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A preliminary profile of HIV risk in a clinic-based sample of MSM in Puerto Rico: implications for sexual health promotion interventions.

Puerto Rico (PR) has one of the highest HIV incidence rates in the U.S. (45.0 per 100,000), twice that of the overall U.S. population and nearly double that of overall U.S. Hispanic population (1, 2). Although the early HIV epidemic in PR was principally driven by injection-mediated transmission, data on new infections shows the increased influence of sexual transmission in the local epidemic consistent with patterns observed in the Caribbean region as a whole-, including escalating rates among men who have sex with men (MSM) (3, 4). Substantive increases in sexually transmitted infections (STI) have also been observed among MSM in PR, notably ulcerative STI such as syphilis that are known to have a synergistic impact on HIV transmission risk (5, 6).

Despite the importance of MSM in the emerging HIV epidemic in PR most of the available epidemiological research has focused on injection risk and there is a remarkable absence of detailed epidemiological information about the MSM population. With a few notable exceptions (3, 7, 8, 9, 10, 11), there is little information available about sexual practices and partnering of MSM in PR, or contact and engagement in prevention services in this group. Similarly there is no information about STI screening and treatment among MSM, nor about HIV testing, enrollment in antiretroviral therapy, and treatment compliance. Similar limitations in both epidemiology and targeted prevention exist for MSM populations throughout the Caribbean region.

In an effort to begin to redress these gaps in the available epidemiological information about MSM in PR, the objective of this paper is to use data derived from an ongoing clinic-based study as the basis for developing a preliminary epidemiological description of behavioral risk and to identify priorities for sexual health promotion. Since half of the currently sexually active MSM in the sample are living with HIV, and with the goal of informing both primary and secondary prevention needs, the paper is structured as a comparison between these two subgroups.

Methods

In 2007, researchers from the School of Public Health at the University of PR initiated a strategic research collaboration with the clinical staff of Centro Latinoamericano de Enfermedades de Transmision Sexual (CLETS), one of the largest publicly funded centers for STI/HIV screening and treatment in the San Juan metropolitan area. The study design and data collection procedures have been detailed elsewhere (12). Briefly, the design involves random selection of subjects from the patient waiting room, a brief screening to assess eligibility, written informed consent, and participation in a face-to-face computer-assisted behavioral risk survey interview.

The interview is divided into four sections: The first section, sociodemographic characteristics, includes questions on date of birth, education, sources of income, sexual self-concept and identification, history of incarceration, military services, and history of suicide. Section 2 includes a detailed assessment of drug use, including lifetime exposure to a broad range of substances, the year that the individual first used the substance, age at first injection, use of drugs in the 90 days prior to the interview, and injection in the past 90 days. Section 3 involves an assessment of sexual risk included onset of oral, vaginal, and anal sex, sexual practices and partners in the last 90 days, experience in buying or selling sex, participation on group sex in the last year, and details of the individual last sexual contact (13). The fourth and final section includes questions about health history and utilization of health services, including the subjects' purpose for visiting the clinic, self-reported history of STI, Hepatitis B Vaccination, and circumcision status. Additionally, selected clinical data are recovered from the patient's medical files, including current STI and HIV status, HIV treatment status, and indicators of HIV disease (including CD4 and viral load tests).

Frequency distributions and summary measures are used to describe the study sample. Univariate relationships between sexual practices and participants' HIV status were assessed using chi-square tests and t tests. Median values for lifetime measures and mode values for measures of current practices (last 90 days) were used as cut-offs to compare numbers of partners and number of events and to support comparisons between HIV-negative and HIV-positive MSM. All statistical analyses were performed using SPSS version 20.

Study participation was voluntary and included written informed consent. Participants received a small interview fee ($5.00) in compensation for their time in participating in the interview. Study procedures were approved by the Human Research Subjects Protection Office of the University of Puerto Rico--Medical Sciences Campus.

