1. High Risk Sexual Behaviour in Men Who Have Sex With Men: The Development of a Sexual Risk Behaviour Screening Tool Gibbie T 1,5, Hellard M 2, Ellen S 3,5, Read T 4, Fairley C 4, Lewis J & Mijch A 1,5 1 Victorian HIV Service, The Alfred; 2 Centre for Epidemiology and Population Health Research, Burnet Institute; 3 Department of Psychiatry, The Alfred; 4 Melbourne Sexual Health Centre; 5 Monash University; Melbourne, Victoria, Australia

2. The team

3. Background Dramatic increases in HIV/STIs in Victoria since 1999  HIV: 132 - 260  Syphilis: 9 - 418  80% Men who have sex with men (MSM)

4. Risk Factors for HIV/STI transmission in MSM Increased unprotected anal intercourse (UAI) with casual partners Increased number of sexual partners Substance Use  Alcohol use associated with ↑ UAI with casual partners  Methamphetamines, inhalants, cocaine, ‘club drugs’ VIC Periodic surveys, 1998-2006, men aged 30-49; Clutterbuck et al. (2001). AIDS Care, 13(4), 527– 535; Stueve et al. (2002). AIDS Educ Prev. 14(6), 482-95; Koblin et al. (2006). AIDS, 20, 731-739.

5. Depression (inconsistent relationship)  ↓ risk with serodiscordant partner but ↑ sex partners  Dysthymia – twice as likely to engage in UAI Psychological Constructs  Personality variables (impulsivity/sensation seeking)  Self-efficacy, Social skills, Assumptions of partner status Rogers et al (2003). HIV Medicine; 4(3), 271-275. Bradley, Remien, Dolezal (2008). Psychosomatic Medicine; 70(2), 186-191. Risk Factors for Sexual Risk Behaviour in MSM

6. To examine the predictors of sexual risk taking behaviour in MSM in Victoria To develop a brief, practical, clinic-based assessment tool that will identify MSM at risk of increased sexual risk taking Aims

7. Methods Information collected at interview Socio-demographics Medical history (HIV & sexual health testing history) Substance Use HIV treatment beliefs Sexual Behaviour  Recent sexual behaviour (regular & casual partners)  STI test result (biological measure of risk)

8. Methods Sexual Sensation Seeking Questionnaire personality measure Personal characteristics involved in negotiating safe sex self worth capacity to assert yourself knowledge of safe sex practices capacity to negotiate safe sex capacity to say no under pressure frequency of use of skills Kalichman & Rompa (1995). J Personality Assessment, 76(3), 379-395

9. Methods Mood Disorder Center for Epidemiologic Studies Depression Scale  measures symptoms of depression Mini International Neuropsychiatric Interview  diagnostic interview for Major Depressive Episode (MDE) and Dysthymia Follow-up (telephone assessment) Sexual behaviour over past 3 months

10. Results - Participants 152 MSM (recruited from GP, sexual health, hospital clinic) Average age 36 (SD = 10) Tertiary educated (59%) In a relationship (40%) Having had previous HIV (94%) or STI (70%) test 35% HIV positive, 25% had a past STI Mood Disorder - 24% MDE, 4% Dysthymia

11. Results - Participants 82% (n = 126) sexually active in past 3 months Sexual partners - median 2 (range 0 - 68) Sexual Risk Behaviour (SRB) – defined as UAI with casual or serodiscordant partner, or a positive STI result 42% (n = 53) of sexually active participants met SRB criteria  UAI serodiscordant regular partners 9% (n = 5)  UAI with casual partners 33% (n = 18)  Positive STI test result9% (n = 5)

12. Results – Comparison of Sexual Risk Groups *SRBNo SRB n = 53n = 73 Casual sexual partners - mean (SD)8 (11)4 (9)* Mood Disorder13 (10%) Drug Use # 33 (26%)27 (21%)* HIV infected16 (12%)20 (15%) Belief HAART prevents transmission n (%)4 (3%)12 (9%) Sexual Sensation Seeking Score - mean (SD)28 (4.6)25 (5.8)* Personal characteristics involved in safe sex (mean score) (SD) knowledge3.7 (0.5)3.9 (0.3)* negotiation ability3.3 (0.7)3.8 (0.4)* say no under pressure3.3 (0.7)3.7 (0.6)* frequency of use of skills1.5 (0.9)2.2 (1.0)* *SRB defined as UAI casual or serodiscordant partner or positive STI; # Drug Use - > monthly use amyl nitrate/amphetamines; *p < 0.05

13. Variable Adjusted OR (95% CI), p-value BehaviourCasual Partners 01.0 1 - 36.7 (1.32 - 34.32) 0.022 > 419.5 (3.43 - 111.6) 0.001 SkillsUsed these skills in past 3 months? Always1.0 Usually5.2 (0.94 - 28.8) 0.058 Sometimes/never9.07 (2.11 - 38.96) 0.003 BeliefsHAART beliefs Yes1.0 No15.36 (1.88 – 125.2) 0.011 Do not know11.33 (1.34 – 95.84) 0.026 PersonalitySSS item 3 – ‘I enjoy the sensation of intercourse without a condom’ Not at all like me 1.0 A little like me6.69 (1.13 - 39.53) 0.036 Like me10.45 (1.7 - 64) 0.011 Very much like me27.72 (3.79 - 202.7) 0.001 BehaviourMarijuana Not in the last 6 month1.0 Use in the last 6 month6.64 (1.70 – 25.97) 0.007

14. Sexual Risk Behaviour Screening Tool 1. How many casual partners have you had anal sex with in the past 3 months? 0 1-3 4 or more 2. In the past 3 months, how often have you used the following skills to increase your safety during sex? The capacity to assert yourself, negotiate safe sex, say ‘no’ under pressure, knowledge of safe sex practices. Always Usually Sometimes Never 3. Do you believe anti-retroviral therapy (HIV treatment) has reduced your risk of catching or transmitting HIV? Yes No Don’t know 4. Please indicate the extent of your agreement to the following statement: I enjoy the sensation of intercourse without a condom. Not at all like me A little like me Like me Very much like me 5. In the past 6 months, have you used Marijuana? No Yes Total Score Please Circle Response 0 20 30 0 16 22 0 27 24 0 19 23 33 0 19

15. Sensitivity & Specificity for detecting high risk sexual behaviour Cut-off scores to separate the groups 30/131 cut-off score  correctly classifying 96% of high risk takers  incorrectly classifying 22% of non-risk takers

16. Receiver Operating Curve (ROC) Area under ROC = 0.92 The model had high accuracy in separating the two groups

17. Summary High prevalence of depression (28%) & sexual risk (42%) ↑ sexual risk behaviour in participants who reported:  > 4 casual partners in the previous 3 months  ‘sometimes’ / ‘never’ using personal skills to negotiate safe sex  ‘no’ / ‘don’t know’ if HAART reduces risk of HIV transmission  SSS item 3 ‘I enjoy the sensation of sex without a condom’  marijuana use in the past 6 months

18. Summary 5 question - 5 minute screening tool  Immediate score identifying risk  96% of sexual risk takers, 22% of non sexual risk takers Where to from here? Larger sample size Intervention trials to support behaviour change Enhance routine care in primary health settings

19. Acknowledgements Nursing Staff at Melbourne Sexual Health Centre, The Alfred hospital’s Infectious Diseases Unit & Prahran Market Clinic RA: Emily Mann & David Wain Dr Michelle Earle, Senior Clinical Psychologist, Sex, Health & Well-being Service, The Alfred Funding Source Victorian Department of Human Services Public Health Research Projects Email: t.gibbie@alfred.org.au