1. Problem drinking and sexual risk behavior among MSM in Peru RG Deiss, JL Clark, KA Konda, S Leon, JD Klausner, CF Caceres, TJ Coates Meeting of the American Public Health Association October 29, 2012

2. No Disclosures

3. Background Alcohol increases risk behavior through disinhibition, impairment of decision-making, and alteration of expectations with respect to sexual encounters Many cross-sectional studies find associations between alcohol consumption and sexual risk behaviors Compared with other regions, however, few studies among MSM and even fewer among Latin American MSM

4. Alcohol Use in Peru Frequently a social experience WHO: 8% of all men have alcohol use disorders Increase over prior decade In sub-populations, numbers may be even higher (22-33% of men are heavy episodic drinkers in studies of “distritos emergentes” of Lima) Instituto Nacional de Salud Mental, 2008. Galvez-Buccollini et al. 2008. Rev Panam Salud Publica 25;499-505.

5. Alcohol in Peru (2) Alcohol consumption prior to sex has been independently associated with sexual risk behaviors Case control study: alcoholism and sexual orientation were associated with HIV positivity HIV epidemic concentrated among MSM (11% and rising) The present study is among the first to examine the relationship between alcohol consumption and sexual risk among Peruvian MSM. Chincha et al. 2008. Rev Chilena Infectol 25;49-53. UNAIDS. Global Report. 2012

6. Data Collection Comunidades Positivas: Snowball sample from 16 neighborhoods of Lima, Peru (2008) Men 18-45 years of age with >1 sexual encounter with male/transgender person (TGP) in the past 12 months Acknowledged sexual preference toward men or TGP Live/work near the intervention area Plan to stay in the area for the whole study period (18 months) Willing/able to provide informed consent. STI Testing: HIV, HSV-2, Syphilis, oral/rectal GC/chlamydia

7. Data Collection Computer-Assisted Personal Interview: sociodemographics, health care seeking behavior, sexual risk behaviors and substance use. Audio-assisted self interview: HIV history/status Alcohol consumption (frequency of consumption and episodic drinking) CAGE questionnaire attempt to Cut back on drinking Annoyed over criticism of drinking Guilt over drinking “Eye opener”

8. Data Analysis Primary outcome variable: CAGE-positive (meets 2 of 4 criteria) To compare Cage+/- we performed chi-square and Mann-Whitney tests Multivariate logistic regression for all variables with p < 0.10

9. Results

10. CAGE responses %POSITIVE%POSITIVE

11. Demographics CAGE+ (n=415) % CAGE- (n=303) % Age (median, IQR)29 (23,35)29 (23,36) Born outside of Lima4943 Completed high school7370 *Self-identify as gay/bisexual3323 *Self identify as transgendered/ transsexual 4455 *Median age at first sexual encounter (IQR)14 (12,16)15 (13,17) *p<0.01

12. Health Care CAGE+ (n=415) % CAGE- (n=303) % P-value Report prior test for HIV74810.05 Reported HIV+ at time of study480.01 --Of these, taking HAART53 (n=15)68 (n=25)0.35 Found HIV+ by Western Blot15170.48 HSV-2 infection66640.81 C. trachomatis infection (oral or rectal)25190.09 N. gonorrhea infection (oral or rectal)13 0.73 History of syphilis infection (RPR/TPPA+)25240.75 Active syphilis infection (titer > 1:8)108.90.51

13. Sexual Risk behavior CAGE+ (n=415) % CAGE- (n=303) % P-value Used condoms less than always in last six months 66580.03 Ever forced to have sex3620<0.01 Used alcohol at last sexual encounter5336<0.01 Used drugs at last sexual encounter8.83.7<0.01 Received compensation for sex in last six months 6245<0.01 --Always used condom in these encounters55 (n=151)64 (n=61)0.26 Paid for sex in last six months2819<0.01 --Always used condom in these encounters54 (n=115)59 (n=48)0.34 Median number of partners in last six months (IQR 4 ) 6 (2,20)4 (2,10)<0.01 Median number of lifetime partners (IQR)100 (20,500) 40 (15,200)<0.01

14. Adjusted Odds Ratios % Ever forced to have sex1.8 (1.2, 2.6) Used alcohol at most recent sexual encounter2.1 (1.5, 2.9) Received compensation for sex in last six months 1.5 (1.0, 2.1) Reported HIV+ at time of study0.4 (0.2, 0.9) Multivariate Analysis

15. Conclusions High prevalence of problem drinking and sexual risk behaviors among Peruvian MSM Association between problem drinking and sexual risk behavior Number of partners, self-identity, alcohol before sex and age at sexual initiation Individuals with known HIV at the time of study entry were less likely to be problem drinkers HIV care as alcohol intervention?

16. Study Limitations Sub-analysis of a larger study Cross-sectional analysis, therefore causal inferences cannot be drawn Association between alcohol and sexual risk difficult to disentangle “Drinking before sex” may simply reflect more frequent alcohol consumption Quantification of drinking is sometimes difficult in Peru, given the shared/social experience of alcohol consumption Use of validated instrument/scale such as CAGE may overcome this challenge

17. Implications Efforts to reduce problem drinking among high- risk MSM should be considered a priority For HIV+ individuals, these efforts would impact linkage/retention in care Present study offers a unique opportunity to examine the effects of alcohol (as opposed to polysubstance abuse) on sexual behavior alone Interventions and further study to reduce sexual risk behaviors among high-risk MSM are warranted

18. Acknowledgments NIH Grant R01MH078752 Project Staff and Co-Authors Most importantly, study participants who gave their time

19. Thank you Autumn in Lima, Peru Autumn in Lima, Ohio