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"Patrick Ashley Meuser"-Bianca"" <pmeuser@cogeco.ca> wrote in message
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Beware the black hole
Surveillance Summaries
July 7, 2006 / 55(SS06);1-16
Human Immunodeficiency Virus (HIV) Risk, Prevention, and Testing Behaviors --- United States,
National HIV Behavioral Surveillance System: Men Who Have Sex with Men, November 2003--April
2005
Please note: An erratum has been published for this article
Travis Sanchez, DVM1
Teresa Finlayson, MPH1
Amy Drake, MPH1
Stephanie Behel, MPH1
Melissa Cribbin, MPH1
Elizabeth DiNenno, PhD1
Tricia Hall, MPH2
Stacy Kramer, MPH2
Amy Lansky, PhD1
1Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and TB
Prevention (proposed)
2Northrup Grumman Corporation (contracting company with CDC)
Corresponding author: Travis Sanchez, DVM, National Center for HIV/AIDS, Viral Hepatitis, STD
and TB Prevention (proposed), 1600 Clifton Road, NE, MS E-46, Atlanta, GA 30333. Telephone:
404-639-1742; Fax: 404-639-8640; E-mail: Tsanchez@cdc.gov.
Abstract
Problem/Condition: For CDC's goal of reducing the number of new human immunodeficiency virus
(HIV) infections to be achieved, data are needed to assess the prevalence of HIV-related risk
behaviors at a given time, monitor trends in these behaviors, and assess the correlates of
risk. These data also can be used to evaluate the extent to which current HIV-prevention
programs are reaching targeted communities and direct future HIV-prevention activities to
reduce HIV transmission.
Reporting period: November 2003--April 2005.
Description of system: The National HIV Behavioral Surveillance (NHBS) System collects risk
behavior data from three populations at high risk for HIV infection: men who have sex with men
(MSM), injection-drug users, and heterosexual adults in areas in which HIV is prevalent. Data
collection began in 2003 among MSM in 17 U.S. metropolitan statistical areas (MSAs), and
surveys have been conducted in 25 MSAs since 2005. Participants must be aged >18 years and
reside in a participating MSA.
Results: This report summarizes data gathered during the first cycle (i.e., data collection
period) of NHBS (November 2003--April 2005) from approximately 10,000 MSM. The results
indicated that >90% of participants had ever been tested for HIV. Of those, 77% had been tested
during the preceding 12 months. In addition to their male sex partners, 14% of participants
also had at least one female sex partner during the preceding 12 months. Unprotected anal
intercourse was reported by 58% with a main male partner (someone with whom the participant had
sex and to whom he felt most committed [e.g., a boyfriend, spouse, significant other, or life
partner]) and by 34% with a casual male partner (someone with whom the participant had sex but
who was not considered a main partner). Noninjection drugs were used by 42% of participants
during the preceding 12 months; the most commonly used drugs were marijuana (77%), cocaine
(37%), ecstasy (29%), poppers (28%), and stimulants (27%). A substantial proportion (80%) of
participants had received free condoms during the preceding 12 months, but fewer had
participated in individual- or group-level HIV prevention programs (15% and 8%, respectively).
Interpretation: MSM surveyed engaged in sexual and drug-use behaviors that placed them at
increased risk for HIV infection. The majority of MSM surveyed had been tested for HIV
infection. Although a substantial proportion of participants had received free condoms, a much
smaller proportion had participated in more intensive HIV-prevention programs.
Public Health Action: NHBS data are used to assess and develop effective HIV-prevention
programs and services. Continued collection and reporting of NHBS data from all targeted
high-risk populations is needed to monitor behavior trends and assess future HIV prevention
needs in these populations. The data are used for local HIV-prevention planning and monitoring
in MSAs in which NHBS is conducted.
Introduction
At the end of 2004, approximately 500,000 persons were living with human immunodeficiency virus
(HIV) or acquired immunodeficiency syndrome (AIDS) in the 35 U.S. areas with confidential
name-based HIV infection reporting since 2000 (1). Certain behaviors (e.g., unprotected sexual
intercourse and injection-drug use) are associated with high risk for HIV transmission. Through
2004, of all cases of HIV infection in the United States reported to CDC, 34% were attributed
to male-male sexual contact, 14% to injection-drug use, and 20% to heterosexual contact (1).
HIV testing is a cornerstone of HIV prevention in the United States (2). Persons who learn
their HIV status might reduce risk behaviors and can be referred to appropriate care and
treatment services. In addition to testing, other prevention activities in the United States
are focused on behavior-change strategies and the provision of prevention information and
materials (e.g., condoms).
In 2002, CDC developed the National HIV Behavioral Surveillance (NHBS) System to help state and
local health departments monitor selected behaviors and assess the use of prevention programs
and services in groups at highest risk for HIV infection. Findings from NHBS enhance
understanding of HIV risk and testing behaviors and can be used to develop and evaluate the use
of HIV-prevention programs in these communities.
This report summarizes results from the first NHBS cycle (i.e., data collection period), which
was conducted during November 2003--April 2005 among men who have sex with men (MSM). This
report provides descriptive data that serve as a baseline to monitor trends in behavior
prevalence and that aid in assessing the scope of the problem and in identifying potential
opportunities for HIV prevention in this population.
