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Objectives With the increasing momentum to maximize the benefits of antiretroviral therapy ( ART), better understanding of opportunities and challenges in increasing ART coverage and promoting early ART initiation is urgently needed. Key sociodemographic, clinical and behavioural factors associated with Australian HIV-positive gay men's current nonuse of ART were systematically examined. Methods Data were based on 1911 responses from HIV-positive men who had participated in the Australian Gay Community Periodic Surveys ( GCPS) between 2010 and 2012. Stratified univariate analysis and multivariate logistic regression were used. Results A majority of the participants were recruited from gay community venues and events and self-identified as gay or homosexual. On average, they were 44 years old and had been living with HIV for at least 10 years. Close to 80% ( n = 1555) were taking ART, with >90% further reporting an undetectable viral load at the time of the survey. From 2010 to 2012, there had been a moderate increase in ART uptake [adjusted odds ratio ( AOR) 1.40; 95% confidence interval ( CI) 1.20-1.65]. In addition, younger age ( AOR 1.66; 95% CI 1.45-1.92), recent HIV diagnosis ( AOR 1.78; 95% CI 1.59-1.98), not receiving any social welfare payments ( AOR 2.20; 95% CI 1.05-2.54) and no annual screening for sexually transmissible infections ( AOR 1.55; 95% CI 1.03-2.34) were independently associated with ART nonuse. Conclusions Current ART coverage among HIV-positive gay men in Australia is reasonably high. To further increase ART coverage and promote early ART initiation in this population, better clinical care and sustained structural support are needed for HIV management throughout their life course. [ABSTRACT FROM AUTHOR]

The population of people living with HIV in Australia is increasing, requiring an expert primary care workforce to provide HIV clinical care into the future. Yet the numbers of family doctors or general practitioners (GPs) training as community-based HIV medication prescribers may be insufficient to replace those retiring, reducing hours or changing roles. We conducted semi-structured interviews between February and April, 2010, with 24 key informants holding senior roles in organisations that shape HIV-care policy to explore their perceptions of contemporary issues facing the HIV general practice workforce in Australia. Informed by interpretive description, our analysis explores how these key informants characterised GPs as being 'moved' by the clinical, professional and political dimensions of the role of the HIV general practice doctor. Each of these dimensions was represented as essential to the engagement of GPs in HIV as an area of special interest, although the political dimensions were often described as the most distinctive compared to other areas of general practice medicine. Our analysis explores how each of these dimensions contributes to shaping the contemporary culture of HIV medicine and suggests that such an approach could be useful for understanding how health professionals become engaged in other under-served areas of medical work. [ABSTRACT FROM AUTHOR]

Background: This paper describes the experiences of Australian general practitioners (GPs) in managing problematic crystal methamphetamine (crystal meth) use among two groups of male patients: gay men and HIV positive men. Methods: Semi-structured qualitative interviews with GPs with HIV medication prescribing rights were conducted in Sydney, Adelaide and a rural-coastal town in New South Wales between August and October 2006. Participants were recruited from practices with high caseloads of gay and HIV positive men. Results: Sixteen GPs were recruited from seven practices to take part in interviews. Participants included 14 male GPs and two female GPs, and the number of years each had been working in HIV medicine ranged from two to 24. Eleven of the GPs who were based in Sydney raised the issue of problematic crystal meth use in these two patient populations. Five key themes were identified: an increasing problem; associations with depression; treatment challenges; health services and health care; workforce issues. Conclusion: Despite study limitations, key implications can be identified. Health practitioners may benefit from broadening their understandings of how to anticipate and respond to problematic levels of crystal meth use in their patients. Early intervention can mitigate the impact of crystal meth use on co-morbid mental illness and other health issues. Management of the complex relationships between drug use, depression, sexuality and HIV can be addressed following a 'stepped care' approach. General practice guidelines for the management of crystal meth use problems should address specific issues associated with gay men and HIV positive men. GPs and other health practitioners must appreciate drug use as a social practice in order to build trust with gay men to encourage full disclosure of drug use. Education programs should train health practitioners in these issues, and increased resourcing provided to support the often difficult task of caring for people who use crystal meth. Greater resourcing of acute care and referral services can shift the burden away from primary care and community services. Further investigation should consider whether these findings are reproducible in other general practice settings, the relationship between depression, drug use and HIV medication, and challenges facing the HIV general practice workforce in Australia. [ABSTRACT FROM AUTHOR]

