual men (GBM) (n = 545), heterosexual men (HSM, n = 223), or women (n = 214). Of 982 participants, 27.1% reported serodiscordant unprotected anal or vaginal sex (SDUAV). SDUAV was associated with multiple (2 or more) partners, using poppers, and lower safer sex self-efficacy among GBM. SDUAV was associated with multiple partners among HSM. Among women, factors examined were not associated with SDUAV. These findings are consistent with prior research and facilitate our ability to target those who may be most at risk for transmitting HIV among HIV-positive GBM. More research must be conducted to identify factors associated with risk behavior among HSM and women.

Objective: To assess the interest of out-of-treatment methamphetamine-using men who have sex with men (MSM) seen at public health STD clinics in an intervention specifically targeting their drug use. Study Design: An anonymous, self-administered survey of MSM who use methamphetamine attending public health STD clinics in Seattle and San Francisco. Results: Among 174 men surveyed, 36% reported being considerably or extremely troubled or bothered by their methamphetamine use, 62% reported a considerable or extreme desire to reduce or stop their use of methamphetamine, and 52% reported considerable or extreme interest in attending a program to stop or decrease methamphetamine use. While 70% of the men surveyed had attempted to stop using methamphetamine, only 12% had ever been in drug treatment. Conclusions: In a two-city sample of MSM who use methamphetamine, interest in an intervention to help men stop or decrease their methamphetamine use is high. Interventions that target methamphetamine use and are delivered through the public health system merit further investigation.

Case management (CM) coordinates care for persons with complex health care needs. It is not known whether CM is effective at improving biological outcomes among homeless and marginally housed persons with human immunodeficiency virus (HIV) infection. Our goal was to determine whether CM is associated with reduced acute medical care use and improved biological outcomes in homeless and marginally housed persons with HIV infection.We conducted a prospective observational cohort study in a probability-based community sample of HIV-infected homeless and marginally housed adults in San Francisco, California. The primary independent variable was CM, defined as none or rare (any CM inor=25% of quarters in the study), moderate (25% butor=75%), or consistent (75%). The dependent variables were 3 self-reported health service use measures (receipt of primary care, emergency department visits and hospitalizations, and antiretroviral therapy adherence) and 2 biological measures (increase in CD4(+) cell count ofor=50% and geometric mean HIV load ofor=400 copies/mL).In multivariate models, CM was not associated with increased primary care, emergency department use, or hospitalization. Moderate CM, compared with no or rare CM, was associated with an adjusted beta coefficient of 0.13 (95% confidence interval [CI], 0.02-0.25) for improved antiretroviral adherence. Consistent CM (adjusted odds ratio [AOR], 10.7; 95% CI, 2.3-49.6) and moderate CM (AOR, 6.5; 95% CI, 1.3-33.0) were both associated withor=50% improvements in CD4(+) cell count. CM was not associated with geometric HIV load400 copies/mL when antiretroviral therapy adherence was included in the model. Study limitations include a lack of randomization.CM may be a successful method to improve adherence to antiretroviral therapy and biological outcomes among HIV-infected homeless and marginally housed adults.

Objectives Risk factors for HIV acquisition were examined in a recent cohort of men who have sex with men (MSM). Design A longitudinal analysis of 4295 HIV-negative MSM enrolled in a randomized behavioral intervention trial conducted in six US cities. Methods MSM were enrolled and assessed for HIV infection and risk behaviors semi-annually, up to 48 months. Results In multivariate analysis, men reporting four or more male sex partners, unprotected receptive anal intercourse with any HIV serostatus partners and unprotected insertive anal intercourse with HIV-positive partners were at increased risk of HIV infection, as were those reporting amphetamine or heavy alcohol use and alcohol or drug use before sex. Some depression symptoms and occurrence of gonorrhea also were independently associated with HIV infection. The attributable fractions of high number of male partners, use of alcohol or drugs before sex, and unprotected receptive anal intercourse with unknown status partners and the same with presumed negative partners accounted for 32.3, 29.0, 28.4 and 21.6% of infections, respectively. Conclusions The challenge is to develop strategies to identify men in need. Interventions are needed to help men reduce their number of sexual partners, occurrences of unprotected anal intercourse, alcohol or drug use before sex and address other mental health issues.

