1. Men who have sex with men

3. This slide shows the proportional distribution of HIV/AIDS cases diagnosed from 2001 through 2004, by transmission category, for 35 areas with confidential name-based HIV infection surveillance.
The proportion of HIV/AIDS cases attributed to male-to-male sexual contact increased from 41% in 2001 to 47% in HIV/AIDS cases attributed to high risk heterosexual contact remained stable from 2001 (35%) to 2004 (33%) and cases attributed to injection drug use decreased from 20% in 2001 to 15% in HIV/AIDS cases attributed to male-to-male sexual contact and injection drug use remained stable from 2001 (4%) to 2004 (4%).
The remaining HIV/AIDS cases were those attributed to hemophilia or the receipt of blood or blood products, and those in persons without an identified risk factor.
The following 35 areas have had laws or regulations requiring confidential name-based HIV infection surveillance since at least 2000: Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, Wyoming, Guam and the US Virgin Islands.
The data have been adjusted for reporting delays and cases without risk factor information were proportionally redistributed.

4. In 2004, an estimated 18,203 HIV/AIDS cases diagnosed in 35 areas with confidential name-based HIV infection surveillance were attributed to male-to-male sexual contact.
Almost half of the cases associated with male-to-male sexual contact were in non-Hispanic whites (43%). Most of the remaining cases were in non-Hispanic blacks (36%) or Hispanics (20%). American Indians/Alaska Natives and Asians/Pacific Islanders each accounted for approximately 1% of all cases.
The following 35 areas have had laws or regulations requiring confidential name-based HIV infection surveillance since at least 2000: Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Kansas, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, Wyoming, Guam and the US Virgin Islands.
The data have been adjusted for reporting delays and cases without risk factor information were proportionally redistributed.

6. HIV prevalence in selected high risk groups: Mexico-U.S. Border States
Sources: CENSIDA, Viani et al, in press; Patterson et al, in press; Strathdee et al, in prep

7. HIV Prevalence, Risk Behaviors, and Access to Care Among MSM in San Diego, California and Tijuana, Mexico Juan D. Ruiz, M.D., Dr.P.H. Office of AIDS California Department of Health Services 2002
Latino MSM aged 18 to 29 in Tijuana, Mexico and San Diego, CA (about 250 from each site)
Tijuana sample: Mainly from public park reputed for prostitution (N=249)
San Diego sample: Mainly from gay bars/dance clubs (N=125)
Data
Standardized questionnaire (English or Spanish) on HIV risk behavior, attitudes, and access to care
blood sample for HIV antibody testing

8. MSM HIV Testing and Access to Prevention and Care (Ruiz, 2002)
Report ever receiving HIV prevention information
Tijuana: 141/249 = 56.6%
San Diego: 96/125 = 76.8%
Report ever testing for HIV antibodies:
Tijuana: /249 = 46.2%
San Diego: 78/125 = 62.4%
HIV seroprevalence:
Tijuana: 47/249 = 18.9%
San Diego: /125 = 35.2%
Of those who tested positive and reported a previous positive test, over 70% reported ever using AIDS drug therapy

9. MSM Sexual Behavior with Females (UVI = unprotected vaginal intercourse; UAI = unprotected anal intercourse) (Ruiz. 2002)
Over 10 sex partners in life
UVI, lifetime
UVI, last 4 months
UAI, lifetime
UAI, last 4 months
Exchange partner, lifetime
Sex partner from across the border, lifetime
35.3%
77.5%
43.4%
43.0%
18.1%
32.9%
39.4%
6.4%
36.8%
8.0%
13.6%
3.2%
5.6%
27.2%

10. MSM Sexual Behavior with Males (UAI = unprotected anal intercourse) (Ruiz, 2002)
Tijuana San Diego
70.7% %
27.3% %
28.1% %
12.0% %
32.9% %
45.4% %
Over 10 sex partners in life
Insertive UAI, lifetime
Ins. UAI, last 4 months
Receptive UAI, lifetime
Rec. UAI, last 4 months
Exchange partner, lifetime
Sex partner from across the border, lifetime