Objective: We assessed interest in using rectal microbicides to prevent HIV transmission among gay men in Australia., Methods: A national online survey was conducted in 2013. Interest in using rectal microbicides was measured on a seven-item scale (α=0.81). Factors independently associated with greater interest in using a microbicide were identified using multivariate logistic regression., Results: Data were collected from 1223 HIV-negative and untested men. Mean age was 31.3 years (SD=10.8, range 18-65); 77% were born in Australia and 25% reported any condomless anal sex with a casual partner in the previous 6 months. Overall, there was moderate interest in using rectal microbicides (M=3.33, range 1-5). In multivariate analysis, greater interest in using microbicides was independently associated with being born outside Australia (adjusted OR (AOR)=1.59; p=0.009), greater self-perceived likelihood of becoming HIV positive (AOR=3.40; p<0.001), less uncertainty about the efficacy of microbicides (AOR=0.65; p=0.009), any condomless anal sex with casual partners in the previous 6 months (AOR=1.78; p=0.03) and ever having received postexposure prophylaxis (AOR=1.53; p=0.04). Interest in using microbicides was not associated with age, number of male sex partners or the HIV status of regular male partners., Conclusions: Interest in using rectal microbicides was associated with self-perceived vulnerability to HIV, engaging in sexual practices that increase the risk of HIV acquisition and less uncertainty about the efficacy of microbicides. There appears to be a group of men who would benefit from, and are highly motivated to use, a rectal microbicide product., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: Assess the acceptability of HIV treatment as prevention and early antiretroviral treatment among gay and bisexual men in Australia and any changes in attitudes over time., Methods: National, online, cross-sectional surveys of gay and bisexual men were repeated in 2011 and 2013. Changes in attitudes to HIV treatment over time were assessed with multivariate analysis of variance. The characteristics of men who agreed that HIV treatment prevented transmission and thought that early treatment was necessary were identified with multivariate logistic regression., Results: In total, 2599 HIV-negative, untested and HIV-positive men participated (n = 1283 in 2011 and n = 1316 in 2013). Attitudes changed little between 2011 and 2013; most participants remained sceptical about the preventative benefits of HIV treatment. In 2013, only 2.6% of men agreed that HIV treatment prevented transmission; agreement was associated with being HIV-positive, having an HIV-positive regular partner, and having received HIV post-exposure prophylaxis. In contrast, 71.8% agreed that early antiretroviral treatment is necessary; younger men were more likely and HIV-positive men and participants with HIV-positive partners were much less likely to agree with this., Conclusions: Promoting the individual health benefits of HIV treatment rather than its preventative benefits remains more acceptable to Australian gay and bisexual men.

Research has shown that social representations of HIV can constitute barriers to health workers' willingness to provide HIV care. Considering a growing shortage in the HIV primary workforce in Western countries, we examine how HIV is perceived today by doctors involved in its care. In 1989 Sontag predicted that once the virus became better understood and treatable, the dehumanizing meanings that defined the early epidemic would vanish and HIV would turn into an ordinary illness. However, research shows that HIV still carries stigma, including in the health care sector. Drawing on qualitative interviews, we found that HIV doctors in Australia perceived HIV as a far-from-ordinary chronic illness because of its extraordinary history and its capacity to extend in multiple clinical and social directions. These rarely explored perspectives can contribute to the social reframing of HIV and to strategies to build a dedicated HIV workforce in Australia and elsewhere.

