RESEARCH AND PRACTICE

Drug Use, Sexual Risk, and Syndemic Production Among Men Who Have Sex With Men Who Engage in Group Sexual Encounters Sabina Hirshfield, PhD, Eric W. Schrimshaw, PhD, Ronald D. Stall, PhD, MPH, Andrew D. Margolis, MPH, Martin J. Downing Jr, PhD, and Mary Ann Chiasson, DrPH

Men who have sex with men (MSM) continue to be disproportionately affected by HIV and are more than 40 times more likely to be HIV-infected than other men.1,2 This disparity in HIV disease burden can be largely attributed to the high per-act and per-partner HIV transmission probability in receptive anal intercourse, coupled with the lack of awareness of one’s HIV serostatus.3,4 Recent attention in the literature has been given to group-sex environments that facilitate concurrent sexual partnerships, drug use, and lack of serostatus disclosure among MSM, thus representing a challenge to HIV prevention.5---10 Beyond the traditional bathhouse, group sex (i.e., sexual intercourse with 2 or more partners at the same time) is being increasingly reported as occurring in private locations and planned online, thus eluding public health involvement (e.g., HIV testing, sexually transmitted infection [STI] screening, condom distribution).5,6 Group sex among MSM is not a new phenomenon; however, the increasing availability of technology (e.g., advertisements on Web sites and smartphone apps) is likely responsible for creating easier access to group-sex events and like-minded people. This, in turn, may be increasing the potential for HIV transmission in private settings.11 Among the recent studies that have assessed characteristics of MSM who engage in group sex,6,7,9---15 little research has examined psychosocial problems experienced by these men,6 as well as specific rates of overall and polydrug use. The limited extant research, however, suggests that they are more likely to report higher rates of psychosocial problems (e.g., depression and drug abuse6,7), lack of HIV disclosure,14 lower likelihood of HIV testing,6,7,16 and sexual risk (i.e., condomless anal sex [CAS]) than MSM not reporting group sex.9 When cooccurring, these psychosocial problems suggest the presence of intertwining epidemics

Objectives. We surveyed men who have sex with men (MSM) to determine whether sexual risk behaviors, recent drug use, and other psychosocial problems differed between men who engaged in one-on-one and group sexual encounters. Methods. We conducted an Internet-based cross-sectional survey of 7158 MSM aged 18 years or older in the United States recruited from a gay-oriented sexual networking Web site in 2008. Among MSM who engaged in group sexual encounters, we compared their past-60-day sexual behaviors in one-on-one encounters and group sexual encounters. We also compared risk profiles and syndemic production between men who did and did not participate in group sex. Results. Men reporting a group-sex encounter had significantly higher polydrug use and sexual risk than did the men not reporting group sex in the past 60 days. The odds of engaging in group sex with 4 or more sexual partners significantly increased with the number of psychosocial problems, supporting evidence of syndemic production. Conclusions. We identified a particularly high-risk subgroup in the MSM population with considerable psychosocial problems that may be reached online. Research is needed on how to engage these high-risk men in combination prevention interventions. (Am J Public Health. 2015;105:1849–1858. doi:10. 2105/AJPH.2014.302346)

(i.e., syndemics),17---19 which have not been examined within the context of group sex. When syndemic conditions overlap they can have additive effects in which rises in 1 syndemic condition are hypothesized to be associated with rises in other syndemic conditions. The theory of syndemic production asserts that intertwining epidemics that exist among MSM are largely socially produced, developmental in nature, and associated with early adolescent male socialization among MSM, in addition to the added stressors associated with migration to urban areas with large gay populations.20 In this study, we defined syndemic production as intersecting psychosocial conditions (i.e., polydrug use, early onset of alcohol use, depression, and incarceration history) that exacerbate one another to produce an overall health effect more negative than any individual condition. Men who have sex with men who engage in group sex have received recent

September 2015, Vol 105, No. 9 | American Journal of Public Health

attention in the literature, with researchers calling for more attention to syndemics within this context6,7,21 and for additional research with larger samples of MSM who report sex party attendance to test additional hypotheses concerning constellations of risk behaviors among this subpopulation of men.7 A limitation of these group-sex studies is that they have examined the overall level of sexual risk of MSM who have and have not engaged in group sex, rather than examining what specific risk behaviors men engage in within the group-sex encounter. Although such studies suggest that men who engage in group sex also engage in more sexual risk, they do not address syndemic conditions among group-sex participants that contribute to this risk. Furthermore, past research has not assessed differences in sexual risk across types of sexual encounters, such as one-on-one encounters, threesomes, and sexual activity with 4 or more partners at

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RESEARCH AND PRACTICE

the same time.6,7,10,12 Therefore, to determine whether risk behaviors differ by encounter type among MSM who engaged in group sex, we compared their past-60-day sexual behaviors in one-on-one encounters and group-sex encounters. We also compared risk profiles and syndemic production between men who did and did not have group sex. We hypothesized that MSM who had more psychosocial health problems (i.e., syndemics) were more likely to engage in group sex.

METHODS We recruited participants online between April and June 2008. A gay-oriented US sexual networking Web site sent e-mails to all of its US members (n = 609 960). All e-mail recipients were considered potentially eligible (i.e., US male residents, aged 18 years and older) for study inclusion.22 Details of recruitment have been described in detail elsewhere.23 Those who clicked on the recruitment banner were routed to a consent form on a secure study Web site. The online survey took 10 to 15 minutes to complete and assessed demographic characteristics, substance use, sexual behaviors, and HIV and STI testing. No incentives were offered to study participants. A waiver of documentation of written consent was obtained, given the Internet-based research approach.