Methods
Overview
The overall strategy for NHBS involves conducting rotating cycles of surveillance in three
populations at high risk for HIV: MSM (NHBS-MSM), injection-drug users (NHBS-IDU), and
heterosexual adults in high-prevalence areas (NHBS-HET). The same basic eligibility criteria
are used in all MSAs: being aged >18 years, a current resident of an MSA, not a previous
participant in NHBS during the current cycle, and able to provide informed consent.
For each survey cycle, a standardized questionnaire is used to collect information about
behavioral risks for HIV, HIV testing history, and use of HIV-prevention services and programs.
The face-to-face survey is administered by a trained interviewer using a handheld computer. A
minimum of 500 eligible persons from each MSA are interviewed during each cycle. CDC has
determined that NHBS is public health surveillance and is not classified as a research
activity; all state and local jurisdictions are responsible for performing their own local
human subjects protections review.
Participating MSAs
State and local health departments that were eligible to participate in NHBS were those whose
jurisdictions included MSAs with the highest estimated prevalence of persons living with AIDS
(Figure 1). Interviews were conducted in 17 eligible MSAs during the first cycle of NHBS-MSM:
Atlanta, Georgia; Baltimore, Maryland; Boston, Massachusetts; Chicago, Illinois; Dallas, Texas;
Denver, Colorado; Fort Lauderdale, Florida; Houston, Texas; Los Angeles, California; Miami,
Florida; Newark, New Jersey; New York City, New York; Philadelphia, Pennsylvania; San Diego,
California; San Francisco, California; San Juan, Puerto Rico; and Washington, District of
Columbia. In the subsequent NHBS cycle (NHBS-IDU), data collection began in the following eight
MSAs: Detroit, Michigan; Las Vegas, Nevada; Nassau-Suffolk, New York; New Haven, Connecticut;
New Orleans, Louisiana; Norfolk, Virginia; Seattle, Washington; and St. Louis, Missouri.
NHBS-MSM Sampling Method
Interviews for NHBS-MSM were obtained using time-space sampling methods (3). Details about the
NHBS-MSM method will be described subsequently (4); the main steps are as follows:
Identify venues frequented by MSM. In each MSA, a team of local staff members familiar with the
local MSM community was assembled to establish a list of venues frequented by MSM. To identify
possible venues for inclusion in the list, the team consulted local publications, online media,
members of the local MSM community, business owners, staff at community-based organizations,
key health department staff, and persons providing medical and social services to MSM. If a
venue did not serve MSM exclusively, the team conducted observations and brief interviews at
the venue. Brief interviews were used to assess the male patrons' eligibility for NHBS and
their sexual history with other men. If >50% of the men were found to be eligible MSM and the
venue was estimated to yield a sufficient number of interviews during a standard sampling
period (i.e., eight interviews during a 4-hour period), the venue was included on the list.
Clinics and health-care settings were specifically excluded because of the potential for
introducing bias in certain key indicators (e.g., HIV testing history). Venues on the list were
categorized into types as follows: bar, dance club, fitness club, Gay Pride event, park or
beach, rave or circuit party, restaurant or café, retail business, sex establishment or sex
environment, social organization, street location, or other venue type.
Determine the best time for sampling at each venue. After the venues frequented by MSM were
identified, the team determined the best days of the week and the best times (typically 4-hour
slots) at each venue to interview a sufficient number of men. Days and times for each venue
were placed on a list that was later used to determine sampling events for each month. This
list became the sampling frame.
Determine the sampling events for a given month. On average, 14 sampling events were conducted
in each MSA every month to obtain a minimum sample of 500. A sampling event consisted of a
single visit to a venue during one identified period for that venue. From the sampling frame,
the team first would randomly select 14 venues without replacement. Next, a sampling time for
each venue was randomly selected. These sampling periods were scheduled on a calendar for the
month, so the local field team would know where to conduct sampling events.
Select and recruit men at venues. During the sampling event, a local field team of interviewers
attended the venues to enroll persons in the study. This team would establish boundaries (an
area or a line) for the selection of men at the venue. Men entering the defined area or
crossing the defined line were approached systematically for recruitment. A brief interview was
conducted to determine eligibility for NHBS, and the men determined to be eligible were invited
to participate.
NHBS-MSM Data Collection
Men who accepted the invitation to participate were escorted to a private area for the
interview. Interviewers obtained informed consent and conducted face-to-face interviews with
all participants. Each interview averaged 20 minutes and consisted of questions concerning
participants' demographic characteristics, HIV testing history, sexual and drug-use behaviors,
hepatitis vaccination, sexually transmitted disease (STD) diagnosis and testing, and use of HIV
prevention services and programs. In exchange for their time in taking part in the interview,
participants received $25 in cash or a gift certificate. HIV testing was conducted only in
those NHBS MSAs that had participated in an earlier study of MSM (5). These HIV testing data
have been published previously (6).
Data Analysis
Participants
This surveillance summary presents the results of a descriptive analysis (no statistical tests
were performed) of key behavioral surveillance indicators for MSM from the following MSAs that
collected and submitted requested data during the NHBS-MSM cycle: Atlanta, Georgia; Baltimore,
Maryland; Boston, Massachusetts; Chicago, Illinois; Denver, Colorado; Fort Lauderdale, Florida;
Houston, Texas; Los Angeles, California; Miami, Florida; New York, New York; Newark, New
Jersey; Philadelphia, Pennsylvania; San Diego, California; San Francisco, California; and San
Juan, Puerto Rico.