Background: The science of HIV prevention and treatment is evolving rapidly, resulting in renewed calls to increase rates of HIV testing and, in particular, facilitate the timely and possibly earlier initiation of treatment, as this has the potential to dramatically reduce new infections. Little is known about how to engage non HIV specialist Australian general practitioners (GPs) with these new priorities., Methods: Content related to the engagement of non HIV specialist GPs in the HIV response was identified within the transcripts of in-depth interviews with policy key informants (n=24) and general practice clinicians (n=47) engaged with HIV medicine. A qualitative analysis of the semantic meaning of this content identified three categories of 'issues' described by participants., Results: Educational issues referred to a lack of attention to HIV in medical curricula, a perception that HIV care is only provided by HIV-specialist GPs, a need to make HIV testing more 'routine' in GP education and a need to strengthen GP awareness of referral options. Organisational issues encompassed time pressures in general practice, and a need for general practice nurses and for rapid testing to become available, as well as formalised peer mentoring and comanagement opportunities. Societal issues included the changing dynamics of HIV transmission and a need to reconnect GPs with the Australian HIV response., Conclusions: To successfully engage non HIV specialist GPs in the promotion of regular HIV testing and timely initiation of treatment, challenging issues affecting their capacity and willingness must be urgently addressed.

Background: HIV has become a chronic manageable infection in the developed world, and early and lifelong treatment has the potential to significantly reduce transmission rates in the community. A skilled and motivated HIV medical workforce will be required to achieve these health management and prevention outcomes, but concerns have been noted in a number of settings about the challenges of recruiting a new generation of clinicians to HIV medicine., Methods: As part of a larger qualitative study of the HIV general practice workforce in Australia, in-depth interviews were conducted with 31 general practitioners accredited to prescribe HIV medications in community settings. A thematic analysis was conducted of the de-identified transcripts, and this paper describes and interprets accounts of the rewards of pursuing and sustaining an engagement with HIV medicine in general practice settings., Results: The rewards of initially becoming involved in providing care to people living with HIV were described as interest and inspiration, community calling and right place, right time. The rewards which then supported and sustained that engagement over time were described as challenge and change, making a difference and enhanced professional identity. Participants viewed the role of primary care doctor with special expertise in HIV as occupying an ideal interface between the 'coalface' and the 'cutting edge', and offering a unique opportunity for general practitioners to feel intimately connected to both community needs and scientific change., Conclusions: Approaches to recruiting and retaining the HIV medical workforce should build upon the intellectual and social rewards of this work, as well as the sense of professional belonging and connection which is imbued between both doctors and patients and across the global and national networks of HIV clinicians. Insights regarding the rewards of engaging with HIV medicine may also be useful in enhancing the prospect of general practice as a career, and strengthening retention and job satisfaction among the existing general practice workforce.

High rates of both illicit drug use and depression are consistently reported among gay men. However, little is known about how beliefs about drug use shape clinical encounters between gay men and health professionals, and that in turn affect clinical communication and care, particularly in relation to depression. We compared 'doctor' and 'patient' beliefs about the role of illicit drug use in gay men's depression. Semi-structured interviews were conducted during August-December 2006 with 16 general medical practitioners working in seven 'gay-friendly' practices in Sydney, Adelaide and a rural-coastal city in New South Wales, and during February-May 2008 with 40 gay men with depression recruited through four Sydney and Adelaide practices. A thematic analysis of these two sets of interviews found that doctors expressed the beliefs that: illicit drug use is related to depression in gay men; illicit drug use impedes effective diagnosis and treatment of depression in gay men; and illicit drug use increases the level of complexity involved in caring for gay men with depression. Gay men expressed the beliefs that: illicit drug use is closely related to depression; illicit drug use can be helpful in dealing with difficult experiences; and illicit drug use is just what you do as a gay man living in a big city. Both groups believed drug use and depression were related, but doctors emphasised the negative outcomes of drug use and interpreted these in relation to health. Gay men believed that drugs could have both negative and positive uses and differentiated between health and social outcomes. While the doctors articulated a pragmatic position on drug use, which is consistent with harm reduction principles, communication with gay male patients could be enhanced if both groups acknowledged their divergent views of illicit drugs and their potential role in mental health., (© 2011 Blackwell Publishing Ltd.)