Methamphetamine and related amphetamine compounds are among the most commonly used illicit drugs, with over 35 million users worldwide. In the United States, admissions for methamphetamine treatment have increased dramatically over the past 10 years. Methamphetamine use is prevalent among persons with HIV infection and persons at risk for HIV, particularly among men who have sex with men. In addition to being associated with increased sexual risk behavior, methamphetamine causes significant medical morbidity, including neurologic deficits, cardiovascular compromise, dental decay, and skin infections, all of which may be worsened in the presence of HIV/AIDS. Methamphetamine use may also result in decreased medication adherence, particularly during "binging" episodes. Behavioral counseling remains the standard of treatment for methamphetamine dependence, although the effectiveness of most counseling interventions has not been rigorously tested. Pharmacologic and structural interventions may prove valuable additional interventions to reduce methamphetamine use.

Understanding why people join HIV vaccine efficacy trials is critical for trial recruitment and education efforts. We assessed participants' motivations for joining the VaxGen VAX004 study, a randomized, double-blind, placebo-controlled, phase 3 multicenter trial. Of 5417 participants, 94% were men who have sex with men (MSM) and 6% were women at risk for heterosexual transmission of HIV. Most participants gave altruistic reasons for trial participation: 99% reported having joined to help find an HIV vaccine, and 98% reported having joined to help their community. Some gave more personal reasons: 56% joined to reduce risk behavior and 46% joined to get protection from HIV Additional reasons related to receiving services or compensation included to obtain information about HIV (75%), to receive free HIV testing (34%), and for financial reimbursement (14%). Multivariate logistic regression analysis showed that female participants were significantly more motivated than male participants to join the trial for protection and to receive services or compensation (all P < 0.05). Participants with 13 or more sex partners in the 6 months before enrollment were more likely than those with fewer sex partners to report having joined the trial for protection but less likely to have joined to reduce risk behavior (both P < 0.05). Because many participants reported personal protection from HIV as their reason for joining, vaccine trial risk-reduction counseling should continue to emphasize the placebo-controlled trial design and unknown efficacy of the test product, particularly for women and persons with large numbers of sex partners. Because a significant minority of participants reported joining to receive HIV information, HIV testing, and financial reimbursement, a need is indicated for provision of HIV prevention services outside research trials and for monitoring to ensure that participants are not motivated to join trials for financial gain.

Objective To examine the prevalence of negotiated safety (NS) in a diverse sample of HIV-negative men who have sex with men (MSM), characteristics of MSM practicing NS, and adherence to NS. Methods This was a cross-sectional survey of San Francisco MSM recruited from venues and community organizations. NS relationships were defined as those in which HIV-negative men were in seroconcordant primary relationships for >/=6 months, had unprotected anal intercourse (UA) together, and had rules prohibiting UA with others. Adherence to NS was determined from self-reported sexual behavior in the prior 3 months. Presence of an agreement with NS partners to disclose rule breaking was also determined. Results Of 340 HIV-negative participants, 76 (22%) reported a current seroconcordant primary relationship for >/=6 months. Of these 76 men, 38 (50%) had NS relationships, 30 (39%) had no UA with primary partners, and 8 (11%) had UA with primary partners without rules prohibiting UA with others. In multivariate analysis, NS was more common than no UA with primary partners in younger men. Among 38 NS men, 29% violated their NS-defining rule in the prior 3 months, including 18% who reported UA with others, and 18% reported a sexually transmitted infection (STI) in the prior year. Only 61% of NS men adhered fully to rules and agreed to disclose rule breaking. Conclusions Although NS was commonly practiced among HIV-negative men in seroconcordant relationships, some men violated NS-defining rules, placing themselves and potentially their primary partners at risk for HIV infection. Prevention efforts regarding NS should emphasize the importance of agreement adherence, disclosure of rule breaking, and routine STI testing.

Background. In the United States, anal cancer in men who have sex with men (MSM) is more common than cervical cancer in women. Human papillomavirus (HPV) is causally linked to the development of anal and cervical cancer. In women, cervical HPV infection peaks early and decreases after the age of 30. Little is known about the age-specific prevalence of anal HPV infection in human immunodeficiency virus (HIV)-negative MSM. Methods. We studied the prevalence and determinants of anal HPV infection in 1218 HIV-negative MSM, 18-89 years old, who were recruited from 4 US cities. We assessed anal HPV infection status by polymerase chain reaction. Results. HPV DNA was found in the anal canal of 57% of study participants. The prevalence of anal HPV infection did not change with age or geographic location. Anal HPV infection was independently associated with receptive anal intercourse (odds ratio [OR], 2.0; P 5 sex partners during the preceding 6 months (OR, 1.5; P