In addition to the overall eligibility criteria, three criteria were applied for inclusion in
this report on MSM. During the interview, participants must have reported 1) being male, 2)
having had at least one male sex partner during the 12 months preceding the interview, and 3)
not being infected with HIV. Persons aware of their HIV infection were excluded from the report
because the purpose of NHBS is to collect and report data on the behaviors of persons at risk
for acquiring HIV infection, not the risk behaviors of those who know they are infected with
HIV.
The data were analyzed according to five demographic characteristics of participants:
race/ethnicity, age group, education level, sexual identity, and MSA. The race/ethnicity
categories were non-Hispanic white, non-Hispanic black, Hispanic, Asian or Pacific Islander,
American Indian or Alaska Native, multiracial, and other. Age was grouped into five categories:
ages 18--24 years, 25--34 years, 35--44 years, 45--54 years, and >55 years. Participants'
education level was categorized as less than high school diploma, high school diploma or
equivalent, and more than high school (i.e., at least some college or technical school
education). Self-reported sexual identity was categorized as homosexual, bisexual,
heterosexual, or other. HIV testing history, hepatitis vaccination, STD testing, and use of
prevention services are presented by the type of health insurance the participant reported at
the time of the interview. Health insurance was categorized as private (including membership in
a health maintenance organization), public (e.g., Medicare or Medicaid), or none.
Behaviors
Three time frames for self-reported behaviors were provided: ever (at any point in the
participant's lifetime), during the preceding 12 months (during the 12 months preceding the
date of the interview), and most recent (the most recent time the participant engaged in the
behavior).
HIV Testing
Because knowledge of one's current HIV status through testing is a key goal of HIV prevention,
data on HIV testing (ever and during the preceding 12 months) are presented. The facility
administering the most recent HIV test and the reasons for not being tested for HIV also are
presented. Participants selected reasons from a list and then were asked which reason was the
main reason for not being tested during the preceding 12 months.
Sexual Behavior
Details about anal sex with male partners (preceding 12 months and most recent) are presented
as high-risk behaviors for HIV transmission among MSM. Male sex partners were further defined
as either main or casual partners. A main sex partner was someone with whom the participant had
sex and to whom he felt most committed (e.g., a boyfriend, spouse, significant other, or life
partner). A casual sex partner was someone with whom the participant had sex but who was not
considered a main partner. Insertive anal sex was defined as a male participant placing his
penis in the anus of his partner. Receptive anal sex was defined as a male partner placing his
penis in a participant's anus. HIV serostatus of the sex partner was reported by all
participants. For participants who reported that their most recent HIV test result was
negative, the HIV serostatus of the most recent male sex partners is presented in the context
of the type of anal sex behavior (condom use or insertive or receptive activity) during their
most recent sexual encounter. For participants who reported both male and female sex partners,
sexual behaviors during the preceding 12 months with partners of both sexes are presented.
Drug Use
Drug use can either lead directly to HIV transmission (injection-drug use) or facilitate sexual
risk taking (any drug use). The use during the preceding 12 months of drugs that were not
injected (noninjection drugs) and that were not prescribed for the participant is reported as
the use of any type of drug, specific type of drug used, and whether the participant was under
the influence of the drug during sex. Participants could report the use of multiple types of
drugs during the preceding 12 months. Ever having participated in a drug and alcohol treatment
program is reported for injection and noninjection-drug users.
Hepatitis Vaccination and STD Testing
Public health recommendations for sexually active MSM include vaccination for viral hepatitis
and annual screening for STDs (7). Hepatitis vaccination was defined as having ever received a
hepatitis vaccine (even 1 dose of hepatitis A vaccine, hepatitis B vaccine, or both). STD
testing was defined as having a test for syphilis, gonorrhea, or some other STD during the
preceding 12 months.
Use of HIV Prevention Services and Programs
Understanding the current use of HIV-prevention services and programs can assist in evaluating
whether prevention activities are reaching the intended populations and can identify potential
opportunities for additional services or programs. Data on the use of three HIV-prevention
activities during the preceding 12 months are presented: receipt of free condoms, participation
in an individual-level intervention, and participation in a group-level intervention. Free
condoms might have been received at any location and need not have been provided as a specific
part of a concerted HIV-prevention activity (e.g., provided for general STD prevention or for
pregnancy prevention). Individual-level interventions were defined as one-on-one conversations
with an outreach worker, counselor, or prevention worker concerning how to protect oneself
against HIV and other STDs. Conversations that took place solely as a part of obtaining HIV
testing (pretest and posttest counseling) were excluded. Group-level interventions were defined
as small-group discussions about ways to protect oneself against HIV and other STDs.
Definitions for both intervention levels were based on the intervention types in CDC's
evaluation system (8). The type of provider of the prevention activity also is presented.
Results
During November 2003--April 2005, local staff approached 23,861 persons; brief eligibility
interviews were completed with 19,488 (82%) persons, 17,322 (89%) of whom were eligible for an
interview. Those not eligible were previous participants (407), persons aged <18 years (93), or
persons not currently residing in the MSA (1,666). Of 17,322 persons determined to be eligible,
14,049 (81%) agreed to participate, 13,670 (97%) of whom completed an interview (response rate:
79%.) For purposes of this report, 3,640 interviews were excluded from participants who did not
report having sex with another man during the 12 months before the interview, did not report
being male, or reported being infected with HIV. This report includes data from 10,030
interviews.
