JAIDS Journal of Acquired Immune Deficiency Syndromes 23:272–278 2000 Lippincott Williams & Wilkins, Inc., Philadelphia
Correlates of Risky Behaviors Among Young and Older Men
Having Sexual Relations With Men in Montre´al,
*Annie Dufour, *†Michel Alary, ‡Joanne Otis, ‡Roger Noe¨l, §Robert S. Remis, *Benoît Maˆsse,
†Raymond Parent, Bruno Turmel, ¶Rene´ Lavoie, #Roger LeClerc, **Jean Vincelette, and the
´ pide´miologie de l’Universite´ Laval, Centre Hospitalier Affilie´ Universitaire de Que´bec, Que´bec;†Centre de Sante´ Publique de Que´bec, Beauport, Que´bec; ‡De´partement de Sexologie, Universite´ du Que´bec a` Montre´al,Montre´al, Que´bec; §Department of Public Health Sciences, University of Toronto, Toronto, Ontario; Direction de la Sante´Publique de Montre´al-Centre, Montre´al, Que´bec; ¶Action Se´ro-Ze´ro, Montre´al, Que´bec; ¶COCQ-Sida, Montre´al, Que´bec; and**Service de Microbiologie, Centre Hospitalier de l’Universite´ de Montre´al, Campus Saint-Luc, Montre´al, Que´bec, CanadaObjective: To assess characteristics associated with 1) age and 2) recent unpro-
tected anal sex with casual partners among men having sexual relations with men(MSM) participating in the Omega Cohort, Montre´al, Que´bec, Canada. Methods: The Omega Cohort is a study of the incidence and psychosocial deter-
minants of HIV infection among MSM living in Montre´al. MSM complete a ques-tionnaire and are tested for HIV every 6 months. Results: Thirteen percent of young MSM (<30 years of age, n ס 355) and 12% of
older MSM (Ն30 years of age, n ס 455) reported recent unprotected anal sex withcasual partners. The predictors of this latter behavior were: not living with a malesexual partner, unprotected anal sex with regular partner, >5 casual partners, alcohol/drug use before anal sex, and having difficulties with procedures needed for safe sex. Among young MSM, additional predictors were: to have been living in Montre´al forless than 1 year and to have exchanged money for sex. Among older MSM, additionalpredictors were: female sexual partners, unprotected anal sex with an HIV-infectedpartner, and feeling invulnerable to AIDS. Conclusion: Young Omega participants do not have more risky behaviors than
older participants. Some predictors of recent risk behaviors with casual partners weredifferent between the two groups. Prevention programs should be adapted conse-quently. Key Words: MSM—Risk behaviors—Unprotected anal sex—HIV
In the early 1980s, several cohort studies have as-
cross-sectional studies have documented high levels of
sessed HIV incidence and associated factors among men
risky behaviors among young MSM (4–7), several cohort
having sexual relations with men (MSM) (1–3). How-
studies recruiting young MSM were implemented at the
ever, given that most men in these studies were recruited
more than 10 years ago, we have limited information on
In the United States, cohort studies among young
younger MSM. To resolve this problem and also because
MSM have observed an HIV prevalence of 18% and 9%in San Francisco (8,9), 9% in New York City (HIV in-cidence was 2/100 person-years [p-y]) (10), and 2% in
Address correspondence and reprint requests to Michel Alary,
Boston (12). According to the Vanguard Project imple-
´ pide´miologie, CHA, Pavillon St-Sacrement,
mented in Vancouver, British Columbia, Canada in 1995
1050 Chemin Ste-Foy, Que´bec, Que´bec, G1S 4L8 Canada.
Manuscript received August 15, 1999; accepted December 10, 1999.
(11), HIV incidence was 2/100 p-y at the end of 1997. CORRELATES OF RISK BEHAVIORS AMONG MEN WHO HAVE SEX WITH MEN
Moreover, 4% of young MSM from a cohort study in
Amsterdam in the Netherlands were HIV positive at en-
The age-based dichotmization at 30 years is interesting because it
creates two separate groups according to the pre- and post-AIDS pe-
In the province of Que´bec, Canada, little is known
riods. The MSM <30 years old began their sexual life, generally, after
about the HIV epidemic among MSM. The only specific
AIDS had become a major health problem. MSM or 30 years or olderbegan their sexual life before AIDS and were obliged to adjust their
study among MSM in Montre´al was carried out in 1989
sexual lifestyle to this new reality. However, the analyses were also
(14). The Omega cohort was implemented in 1996 to
performed using age as a continuous variable and a similar final re-
assess HIV incidence and associated determinants
gression model such as when using the two age groups was obtained.