Results

As of June 2011, a total of 626 male clinic patients have participated in the study. Almost a third (29.2%, n=183) have had sexual contact with another male in their lifetime and within this group, roughly two-thirds (65.6%, n = 120) have had sexual contact with a male partner within the last 90 days. Since the primary objective of this paper is to profile current sexual risk among HIV+ and HIV- MSM, the following analysis is limited to men who reported current sexual activity with a male partner within the last 90 days (n=120).

Sociodemographic characteristics

As included in Table 1, mean age of the sample is 34.2 years (SD=11.3, Range =17-63) with most (52.5%) being older than 30 years. Overall, the majority (87.5%) of MSM report having been born in PR and most (85.8%) are residing in the San Juan metropolitan area. Nearly a third (28.3%) are students. Three-quarters (79.3%) have attended college and 35.0% have at least a Bachelor's degree. About two thirds (65.0%) have at least part time employment. Nearly half (40.8%) are living alone, a third (33.3%) with their family, 13.3% with a sex partner, and 11.7% with a non-family, non-sex partner roommate.

Almost all (95.0%) described their gender as male, with four participants identifying as female and three as transgender. More than half (63.3%) describe themselves as exclusively attracted to men, 21.7% are primarily attracted to men but sometimes to women, 10.0% are equally attracted to men and women, and 5.0% are primarily or exclusively attracted to women. 75.6% describe themselves as homosexual or "Gay," and 21.8% as bisexual.

HIV-positive MSM are significantly older (mean age = 39.9 years) than HIV-negative MSM (mean age = 27.9 years; p-value = <0.001).

Lifetime and current use of tobacco, alcohol, and other drugs

As shown in Table 2, almost two-thirds (63.3%) have used tobacco in their lifetime. Among those who have ever used tobacco, two-thirds (71.9%) are current tobacco users (defined as within the last 90 days). Similarly, most (92.5%) have used alcohol in their lifetime and most of these (82.0%) are current alcohol users. Lifetime exposure to a wide range of illicit or illegal drugs is relatively high (55.0%), including cannabis (48.3%), nitrate inhalants (40.8%), cocaine (28.3%), heroin (7.6%), methamphetamine (5.8%), and one or more types of club drugs including Hydroxybutyric acid (GHB), Ketamine, and 3,4-methylenedioxy-N-methylamphetamine (MDMA) (9.2%). 15.2% have a prior history of injection drug use.

Levels of current drug use are considerably lower, including marijuana (39.7%), nitrate inhalants (38.8%), and cocaine (14.7%). However, among those MSM who have ever used an illicit drug, 40.9% have used at least one illicit drug during the last 90 days.

HIV-positive MSM have higher prevalence of lifetime illicit drug use (excluding marijuana) than HIV-negative MSM (68.3% vs. 40.4%, p=0.002), but did not significantly differed in relation to current drug use.

Selected mental health and clinical indicators

Overall, nearly a quarter (22.2%) of the MSM had one or more suicide attempts in their lifetime, and nearly half of these (45%) had multiple attempts (see Table 3). Two-thirds (61.7%) self-report diagnosis with one or more STI (excluding HIV), including Syphilis (33.3%), Gonorrhea (19.2%), Herpes (17.5%), Genital Warts (16.8%), Chlamydia (7.6%), Hepatitis B (6.7%), and Hepatitis C (5.9%). A large proportion (43.3%) has had two or more STI diagnoses. Only a third of these men (38.5%) are circumcised. Only half (52.5%) could confirm being vaccinated against Hepatitis B.