Characteristics of Participants
Participants were of diverse racial and ethnic backgrounds and age groups but were most
commonly non-Hispanic whites aged 25--44 years; 78% reported at least some college or technical
school education (Table 1). Nearly all (98%) participants reported being homosexual or
bisexual. The majority (66%) reported having private health insurance, but a substantial
proportion (25%) had no health insurance. Although all venues on the sampling frame had an
equal probability of being selected for sampling events, the majority of venues on the NHBS
frame were bars, dance clubs or streets; 67% of participants were recruited in those venues.
HIV Testing
Of 9,249 (92%) participants who reported ever having an HIV test, 8,967 (97%) participants had
received the results of their most recent HIV test, and 7,057 (77%) had been tested during the
preceding 12 months (Table 2). HIV testing rates were high for all races and ethnicities and
education levels. The primary venues in which HIV tests were administered included offices of
private physicians (36%), public health clinics and community health centers (26%), and HIV
counseling and testing programs (12%) (Table 3).
A total of 2,973 (30%) participants had not been tested during the preceding 12 months. The
most common reason for not having an HIV test was that the participant believed he had not done
anything to acquire HIV. Other frequently reported reasons were fear of testing positive and
lack of time for testing. Although structural barriers (e.g., lack of transportation, money, or
insurance; not knowing where to get tested) and concerns about the confidentiality of HIV
testing were commonly identified as one reason for not getting an HIV test, they were
infrequently specified as the main reason for not being tested (Table 4).
Sexual Behavior
Type of Partner
Of 10,030 participants, 7,628 (76%) reported having more than one male sex partner during the
preceding 12 months. A total of 7,547 (75%) reported having a casual male sex partner (median:
four; range: one to 300), 6,856 (68%) reported a main male sex partner (median: one; range: one
to 100), and 4,373 (43%) reported having both types of partners during the preceding 12 months.
Sexual Behavior with Male Partners
A total of 4,699 (47%) participants reported having unprotected anal sex with a male partner
during the preceding 12 months. The prevalence of anal sex with main male partners was highest
for younger participants (Table 5). Anal sex was reported by a larger proportion of the men who
identified themselves as homosexual or bisexual. Unprotected anal sex, however, was reported by
similar proportions of men in all categories of sexual identity. Unprotected anal sex was more
commonly reported with main male partners than with casual male partners. Although rates of
anal sex and unprotected anal sex were similar for participants of all races and ethnicities,
the rate of unprotected anal sex was highest for non-Hispanic white participants with their
main male sex partners. Unprotected anal sex with casual male partners was least common among
those with some college or technical school education.
Of 8,947 HIV-negative participants, 4,165 (47%) did not know the serostatus of their most
recent casual male partner, and 1,237 (14%) did not know that of their most recent main male
partner (Figure 2). Of the 4,635 who did not know the serostatus of their male sex partner
(either casual or main), 990 (21%) reported having unprotected anal sex during the most recent
sexual encounter with that partner. The prevalence of anal sex and unprotected anal sex during
the most recent sexual encounter was highest with main male partners (Table 6). More
participants reported insertive anal sex than receptive anal sex, regardless of the partner's
serostatus. Unprotected sex with HIV-positive main partners was generally less common than with
HIV-negative partners. Although the total numbers were small, the highest prevalence of
unprotected sex with an HIV-positive partner was during insertive anal sex with a casual
partner.
Sexual Behavior with Male and Female Partners
Of 10,030 participants who reported having sex with men during the preceding 12 months, 1,450
(14%) reported having also engaged in anal, vaginal, or oral sex with a female partner during
the preceding 12 months; of these, 209 (14%) had engaged only in oral sex with their male
partners, and 120 (8%) had engaged only in oral sex with their female partners. Of participants
who had vaginal or anal sex with both male and female partners, the highest prevalence of
unprotected intercourse was with female partners (53%) (Table 7). However, this was not true of
the participants who identified themselves as homosexual: more of them reported unprotected sex
with their male partners.
Drug Use
Noninjection-Drug Use
A total of 4,322 (43%) participants reported using a noninjection drug during the preceding 12
months; the prevalence of noninjection-drug use among participants did not differ by race or
ethnicity or by education (Table 8). Among 4,322 participants who reported noninjection-drug
use, the highest proportion (77%) used marijuana, followed by cocaine (37%), ecstasy (29%),
poppers (amyl nitrate) (28%), and stimulants (27%) (Table 9). A total of 3,198 (74%)
noninjection-drug users reported being under the influence of a drug during sex during the
preceding 12 months; of 1,226 participants who reported using poppers, 1,097 (89%) reported
being under the influence of poppers during sex. Other drugs commonly reported in conjunction
with sex included marijuana, stimulants, noninjection cocaine and crack, and club drugs (e.g.,
ecstasy, gamma hydroxybutyrate [GHB], and ketamine). Of those who used a noninjection drug
during the preceding 12 months, 670 (16%) had ever participated in a drug or alcohol treatment
program.
Injection-Drug Use
A total of 566 (6%) participants reported having ever injected drugs for nonmedical purposes,
and 194 (2%) had injected drugs during the preceding 12 months. Of these 194 participants, 52
(27%) had shared needles, syringes, or other drug-injection or preparation equipment during the
preceding 12 months, and 101 (52%) had ever participated in a drug or alcohol treatment
program.