11. MSM Drug Using Behaviors (Ruiz, 2002)
Tijuana San Diego
41.4% 7.2%
25.3% 3.2%
37.3% 4.8%
24.1% 3.2%
38.2% %
27.3% [ 8.8%
16.9% 4.0%
4.8% %
Injected drugs
Lifetime
Last 4-months
Shared needles/works
Life time
Used drug during sex in the last 4 months
Alcohol
Marijuana
Methamphetamine
Ecstasy

12. Conclusions Ruiz 2002 Study
Risk behaviors of Latino MSM differed between sites
Tijuana MSM were more likely to report engaging in risky sexual behavior with females and risky drug using behaviors
San Diego MSM were more likely to report engaging in risky sexual behaviors with males
MSM at both sites engage in risky sexual behaviors with both men and women from the opposite side of the U.S.-Mexico border
Difficult to generalize results because of sampling scheme

13. HIV Prevalence, Unrecognized Infection, and HIV Testing Among Men Who Have Sex with Men --- Five U.S. Cities, June April 2005   Vol 54, No MM24;59

14. Issues MSM Hidden population Stigma Bisexual Discrimination
Internalized homophobia
Married and fear of identification

15. What changes should we promote among MSM
Refrain from unprotected anal intercourse, and ideally, from other practices that involve sexual fluid exchange
Consistent use of condoms during intercourse
Adoption of sexual practices that do not permit entry of sexual fluids

16. Identifying Clients at Greatest Risk
Homosexually active men who continue to have high-risk sex are at imminent risk for contracting or transmitting HIV infection

17. Elements Critical to HIV Risk Behavior Change
Risk Education
Threat personalization
Practical understanding of factors responsible for risk and behavior changes needed to reduce risk
Accurate appraisal of personal level of risk based upon one’s own behavior

18. Elements Critical to HIV Risk Behavior Change Continued
Perceived efficacy of change
Belief that one is personally capable of implementing risk reduction behavior changes and that these changes if made, will have protective value

19. Elements Critical to HIV Risk Behavior Change Continued
Commitment to initiate personal action to reduce risk
Acquisition and ability to skillfully perform behavioral skills needed to effect risk reduction (including condom use, safer sex guidance, assertiveness skills to refuse coercions, self-management skills needed to implement cognitive and environmental changes to reduce risk vulnerability
Intention to act
Risk reduction behavioral skills acquisition

20. Elements Critical to HIV Risk Behavior Change Continued
Cognitive problem-solving skills for change implementation and maintenance
Reinforcement of behavior change efforts
Planning strategies for implementation of action if obstacles are encountered or lapses occur
Self-reinforcement and social supports needed to sustain behavior changes over time

21. Counselor Characteristics and Attitudes
Positive regard for clients
Comfort discussing sex and drug use
Ability to form an advocacy alliance
Strong reinforcement skills
Listening skills

22. Types of interventions
Media campaigns (general vs. targeted)
Advantage:
Reach large numbers of individuals
to dispel myths about how HIV is transmitted
to fight stigma and discrimination towards at-risk populations subjected to stigma and/or PLWHAs
Disadvantage:
Need to develop new messages to avoid message burnout

23. Examples of Media Campaigns
Côte d’Ivoire, television soap operas on AIDS promoting condom use (Shapiro et al., 2003)
most appealing to viewers who engaged in risky behaviour
Unintended consequences: Promotion of the female condom in San Francisco led to its uptake among men having sex with men, despite that efficacy of the product had not been established for anal sex (Gibson et al., 1999).
Integrated campaigns such as those implemented in Switzerland (Kocher, 1996) have been the exception rather than the rule

24. Individual News Items can have a big impact on risk behavior

25. Media Campaign for MSM in San Francisco

26. Media Campaign for MSM in San Francisco

27. Media Campaign for MSM in San Francisco

28. Internet
Powerful media tool for disseminating HIV/AIDS education and prevention messages
Advantages
Low cost
Access hard to reach populations
Avoid stigma
Disadvantages
Not specific to positives
Anonymous
Technology not available to all

29. Individual-level interventions
Advantages
Target problems unique to individual
Ideally, interventions are based on behavioral theories that guide their development, implementation and evaluation.
Disadvantages
Often require highly skilled interventionists
Delivery and standardization are complex, hence interventions tend to be expensive.
Utility and sustainability in resource-poor settings may be limited.

