To date, traditional behavioral interventions have done little to reduce the prevalence and transmission of HIV among African American men who have sex with men (AAMSM), a highly at risk group. Some researchers theorize that the lack of success may be because these interventions do not address contextual factors among AAMSM. Community-based participatory research (CBPR) is one approach to research with the potential to lead to effective interventions in the future. CBPR is a collaborative, mixed-methods and multidisciplinary, approach to scientific inquiry, which is conducted with, and within, the community. The current study follows the CBPR approach to engage and develop a relationship with the African American communities in the Dallas/Fort Worth Metroplex. Contextual issues were discussed in order to identify emerging themes regarding HIV health related issues among AAMSM to provide the groundwork for continued CBPR research and future interventions with AAMSM in the Dallas/Fort Worth Metroplex. To accomplish this goal, researchers began the CBPR process by conducting interviews and focus groups with a sample of approximately 62 (34 from key informant interviews, 28 from focus groups [gender balanced]) AIDS service organization leaders and workers, advocates, medical doctors and community members with first-hand knowledge of HIV health issues in the AAMSM community. Transcripts of these interviews and focus groups were analyzed to identify emerging themes at the societal (religious doctrine, African American Culture, age-related norms and stigma), community (education, religious views/policy and community norms) and individual (disclosure, personal identity, sexual behavior/risk, accessing care and communication) levels. This data was used to create a holistic narrative report that will be used to direct the community advisory board (CAB) and guide future research and interventions.

Black South African men who have sex with men (MSM) face a set of adverse circumstances, including economic hardship and stigmatization, that combine to put them at an elevated risk for hazardous substance use and HIV infection. This creates a context where substance use is normative and high-risk sexual behavior is often engaged in covertly and under the influence of intoxicating substances. The overarching objective of this dissertation was to explore determinants of hazardous drinking and HIV risk behavior among black South African MSM with a particular focus on the role of social networks. In order to achieve this, I used data drawn from the study, “HIV and Sexual Risk in African MSM in South African Townships” (R01-MH083557; PI: Sandfort, PhD). First, I conducted a systematic literature review to identify studies that used social network analysis to evaluate alcohol use among adults in order to answer the question: how have social network characteristics been shown to influence adults’ drinking behaviors, both in terms of characteristics of their network structures and characteristics of their network ties? Results of the review demonstrated that characteristics of one’s peers as well as social network structure influenced egos’ alcohol consumption in a variety of ways and across settings. Second, I described drug and alcohol use among black South African MSM and identified determinants of hazardous drinking, a highly prevalent form of alcohol use identified in the sample. The results showed that hazardous drinking was highly prevalent and multiple indicators of social vulnerability were identified as independent determinants of hazardous drinking. Third, I assessed the relationship between substance use and sexual risk behavior and explored the moderating effects of psychosocial factors. The results showed that there was not a main effect between substance use and sexual risk behavior; however, among men with high intentions to engage in safer sex, substance use was associated with increased risky sexual behavior. Overall, this dissertation increased our understanding of social networks, substance use and HIV risk behavior among black South African MSM. Our results suggest the importance of using pre-existing social networks to deliver potential interventions. The results also suggest that the most vulnerable members of this community are at increased risk of hazardous drinking. Lastly, efforts to reduce HIV risk behavior should focus on both increasing safer sex intentions and negating the impact of substance use on sexual risk behavior. Taken together, these studies provide insight for developing potential interventions, including intervention that use social network data to facilitate behavioral change, as well as undertaking further research among a critical population.

As rates of HIV transmission have accelerated in Kazakhstan over the past ten years, gay, bisexual, and other men who have sex with men (MSM) in Kazakhstan have experienced a disproportionate burden of the HIV epidemic, including a seven-fold increase in HIV prevalence. Earlier age of first sexual activity (i.e., earlier sexual debut) has been associated with long-term health trajectories among MSM at risk of HIV, however, no previous research has examined associations between earlier sexual debut and HIV-related risk factors among MSM in Kazakhstan. This dissertation tests hypotheses examining whether earlier sexual debut is associated with the following factors associated with HIV infection during adulthood among MSM in Kazakhstan: substance use, exchange sex, and experiences of anti-gay violence. Study data were obtained through a NIDA-funded clinical trial of a behavioral intervention seeking to increase the engagement of MSM who use substances in Kazakhstan in the HIV care continuum. Findings indicate that earlier sexual debut is significantly associated with increased risk of substance use, exchange sex behaviors, and experiences of anti-gay victimization among MSM in Kazakhstan. Future research should examine the contexts of MSM’s sexual debut, including whether this experience was consensual or involved other forms of adverse childhood events. Policy recommendations include increased access to sexual and gender expansive-inclusive comprehensive sexual education, and anti-discrimination policies. Clinical considerations include trauma-informed HIV prevention resources for MSM that recognizes that individuals seeking care may have complex, intersecting, and marginalized life histories, including experiences of violence across the life course.