General practitioners (GPs) identify that depression can be difficult to diagnose in populations with high rates of alcohol and other drug (AOD) use. This is a particular concern with gay men who are a population known to engage in high rates of AOD use and who are vulnerable to depression. This paper uses data from 563 gay men and their GPs to describe concordance between assessments of major depression and, in particular, whether AOD use undermines concordance. Data were collected as part of a larger study of male patients and GPs at high HIV-caseload general practices in Australia. Concordance was measured by comparing patients' scores on the Patient Health Questionnaire-9 screening tool, which is based on the Diagnostic and Statistical Manual of Mental Disorders IV criteria, and GPs' ratings of the likelihood of depression for each participant. We observed high concordance between GPs' assessments of major depression and patients' scores on the PHQ-9 (79% agreement), although our analysis also suggested that concordance was better when it related to cases in which there was no depression. The high concordance observed in our study did not appear to be undermined by gay male patients' AOD use, with the exception of frequent use of crystal methamphetamine. Here, men who reported frequent use of methamphetamine were significantly less likely to have concordant assessments (adjusted odds ratio 0.3, 95% CI 0.1-0.8). Overall, GPs appear to identify depression among many of their gay male patients. While GPs should be aware of the potential complications presented by frequent crystal methamphetamine use, other AOD use may have less impact on the diagnosis of depression.

Objective: Three decades into the HIV epidemic and with the advancement of HIV treatments, condom and non-condom-based anal intercourse among gay men in resource-rich countries needs to be re-assessed., Methods: The proportions of men engaging in a range of anal intercourse practices were estimated from the ongoing cross-sectional Gay Community Periodic Surveys in six states in Australia from 2007 to 2009. Comparisons were made between HIV-negative men, HIV-positive men with an undetectable viral load and those with a detectable viral load., Results: Condoms play a key role in gay men's anal intercourse practices: 33.8% of HIV-negative men, 25.1% of HIV-positive men with an undetectable viral load and 22.5% of those with a detectable viral load reported consistent condom use with all male partners in the 6&emsp14;months before the survey. Among HIV-negative men, the second largest group were men who had unprotected anal intercourse (UAI) only in the context of HIV-negative seroconcordant regular relationships. Among HIV-positive men, the second largest group was men who had UAI in casual encounters preceded by HIV status disclosure to some, but not all, casual partners., Conclusions: A minority, yet sizeable proportion, of men consistently engaged in a number of UAI practices in specific contexts, suggesting they have adopted deliberate HIV risk-reduction strategies. While it is important that HIV behavioural prevention continues to reinforce condom use, it needs to address both the challenges and opportunities of the substantial uptake of non-condom-based risk-reduction strategies.

This supplement to the Journal of the International AIDS Society focuses on the engagement of the social and political sciences within HIV research and, in particular, maintaining a productive relationship between social and biomedical perspectives on HIV. It responds to a number of concerns raised primarily by social scientists, but also recognized as important by biomedical and public health researchers. These concerns include how best to understand the impact of medical technologies (such as HIV treatments, HIV testing, viral load testing, male circumcision, microbicides, and pre-and post-exposure prophylaxis) on sexual cultures, drug practices, relationships and social networks in different cultural, economic and political contexts. The supplement is also concerned with how we might examine the relationship between HIV prevention and treatment, understand the social and political mobilization required to tackle HIV, and sustain the range of disciplinary approaches needed to inform and guide responses to the global pandemic. The six articles included in the supplement demonstrate the value of fostering high quality social and political research to inform, guide and challenge our collaborative responses to HIV/AIDS.