Measures Three survey sections assessed past-60-day sexual risk behaviors that took place within (1) one-on-one encounters, (2) encounters with 2 or 3 partners, or (3) encounters with 4 or more partners. All participants were asked to report up to 3 one-on-one encounters that occurred in the past 60 days. Depending on the number and type of past-60-day sexual partners that were reported, a participant could answer all 3 sections. For example, only men who reported 2 or more anal sexual partners in the past 60 days were asked whether they had multiplepartner encounters during that time period. We defined main partner as a boyfriend, life partner, spouse, or significant other. We defined city size of residence by population size (i.e., £ 49 999, 50 000---249 999, 250 000---1 million, > 1 million). We defined anal sex as insertive or receptive anal intercourse with a male partner. We

defined CAS as any insertive or receptive anal sex without a condom by either the participant or his partner. We constructed serodiscordant CAS from a set of variables including the participants’ self-reported HIV status, whether they had anal sex without a condom, whether they knew the HIV status of their partners, and whether they had insertive or receptive anal sex or both. Men who reported a past-60-day STI diagnosis selected from a list the STIs with which they had been diagnosed: chancroid, chlamydia, gonorrhea, genital herpes, human papillomavirus (genital anal warts), lymphogranuloma venereum, nongonococcal urethritis, syphilis, and hepatitis A, B, and C. Psychosocial problems comprised 4 domains: (1) past-60-day polydrug use, defined as use of 3 or more recreational drugs (e.g., marijuana; cocaine smoked, snorted, or injected; crystal methamphetamine smoked, snorted, or injected; heroin smoked, snorted, or injected; c hydroxybutyrate [GHB]; ketamine; ecstasy; nitrite inhalants [poppers]; downers; and erectile dysfunction medications); (2) current depression symptoms, assessed with the 2-item Patient Health Questionnaire Depression Scale, with scores greater than 3 indicating a positive screen24,25; (3) as arrest history among MSM has been addressed in the syndemics literature,26 we assessed incarceration history with: “Have you ever spent at least 1 night in jail or prison?”; and (4) on the basis of longitudinal research indicating that age 14 years or younger is a vulnerable period for initiation of drinking and is associated with lifetime alcohol dependence, we dichotomized age at onset of alcohol consumption as 14 years or younger versus 15 years or older.27 We dichotomized all psychosocial problems to create a count score of the number of problems experienced for the purpose of examining syndemic production.

Statistical Analysis We performed data analyses with SPSS version 20 (IBM, Somers, NY). We used v2 and logistic regression analyses to assess group differences. Men with encounters with 4 or more partners differed significantly in their risk profile from men with encounters with 2 or 3 partners and we analyzed them separately. We included bivariate associations significant at a P level of less than .05 in multivariate and multinomial logistic regression models.

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We used Stall et al.’s analytic framework18 to test for the presence of syndemic production. We calculated count scores based on the number of psychosocial problems reported, yielding scores ranging from 0 to 3 or more. We then compared the 3 groups on the number of psychosocial problems and additive effects. For post hoc analyses, we used partial v2 and logistic regression to show comparisons across the 3 groups on various characteristics.

RESULTS A total of 23 213 (3.8%) men clicked on the study recruitment e-mail hyperlink that took them to the study landing page. Of those, 9539 (41%) broke off from the landing page immediately and 13 674 (59%) consented to participate in the survey. Among men who consented, 12 109 (88%) completed most of the online survey. The participation rate (i.e., number of respondents providing usable data divided by the number of initial personal invitations requesting participation)22 was 1.9%. A detailed description of the overall sample and exclusions are described elsewhere.23,28 Briefly, we excluded 231 ineligible individuals (i.e., non---male-identified, resided outside the United States) and 311 duplicate cases. Men who dropped out of the survey and were missing data on key outcomes (n = 3114) were slightly younger (median age 38 vs 39 years; P < .001) and had significantly more lifetime male anal sexual partners (‡101 partners: 37% vs 26%; P < .001) compared with men who did not drop out. We omitted men not currently sexually active (n = 1116) or who were missing data on sexual partners (n = 179), resulting in an analytic sample of 7158. We categorized men reporting past-60-day sexual behaviors into 3 groups based on the type of sexual encounter: one-on-one encounters only, encounters with 2 or 3 partners, and encounters with 4 or more partners. In Table 1, the median age was 39 years (range 18---81 years) and most men were White. Men resided in each US state. More than half had at least a college degree and resided in urban areas. Most men self-identified as homosexual (85%); 16% self-reported as HIV-positive; 15% selfreported having a past-60-day STI diagnosis; and 27% reported more than 100 lifetime male anal sexual partners. Regarding psychosocial

American Journal of Public Health | September 2015, Vol 105, No. 9

RESEARCH AND PRACTICE

TABLE 1—Demographic Characteristics Among Men Who Have Sex With Men Reporting Sexual Encounters in the Past 60 Days: United States, 2008 Characteristic

Total Sample,a (n = 7158), No. (%)

Group x: One-on-Oneb Sex (n = 5038), No. (%)

Group y: 2–3 Partners per Encounterc (n = 1320), No. (%)

Group z: ‡ 4 Partners per Encounterd (n = 800), No. (%)

P

Post Hoc Group Comparisonse

Demographics Age, y 18–29 (Ref) 30–39

1970 (27) 1699 (24)

1468 (29) 1170 (23)

337 (26) 319 (24)

165 (21) 210 (26)

40–49

2208 (31)

1494 (30)

424 (32)

290 (36)

‡ 50

1281 (18)

906 (18)

240 (18)

135 (17) 666 (84)

x

Drug Use, Sexual Risk, and Syndemic Production Among Men Who Have Sex With Men Who Engage in Group Sexual Encounters.

We surveyed men who have sex with men (MSM) to determine whether sexual risk behaviors, recent drug use, and other psychosocial problems differed betw...
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