Prior reports associating substance use with sexual risk behavior have generally used summary measures and have not adjusted for participants' background levels of substance use. In this 1999-2001 US study (the EXPLORE study), the authors determined whether substance use during sex was independently associated with sexual risk during recent sexual episodes, as reported by 4,295 human immunodeficiency virus-negative men who have sex with men. The main outcome measure was serodiscordant unprotected anal sex (SDUA). The influence of participant-level characteristics was examined by using repeated-measures logistic models. In assessing the influence of episode-level predictors on SDUA, the influence of participant-level characteristics, including 6-month substance use, was removed by using conditional logistic regression, in effect making each participant his own control. The authors also adjusted for partner characteristics. Eleven percent of participants reported heavy alcohol use, 37% used poppers, 19% sniffed cocaine, and 13% used amphetamines. In the participant-level analysis, use of poppers, amphetamines, and sniffed cocaine as well as heavy alcohol use in the prior 6 months were independently associated with SDUA. In the conditional analysis, consumption of > or = 6 alcoholic drinks or use of poppers, amphetamines, or sniffed cocaine just before or during sex was independently associated with SDUA. The authors concluded that programs aimed at preventing human immunodeficiency virus transmission should emphasize the influence of substance use during sex on increased risk behavior.

Objectives To assess recent rectal use of nonoxynol-9 (N-9), intent to use the product, and factors associated with N-9 use among men who have sex with men (MSM). Design Cross-sectional survey of a diverse sample of MSM in the San Francisco Bay Area. Methods Recruitment conducted at multiple street locations on various days/times or through referral during the Fall of 2001. Results Sixty-one percent (349/573) had heard of N-9, of which 55% (192/349) reported hearing in the prior year that N-9 may not be protective against HIV. Of men aware of N-9, 83% (289/349) knowingly used it in their lifetime, of which 67% (193/289) used it during anal intercourse in the previous year. Forty-one percent (79/193) of those who used N-9 during anal intercourse in the past year did so without a condom because they thought it may protect against HIV. Older men were more likely than younger men to have used N-9 for protection. Men who heard that N-9 may not protect were less likely, and African-Americans (versus Caucasians) were more likely, to say they would definitely use N-9 during anal intercourse in the future. Latinos (versus Caucasians), those with unknown HIV serostatus (versus HIV-negative), and those with lower education were less likely to know about N-9 at all, and thus were at risk for unknowingly using N-9. Conclusions Many MSM used N-9 during or following public health warnings about the product. Actions (e.g., information campaigns, warning labels specific to rectal use) should be considered by communities to reduce rectal use of N-9.

BACKGROUND: In the Democratic Republic of Congo (DRC) men who have sex with men (MSM) and female sex workers (FSW) have the highest HIV prevalence but have the least access to services due to their marginalization within Congolese society. METHODS: The Projet Integre de VIH/SIDA au Congo (ProVIC) aims to reduce the risk and impact of HIV in the DRC through community- and facility-based prevention counseling and testing and treatment strategies aimed at high-risk populations including MSM and FSW. To more effectively meet the needs of key populations ProVIC tailored the existing interventions to better suit MSM and FSW by offering mobile counseling and rapid HIV testing services at night in MSM and FSW "hotspots" targeting outreach to and mobilizing key populations through social networks of MSM and FSW peer educators and recruiters and referring MSM and FSW who test HIV positive to "friendly" clinics. RESULTS: Through these approaches ProVIC was able to reach 2621 MSM and 12746 FSW with targeted prevention messaging in 2013 and provide testing and counseling services to 4366 MSM and 21033 FSW from October 2012 to June 2014. CONCLUSIONS: By applying innovative adaptations geared toward key populations ProVIC has been able to better reach MSM and FSW in the DRC. ProVICs targeted interventions for MSM and FSW provide promising examples of programming that can be used to meet the HIV prevention and testing needs of key populations and improve referrals for care and treatment particularly in complex and unstable settings similar to the DRC.