The introduction of highly active antiretroviral therapy (HAART) is typically represented as a turning point in the social and medical history of HIV/AIDS, leading to a conceptual division into pre- and post-HAART eras. This paper explores how generational discourse is produced in interviews with general practitioners (GPs) and their HIV positive gay male patients in making sense of this moment and related changes in the Australian HIV epidemic. A theme of 'HIV generations' was identified in in-depth interviews with GPs who have HIV medication prescribing rights (based in Sydney, Adelaide and rural-coastal New South Wales) and the HIV positive gay men who attend their practices. In a closer analysis, generational discourse was identified across the interviews with GPs, characterising pre- and post-HAART HIV generations through three main features: treatment histories, socioeconomic status, and modes of survivorship. While generational discourse was less common in the accounts of HIV positive gay men, many of their examples wove together two narrative forms - 'a different time' and 'difference today' - suggesting that concepts of time and inequity are deeply embedded in these men's understandings of the HIV experience. Our analysis indicates that generational concepts play a significant role in shaping both professional and 'lay' understandings of changes and patterns in the HIV epidemic., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Objective: The objective of this study is to estimate per-contact probability of HIV transmission in homosexual men due to unprotected anal intercourse (UAI) in the era of HAART., Design: Data were collected from a longitudinal cohort study of community-based HIV-negative homosexual men in Sydney, Australia., Methods: A total of 1427 participants were recruited from June 2001 to December 2004. They were followed up with 6-monthly detailed behavioral interviews and annual testing for HIV till June 2007. Data were used in a bootstrapping method, coupled with a statistical analysis that optimized a likelihood function for estimating the per-exposure risks of HIV transmission due to various forms of UAI., Results: During the study, 53 HIV seroconversion cases were identified. The estimated per-contact probability of HIV transmission for receptive UAI was 1.43% [95% confidence interval (CI) 0.48-2.85] if ejaculation occurred inside the rectum, and it was 0.65% (95% CI 0.15-1.53) if withdrawal prior to ejaculation was involved. The estimated transmission rate for insertive UAI in participants who were circumcised was 0.11% (95% CI 0.02-0.24), and it was 0.62% (95% CI 0.07-1.68) in uncircumcised men. Thus, receptive UAI with ejaculation was found to be approximately twice as risky as receptive UAI with withdrawal or insertive UAI for uncircumcised men and over 10 times as risky as insertive UAI for circumcised men., Conclusion: Despite the fact that a high proportion of HIV-infected men are on antiretroviral treatment and have undetectable viral load, the per-contact probability of HIV transmission due to UAI is similar to estimates reported from developed country settings in the pre-HAART era.

Background: An increasing incidence of hepatitis C virus (HCV) infection in HIV-positive homosexual men has recently been described, but it is uncertain to what extent this reflects sexual transmission. We report prevalence, incidence and risk factors for HCV infection in community-based cohorts of HIV-negative and HIV-positive homosexual men in Sydney., Methods: Both cohorts recruited participants using similar community-based strategies. Men underwent annual face-to-face interviews, and reported history of injecting-drug use (IDU) and sexual and other behaviours that might lead to blood contact. HCV screening was offered to consenting participants from 2001 to 2007., Results: At baseline, HCV prevalence was 1.07% in the HIV-negative and 9.39% in the HIV-positive men. HCV seropositivity was strongly associated with a history of IDU in both cohorts (OR=56.18, 95% CI 12.55 to 251.5 in HIV-negative, and OR=24.46, 95% CI 5.44 to 110.0 in HIV-positive). In the HIV-negative cohort, five men seroconverted to HCV over 4412.1 person-years of follow-up, an incidence of 0.11 per 100 person-years (95% CI 0.03 to 0.26). Only one seroconverter reported IDU. Of the five, four reported sexual contact with HIV-positive men (HR=8.23, 95% CI 0.91 to 74.28), and two had an incident ulcerative sexually transmitted infection. In the HIV-positive cohort, none seroconverted over 238.1 person-years of follow-up (97.5% CI 0 to 1.54, single-sided)., Conclusion: HCV prevalence was almost 10 times higher in HIV-positive homosexual men. Although incident HCV infection was uncommon in both cohorts, cases of non-IDU-related transmission did occur, possibly linked to sexual contact with HIV-positive men.

Background: We examined a range of common bacterial and viral sexually transmitted infections as risk factors for HIV seroconversion in a community-based cohort of HIV-negative homosexual men in Sydney, Australia., Methods: Detailed information about HIV risk behaviors was collected by interview twice yearly. Participants were tested annually for HIV, anal and urethral gonorrhea and chlamydia, herpes simplex virus types 1 and 2, and syphilis. In addition, they reported annual diagnoses of these conditions and of genital and anal warts., Results: Among 1427 enrolled participants, 53 HIV seroconverters were identified, giving an incidence of 0.78 per 100 person-years. After controlling for number of episodes of insertive and receptive nonseroconcordant unprotected anal intercourse, there were independent associations with anal gonorrhea (adjusted hazard ratio = 7.12, 95% confidence interval: 2.05 to 24.79) and anal warts (hazard ratio = 3.63, 95% confidence interval: 1.62 to 8.14)., Conclusions: Anal gonorrhea and anal warts were independently associated with HIV acquisition. The added HIV prevention value of more frequent screening of the anus to allow early detection and treatment of anal sexually transmitted infections in homosexual men should be considered.

