Non-Metro MSM Strategic Planning Meeting, January 23, 2009

1. Non-Metro MSM Strategic Planning Meeting, January 23, 2009

2. Epi Overview Jan 2007 – Dec 2009 • 1,244 HIV infections newly reported to CDPHE • 804 (64.6%) cases occurred among MSM including MSM IDU. • 129 (16.0%) of MSM cases resided outside metro Denver.

3. HIV cases among Non-Denver MSM • 15 (11.6%) had hx of IDU. • 36 (27.9%) discovered late in the course of their infection. • Median age interval: 30-34 years • Majority of cases were White-NH (68.2%), Hispanic (18.6%), or Black-NH (11.6%).

4. HIV Prevention in Colorado: A Snapshot of Men Who Have Sex with Men residing Outside of Denver Walls, N.E., Seelman. K., Ware, G. & Luerssen, S. (2010)

5. Survey Overview • Internet and hardcopy survey available in late summer, fall 2009 • Targeted MSM living outside metro Denver • 143 MSM participants

6. Participant Characteristics • Gay 93.7%; Bi 4.9%; Other 1.4% • White 89.2%; Afr Amer/Black 1.4%; Asian Pac Islander 4.3% • Hispanic ethnicity 9.9% • 49.6% had education beyond high school. • 75% resided in an urban area (>25,000 population).

7. HIV Risk Behaviors Among MSM

8. Never/Not in the past 12 months 55.0% Once or twice in past 12 months 24.3% About Once a month 9.8% About once a week 4.3% Twice a week or more 6.4% Unprotected insertive anal sex

9. Never/Not in the past 12 months 58.2% Once or twice in past 12 months 28.4% About Once a month 5.7% About once a week 5.7% Twice a week or more 2.1% Unprotected receptive anal sex

10. Never/Not in the past 12 months 75.5% Once or twice in past 12 months 18.7% About Once a month 2.9% About once a week 0.7% Twice a week or more 2.1% Unprotected sex with person of different or unknown HIV status

11. Never/Not in the past 12 months 64.0% Once or twice in past 12 months 23.0% About Once a month 10.1% About once a week 2.2% Twice a week or more 0.7% Sex while drunk or high

12. Context of Risk Behaviors

13. Wider Sociocultural & Structural Environment Individual Level Immediate Social & Structural Environment

14. Political Environment & Policy Economic Environment Classism Availability of Resources Racism Religious Ideals Sexism Cultural Processes Homophobia Media Physical Environment (including HIV)

15. Main Partner Family Teachers Friends Mentors Community Peers Sex Partners Faith Community Service Providers Character of Settings Internet Contacts Coworkers Cultural Processes

16. Economic Environment Political Environment & Policy Main Partner Family Age Gender Race/Ethnicity Sexual Orientation Socioeconomic Situation Personality Personal History Physical Status/Genetics Substance Use Mental Status Spirituality Availability of Resources Teachers Classism Friends Mentors Racism Community Peers Religious Ideals Sexism Faith Community Sex Partners Character Of Settings Homophobia Cultural Processes Service Providers Coworkers Internet Contacts Physical Environment (including HIV) Media

17. Lifetime Experiences of Psychosocial Risks

18. Victimization experiences in past 12 months

19. Never 12.6% At least once in past 12 months 26.6% 2-4 times per month 27.3% 2-3 times per week 17.5% 4 or more times per week 16.1% Alcohol consumption n=143

20. Never 51.7% Less than monthly 28.7% Monthly 9.1% Weekly 8.4% Daily or almost daily 3.1% Consumed 5 or more drinks in one sitting n=143

21. Never 66.9% Less than monthly 22.5% Monthly 5.6% Weekly 2.1% Daily or almost daily 2.8% Drank or used drugs more than meant to n=142

22. Alcohol 87.4% Downers 5.1% Marijuana 40.4% Meth 4.9% Painkillers 25.5% Crack 0.7% Poppers 19.7% Non-injected heroin 0.7% Powder cocaine 9.9% Injected heroin 0.0% Ecstasy, GHB, etc. 7.8% Alcohol and drug use in the previous 12 months

23. Never 70.0% Less than monthly 17.1% Monthly 5.0% Weekly 2.9% Daily or almost daily 5.0% Felt the need to cut down on drinking or drug use n=140

24. Experienced or witnessed traumatic events 63.1% Loss of interest in pleasurable activities for more than 2 weeks 44.3% Sad, blue, depressed for more than 2 weeks in a row 43.6% Felt frightened, anxious, or worried for more than one month 34.3% Extremely energetic, irritable, more talkative than usual 31.4% Mental Health Symptoms in past year

25. Panic attack – emotional 29.8% Took meds for depression or nerve problems 28.4% Flashbacks, nightmares about past traumatic experiences 27.0% Panic attack – physical 24.8% Depressed, sad, or blah mood most of the time for two years 17.9% Mental Health Symptoms in past year continued

26. Isolation/need for community 27.0% Anti-gay bigotry/prejudice 23.8% Contracting HIV/other STI 15.6% Need for legal protection/civil rights 14.8% Financial concerns 3.1% Health needs 11.5% Violence/Fear of violence 5.7% No concerns 3.3% Biggest concerns of gay men

27. Types of Desired Relationships

28. Barriers to Desired Relationships

29. Caught up in the heat of the moment 65.% Want to feel close to someone 30.% Don’t like condoms 30.% Get drunk or high 28.% To demonstrate, love, affection, trust 22.% Feel pressured to have sex without a condom 22.% Have trouble talking to partner about sex 13.% Uncomfortable asking partner to use a condom 13.% Afraid partner may think I don’t trust him/I’ve been unfaithful 9.% Reasons for engaging in HIV risk behaviors

30. Other reasons for engaging in HIV risk behaviors • Don’t have control over my life • Condoms are not easily available. • HIV is not important to me. • HIV meds make HIV more manageable. • HIV meds makes it harder to transmit HIV.