Hepatitis Vaccination and STD Testing
Hepatitis Vaccination
Of the 10,030 participants, 5,333 (53%) reported that they had ever received >1 dose of
hepatitis vaccine. Non-Hispanic black men (44%) and men who identified themselves as
heterosexual (41%) reported the lowest rates of hepatitis vaccination (Table 10). Participants
aged >55 years and those who were less educated were less likely to report hepatitis
vaccination. The prevalence of hepatitis vaccination was lowest for those who had no health
insurance (43%) or only public health insurance (45%) (Table 10).
STD Testing
Overall, 4,266 (43%) participants reported having been tested for syphilis, gonorrhea, or
another STD during the preceding 12 months. STD testing was least common among non-Hispanic
white and Asian/Pacific Islander participants (Table 10). Participants aged >35 years were less
commonly tested than those aged <35 years. The rates of STD testing during the preceding 12
months were lowest for heterosexual participants and participants who had no health insurance.
Use of HIV Prevention Services and Programs
A total of 8,202 (82%) men reported participation in some type of HIV-prevention service or
program during the preceding 12 months. Of these, 8,035 (98%) participants had received free
condoms; 1,505 (15%) had engaged in an individual-level intervention, and 801 (8%) had engaged
in a group-level intervention (Table 11). Non-Hispanic black or young (aged 18--24 years) men
and those who had public health insurance were more likely to have participated in an
individual- or group-level intervention.
HIV/AIDS-focused community-based organizations were the most common providers of all types of
HIV-prevention activities. Nearly one third of the men interviewed had received free condoms
from other types of community venues (e.g., bars, clubs, bathhouses, Gay Pride events,
restaurants, cafes, fitness clubs, and retail stores) (Table 12).
Discussion
HIV Testing
Knowledge of one's HIV serostatus (through HIV testing) has been key to preventing HIV
transmission in the United States (2,9--12). Sexually active MSM should be tested at least
annually for HIV (7). To increase the likelihood that persons at risk for infection are tested
and receive their test results, CDC introduced the Advancing HIV Prevention Initiative in 2003
and has made rapid HIV tests available to health departments and community-based organizations
for use in local HIV prevention programs (2). Key strategies for this initiative include using
new testing technologies (e.g., rapid HIV testing) and integrating testing into medical care to
ensure that persons are aware of their HIV serostatus and that infected persons obtain
appropriate medical care and prevention services. The findings in this report concur with those
from previous investigations that indicated that the majority of MSM had been tested for HIV
and that a substantial proportion had been tested during the preceding 12 months (5,13). The
prevalence of HIV testing (ever and during the preceding 12 months) is relatively consistent
among groups of MSM. Given the reasons provided for not being tested for HIV during the
preceding 12 months, certain MSM might benefit from efforts to increase their perception of
personal risk and reduce structural barriers to annual HIV testing. The monitoring of HIV
testing patterns will continue to be an important use of NHBS data.
Sexual Behavior
MSM continue to be the largest population living with HIV in the United States (1). For the
majority of MSM, unsafe sex with male partners is the most likely route of transmission of HIV
infection (5,14,15). The sexual behavior that carries the highest risk for HIV transmission
between MSM is unprotected anal sex between an infected partner and a partner who is not
infected (16--18). Approximately 11% of HIV-negative participants reported having unprotected
anal sex with a partner whose HIV status was unknown. According to another report of NHBS data,
up to two thirds of non-Hispanic black MSM who reported during the interview that they were
HIV-negative were, when tested, identified as being infected with HIV (6). The sexual
transmission of HIV infection among MSM can be reduced by adopting effective protective
behaviors: disclosure of accurate HIV serostatus between sex partners, reduction of the number
of sex partners or mutual monogamy, and consistent and correct condom usage (2,9,19,20). NHBS
data concerning sexual behavior can be used to monitor the effect of HIV-prevention initiatives
on reducing the sexual transmission of HIV infection among MSM (19).
Drug Use
Drug use is associated with sexual risk behaviors among MSM (21), particularly unprotected anal
sex (22--25). As a result of the changing patterns of drug use and the contexts in which it
takes place, accurately assessing how substance abuse contributes to HIV transmission among MSM
is complicated (26). Among NHBS participants, the prevalence of noninjection-drug use was high
(43%), three quarters of noninjection drugs users reported being under the influence of these
drugs during sex. Few participants who reported noninjection-drug use had ever participated in
a drug treatment program. Treatment programs aimed at MSM, especially services that underscore
HIV prevention, should address the use of drugs that are popular in this population (27--30).
HIV-prevention programs should focus on decreasing drug use and reducing the high-risk sexual
behaviors of MSM (31). NHBS data can be used to monitor emerging drug use trends among MSM and
can inform the development or modification of HIV-prevention interventions for MSM who use
drugs.
Hepatitis Vaccination and STD Testing
Public health recommendations to prevent the spread of viral hepatitis through preexposure
vaccination were first issued in 1982. Children, adolescents, and persons at increased risk for
infection (e.g., MSM, injection-drug users, and health-care workers) should receive vaccine
(7,32--34). Following these recommendations should increase the likelihood that sexually active
MSM are vaccinated for hepatitis, but approximately half of NHBS participants reported never
having received a hepatitis vaccination. Rates were even lower for non-Hispanic black MSM and
those without private health insurance, underscoring the need for additional efforts with these
groups.