Through sequential cross-sectional surveys, we examined intent to use home HIV test collection kits, actual use and barriers to use among persons at high risk for HIV infection. Interest in kits was assessed in the 1995-96 HIV Testing Survey (HITS, n=1683). Kit use, knowledge of kits and barriers to use were assessed in the 1998-99 HITS (n=1788), after kits had become widely available. When asked to choose among future testing options, 19% of 1995-96 participants intended to use kits. Untested participants were more likely than previously tested HIV-negative participants to choose kits for their next HIV test (p < 0.001). Among 1998-99 participants, only 24 (1%) had used kits; 46% had never heard of kits. Predictors of not knowing about kits included never having been HIV tested and black or Latino race. Common reasons for not using kits among participants aware of home test kits were concerns about accuracy, lack of in-person counselling and cost. Despite high rates of anticipated use, kits have had minimal impact on the testing behaviour of persons at high risk for HIV infection. Increasing awareness of kits, reducing price and addressing concerns about kit testing procedures may increase kit use, leading to more HIV testing by at-risk individuals.

To assess the prevalence of improperly discarded syringes and to examine syringe disposal practices of injection drug users (IDUs) in San Francisco, we visually inspected 1000 random city blocks and conducted a survey of 602 IDUs. We found 20 syringes on the streets we inspected. IDUs reported disposing of 13% of syringes improperly. In multivariate analysis, obtaining syringes from syringe exchange programs was found to be protective against improper disposal, and injecting in public places was predictive of improper disposal. Few syringes posed a public health threat.

BackgroundMethamphetamine use has been previously associated with poor medication adherence, but, to date, there have been no studies that have conducted event-level analyses on correlates of medication adherence in studies of pharmacologic agents for methamphetamine dependence.MethodsWe pooled data from two previous, randomized controlled trials (using bupropion and mirtazapine, respectively) for methamphetamine dependence and used a mixed effects logistic model to examine correlates of daily opening of the medication event monitoring system (MEMS) cap as a repeated measure. We explored whether periods of observed methamphetamine use via urine testing were associated with study medication adherence based on MEMS cap openings.ResultsWe found a significant negative association between methamphetamine-urine positivity and event-level study medication adherence as measured by MEMS cap openings (AOR: 0.69; 95% CI: 0.49-0.98). In addition, age (AOR: 1.07; 95% CI: 1.02-1.11) and depressive symptoms (AOR: 0.78; 95% CI: 0.64-0.90) were significantly associated with adherence. Finally, participants were more likely to open their study medication bottles on days when they presented for in-person urine testing.ConclusionsOur event-level analysis shows that methamphetamine use can be associated with reduced medication adherence as measured by MEMS cap openings in pharmacologic trials, which corroborates prior research. These findings may suggest that medication adherence support in pharmacologic trials among methamphetamine users may be needed to improve study compliance and could be targeted towards periods of time when there are more likely to not open their study medication pill bottles.

There is a continuing need to identify factors associated with risk for HIV transmission among men who have sex with men (MSM), including a need for further research in the ongoing scientific debate about the association of internalised homophobia and sexual risk due partly to the lack of specificity in analysis. We assess the association of internalised homophobia by race/ethnicity within HIV serostatus for a large sample of substance-using MSM at high risk of HIV acquisition or transmission.Convenience sample of substance-using (non-injection) MSM reporting unprotected anal sex in the prior 6 months residing in Chicago, Los Angeles, New York and San Francisco. The analytic sample included HIV-negative and HIV-positive black (n=391), Latino (n=220), and white (n=458) MSM. Internalised homophobia was assessed using a published four-item scale focusing on negative self-perceptions and feelings of their own sexual behaviour with men, or for being gay or bisexual. Analyses tested associations of internalised homophobia with recent risk behaviour, stratified by laboratory-confirmed HIV serostatus within race/ethnicity, and controlling for other demographic variables.In multivariate analysis, internalised homophobia was inversely associated (p0.05) with recent unprotected anal sex among black MSM, and not significantly associated with sexual risk behaviour among white and Latino MSM.More research is needed to further identify nuanced differences in subpopulations of MSM, but these results suggest differentially targeted intervention messages for MSM by race/ethnicity.