HIV-positive MSM are significantly more likely than HIV-negative MSM to have had multiple STI diagnoses (p <0.001) and a previous diagnosis of Herpes (p=0.017). Consistent with the fact that the clinic where the sample was drawn is also a primary center for HIV care, nearly half of the MSM (52.5%) are living with HIV infection. Most of these are enrolled in antiretroviral therapy treatment (77.8%). However, consistent with patterns observed in other high risk groups in the study, (14) MSM initiate care at a relatively late stage in the course of HIV disease. In a preliminary analysis of data recovered from chart review, mean CD4 among newly diagnosed HIV+ MSM was 425 cells/[mm.sup.3] (SD=209; Range: 193-806) and mean viral load was 6,947 copies/ml (SD=11,047; Range: 294-28,805), both indicative of substantial immune impairment at time of treatment enrollment.

Onset of sex

Mean age of first oral sex with a male partner was 17.4 years (SD=4.8, Range 10-41). Half the sample (49.5%) had more than 10 male oral sex partners in their lifetime (see Table 4). Mean age of first anal intercourse with a male partner was 18.9 years (SD=5.3, Range 10-41). More than a third (36.7%) had more than 10 anal sex partners in their lifetime. Almost half (47.5%) had sex with a female partner in their lifetime, with a mean age of 18.2 years (SD=5.1, Range 11-40) at first penetrative sex with a female partner. However, only 5.0% had sex with a female partner within the last 90 days (see Table 5).

HIV-positive MSM have had more male sexual partners in anal intercourse (p=0.005) and more likely had a female partner in their lifetime (p=0.063). HIV-negative MSM had an earlier onset (Mean age=15.2 years) of penetrative sex with a female partner (p=<0.001).

Current sexual practices (Last 90 days)

Overall, MSM evidence relatively large numbers of multiple, concurrent sex partners, substantial age-discordance, and limited condom use. As included in Table 5, within the last 90 days, 29.1% performed oral sex on a male partner on 9 or more occasions and 35.0% received oral sex from a male partner on 9 or more occasions during the same interval. Nearly a quarter (22.8%) engaged in more than 6 receptive anal intercourse (RAI) events within the last 90 days and a third (32.9%) engaged in more than 6 insertive anal intercourse (IAI) events in this interval. In the overall 90 days measures, no significant differences were found by HIV status.

Last sexual intercourse

At last RAI, nearly half of the exchanges (47.4%) involved a primary partner, 35.5% were with a casual (repeat) partner, and 17.1% with a new partner (See Table 6). Over half (54.0%) of the last RAI exchanges involved an age-discordant partner ([+ or -] 5 years). More than one quarter of the exchanges involved receptive penetration (27.8%) without a condom, including receipt of ejaculation without a condom (45.5%) or withdraw of the penis before ejaculation (54.4%). At last RAI, HIV-negative MSM were less likely than HIV-positive MSM to use a condom (41.7% vs. 16.3%, p=0.012) and HIV-positive MSM were more likely than HIV-negative MSM to have engaged in receptive penetration with a condom (81.4% vs. 58.3%, p = 0.025).

At last exchange involving IAI, half (50.0%) involved a primary partner, 29.4% involved a causal (repeat) partner, and roughly one fifth were with a new partner (20.6%). Half (51.5%) involved exchanges with an age discordant partners ([+ or -] 5 years). At last IAI, 40.2% of the exchanges involved insertive penetration without a condom, including insertive ejaculation without a condom (51.5%) and withdraw of the penis before ejaculation (53.7%). At last IAI, HIV-negative MSM were more likely to have engaged in insertive penetration without a condom (58.1% vs. 20.5%, p = 0.001), and HIV-positive MSM were more likely to have engaged in insertive penetration with a condom (79.5% vs. 48.8%, p = 0.004).

Discussion

The data are limited to MSM recruited from a clinic environment, notably one that may be expected to select for high risk individuals. Consequently, the findings may not be generalizable to the overall MSM population in PR. Moreover, the measures of sexual risk that were employed were intended for use in a general clinic sample and may not adequately capture the complexity of sexual practices of MSM. Similarly, the modest sample size limits the types of analysis that can be advanced at this time. For example, some differences between HIV-positive and HIV-negative MSM may be an artifact of the significant differences in age between these two groups but we are unable to assess this question in the current sample. Similarly, we note that 21.8% of the sample self-identified as bisexual. However, the current sample does not include a sufficient number of subjects to support independent analysis of this subgroup. There is a growing body of literature which shows that gender identity, sexual identity, and sexual self-concept can have important implications for sexual roles and partnering and additional research on these issues is needed. Lastly, our data is cross-sectional and consequently we cannot assess the way in which sexual risk practices of MSM in PR have changed over time, including for example, whether or not behavioral risks among MSM are increasing or decreasing.