To prevent STDs among sexually active MSM, CDC recommends annual testing for syphilis,
gonorrhea, and chlamydia (7). Fewer than half of the participants in this study reported having
been tested for an STD during the preceding 12 months, and rates were even lower for sexually
active older MSM and those with no health insurance. NHBS provides data for the ongoing
monitoring of implementation of these prevention recommendations for MSM.
Use of HIV-Prevention Services and Programs
Consistent and correct use of condoms during sexual intercourse is effective in preventing
sexually acquired HIV infection (35,36), and access to, and consistent use of, condoms
continues to be an important HIV-prevention tool for sexually active persons (20,37,38). A
substantial proportion of participants had received free condoms from multiple sources during
the preceding 12 months.
In 2001, CDC and its national partners introduced a strategic plan to reduce by 50% the number
of new HIV infections (19). The plan called for increasing the proportion of MSM who
consistently engage in behaviors that reduce their risk for acquiring HIV and urged that
prevention efforts be focused on especially vulnerable MSM: young men and men who are members
of racial or ethnic minority populations. HIV-prevention programs whose effectiveness has been
demonstrated are the focus of these efforts, and they include individual- and group-level
interventions (39). Although only a small proportion of men reported participation in an
individual- or a group-level intervention, the largest proportions of men who had participated
in these types of programs were young or members of racial/ethnic minority populations; these
data suggest that these effective prevention programs are reaching the intended audience. As
HIV-prevention activities for MSM continue to be developed and implemented, NHBS will be able
to provide updated data regarding the delivery of these services and programs to the
populations who most need them.
Limitations
The findings in this report are subject to at least six limitations. First, because a single
standard for obtaining a representative sample of MSM that encompasses the diversity of the
population has not been established, the external validity of the NHBS sample cannot be
determined accurately (40). Second, findings from the MSAs in this study might not be
generalizable to all other U.S. states or cities. Third, because the survey was administered by
an interviewer, certain participants might not have accurately reported their behavior. For
example, participants might have underreported a socially undesirable behavior that they were
practicing (e.g., drug use) or might have overreported a socially desirable behavior that they
were not practicing (e.g., using a condom during anal sex). Fourth, self-reported HIV
serostatus and perceived knowledge of a partner's serostatus should be interpreted
conservatively because this information might be inaccurate, especially in groups for which
high rates of unrecognized HIV infection have been reported (6). Fifth, in certain instances,
stratification by demographic characteristics might produce numbers that are too small for
reliable interpretation. Because statistical tests were not performed, data should be
interpreted with caution. Future statistical analyses of NHBS data are planned. Finally,
although every attempt was made to develop, implement, and monitor a standard data collection
protocol for this first year of NHBS, variations in the timing of data collection and the
relative ease or difficulty of recruiting eligible men led to a wide range of MSA sample sizes.
Conclusion
For CDC's HIV-prevention strategic plan goal of reducing the number of new HIV infections to be
achieved (19), a multifaceted approach is required that includes prevention programs designed
to reduce risk behaviors and increase knowledge of HIV serostatus, especially among populations
at high risk for HIV infection. To monitor progress toward achieving the objective and evaluate
prevention programs, key behavior indicators must be collected from the same populations over
time. NHBS was designed to collect these key indicators from the groups at high risk for
acquiring HIV infection.
This report has described the prevalence of multiple indicators that are relevant to HIV risk
and prevention among MSM and has provided additional detail about MSM of differing backgrounds.
A better understanding of the behaviors and circumstances that are associated with HIV
transmission can improve the ability to develop appropriate prevention responses. Of particular
importance is the high proportion of participants of all races and ethnicities who reported
engaging in unprotected anal sex. Although >90% of participants had been tested for HIV, and
three quarters of participants had been tested recently, MSM should share their HIV test
results with all their sex partners more consistently. Noninjection-drug use can amplify sexual
risk-taking behavior, and the use of noninjection drugs in combination with sex is prevalent
among participants. The combination of drug use and unprotected sex with partners of unknown
HIV serostatus should be studied more fully to better explain how it contributes to sustained
risk behavior and continued HIV transmission among MSM.
NHBS is a key component of CDC's comprehensive approach to reducing the spread of HIV in the
United States and will be the primary source of data for monitoring behaviors of populations at
high risk for HIV infection. The data will be used to assess the local and national prevalence
of HIV-related risk behaviors, monitor behavior trends, and identify the demographic and
behavioral correlates of risk. NHBS data also will be used to assess current local HIV
prevention programs and directing future prevention activities to reduce HIV transmission.