Rapid HIV testing in high-risk populations can increase the number of persons who learn their HIV status and avoid spending clinic resources to locate persons identified as HIV infected.We determined the cost to sexually transmitted disease (STD) clinics of point-of-care rapid HIV testing using data from 7 public clinics that participated in a randomized trial of rapid testing with and without brief patient-centered risk reduction counseling in 2010. Costs included counselor and trainer time, supplies, and clinic overhead. We applied national labor rates and test costs. We calculated median clinic start-up costs and mean cost per patient tested, and projected incremental annual costs of implementing universal rapid HIV testing compared with current testing practices.Criteria for offering rapid HIV testing and methods for delivering nonrapid test results varied among clinics before the trial. Rapid HIV testing cost an average of US $22/patient without brief risk reduction counseling and US $46/patient with counseling in these 7 clinics. Median start-up costs per clinic were US $1100 and US $16,100 without and with counseling, respectively. Estimated incremental annual costs per clinic of implementing universal rapid HIV testing varied by whether or not brief counseling is conducted and by current clinic testing practices, ranging from a savings of US $19,500 to a cost of US $40,700 without counseling and a cost of US $98,000 to US $153,900 with counseling.Universal rapid HIV testing in STD clinics with same-day results can be implemented at relatively low cost to STD clinics, if brief risk reduction counseling is not offered.

Episodic (less than weekly) drug use and binge drinking increase HIV-related sexual risk behaviors among men who have sex with men (MSM), yet no evidence-based interventions exist for these men. We describe an adaptation process of the Personalized Cognitive Counseling (PCC) intervention for utilization with high-risk, HIV-negative episodic, substance-using MSM. Participants (N = 59) were racially diverse, and reported unprotected anal intercourse and concurrent binge drinking (85 %), use of poppers (36 %), methamphetamine (20 %) and cocaine (12 %). Semi-structured interviews with 20 episodic, substance-using MSM elicited sexual narratives for engaging in unprotected anal intercourse while using alcohol or drugs. Emergent qualitative themes were translated into self-justifications and included in a revised PCC self-justification elicitation instrument (SJEI). The adapted SJEI was pretested with 19 episodic, substance-using MSM, and the final adapted PCC was pilot-tested for acceptability and feasibility with 20 episodic, substance-using MSM. This process can be used as a roadmap for adapting PCC for other high-risk populations of MSM.

BackgroundNon-dependent alcohol and substance use patterns are prevalent among men who have sex with men (MSM), yet few effective interventions to reduce their substance use are available for these men. We evaluated whether an adapted brief counseling intervention aimed at reducing HIV risk behavior was associated with secondary benefits of reducing substance use among episodic substance-using MSM (SUMSM).Methods326 episodic SUMSM were randomized to brief Personalized Cognitive Counseling (PCC) intervention with rapid HIV testing or to rapid HIV testing only control. Both arms followed over 6 months. Trends in substance use were examined using GEE Poisson models with robust standard errors by arm. Reductions in frequency of use were examined using ordered logistic regression.ResultsIn intent-to-treat analyses, compared to men who received rapid HIV testing only, we found men randomized to PCC with rapid HIV testing were more likely to report abstaining from alcohol consumption (RR=0.93; 95% CI=0.89-0.97), marijuana use (RR=0.84; 95% CI=0.73-0.98), and erectile dysfunction drug use (EDD; RR=0.51; 95% CI=0.33-0.79) over the 6-month follow-up. PCC was also significantly associated with reductions in frequency of alcohol intoxication (OR=0.58; 95% CI=0.36-0.90) over follow-up. Furthermore, we found PCC was associated with significant reductions in number of unprotected anal intercourse events while under the influence of methamphetamine (RR=0.26; 95% CI=0.08-0.84).ConclusionThe addition of adapted PCC to rapid HIV testing may have benefits in increasing abstinence from certain classes of substances previously associated with HIV risk, including alcohol and EDD; and reducing alcohol intoxication frequency and high-risk sexual behaviors concurrent with methamphetamine use.

The reasons for recent declines in AIDS incidence and mortality may include advances in treatment, but these may be confounded by earlier declines in the incidence of human immunodeficiency virus (HIV) infection. To determine whether the declines in AIDS and mortality may, in part, stem from wider use of combination antiretroviral therapy, 622 HIV-positive men with well-characterized dates of seroconversion were followed. In this group, combination therapy came into widespread use in only 1996. In a Cox proportional hazards model, the 1996 calendar period was significantly associated with slower progression to AIDS (relative hazard [RH] = 0.19, 95% confidence interval [CI], 0.05-0.69, P = .01) and death (RH = 0.45, 95% Cl, 0.21-0.95, P =.04). Declines in incidence of HIV infection, changes in HIV virulence, and end-point underreporting cannot fully explain the decline in AIDS and death in 1996. The introduction of combination antiretroviral therapy as the standard of care may already have had measurable effects.