These limitations notwithstanding, the data support the following preliminary observations about sexual risk among MSM in PR: First, even allowing for the fact that the sample was recruited in an STI clinic, MSM in this sample have an extraordinarily high rate of lifetime diagnosis with STI. Second, sexual profiles of MSM include high rates of multiple, concurrent partners (including both new and repeat partners) as well as substantial age cohort mixing. Third, MSM have relatively high rates of current sex with female partners, suggesting potential for epidemiological bridging between MSM and female partner sexual networks. Fourth, substantial levels of sexual transmission risk remain among both HIV-positive and HIV-negative MSM. For example, at last anal intercourse with a male partner, MSM had relatively high rates of unprotected anal penetration, limited condom use, and high rates of semen exchange. HIV-negative MSM have higher rates of unprotected semen exchange in both RAI and IAI compared to HIV-positive MSM. These behavioral patterns contribute to new infections and suggest the potential for a self-sustaining HIV epidemic among MSM in PR.

The data highlight the critical need for both primary and secondary prevention programming for MSM populations in PR. The following recommendations may be considered: MSM evidenced relatively high rates of oral sex as well as relatively high rates of multiple concurrent partners, a pattern that facilitates diffusion of some types of STI (consistent with the high rates of self-reported STI history evidenced in this sample). Noteworthy is the fact that two of the key STI, HPV and HBV, are preventable by vaccination. Yet MSM evidence low rates of vaccination. Targeted interventions are needed to engage and retain MSM in vaccination programs.

Interventions are needed to engage and retain MSM in preventative health services, including routinization of HIV screening. It may be expected that effective engagement in health services would contribute to earlier detection, more timely engagement in HIV treatment, and reduced risk of secondary transmission. In this context, it should be emphasized that substantial thought must be given as to how to effectively engage younger MSM cohorts, many of whom are sexually active with both men and women, and who may not accessible using identity-based service delivery models. Targeted interventions are also needed for MSM living with HIV in order to improve engagement and retention in HIV care and to reduce secondary infection in their sexual networks.

MSM have high rates of suicide, including substantial rates of multiple attempts, a fact that may reflect high levels of untreated mental health distress. High rates of anxiety, depression, and suicidality may contribute to sexual risk and may also contribute to poor health outcomes among HIV+ MSM (e.g., poor ART treatment compliance, etc.). Increased attention to mental health programming for MSM is needed.

Beyond these specific issues, there is a more fundamental need to reconsider existing approaches to HIV prevention for MSM in PR, most of which are limited to relatively generic testing and counseling programing. MSM in PR are not unique in evidencing substantial rates of behavioral risk. Similar behavioral patterns have been observed in other MSM populations in the US (15, 16), particularly among ethnic and racial minority MSM (17). In reflecting upon the persistence of behavioral risk among MSM populations, a number of recent review articles (18) have suggested that part of the problem may lie in the fact that most behavioral interventions for MSM have been conceptualized within a disease-containment model and largely absent the kind of holistic sexual health promotion programming that is increasingly recognized to be required in order to foster and sustain sexual health. For example, while increasing HIV testing is a necessary and important component to any health promotion program, in and of itself it does not advance sexual health. Yet conventional HIV testing and counseling remains the primary HIV interventions available to MSM in PR. Both behavioral and ecological interventions are needed to promote comprehensive sexual health among MSM in PR and thereby reduce underlying determinants of poor health outcomes in this group. Noteworthy in this socio-cultural context is the fact that MSM face substantial risk for stigma and discrimination, particularly in health care settings. Health services interventions are needed that will change the nature of the health services environment in order to enhance open communication between MSM and health care providers and to foster improved engagement in care. Such models may be expected to contribute to more timely screening and treatment of STIs and earlier engagement in HIV care among HIV-positive MSM. This latter goal is particularly important for reducing secondary HIV infection, a noteworthy outcome given escalating HIV incidence rates.