Acknowledgments
The National HIV Behavioral Surveillance (NHBS) System was developed with the assistance of Ida
M. Onorato, MD, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis,
STD and TB Prevention (proposed), CDC. The following members of the NHBS system working group
developed the protocol and questionnaire for the NHBS-MSM survey: Luke Shouse, MD, Division of
Public Health, Georgia Department of Human Resources, David Holtgrave, PhD, Ben Hadsock,
Rollins School of Public Health, Emory University, Atlanta, Georgia; Liza Solomon, DrPH, Colin
Flynn, ScM, Maryland Department of Health and Mental Hygiene, Frangiscos Sifakis, PhD,
Department of Epidemiology, Johns Hopkins university Bloomberg School of Public Health,
Baltimore, Maryland; Abbie Averbach, MPH, Jennifer Coyle, MPH, Massachusetts Department of
Public Health, Chris Smith, MA, Abt Associates Inc., Boston, Massachusetts; Carol Ciesielski,
MD, Nik Prachand, MPH, Chicago Department of Health, Chicago, Illinois; Sharon Melville, MD,
Richard Yeager, PhD, Texas Department of State Health Services, Austin, Texas; Anne Freeman,
MSPH, Douglas Shehan, Douglas Kershaw, university of Texas Southwestern Medical Center, Dallas,
Texas; Mark Thrun, MD, Julie Subiadur, Denver Public Health Department, Denver, Colorado;
Marcia Wolverton, MPH, Hafeez Rehman, MD, City of Houston Department of Health, Jan Risser,
PhD, Bernardo Useche, PhD, university of Texas at Houston School of Public Health, Houston,
Texas; Trista Bingham, MPH, Denise Johnson, MPH, Nina Harawa, PhD, County of Los Angeles
Department of Health Services, Los Angeles, California; Marlene LaLota, MPH, Florida Department
of Health, Tallahassee, Florida; Lisa Metsch, MD, David Forrest, PhD, university of Miami
School of Medicine, Miami and Fort Lauderdale, Florida; Chris Murrill, PhD, New York City
Department of Health, Beryl Koblin, PhD, Michael Camacho, New York Blood Center, New York City,
New York; Helene Cross, PhD, Barbara Bolden, PhD, Sally D'Errico, MEd, New Jersey Department of
Health and Senior Services, Trenton, New Jersey; Henry Godette, North Jersey Community Research
Initiative, Newark, New Jersey; Kathleen Brady, MD, Philadelphia Department of Public Health,
Philadelphia, Pennsylvania; Assunta Ritieni, MHS, California Department of Health Services,
Sacramento, California; Al Valesco, PhD, Velasco Consulting, Leticia Cazares, San Ysidro Health
Center, San Diego, California; Willi McFarland, MD, H. Fisher Raymond, San Francisco Department
of Public Health, San Francisco, California; Sandra Miranda De León, MPH, Yadira Rolón Colón,
MS, Departmento de Salud, San Juan, Puerto Rico; Leonard Bates PhD, Christopher Hucks-Ortiz,
MPH, Christopher Lane, District of Columbia HIV/AIDS Administration, Washington, DC; and
members of the NHBS team, Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral
Hepatitis, STD and TB Prevention (proposed), CDC. Additional assistance in the production of
this report was provided by Marie Morgan, Division of HIV/AIDS Prevention, National Center for
HIV/AIDS, Viral Hepatitis, STD and TB Prevention (proposed), CDC.
References
CDC. HIV/AIDS surveillance report, 2004. Vol. 16. Atlanta, GA: US Department of Health and
Human Services, CDC; 2005:1--46. Available at
http://www.cdc.gov/hiv/topics/surve...orts/index.htm.
CDC. Advancing HIV prevention: new strategies for a changing epidemic---United States, 2003.
MMWR 2003;52:329--32.
MacKellar D, Valleroy L, Karon J, Lemp G, Janssen R. The Young Men's Survey: methods for
estimating HIV seroprevalence and risk factors among young men who have sex with men. Public
Health Rep 1996;111(Suppl 1):138--44.
MacKellar D, Gallagher K, Finlayson T, Sanchez T, Lansky A, Sullivan P. Surveillance of HIV
risk and prevention behaviors of men who have sex with men---a national application of
venue-based, time-space sampling. Public Health Rep. In press.
Valleroy LA, MacKellar DA, Karon JM, et al. HIV prevalence and associated risks in young men
who have sex with men. JAMA 2000;284:198--204.
CDC. HIV prevalence, unrecognized infection, and HIV testing among men who have sex with
men---five US cities, June 2004--April 2005. MMWR 2005;54:597--601.
CDC. Sexually transmitted diseases treatment guidelines, 2002. MMWR 2002;51(No. RR-6):1--80.
CDC. Evaluating CDC-funded health department HIV prevention programs. Vol. 1: guidance.
Atlanta, GA: US Department of Health and Human Services, CDC; 2001. Available at:
http://www.cdc.gov/hiv/aboutdhap/perb/hdg.htm.
Janssen RS, Holtgrave DR, Valdiserri RO, Shepherd M, Gayle HD, De Cock KM. The serostatus
approach to fighting the HIV epidemic: prevention strategies for infected individuals. Am J
Public Health 2001;91:1019--24.
CDC. Perspectives in disease prevention and health promotion public health service guidelines
for counseling and antibody testing to prevent HIV infection and AIDS. MMWR 1987;36:509--15.
CDC. Technical guidance on HIV counseling. MMWR 1993;42 (No. RR-2):11--17.
CDC. Revised guidelines for HIV counseling, testing, and referral. MMWR 2001;50(No.
RR-19):1--58.
CDC. HIV testing survey, 2002. Atlanta, GA: US Department of Health and Human Services, CDC;
2004:1--27. Available at http://www.cdc.gov/hiv/stats/HIV-Test-Survey2002.pdf.
Buchbinder SP, Vittinghoff E, Heagerty PJ, et al. Sexual risk, nitrite inhalant use, and lack
of circumcision associated with HIV seroconversion in men who have sex with men in the United
States. J Acquir Immune Defic Syndr 2005;39:82--9.
Stall RD, Hays RB, Waldo CR, Ekstrand M, McFarland W. The gay '90s: a review of research in the
1990s on sexual behavior and HIV risk among men who have sex with men. AIDS 2000;14(Suppl
3):S101--14.