Background: The purpose of this research was to examine how the Three Bridges Community Health Centre conceptualizes and addresses the issue of accessibility for gay men. This research explored the intersection and disjuncture of how accessibility for gay men is understood and practiced from multiple perspectives (staff and clients). It revealed perceived and real barriers and opportunities for gay men in accessing health services, and provides insight into the mechanisms Three Bridges Community Health Centre employs to provide comprehensive health care to a local population that is not easily identifiable. Methods: Case study is the central defining methodological feature of this research. This study applies both inductive and deductive approaches. The data are qualitative, derived from 14 semi-structured interviews, document analysis (25 documents with a total of 398 pages) and participant observation (approximately 33 hours). Analysis and interpretation of the data were accomplished through the various procedures and techniques associated with qualitative data analysis, including the use of a qualitative software package - NUD*IST 4.0. Results: The study revealed twelve main factors that facilitate (and obstruct) accessibility for gay men. They were developing a mission of accessibility for vulnerable populations; assessing gay men's health issues, barriers and needs; utilization of the clinic; delivery of appropriate programs and services; available providers with appropriate knowledge, attitudes and behaviour; cultural accessibility (e.g., gay-friendly environment, multiple languages); geographic accessibility (location); physical accessibility (architecture); financial accessibility (affordability); functional accessibility (convenience); awareness (marketing & publicity of services and location); and partners in accessibility (e.g., community, health authorities, government). Each section of this chapter details how Three Bridges addresses each of these elements (the strengths), the challenges (e.g., time, money and personnel) in addressing these issues, as well as suggestions for improving accessibility. These factors would also be relevant for any primary care setting about to embark upon an examination of how (well) it addresses access for gay men, and other vulnerable populations. Conclusions: Partnerships with community-based agencies and recruitment of queer staff are critical in creating cultural accessibility for queer people. Many of the challenges raised by staff need to be addressed at a policy, region-wide level. Cultural accessibility for queer people also needs to be addressed by other healthcare settings.

BACKGROUND The coverage of HIV/AIDS behavioral surveillance among MSM in China falls far short of what is necessary as the current approach is expensive and time consuming. In addition MSM are difficult to reach in China. Internet-based behavioral surveys have demonstrated a number of advantages compared with the traditional paper-pen method. Chinese MSM are avid users of the Internet. Use of the internet provides an opportunity to access this hard-to-reach population and explore their use of the Internet for sexual purposes as well as to assess risk behaviors among MSM internet users. This thesis aimed to explore the trends in risk behaviors and HIV prevalence among MSM using traditional community-based surveys and Internet surveys, and to analyze the potential of web-based behavioral surveillance among MSM by comparing the differences between Internet and community-based MSM samples, and then to provide insights for the future HIV/AIDS behavioral surveillance, epidemic estimation and prediction as well as health intervention among the Chinese MSM population. METHODS This study has three components. The first focuses on trends in HIV risk behaviors and prevalence among MSM in Harbin in northeast China, based on community-based surveys. Eligible participants were approached by peer recruiters in traditional gay venues and then interviewed by health professionals with a standard questionnaire. Urine samples were collected to screen their HIV status. The second part presents two cross-sectional, Internet-based surveys among MSM in China in 2006 and 2007. The study website was advertised on three selected gay websites using a series of banners, pop-ups and text notifications. After providing consent to the survey, eligible participants were invited to complete an online questionnaire. The third component compares the demographic characteristics and risk behaviors of two samples of Chinese MSM. Participants living in Heilongjiang Province were extracted from the 2006 online survey dataset to compare with the community sample of MSM recruited in Harbin, the capital city of Heilongjiang Province in the same year. KEY FINDINGS Community-based behavioral surveillance Among MSM in Harbin, a trend was observed towards more self-identifying as homosexual (from 58% to 80%) and more living with a male partner (from 12% to 41%) over the study period 2002-06. Although there was a trend towards a reduction in the rate of never using a condom and an increase in the rate of always using condoms during anal sex in the past six months, the prevalence of unprotected anal intercourse (UAI) still remained at high level (from 90% in 2002 to 72% in 2006). Most respondents reported having multiple male sexual partners (≥ 2) in the past six months: 86.5% in 2002, 76.0% in 2004 and 91.6% in 2006. The HIV prevalence (2.2%, 15/674) among MSM in Harbin in 2006 was higher than that in previous survey years (1.3% in 2002 and 0.94% in 2004), but no statistically significant change was detected. Internet-based behavioral surveys Gay website users in China are young and well educated. The majority (85%) have used the Internet to seek sex and meeting sexual partners online, which is one of the most common reasons for visiting gay websites. Traditional gay venues still play an important role in the sex seeking process, especially for MSM who are older and less educated. Gay website users are vulnerable to HIV/AIDS given their high prevalence of UAI (56.6%) and multiple male sexual partners (66.5%). The type of partners plays an important role in determining consistent condom use. An increase in condom use was observed among MSM having sex between commercial partners relative to those having sex with non-regular partners and regular partners. Among the Internet sample, participants who have regular partners are less likely to have sex with females, less likely to have multiple partners and less likely to engage in commercial sex behaviors than those who do not. Comparisons between Internet and community samples There are significant differences in terms of demographic characteristics and risk behaviors between the Internet and community samples of MSM. The Internet sample was significantly younger, more educated and more likely to be students and self identify as homosexual. Among those who had anal sex in the past six months, the Internet sample tended to use condoms less consistently than the community sample. However, using the total sample size as the denominator to calculate the prevalence of UAI, no significant difference between the two samples was observed (AOR 1.02, CI 0.73-1.43, p = 0.905). After adjusting for differences in demographic characteristics, the community sample was more likely to have had sex with females (AOR 2.01, CI 1.22-3.30, p = 0.006) and have had ≥ 6 male partners in the previous six months than the Internet sample (46.1% vs. 20.2%; AOR 4.88, CI 3.51-6.80, p < 0.001). The mean number of male partners for the community sample was 13.5 ± 16.8, whereas it was 6.0 ± 12.2 for the Internet sample. CONCLUSIONS Although there is a trend towards an increase in condom use among MSM in China, they are vulnerable to HIV/AIDS infection given their high prevalence of UAI and multiple sexual partners. Public sector officials at all levels need to recognize this risk for HIV transmission. Health promotion and behavioral interventions should be enforced and scaled up to meet the need for controlling HIV transmission among MSM in China. Since the Internet has become a risk environment for MSM and the online MSM population is significantly different from the traditional community MSM group, online MSM should be included as a risk group in national HIV sentinel and behavioral surveillance and the coverage of surveillance for this specific group should be expanded to better understand the health promotion needs of this community as part of an HIV/AIDS strategy in China. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1339648 / Thesis (Ph.D.) - University of Adelaide, School of Population Health and Clinical Practice, 2008