Acknowledgments

We wish to thank the men who agreed to participate in the study. Additionally, we thank the UPR undergraduate and graduate students who assisted in data collection. Finally, we wish to extend our gratitude to the clinical staff at Centro Latinoamericano de Enfermedades de Transmision Sexual (CLETS) for their assistance in facilitating the data collection.

References

(1.) Centers for Disease Control and Prevention. Estimated lifetime risk for diagnosis of HIV infection among Hispanic/Latino--37 States and Puerto Rico, 2007. MMWR Morb Mortal Wkly Rep 2010;59:1297-1301.

(2.) Centers for Disease Control and Prevention. Incidence and diagnoses of HIV Infection--Puerto Rico. MMWR Morb Mortal Wkly Rep 2006;58:589-591.

(3.) Colon-Lopez V, Rodriguez-Diaz CE, Ortiz AP, et al. HIV-related risk behaviors among a sample of men who have sex with men in Puerto Rico: An overview of substance use and sexual practices. PR Health Sci J 2011;30:65-68.

(4.) Puerto Rico Health Department. People diagnosed and living with HIV/ AIDS in Puerto Rico. HIV/AIDS Surveillance System. 2012.

(5.) Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999;75:3-17.

(6.) Puerto Rico Health Department. Sexually transmitted diseases reported by municipality and regions. OCASET Program for STD/HIV/AIDS Prevention: Office of STD Surveillance System. 2011.

(7.) Neumann MS, O'Donnell L, Doval AS, et al. Effectiveness of the VOICES/VOCES sexually transmitted disease/human immunodeficiency virus prevention intervention when administered by health department staff: Does it work in the "real world"? Sex Transm Dis 2011;38: 133-139.

(8.) Stein R, Green K, Bell K, et al. Provision of HIV counseling and testing services at five community-based organizations among young men of color who have sex with men. AIDS Behav 2011;15:743-750.

(9.) Toro-Alfonso J, Varas-Diaz N, Andujar-Bello I. Evaluation of an HIV/ AIDS prevention intervention targeting Latino gay men and men who have sex with men in Puerto Rico. AIDS Educ Prev 2002;14:445-456.

(10.) Finlinson HA, Colon HM, Robles RR, et al. Sexual identity formation and AIDS prevention: An exploratory study of non-gay-identified Puerto Rican MSM from working class neighborhoods. AIDS Behav 2006;10: 531-539.

(11.) Finlinson HA, Colon HM, Robles RR, et al. An exploratory study of Puerto Rican MSM drug users: The childhood and early teen years of gay males and transsexual female. Youth Soc 2008;39:362-384.

(12.) Clatts MC, Rodriguez-Diaz CE, Garcia H, et al. The use of STI clinics in Puerto Rico as strategic venues for accessing high risk populations for targeted HIV research and intervention. PR Health Sci J 2011;30:101-107.

(13.) McMahon JM, Tortu S, Pouget ER, et al. Contextual determinants of condom use among female sex exchangers in East Marlem, NYC: An event analysis. AIDS Behav 2006;10:731-741.

(14.) Clatts MC, Rodriguez-Diaz CE, Garcia H, et al. Preliminary evidence of significant gaps in continuity of HIV care among excarcerated populations in Puerto Rico. J Int Assoc Physicians AIDS Care 2011;10:339-341.

(15.) Clatts MC, Goldsamt LA, Yi, H. Drug and sexual risk in four men who have sex with men populations: Evidence for sustained HIV epidemic in New York City. J Urban Health 2005;82(Suppl 1):i9-i17.

