Psychosocial and behavioral predictors of partner notification for STD and HIV exposure among MSM Matthew J. Mimiaga, ScD, MPH, Sari L. Reisner, MA, Ashley M. Tetu, BS, Kevin Cranston, MDiv, David S. Novak, MSW, Kenneth H. Mayer, MD

Background Men who have sex with men (MSM) continue to be at increased risk for STDs and HIV Partner notification (PN) is an essential element of local and state-level STD and HIV prevention and control programs Psychosocial risk factors such as depression, PTSD, and substance use play a role in STD and HIV acquisition and transmission Few studies to date have explored the impact of psychosocial and behavioral constructs on PN activities; none have focused on predictors of PN use among MSM More likely to engage in behavior that puts them at risk for HIV and STDs

Epidemiology: HIV (MA) Percentage distribution of males diagnosed with HIV by exposure mode and year of diagnosis, Massachusetts, 1999-2005 MDPH, 2007

Epidemiology: STDs (MA) Increases in STD and HIV among Massachusetts MSM, 2001-2005 MDPH, 2007

Study Aims To assess psychosocial and behavioral factors most predictive of MSM utilizing department of public health (DPH) services to assist in PN after HIV or STD infection To secondarily assess willingness and intentions Willingness was defined as an openness to risk opportunity which was highly reactive to social circumstances and was conceived of as less effective at predicting behavior than intentions Intentions were conceived of as proximal plans or goals and the best proximal predictor of a given behavior In alignment with prior research on avoidant coping, we anticipated that more psychological distress (indicated by higher scores on psychosocial measures) would be predictive of increased willingness to use a state DPH for informing partners of STD exposure in the future, but not with increased intentions to notify

Methods Participants and Procedures March 2006 and May 2007, 189 participants completed a quantitative survey Participants were eligible if they were: 18 years of age or older Massachusetts resident MSM Recruitment included: Convenience sample (n = 63) Modified RDS sample (n = 126)

Methods Predictors of Interest Demographic, sexual behavior, and drug use questions were adapted from the CDC’s Behavioral Surveillance Survey Condom Use Self-Efficacy Scale (CUSES) Center for Epidemiologic Studies Depression Scale (CES-D) SPAN: Post traumatic stress disorder (PTSD) symptomatology SPIN: Symptoms of social anxiety The CAGE: Screening instrument for alcoholism

Methods Outcome variables Three separate dichotomous outcomes were assessed Outcome 1: Prior PN use: Participants were asked about prior use of PN—either direct self-notification or use of state DPH services—for notifying their past sexual partners about HIV or STD exposure Outcome 2: Willingness to use PN in the future: Participants were asked if they would be willing to use state DPH PN services in the future (if infected with HIV or a treatable STD) for notifying sexual partners of HIV or STD exposure

Methods Outcome 3: Intentions to use PN in the future: Participants were asked about their intention to use state DPH services in the future (if infected with HIV or an STD) for notifying their sexual partners of exposure to HIV/STD

Methods Data Analysis SAS version 9.1 We combined both recruitment groups for analyses due to their similarities with respect to outcome variables and other demographics Bivariate and multivariable logistic regression Variables that were statistically significant in the bivariate regression analyses were retained in the final multivariable logistic regression models All models controlled for age and race/ethnicity

Results: Demographics Age: 19 to 66 (mean=41.48, SD=8.47) 66% ethnic/racial minorities HIV and STD History 57% HIV-infected 54% had one or more STDs 17% syphilis, 35% gonorrhea, 12% chlamydia, and 13% other STDs Sexual Risk Taking Unprotected anal insertive (58%) and anal receptive (42%) sex with at least one non-monogamous male partner were commonly reported

Results: Demographics Prior PN 37% reported that they had never engaged in PN activities in the past Mental Health 50% had depressive symptoms; 60% positive for PTSD; 57% social anxiety symptoms Substance and Alcohol Use 42% CAGE positive 48% marijuana, 40% poppers, 20% crystal methamphetamine, and 14% ecstasy

Odds Ratio (unadjusted) Odds Ratio* (adjusted) Results Predictors of prior partner notification of STD/HIV exposure Odds Ratio (unadjusted) P value Odds Ratio* (adjusted) HIV-infection 3.87 0.001 3.68 0.007 History or one or more STD (Chlamydia, gonorrhea or syphilis) 3.54 0.002 3.64 0.006 Gonorrhea 2.73 0.02 -- Syphilis 3.45 0.03 Unprotected insertive anal sex in the 12-months prior to study enrollment 2.12 0.05 2.25 0.09 Popper use during sex in the 12-months prior to study enrollment 2.65 0.018 1.57 0.35 *Final multivariable logistic regression model controlled for age and race/ethnicity

Odds Ratio (unadjusted) Odds Ratio* (adjusted) Results Only 34% of the sample reported that they would not be willing to use state DPH PN services in the future Predictors of willingness to use state DPH PN services in the future for notifying sexual partners of HIV/STD exposure Odds Ratio (unadjusted) P value Odds Ratio* (adjusted) Social anxiety (SPIN) 2.63 0.016 2.42 0.05 Drinking problem (CAGE) 2.27 2.59 0.04 *Final multivariable logistic regression model controlled for age and race/ethnicity

Odds Ratio (unadjusted) Results Intention to use state DPH PN services in the future for notifying sexual partners of either STD (42% of the sample) or HIV (47% of the sample) exposure were robust Predictors of Intentions to use state DPH PN services in the future for notifying sexual partners of HIV/STD exposure Odds Ratio (unadjusted) P value History or one or more STD 2.30 0.03 Crystal meth use 2.41 0.06 Number of HIV infected partners 1.13

Discussion Efforts to increase PN acceptability should focus on HIV-uninfected MSM, particularly those with a history of one or more STDs Results further underscore the need for counseling as part of the notification process Although some MSM may be willing to use PN in the future, avoidant-oriented coping may contribute to preventing them from translating willingness into action (intention) Identifying psychosocial and behavioral predictors of PN provides vital information about how to increase acceptability and use of PN as a public health strategy for preventing STDs and HIV among at risk MSM