Morin SF, Steward WT, Charlebois ED, et al. Predicting HIV transmission risk among HIV-infected
men who have sex with men: findings from the Healthy Living Project. J Acquir Immune Defic
Syndr 2005;40:226--35.
Ekstrand ML, Stall RD, Paul JP, Osmond DH, Coates TJ. Gay men report high rates of unprotected
anal sex with partners of unknown or discordant HIV status. AIDS 1999;13:1525--33.
Chen SY, Gibson S, Weide D, McFarland W. Unprotected anal intercourse between potentially
HIV-serodiscordant men who have sex with men, San Francisco. J Acquir Immune Defic Syndr
2003;33: 166--70.
CDC. HIV prevention strategic plan through 2005. Atlanta, GA: US Department of Health and Human
Services, CDC; 2001. Available at http://www.cdc.gov/hiv/pubs/prev-strat-plan.pdf.
CDC. A glance at HIV/AIDS among men who have sex with men [Fact sheet]. Atlanta, GA: US
Department of Health and Human Services, CDC; 2006. Available at
http://www.cdc.gov/hiv/resources/fa...msm_glance.htm.
Stall R, Purcell DW. Intertwining epidemics: a review of research on substance use among men
who have sex with men and its connection to the AIDS epidemic. AIDS and Behavior
2000;4:181--92.
Purcell DW, Moss S, Reimien RH, Woods WJ, Parson JT. Illicit substance use, sexual risk, and
HIV-positive gay and bisexual men: differences by serostatus of casual partners. AIDS
2005;19(Suppl 1): S37--47.
Mansergh G, Colfax GN, Marks G, Rader M, Guzman R, Buchbinder S. The Circuit Party Men's Health
Survey: findings and implications for gay and bisexual men. Am J Public Health 2001;91:953--8.
Hirshfield S, Remien RH, Humberstone M, Walavalkar I, Chiasson MA. Substance use and high-risk
sex among men who have sex with men: a national online study in the USA. AIDS Care 2004;16:
1036--47.
Celentano DD, Valleroy LA, Sifakis F, et al. Associations between substance use and sexual risk
among very young men who have sex with men. Sex Transm Dis 2005;33:1--7.
Lambert E, Normand J, Stall R, Sevgi A, Vlahov D. Introduction: new dynamics of HIV risk among
drug-using men who have sex with men. J Urban Health 2005;82:i1--8.
Stall R, Paul JP, Greenwood G, et al. Alcohol use, drug use and alcohol-related problems among
men who have sex with men: the Urban Men's Health Study. Addiction 2001;96:1589--601.
Irwin TW, Morgenstern J. Drug-use patterns among men who have sex with men presenting for
alcohol treatment: differences in ethnic and sexual identity. J Urban Health 2005;82:i127--33.
Patterson TL, Semple SJ, Zians JK, Strathdee SA. Methamphetamine-using HIV-positive men who
have sex with men: correlates of polydrug use. J Urban Health 2005;82:i120--6.
Substance Abuse and Mental Health Services Administration. A provider's introduction to
substance abuse treatment for lesbian, gay, bisexual, and transgender individuals. Rockville,
MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services
Administration; 2001. Available at http://kap.samhsa.gov/products/manuals/pdfs/lgbt.pdf.
Colfax G. The epidemiology of substance use and sexual risk behavior among men who have sex
with men: implications for HIV prevention interventions [Abstract No. 55]. In: Program and
abstracts of the 12th Conference on Retroviruses and Opportunistic Infections, Boston,
Massachusetts; February 22--25, 2005. Available at
http://www.retroconference.org/2005...acts/25846.htm.
CDC. Recommendation of the Immunization Practices Advisory Committee (ACIP): recommendations
for protection against viral hepatitis. MMWR 1985;34:313--24,329--35.
CDC. Immunization of adolescents: recommendations of the Advisory Committee on Immunization
Practices, the American Academy of Pediatrics, the American Academy of Family Physicians, and
the American Medical Association. MMWR 1996;45(No. RR-13):1--16.
CDC. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus
infection in the United States: recommendations of the Advisory Committee on Immunization
Practices (ACIP), part 1: immunization of infants, children, and adolescents. MMWR 2005;54(No.
RR-16):1--32.
CDC. Update: barrier protection against HIV infection and other sexually transmitted diseases.
MMWR 1993;42:589--91.
Varghese B, Maher JE, Peterman TA, Branson BM, Steketee RW. Reducing the risk of sexual HIV
transmission: quantifying the per-act risk for HIV on the basis of choice of partner, sex act,
and condom use. Sex Transm Dis 2002;29:38--43.
CDC. Incorporating HIV prevention into the medical care of persons living with HIV:
recommendations of CDC, the Health Resources and Services Administration, the National
Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of
America. MMWR 2003;52(No. RR-12):1--24.
Presidential Advisory Council on HIV/AIDS. Achieving an HIV-free generation: recommendations
for a new American HIV strategy. Washington, DC: US Department of Health and Human Services;
2005. Available at http://www.pacha.gov/pdf/PACHArev113005.pdf.
CDC. Compendium of HIV prevention interventions with evidence of effectiveness. Atlanta, GA: US
Department of Health and Human Services, CDC; 1999. Available at
http://www.cdc.gov/hiv/projects/rep/compend.htm.
Lansky A, MacKellar D, Gallagher KM, Lin LS, Sullivan PS, Onorato IM [Letter]. Sex Transm Dis
2006;33:272--3.
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