(16.) Lansky A, Brooks JT, DiNenno E, et al. Epidemiology of HIV in the United States. J Acquir Immune Defic Syndr 2010;55:S64-S68.

(17.) Centers for Disease Control and Prevention. Prevalence and awareness of HIV infection among men who have sex with men--21 cities, United States, 2008. MMWR Morb Mortal Wkly Rep 2010;59:1201-1207.

(18.) Coleman, E. What is Sexual Health? Articulating a sexual health approach to HIV prevention for men who have sex with men. AIDS Behav 2011;15(Suppl 1):S18-24.

Michael C. Clatts, PhD *; Carlos E. Rodriguez-Diaz, PhD, MPHE *; Hermes Garcia, MD, MPH ([dagger]); Ricardo L. Vargas-Molina, MA *; Gerardo G. Jovet-Toledo, BS *; Lloyd Goldsamt, PhD ([double dagger])

* Graduate School of Public Health, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico; ([dagger]) Centro Latinoamericano de Enfermedades de Transmision Sexual (CLETS), Puerto Rico Department of Health, San Juan, Puerto Rico; ([double dagger]) National Development and Research Institutes, Inc. New York, New York, United States of America

The authors have no conflict of interest to disclose.

Address correspondence to: Michael C. Clatts, PhD, PO Box 365067, San Juan, PR 00936-5067. Email: michael.clatts@upr.edu
Table 1. Sociodemographic characteristics of a sample of men
Who Have Sex with Men (MSM) in Puerto Rico by HIV serostatus
(n=120)

Characteristics       All MSM       HIV+ MSM     HIV- MSM
                      n (%)         n (%)        n (%)        p-value

Age (mean, SD)        34.2 (11.3)   39.9 (9.6)   27.9 (9.6)   <0.001 *
Education
  <High School        26 (21.7)     12 (19.0)    14 (24.6)    0.464
  >High School        94 (78.3)     51 (81.0)    43 (75.4)
Employment
  At least            78 (65.0)     42 (66.7)    36 (63.2)    0.687
    part-time
  Unemployed
  (Excluding          20 (16.7)     14 (22.2)    6 (10.5)     0.086 **
    students)
Annual Incomme                                                 0.064 **
None                  20 (16.8)     9 (14.3)     11 (19.6)
  < $20,000           68 (57.1)     32 (50.8)    36 (64.3)
  [greater than       31 (26.1)     22 (34.9)    9 (16.1)
    or equal to]
    $20,000
Area of residence
  San Juan
  Metropolitan Area   103 (85.8)    50 (79.4)    53 (93.0)    0.033 *
  Non-San Juan
  Metropolitan Area   17 (14.2)     13 (20.6)    4 (7.0)
Sexual identity
  Homosexual or gay   90 (75.6)     48 (77.4)    42 (73.7)    0.635

* Significant at p<0.05; ** Significant at p<0.10

Table 2. Lifetime and current (Last 90 days) tobacco, alcohol, and
illicit drug use among a sample of MSM in Puerto Rico by HIV
serostatus (n=120)

Practices                  All MSM     HIV+ MSM    HIV- MSM    p-value
                           n (%)       n (%)       n (%)
Drug use
Lifetime use of
tobacco, alcohol
and other illicit/
illegal drugs
  Tobacco                  57 (63.3)   33 (63.5)   24 (63.2)   0.976
  Alcohol                  111 (92.5)  58 (92.1)   53 (93.0)   0.849
At least one
Illicit/Illegal drug
(excluding
marijuana)                 66 (55.0)   43 (68.3)   23 (40.4)   0.002 *
Injecting drug use         10 (15.2)   6 (14.0)    4 (17.4)    0.711
Current use of tobacco,
alcohol and other
illicit/illegal drugs
(<90 days)
  Tobacco                  41 (71.9)   24 (72.7)   17 (70.8)   0.875
  Alcohol                  91 (82.0)   45 (77.6)   46 (86.8)   0.207
  Used one or more least
  one Illicit/Illegal
  drug (excluding
  marijuana)               27 (40.9)   16 (37.2)   11 (47.8)   0.403
  Injected illicit drug    2 (20.0)    2 (33.3)    0 (-)       --