Background: Circumcision status was examined as an independent risk factor for sexually transmissible infections (STIs) in the Health in Men cohort of homosexual men in Sydney., Methods: From 2001 through 2004, 1427 initially human immunodeficiency virus (HIV)-negative men were enrolled and followed up until mid-2007. All participants were offered annual STI testing. The history of STIs was collected at baseline, and information on sexual risk behaviors was collected every 6 months. At annual face-to-face visits, participants reported STI diagnoses received during the previous year., Results: Circumcision was not associated with prevalent or incident herpes simplex virus 1, herpes simplex virus 2, or self-reported genital warts. There was also no independent association of circumcision with incident urethral gonorrhea or chlamydia. Being circumcised was associated with a significantly reduced risk of incident (hazard ratio, 0.35 [95% confidence interval, 0.15-0.84]) but not prevalent (odds ratio, 0.71 [95% confidence interval, 0.35-1.44]) syphilis. The association was somewhat stronger among men who reported predominantly insertive unprotected anal intercourse (hazard ratio, 0.10 [95% confidence interval, 0.01-0.82])., Conclusions: These are the first prospective data obtained from homosexual men to assess circumcision status as a risk factor for STIs. Circumcised men were at reduced risk of incident syphilis but no other prevalent or incident STIs. Circumcision is unlikely to have a substantial public health impact in reducing acquisition of most STIs in homosexual men.

Background: Syphilis has re-emerged and become established in gay communities in most developed countries since the late 1990s. HIV infected men have been disproportionately affected by this endemic, but it is unclear whether this is due to behavioural or biological reasons. We report incidence and risk factors for syphilis in two community-based cohorts of HIV-negative and HIV-positive homosexual men in Sydney, Australia., Methods: Participants were recruited using similar community-based strategies in both cohorts and underwent annual face-to-face interviews. Syphilis screening was offered to all consenting participants at annual visits., Results: In the HIV-negative cohort, 21 men seroconverted to syphilis and one man had a syphilis re-infection during 2001-07, an incidence of 0.49 per 100 person-years (95% CI: 0.31-0.74). In the HIV-positive cohort during 2005-07, eight men seroconverted and one man had a syphilis re-infection, giving an incidence of 3.62 per 100 person-years (95% CI: 1.67-6.48). All nine reported a recent CD4 count of more than 350 cells microL(-1). Syphilis incidence was significantly higher in the HIV-positive cohort after adjustment for age (hazard ratio (HR) = 9.20, 95% CI: 3.63-23.31). Unprotected anal intercourse (UAI) with HIV-positive partners was significantly associated with incident syphilis in both cohorts (HR = 4.45, 95% CI: 1.37-14.45 in HIV-negative; HR = 8.67, 95% CI: 1.03-72.76 in HIV-positive)., Conclusion: Syphilis incidence was almost 10-fold higher in HIV-positive than in HIV-negative homosexual men, and it was not related to a CD4 count below 350 microL(-1). UAI with HIV positive partners was of particular importance in the transmission of syphilis.