Importance To increase human immunodeficiency virus (HIV) testing rates, many institutions and jurisdictions have revised policies to make the testing process rapid, simple, and routine. A major issue for testing scale-up efforts is the effectiveness of HIV risk-reduction counseling, which has historically been an integral part of the HIV testing process. Objective To assess the effect of brief patient-centered risk-reduction counseling at the time of a rapid HIV test on the subsequent acquisition of sexually transmitted infections (STIs). Design, Setting, and Participants From April to December 2010, Project AWARE randomized 5012 patients from 9 sexually transmitted disease (STD) clinics in the United States to receive either brief patient-centered HIV risk-reduction counseling with a rapid HIV test or the rapid HIV test with information only. Participants were assessed for multiple STIs at both baseline and 6-month follow-up. Interventions Participants randomized to counseling received individual patient-centered risk-reduction counseling based on an evidence-based model. The core elements included a focus on the patient’s specific HIV/STI risk behavior and negotiation of realistic and achievable risk-reduction steps. All participants received a rapid HIV test. Main Outcomes and Measures The prespecified outcome was a composite end point of cumulative incidence of any of the measured STIs over 6 months. All participants were tested for Neisseria gonorrhoeae , Chlamydia trachomatis , Treponema pallidum (syphilis), herpes simplex virus 2, and HIV. Women were also tested for Trichomonas vaginalis . Results There was no significant difference in 6-month composite STI incidence by study group (adjusted risk ratio, 1.12; 95% CI, 0.94-1.33). There were 250 of 2039 incident cases (12.3%) in the counseling group and 226 of 2032 (11.1%) in the information-only group. Conclusion and Relevance Risk-reduction counseling in conjunction with a rapid HIV test did not significantly affect STI acquisition among STD clinic patients, suggesting no added benefit from brief patient-centered risk-reduction counseling. Trial Registration clinicaltrials.gov Identifier:NCT01154296

We evaluated the relationship between frequency and number of substances used and HIV risk [ie, serodiscordant unprotected anal intercourse (SDUAI)] among 3173 HIV-negative substance-using MSM. Compared with nonusers, the adjusted odds ratio (AOR) for SDUAI among episodic and at least weekly users, respectively, was 3.31 [95% confidence interval (CI), 2.55 to 4.28] and 5.46 (95% CI, 3.80 to 7.84) for methamphetamine, 1.86 (95% CI, 1.51 to 2.29) and 3.13 (95% CI, 2.12 to 4.63) for cocaine, and 2.08 (95% CI, 1.68 to 2.56) and 2.54 (95% CI, 1.85 to 3.48) for poppers. Heavy alcohol drinkers reported more SDUAI than moderate drinkers [AOR, 1.90 (95% CI, 1.43 to 2.51)]. Compared with nonusers, AORs for using 1, 2, and ≥3 substances were 16.81 (95% CI, 12.25 to 23.08), 27.31 (95% CI, 18.93 to 39.39), and 46.38 (95% CI, 30.65 to 70.19), respectively. High-risk sexual behaviors were strongly associated with frequency and number of substances used.

The President's National HIV/AIDS Strategy calls for coupling HIV screening and prevention services with substance abuse treatment programs. Fewer than half of US community-based substance abuse treatment programs make HIV testing available on-site or through referral.We measured the cost-effectiveness of three HIV testing strategies evaluated in a randomized trial conducted in 12 community-based substance abuse treatment programs in 2009: off-site testing referral, on-site rapid testing with information only, on-site rapid testing with risk-reduction counseling. Data from the trial included patient demographics, prior testing history, test acceptance and receipt of results, undiagnosed HIV prevalence (0.4%) and program costs. The Cost-Effectiveness of Preventing AIDS Complications (CEPAC) computer simulation model was used to project life expectancy, lifetime costs, and quality-adjusted life years (QALYs) for HIV-infected individuals. Incremental cost-effectiveness ratios (2009 US $/QALY) were calculated after adding costs of testing HIV-uninfected individuals; costs and QALYs were discounted at 3% annually.Referral for off-site testing is less efficient (dominated) compared to offering on-site testing with information only. The cost-effectiveness ratio for on-site testing with information is $60,300/QALY in the base case, or $76,300/QALY with 0.1% undiagnosed HIV prevalence. HIV risk-reduction counseling costs $36 per person more without additional benefit.A strategy of on-site rapid HIV testing offer with information only in substance abuse treatment programs increases life expectancy at a cost-effectiveness ratio$100,000/QALY. Policymakers and substance abuse treatment leaders should seek funding to implement on-site rapid HIV testing in substance abuse treatment programs for those not recently tested.