31. Never happens 2.1% Rarely happens 18.3% Happens Occasionally 45.8% Pretty common 25.4% Very common 7.7% Perceived frequency of HIV status disclosure n=140

32. What affects whether or not men discuss HIV status with sexual partners

33. Places for Meeting Sexual Partners

34. Use and Perceptions of HIV Prevention Services and Activities

35. HIV Testing History • 93.6% of respondents had been tested for HIV. • 51.7% had been tested in the past year. • 48.3% had never tested or tested more than a year ago.

36. Reasons Reported for Not Being Tested in Prior 12 Months (Percentages)

37. Somewhat/Very Useful Tested for HIV (n=95) 94.7% Written Information (n=123) 83.7% Info at community events (n=92) 83.7% Talking with a medical worker (n=89) 83.1% Helpfulness of HIV prevention services and activities

38. Somewhat/Very Useful Free condoms, safer sex kits (n=97) 79.4% Talked to someone from health department (n=53) 79.2% Group to learn HIV prevention skills (n=73) 78.0% HIV pamphlet/brochure (n=96) 74.0% Talked to substance use counselor (n=14) 71.4% Helpfulness of HIV prevention services and activities

39. Somewhat/Very Useful Info from school or college (n=41) 68.3% Picked up bleach kit (n=3) 66.6% Needle exchange/free needles (n=3) 66.6% Approached in a public place to talk about HIV (n=36) 61.1% Helpfulness of HIV prevention services and activities

40. Somewhat/Very Useful Talked to mental health worker about HIV (n=31) 53.8% Info on radio or TV (n=91) 52.7% On the Internet (n=91) 47.2% HIV info in prison or jail (n=8) 25.0% Helpfulness of HIV prevention services and activities

41. Healthcare clinics 57.3% Community-based organizations 51.0% Internet 46.9% Bar or nightclub 34.3% Health department 34.3% Drop-in center 26.6% High-risk behavior venues (e,g., bathhouses, parks) 25.2% Radio, television 22.4% With mental health services 16.1% Where respondents would likely use HIV prevention services (n=143)

42. In someone’s home 14.7% In my own neighborhood 11.2% On the street/other public place 10.5% With basic services 10.5% Substance use treatment centers 9.8% Places of worship 9.1% Other preferred prevention venues

43. Focus groups and interviews of MSM living outside metro Denver John Peters-Campbell

44. Growing Up • Homophobic environment affected self-esteem • Poor education about sexuality or gay sex • Taught being gay wasn’t normal • No role models; didn’t see healthy gay relationships

45. Mental health • Two bipolar; five had depression; several had history of trauma • Influences on risk behavior • Low self-esteem common

46. Sexual abuse • Three sexually abused as children; two as adults • Affected later risk behaviors and ability to establish relationships Substance use • Past use and addictions associated with high-risk behavior • No current high-risk behavior with substance abuse

47. Social Environment and gay community • Half currently live in conservative, homophobic areas • Many MSM aren’t out and those who are keep it quiet • Affects high-risk behavior, especially among NGI MSM • Few social outlets for gay men; few places to meet other gay men • Bars not good for establishing healthy relationships • Difficult to form community as gay men stay invisible • Gay community seen as divided, not supportive, non-accepting of some gay men, not political around important issues, etc. • Partners found on Internet, bars, public sex environments, baths

48. Sexual activities • Most seemed to think they were low risk for HIV; most episodes of unprotected sex occurred in the context of a steady relationship. • Sex had many meanings: pleasing physical act; best in context of love or emotional connection; unprotected anal sex more intimate; way to give pleasure and share pleasure; associated with negative experiences such as rape or being cheated on by a partner, etc. • Majority thought sex very important; a few offered that other ways of connecting were more important .

49. Sexual activities • Wide range of sexual behaviors • Sexual activities changed over time (types, frequency, safe or unsafe, etc) • Unsafe sex explained by: emotional stress; inability to negotiate safer sex; insecurity; lack of role models around sexuality; excitement of coming out; heat of the moment; willingness to accept some level of risk

50. Why men engage in high-risk sex • High risk men have misunderstandings about HIV and risks: think being a top is low risk; think their partners are low risk; are too trusting when partners say they are negative; don’t know what living with HIV is like • Poor mental health influences high-risk behavior: lack of confidence; low self-esteem; depression; loneliness; need to be accepted • High-risk behavior influenced by substance abuse, especially alcohol and meth • Condom fatigue, heat of the moment, complacency, and fatalism also factors influencing high risk behaviors.