Objective: To investigate the relationship between nonoccupational postexposure prophylaxis (NPEP) use and future HIV risk behaviours and HIV infection in a cohort of HIV-negative homosexual men in Sydney, Australia., Design: Prospective analysis of NPEP use in a community cohort from 2001 to 2007., Methods: In the Health in Men study cohort, men were annually questioned about NPEP use and tested for HIV. Every 6 months, detailed quantitative data on unprotected anal intercourse were collected. Cox regression models examined risk factors for incident NPEP use, HIV seroconversion and time trends in NPEP use. The change in the number of unprotected anal intercourse acts with nonseroconcordant partners before and after NPEP was examined using the Wilcoxon signed-rank test., Results: One thousand four hundred and twenty-seven participants were enrolled. At baseline, 78.5% of participants had heard of NPEP, which increased to 97.4% by the fifth annual interview. NPEP use increased significantly from 2.9 per 100 person-years in 2002 to 7.1 per 100 person-years in 2007 (P = 0.007). Unprotected anal intercourse was a strong predictor of incident NPEP use. Use of NPEP was not associated with changes in HIV risk behaviour. Men who received NPEP had a significantly higher rate of subsequent HIV seroconversion (hazard ratio 2.67, 95% confidence interval 1.40-5.08, P = 0.003)., Conclusion: Awareness of the availability of NPEP in this cohort was nearly universal. Use was common and increased rapidly over the study period. NPEP was targeted mostly towards high-risk behaviours. Use of NPEP was not associated with reductions in risk behaviour, and men who received NPEP continued to be at high risk of subsequent HIV infection.

Introduction: Sexual expression affects physical, mental and social well-being. There is a lack of understanding of male sexual dysfunction in homosexually active men. Aim. We investigated gay men's self-report of a number of sexual problems., Methods: The survey data were from a sample of 542 self-identified gay men, 40% of whom were HIV positive, recruited from six high HIV-caseload general practices in Australia., Main Outcome Measures: The reporting of experiencing three or more sexual problems over a period of at least 1 month in the 12 months prior to a survey was defined here as having "multiple" sexual problems. We explored a number of factors, including HIV status, depression, alcohol and other drug use, and sexual risk-taking with casual male partners, in association with multiple sexual problems., Results: Rates of a range of self-reported sexual problems were high, with erectile dysfunction and lack of sexual desire being the most commonly reported. These high rates were consistent with the limited data from previous Australian studies. Men who had multiple sexual problems were likely to suffer from major depression (P < 0.001). A higher proportion of the HIV-positive gay men (48.4%) reported multiple sexual problems than the HIV-negative men (35.1%, P = 0.002). Factors independently associated with multiple sexual problems among the HIV-negative gay men were poorer general health and interpersonal isolation, whereas for the HIV-positive gay men, they were adoption of avoidant strategies to cope with daily life stress, sexual risk-taking in casual encounters, and the use of antidepressants., Conclusions: Our findings underscore the complex interactions between depression, sexual dysfunction, sexual risk taking, HIV infection, and general well-being among homosexually active men.

Objectives: Social factors associated with Major Depressive Disorder (MDD) were identified among gay men attending high HIV caseload general practices in Sydney and Adelaide., Methods: Men who visited four participating practices were invited to self-complete a survey. A self-screening tool (PHQ-9), based on the Diagnostic and Statistical Manual of Mental Disorders, version four (DSM-IV), was used to measure depressive disorders., Results: The rate of MDD (PHQ-9 score 10 or above) among the 195 HIV-positive gay men was significantly higher than that among the 314 non-HIV-positive gay men (31.8% vs 20.1%, p=0.002). Current MDD was independently associated with younger age, lower income, recent major adverse life events, adopting denial and isolation as coping strategies, less social support, less gay community involvement and recent sexual problems. HIV-status, however, was not independently associated with MDD., Conclusion: Socio-economic hardship, interpersonal isolation and personal withdrawal were significantly and independently associated with major depression in this population of gay men., Implications: The study provides further evidence of health inequity affecting gay men in Australia. Structural health promotion approaches focused on homophobia and discrimination, as well as community-engaged primary health care responses are called for to mitigate this inequity.