* Significant at p<0.05

Table 3. Self-reported mental health and clinical indicators
among a sample of MSM in Puerto Rico by HIV serostatus (n=120)

Indicators           All MSM       HIV+ MSM      HIV- MSM     p-value
                     n (%)         n (%)         n (%)

History of suicide
attempts
  At least one
  suicide
  attempt           20 (22.2)     13 (25.0)     7 (18.4)      0.458
  Age at first
  suicide
  attempt
  (mean, SD)        28.8 (12.4)   30.3 (12.6)   25.9 (12.6)   0.461
  Multiple
  suicide
  attempts          9 (45.0)      7 (53.8)      2 (28.6)      0.287
History of STI
  Syphilis          40 (33.3)     24 (38.1)     16 (28.1)     0.245
  Gonorrhea         23 (19.2)     12 (19.0)     11 (19.3)     0.972
  Herpes            21 (17.5)     16 (25.4)     5 (8.8)       0.017 *
  Warts             20 (16.8)     12 (19.0)     8 (14.3)      0.488
  Chlamydia         9 (7.6)       4 (6.3)       5 (8.9)       0.597
  HBV               8 (6.7)       6 (9.5)       2 (3.6)       0.213
  HCV               7 (5.9)       5 (7.9)       2 (3.6)       0.325
  At least one
  STI (not HIV)     74 (61.7)     42 (66.7)     32 (56.1)     0.236
  Two or more STI   52 (43.3)     42 (66.7)     10 (17.5)     <0.001 *
Circumcised         45 (38.5)     28 (46.7)     17 (29.8)     0.061 **
HBV vaccination     63 (52.5)     28 (44.4)     35 (61.4)     0.063 **
HIV treatment       63 (52.5)     49 (77.8)     --            --

* Significant at p<0.05
** Significant at p<0.10

Table 4. Onset and cumulative sexual risk among a sample of MSM
in Puerto Rico by HIV serostatus (n=120)

                          All MSM           HIV+ MSM
                          n (%)             n (%)
Lifetime Sex with Men
  Age at first oral sex   Mean = 17.4,      17.8 (4.9)
                          SD = 4.8,
                          Range = [10,41]
Number of oral sex        More than         35 (60.3)
partners                  10 Partners:
                          55 (49.5)
Age at first anal sex     Mean = 18.9,      19.1 (5.2)
                          SD = 5.3,
                          Range = [10,41]
Number of anal sex        More than         28 (49.1)
partners                  10 Partners:
Lifetime Sex with         40 (36.7)
Women
  Oral, vaginal or        57 (47.5)         35 (55.6)
  anal sex
  Age at first            Mean=18.2,        19.9 (5.4)
  penetrative sex         SD=5.0,
                          Range = [11,40]

                          HIV- MSM     p-value
                          n (%)
Lifetime Sex with Men
  Age at first oral sex   17.0 (4.8)   0.428

Number of oral sex        20 (37.7)    0.017 *
partners

Age at first anal sex     18.7 (5.5)   0.671

Number of anal sex        12 (23.1)    0.005 *
partners
Lifetime Sex with
Women
  Oral, vaginal or        22 (38.6)    0.063 **
  anal sex
  Age at first            15.2 (2.0)   <0.001 *
  penetrative sex

* Significant at p<0.05; "Significant at p<0.10

Table 5. Current (Last 90 days) sexual practices and partners
among a sample of MSM in Puerto Rico by HIV serostatus (n=120)