30. Group-based interventions
Advantages
Ability to intervene with more than one person at a time
Participants can problem-solve and role-play with others
Disadvantages
Costs not always lower compared to interventions involving individual
Due to costs to screen/locate eligible participants to form groups

31. Examples
MSM small groups, mix of positive and negatives, produced significant improvements (Johnson et al., 2002)
Social Cognitive Theory based intervention to reduce sexual risks among HIV-infected individuals (Kalichman et al. 2001).
Groups: five-session group-based, safer sex intervention condition vs. social support group condition,
Participants in the risk reduction intervention condition had significantly lower rates of unprotected sex, fewer total sex acts, fewer HIV-uninfected partners and a larger percentage of sex acts involving condom use at six-month follow-up, compared to the control condition.

32. Community-level interventions
Advantages
Reach large numbers of vulnerable individuals
Potential to change the behaviour of whole groups by providing education, increasing motivation and creating new social norms.
Disadvantages
Requires detailed knowledge of community
Messages become stale unless changed

33. Example
Community Popular Opinion Leader Model (C-POL) (Kelly et al. 1992; 1997)
Developed and tested an intervention for MSM based on the ideas of Rogers (1985), which suggested that behavioural innovations often originate among a subgroup of individuals who are the community’s popular opinion leaders.
Currently being tested in many countries

34. Intervention Settings
Integration of HIV prevention counseling in Social and Health Care Settings
STD clinics (HIV-negative MSM)
HIV treatment Clinics (HIV+ MSM)
Community Outreach Settings
Bars, Bath houses

35. Why Focus on HIV-Positives?
New infections are acquired via direct or indirect contact with HIV+ persons
The U.S. Centers for Disease Control have named this a priority
HIV+ individuals are living longer with access to ARVs in many countries
Some HIV+ persons continue to have unprotected sex, share drug paraphernalia, etc.
There are fewer HIV+ than HIV-negatives, therefore prevention resources can be better targeted

36. Interventions among HIV+ populations to reduce HIV transmission
Biomedical:
Increase access and adherence to ARVs to reduce morbidity/mortality and potentially decrease HIV transmission
Treat ulcerative STDs (e.g., syphilis, chancroid, HSV-2)
Integrating therapyfor HIV and drug abuse treatment (e.g. using sublingual methadone)
Therapeutic HIV vaccines: (under development)

37. Interventions among HIV+ MSM reduce transmission
MSM Sex workers
Client- and location-oriented (e,g. truck stops)
Economic based – microcredit interventions (e.g. Zambia, Calcutta)
Structural interventions (e.g., 100% condom campaigns)
MSM Injection drug users
Drug abuse treatment programs
Needle exchange programs (NEPs)
Outreach and network-oriented interventions

40. AIDS Community Demonstration Project

41. Mpowerment Project

42. Behavioral Self-assertiveness Skills

43. Popular Opinion Leader Intervention for MSM

44. AIDS Prevention Program (Valdiserri, et al., AIDS 3, 21-26, 1989)

45. Drugs and Sex
Methamphetamine
Alcohol
Polydrug use

46. Intervention for HIV+ Methamphetamine MSM (Patterson et al
Intervention for HIV+ Methamphetamine MSM (Patterson et al., submitted)
Question: Can we change sexual risk behavior in groups of active drug users?
Sample
350 HIV+ methamphetamine-using MSM
San Diego, California
Targeted behaviors
Motivation to change (Motivational Interviewing)
Knowledge, self-efficacy, outcome expectancy, expectancies (Theory of Reasoned Action, Social Cognitive Theory)
Negotiation of safer sex
Disclosure of HIV status
NOT drug use (harm-reduction approach)
Design of study
# of sessions
Follow-up 6-, 12-, 18-month Supported by NIMH

47. HIV+ Methamphetamine Using MSM