Objective: A range of risk reduction behaviours in which homosexual men practise unprotected anal intercourse (UAI) has been described. We aimed to assess the extent of any reduction in HIV risk associated with these behaviours., Design: A prospective cohort study of HIV-negative homosexual men in Sydney, Australia., Methods: Men were followed up with 6-monthly detailed behavioural interviews and annual testing for HIV. The four risk reduction behaviours (behaviourally defined) examined were serosorting, negotiated safety, strategic positioning, and withdrawal during receptive UAI (UAI-R)., Results: In 88% of follow-up periods in which UAI was reported, it occurred in the context of consistent risk reduction behaviours. Compared with those who reported no UAI, the risk of HIV infection was not raised in negotiated safety [hazard ratio = 1.67, 95% confidence interval (CI) 0.59-4.76] and strategic positioning (hazard ratio = 1.54, 95% CI 0.45-5.26). Serosorting outside negotiated safety was associated with an intermediate rate of HIV infection (hazard ratio = 3.11, 95% CI 1.09-8.88). Withdrawal was associated with a higher risk than no UAI (hazard ratio = 5.00, 95% CI 1.94-12.92). Patterns of UAI differed greatly according to partner's serostatus. Men who reported serosorting were less likely to report either strategic positioning or withdrawal., Conclusion: Each behaviour examined was associated with an intermediate HIV incidence between the lowest and highest risk sexual behaviours. The inverse association between individual behaviours suggests that men who practise serosorting rely on this protection. The high prevalence of these behaviours demands that researchers address the contexts and risks associated with specific types of UAI.

Introduction: The relevance of circumcision in preventing male-to-male sexual transmission of HIV is poorly understood, in particular because any potential beneficial effect could be diminished by the impact of circumcision on sexual behavior., Aim: We examined the impact of circumcision on sexual experience., Methods: Univariate and multivariate logistic regressions were performed on data from 1,426 HIV-negative homosexually active men., Main Outcome Measures: We compared the sexual behaviors and preferences of circumcised with uncircumcised men, and men who were circumcised at infancy with those who were circumcised after infancy., Results: Overall, 66% of men (N = 939) in the cohort were circumcised. After adjusting for age and ethnicity, we found no differences between circumcised and uncircumcised men in any insertive or receptive anal intercourse, difficulty using condoms, or sexual difficulties (e.g., loss of libido). Among the circumcised men, we compared those circumcised at infancy (N = 854) with those circumcised after infancy (N = 81). The majority cited phimosis (i.e., an inability to fully retract the foreskin) and parents' decision as the main reasons for circumcision after infancy. After adjusting for age and ethnicity, the men circumcised after infancy were more likely to practice any receptive anal sex (88% vs. 75%, P < 0.05) and to experience erection difficulties (52% vs. 47%, P < 0.05), but less likely to practice any insertive anal sex (79% vs. 87%, P < 0.05) and to experience premature ejaculation (15% vs. 23%, P < 0.05) than those circumcised at infancy., Conclusions: Our data suggest that overall circumcision status does not affect the HIV-negative gay men's anal sexual behaviors, experience of condom use, or likelihood of sexual difficulties. However, there is some suggestion of differences in sexual practices and preferences among circumcised gay men depending on the age at circumcision. In particular, gay men circumcised later are more likely to engage in and prefer receptive anal intercourse.

Objectives: To determine the incidence of HIV seroconversion in a community-based cohort of homosexual men in Sydney from 2002 to 2006., Methods: Participants were recruited between 2001 and 2004 from community-based events and venues. They were tested for HIV annually at follow-up interviews. Each year, the study database was matched against the national HIV register to identify additional HIV seroconversions among men lost to active follow up. The trend in HIV incidence over time was examined using Cox regression., Results: Among 1426 participants, 52 cases of HIV seroconversion were identified between 2002 and 2006, an incidence of 0.87 per 100 person-years (95% CI: 0.65-1.14). HIV incidence varied from 1.67 per 100 person-years in 2002 to 0.39 in 2006 (P trend = 0.282). The median age of HIV seroconversion was 36.9 years, ranging from 22 to 63 years., Conclusion: In this community-based cohort of highly sexually active homosexual men in Sydney, HIV incidence was close to 1% each year and declined non-significantly between 2002 and 2006. These data are consistent with surveillance data suggesting no increase in recent HIV incidence in homosexual men in New South Wales.

This paper compares rates of current depression among men attending high-HIV-caseload general practices in New South Wales and South Australia. Current depression was assessed by the treating general practitioner (GP), using the nine-item Patient Health Questionnaire (PHQ-9), and by patient self-reporting. The study found that GPs, the PHQ-9 screening tool and patients were equally likely to identify current depression. High rates of depression were observed among the men attending general practice, with the highest rates among men with HIV and men who did not identify as either heterosexual or homosexual.