                        All MSM       HIV+ MSM    HIV- MSM    p-value
                        n (%)         n (%)       n (%)
Oral Sex
  Frequency of          More than 9
    performing oral     Events: 32
    sex                 (29.1)        19 (33.3)   13 (24.5)   0.310
  Frequency of          More than 9
    receiving oral      Events: 36
    sex                 (35.0)        17 (31.5)   19 (38.8)   0.438
Anal Intercourse
  Frequency of anal     More than 8
  intercourse           Events: 26
                        (24.8)        14 (27.5)   12 (22.2)   0.535
  Frequency of RAI      More than 6
                        Events: 18
                        (22.8)        10 (23.3)   8 (22.2)    0.913
  Numbers of partners   More than 2
  in RAI                Events: 17
                        (22.4)        11 (25.6)   6 (18.2)    0.443
  Frequency of IAI      More than 6
                        Events: 27
                        (32.9)        14 (35.9)   13 (30.2)   0.586
  Numbers of partners   More than 2
  in IAI                Events: 15
                        (18.5)        8 (21.1)    7 (16.3)    0.581
  Oral, vaginal or
  anal sex with
  female partner        6(5.0)        2 (3.2)     4 (7.0)     0.347

* Significant at p<0.05; ** Significant at p<0.10

Table 6. Sexual practices at last sexual encounter among a sample
of MSM in Puerto Rico by HIV serostatus (n=120)

                     All MSM     HIV+ MSM    HIV- MSM    p-value
                     n (%)       n (%)       n (%)
Last RAI             79 (65.8)   43 (68.3)   36 (63.2)   0.557
Repeat primary
sex partner          36 (47.4)   16 (38.1)   20 (58.8)   0.114
Repeat casual
partner              27 (35.5)   16 (38.1)   11 (32.4)   0.114
New partner          13 (17.1)   10 (23.8)   3 (8.8)     0.114
Age discordance
([+ or -] 5 years)   41 (54.0)   25 (59.5)   16 (47.1)   0.278
Receptive
penetration
without condom       22 (27.8)   7 (16.3)    15 (41.7)   0.012
Receipt of
ejaculation
without condom       10 (45.5)   2 (28.6)    8 (53.3)    0.286
Receptive
penetration
with condom          56 (70.9)   35 (81.4)   21 (58.3)   0.025 *
Receipt of
ejaculation
with condom          30 (53.6)   15 (42.9)   15 (71.4)   0.038 *
Partner withdrew
before ejaculation   43 (54.4)   25 (58.1)   18 (50.0)   0.469
Last IAI             82 (68.3)   39 (61.9)   43 (75.4)   0.111
Repeat primary
sex partner          34 (50.0)   14 (43.8)   20 (55.6)   0.598
Repeat casual
partner              20 (29.4)   11 (34.4)   9 (25.0)    0.598
New partner          14 (20.6)   7 (21.8)    7 (19.4)    0.598
Age discordance
([+ or -] 5 years)   35 (51.5)   20 (62.5)   15 (41.7)   0.086 **
Insertive
penetration
without a condom     33 (40.2)   8 (20.5)    25 (58.1)   0.001 *
Insertive
ejaculation
without a condom     17 (51.5)   3 (37.5)    14 (56.0)   0.367
Insertive
penetration
with a condom        52 (63.4)   31 (79.5)   21 (48.8)   0.004 *
Insertive
ejaculation
with a condom        25 (48.1)   15 (48.4)   10 (47.6)   0.957
Withdraw before
ejaculation          44 (53.7)   21 (53.8)   23 (53.5)   0.974

* Significant at p<0.05; ** Significant at p<0.10
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Title Annotation:FULL-LENGTH ARTICLE
Author:Clatts, Michael C.; Rodriguez-Diaz, Carlos E.; Garcia, Hermes; Vargas-Molina, Ricardo L.; Jovet-Tole
Publication:Puerto Rico Health Sciences Journal
Date:Sep 1, 2012
Words:5175
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