Background: The purpose of this research was to examine how the Three Bridges Community Health Centre conceptualizes and addresses the issue of accessibility for gay men. This research explored the intersection and disjuncture of how accessibility for gay men is understood and practiced from multiple perspectives (staff and clients). It revealed perceived and real barriers and opportunities for gay men in accessing health services, and provides insight into the mechanisms Three Bridges Community Health Centre employs to provide comprehensive health care to a local population that is not easily identifiable. Methods: Case study is the central defining methodological feature of this research. This study applies both inductive and deductive approaches. The data are qualitative, derived from 14 semi-structured interviews, document analysis (25 documents with a total of 398 pages) and participant observation (approximately 33 hours). Analysis and interpretation of the data were accomplished through the various procedures and techniques associated with qualitative data analysis, including the use of a qualitative software package - NUD*IST 4.0. Results: The study revealed twelve main factors that facilitate (and obstruct) accessibility for gay men. They were developing a mission of accessibility for vulnerable populations; assessing gay men's health issues, barriers and needs; utilization of the clinic; delivery of appropriate programs and services; available providers with appropriate knowledge, attitudes and behaviour; cultural accessibility (e.g., gay-friendly environment, multiple languages); geographic accessibility (location); physical accessibility (architecture); financial accessibility (affordability); functional accessibility (convenience); awareness (marketing & publicity of services and location); and partners in accessibility (e.g., community, health authorities, government). Each section of this chapter details how Three Bridges addresses each of these elements (the strengths), the challenges (e.g., time, money and personnel) in addressing these issues, as well as suggestions for improving accessibility. These factors would also be relevant for any primary care setting about to embark upon an examination of how (well) it addresses access for gay men, and other vulnerable populations. Conclusions: Partnerships with community-based agencies and recruitment of queer staff are critical in creating cultural accessibility for queer people. Many of the challenges raised by staff need to be addressed at a policy, region-wide level. Cultural accessibility for queer people also needs to be addressed by other healthcare settings. / Education, Faculty of / Educational Studies (EDST), Department of / Graduate