In this study, a casual partner was defined as someone with whom
The objectives of this study were to assess risk behav-
the participant had sex only once (a “one-night stand”), someone he didnot intend to see again; if he had a subsequent sexual encounter with
iors associated with age (<30 versus Ն30 years old)
him, it was by chance. The variable “unprotected anal sex with casual
among MSM participating in the Omega Cohort in Mon-
partners” had a value of zero when the participant avoided unprotected
tre´al and to assess demographic, sexual, and psychoso-
anal sex with casual partners, avoided anal sex, or did not report any
cial factors associated with the practice of unprotected
casual partner. It had a value of one when condoms were not used
anal sex with casual partners during the previous 6
systematically during anal sex with casual partners. The analyses werealso performed using only MSM who avoided unprotected anal sex
with casual partners as the comparison group and essentially the samefinal logistic regression model was obtained. Moreover, because the
predictors of unprotected receptive and insertive anal sex were similar,these two sexual behaviors were considered together in the analyses. Background
The Omega Cohort project is an ongoing prospective study of HIV
incidence and associated determinants among MSM living in the Mon-
Psychosocial variables were developed using several different mod-
tre´al metropolitan area. Recruitment started in October 1996 and was
els such as the AIDS Risk Reduction Model (15), the Protection Mo-
carried out through the following strategies: a bilingual publicity cam-
tivation Theory (16), and the Theory of Planned Behavior (17,18).
paign in print general and gay media; collaboration with gay commu-
Health concerns: Participants responded to statements related to
nity organizations and medical clinics where the study was discussed
some health concerns using a 5-point Likert scale (1 ס not at all–5 ס
with eligible men; individual contacts with eligible men during gay
very often). After factor analysis was performed, four different factors
pride events; and use of posters and leaflets placed at strategic sites in
measuring health concerns were constructed: “surrounding oneself with
gay venues and clinics. The study population consists of MSM aged 16
friends,” “taking care of one’s health,” “find ways to reduce stress,”
years and older who have had sex with another man at least once in the
preceding year and are HIV negative or do not know their serostatus at
Social concerns: Participants responded to statements related to
baseline. Interviews are mainly carried out at a community organization
some social concerns using a 5-point Likert scale (1 ס not at all–5 ס
called Centre des Gais et Lesbiennes de Montre´al (Montre´al Gay and
a lot). Four factors were constructed: “loneliness”; “job, study and
Lesbian Center) but also at one of three private medical clinics and a
money problems, concerns about future and difficulty finding support
when necessary”; “heavy responsibilities”; and “difficulties in accept-ing one’s sexual orientation”. For each factor, a low score corresponds
Data Collection
to a high social concern whereas a high score corresponds to a lowsocial concern.
At the first interview, after informed written consent, participants
Attitudes toward AIDS: Participants responded to statements related
complete the questionnaire and blood is collected t test for HIV, hepa-
to their attitudes toward AIDS using a 5-point Likert scale (1 ס
titis B, and syphilis. Three weeks after the first appointment, partici-
never–5 ס very often). Five factors were constructed: “anxiety toward
pants return to receive their test results and posttest counseling. Par-
AIDS”; “feeling invulnerable to AIDS”; “avoiding thinking about
ticipants who test positive fr HIV are excluded from the study and
AIDS”; “taking AIDS as a banality” and “underestimation of the im-
referred to appropriate services. Participants return every 6 months to
complete a follow-up questionnaire and to be retested for HIV and
Attitudes toward condom use during anal sex: Participants re-
sponded to statements related to their attitudes toward condom useduring anal sex using a 5-point Likert scale (1 ס not at all–5 ס verymuch). Three factors were constructed: “sense of security,” “feeling of
Statistical Analyses
trust between partners,” and “interference with eroticism.” For each
The prevalence odds ratio (POR) was used as the measure of asso-
factor, a low score corresponds to a negative attitude toward condom
ciation. In addition, 2 for trend and Fisher’s exact test were used for
use whereas a high score corresponds to a positive attitude toward
categoric variables and the Mann-Whitney U-test for continuous vari-
ables. We performed logistic regression analysis to identify variables
Perceived behavioral control toward condom use during anal sex:
independently associated with age and with the practice of unprotected
Participants responded to statements related to their perceived behav-
anal sex with casual partners. We calculated an adjusted R with 95%
ioral control toward condom use during anal sex using a 5-point Likert
likelihood ratio–based confidence intervals (CI) for variables that re-
scale (1 ס not difficult at all–5 ס very difficult). Five factors were
mained in the final models. All analyses were performed using SAS,
constructed: “difficulties in handling safe sexual encounter”; “difficul-
version 6.12 (SAS Institute, Cary, NC, U.S.A.).