Renewed efforts are needed to address rapidly rising HIV incidence among sexual and gender diverse (SGD) individuals—particularly cisgender gay, bisexual, and other men (MSM) and transgender and nonbinary individuals (TSM) who have sex with men—in Kazakhstan. Intervention research is uniquely positioned to advance HIV prevention through surveying factors shaping the HIV epidemic among MSM and TSM in Kazakhstan, developing and testing the effects of an HIV prevention intervention, and assessing overall social impacts of conducting research. This research proceeded to describe strategies and lessons learned during implementation of a stepped wedge clinical trial of an intervention designed to increase the number of MSM and TSM in the HIV care continuum in Kazakhstan cities of Almaty, Shymkent, and Nur-Sultan. Thus, this three-paper dissertation aimed to: (1) identify psychosocial factors associated with lifetime, past-12-month, and past-6-month HIV testing among a sample of MSM and TSM enrolled in the clinical trial; (2) describe the process of implementing remote training of facilitators for remotely delivering the HIV preventive intervention; and (3) assess social impacts of participating in the clinical trial. MSM and TSM from the study cities were recruited into the clinical trial and administered a structured behavioral survey at their primary visit and at follow-up visits every six months thereafter. After a period of no intervention implementation (‘pre-implementation period’), the intervention was implemented sequentially every six months in the study cities. Among 304 MSM and TSM enrolled in the clinical trial during the pre-implementation period, lifetime and past-12-month HIV testing were positively associated with polydrug use and negatively with sexual transmission HIV risk, and past-6-month HIV testing was negatively associated with sexual risk. The process of developing and implementing remote training of facilitators was guided by a protocol outlining phases involving formative assessment and planning, fundamentals training, and feedback loop and technical assistance. Out of 627 MSM and TSM who completed their primary assessment during the clinical trial, 579 (92%) returned for at least one follow-up visit; of these individuals, 88% reported at least one positive social impact, while 2% reported at least one negative social impact. Findings underscore the value of expanding access to substance use treatment for HIV prevention among MSM and TSM in Kazakhstan, the viability of remote training of facilitators for remote intervention delivery, and the feasibility of conducting HIV prevention research involving MSM and TSM with many benefits and few risks.

Evidence of male sex work has a history as long as female sex work. There is century old evidence of male Sumarians and Greeks selling sex to other men. Men are today still selling sex to other men. This study showed that the elimination of sex work is practically impossible, and could only be accomplished by the gross denial of basic human rights. Male sex workers have not received the same attention from researchers as have their female counterparts. This is so despite the large numbers of male sex workers in cities all over the world who potentially contribute to the worldwide sexually transmitted infection rates. It is known that wherever indiscriminate sexual activities take place, the risk of transmission of infections are greater. The activities between the male sex worker and his client(s) determine the health problems they are exposed to. The purpose of this research was to determine what transpires between male sex workers and their client(s) in order to provide the sex workers with knowledge to better take care of their own health as well as the health of their clients. A qualitative research design was used to collect data by means of in-depth interviews and participant observation sessions. Research strategies that were also used included: description, ethnography, phenomenology, and the biographic methods of qualitative research. The research revealed that men who have sex with men (MSM) were exposed to forty-nine different preventable sexually transmitted infections including HIV/AIDS, trauma, violence, and alcohol and drug abuse. All these conditions relate to the lifestyle and activities of male sex workers. Recommendations were made regarding the removal of factors that hinder the delivery of programmes on safer sex to MSM. A booklet on safer sex for MSM was compiled by the researcher and distributed to all informants upon completion of the research. The neglected topic of male sex work was highlighted and health practitioners and other decision makers can now use the information in this thesis to make a contribution towards the better management of male sex work in South Africa in the interest of public health. / Health Studies / D.Litt et Phil. (Health Studies)

Evidence of male sex work has a history as long as female sex work. There is century old evidence of male Sumarians and Greeks selling sex to other men. Men are today still selling sex to other men. This study showed that the elimination of sex work is practically impossible, and could only be accomplished by the gross denial of basic human rights. Male sex workers have not received the same attention from researchers as have their female counterparts. This is so despite the large numbers of male sex workers in cities all over the world who potentially contribute to the worldwide sexually transmitted infection rates. It is known that wherever indiscriminate sexual activities take place, the risk of transmission of infections are greater. The activities between the male sex worker and his client(s) determine the health problems they are exposed to. The purpose of this research was to determine what transpires between male sex workers and their client(s) in order to provide the sex workers with knowledge to better take care of their own health as well as the health of their clients. A qualitative research design was used to collect data by means of in-depth interviews and participant observation sessions. Research strategies that were also used included: description, ethnography, phenomenology, and the biographic methods of qualitative research. The research revealed that men who have sex with men (MSM) were exposed to forty-nine different preventable sexually transmitted infections including HIV/AIDS, trauma, violence, and alcohol and drug abuse. All these conditions relate to the lifestyle and activities of male sex workers. Recommendations were made regarding the removal of factors that hinder the delivery of programmes on safer sex to MSM. A booklet on safer sex for MSM was compiled by the researcher and distributed to all informants upon completion of the research. The neglected topic of male sex work was highlighted and health practitioners and other decision makers can now use the information in this thesis to make a contribution towards the better management of male sex work in South Africa in the interest of public health. / Health Studies / D.Litt et Phil. (Health Studies)