ties in getting condoms”; “difficulties in using a condom when very
JAIDS Journal of Acquired Immune Deficiency Syndromes, Vol. 23, No. 3, March 1, 2000
aroused sexually or the partner appeared safe”; “difficulties in using a
between young MSM and older MSM with regard to
condom when they did not want to disappoint the partner or were afraid
other sexual behaviors. Table 1 presents data on safe sex
of him”; and “difficulties in using a condom when they were under the
separately by type of partner, type of anal sex, and age
influence of alcohol/drugs”. For each factor, a low score corresponds toa high perceived behavioral control toward condom use during anal sex
whereas a high score corresponds to a low perceived behavioral control
Among MSM who reported only one casual partner,
5% (n ס 2 of 37) of young MSM and 4% (n ס 2 of 46)of older MSM reported unprotected anal sex during the
previous 6 months (p ס 1.00). Among MSM who re-ported between 2 and 5 casual partners, these proportions
Sociodemographic Characteristics
were 10% (n ס 11 of 111) and 6% (n ס 7 of 113),respectively (p ס .34). Among MSM who reported be-
As of the end of 1997, 810 MSM with a mean age of
tween 6 and 19 casual partners, these proportions were
33 years (median ס 32; range 16–73) completed their
28% (n ס 19 of 69) and 21% (n ס 22 of 104), respec-
baseline interview in the Omega Cohort. Most (79%)
tively (p ס 0.37) whereas for >19 casual partners, it was
were born in the province of Que´bec, were living on the
40% (n ס 14 of 35) and 24% (n ס 22 of 90), respec-
island of Montre´al (90%), were single (74%) and well
tively (p ס .12). The proportion of MSM who reported
educated (44% attended college). Half the participants
unprotected anal sex increased as the number of casual
reported a yearly income of less than $CDN 20,000
partners increased (p ס .036, 2 for trend). Table 2
(mean of $CDN 24,000 compared with $CDN 30,000
shows the variables that remained associated with age in
among the general population of men in Montre´al, ac-
cording to census data [19]), 45% worked full-time at thetime of interview, 20% studied full time, and 17% re-
Factors Associated With the Practice of
ceived welfare or unemployment insurance benefits. Unprotected Anal Sex With Casual Partners During the Previous 6 Months Risky Behaviors Associated With Age
Overall, 46 (13%) MSM <30 years of age reported
In the univariate analysis comparing young MSM
unprotected anal sex with casual partners during the pre-
(<30 years, n ס 355) with older MSM (Ն30 years, n ס
vious 6 months whereas 54 of those aged 30 years or
455) with regard to risk behaviors, fewer young MSM
more did so (12%). In a logistic regression analysis in-
reported sex in bathhouses (34% versus 52%; p Յ .001)
cluding the two age groups and in which the interactions
and having had more than 5 casual partners during the
with age were tested systematically (Table 3), variables
previous 6 months (30% versus 44%; p Յ .001) whereas
that remained associated with the practice of unprotected
a greater proportion reported anal sex with their regular
anal sex with casual partners among 810 Omega partici-
partners during the same period (68% versus 54%; p Յ
pants were: not living with a male sexual partner, had
.001). There was no statistically significant difference
unprotected anal sex with regular partners during one’s
TABLE 1. Safe sex in the previous 6 months among 810 men who have sex with men (MSM) participating in the a Includes MSM who avoided anal sex or did not have sexual partners during the previous six months. b Mann Whitney U-test comparing safe sex between young and older MSM, for each type of sexual partners (regular or
casual) and each type of anal sex (insertive or receptive). c Numbers do not total 355 because of missing values. d Numbers do not total 455 because of missing values. JAIDS Journal of Acquired Immune Deficiency Syndromes, Vol. 23, No. 3, March 1, 2000CORRELATES OF RISK BEHAVIORS AMONG MEN WHO HAVE SEX WITH MENTABLE 2. Prevalence odds ratio (POR) and 95% confidence interval (CI) of variables associated with young age (<30 years) among 810 men who have sex with men (MSM) participating in the Omega Cohort
* Adjusted for other variables listed in the table.
lifetime, had >5 casual partners during the previous 6
protected anal sex with regular partners during the pre-
months, used alcohol or drugs before anal sex with ca-
vious 6 months, sex with female partners during the pre-
sual partners, and had lower perceived behavioral control
vious year, unprotected anal sex with an HIV-infected
with regard to one’s capacity to handle safe sexual en-
partner during one’s lifetime, and feeling invulnerable to
counter. Among young MSM, additional variables asso-
ciated with the practice of unprotected anal sex with
It is interesting to note that the other variables related
casual partners were: not being a practicing Roman
to perceived behavioral control toward condom use dur-
Catholic, to have been living in Montre´al for Յ1 year,
ing anal sex (in men of all ages, difficulties in using a
and to have ever given money for sex. Among older
condom: “when very aroused sexually or the partner ap-
MSM, additional variables associated with the practice
peared safe,” “when they did not want to disappoint the
of unprotected anal sex with casual partners were: un-
partner or were afraid of him,” “when they were under
TABLE 3. Prevalence odds ratio (POR) and 95% confidence interval (CI) of variables associated (with multivariate analysis) with the practice of unprotected anal sex with casual partners during the previous sixmonths among 810 men who have sex with men (MSM) participating in the Omega Cohorta Adjusted for other variables listed in the table. NA, not applicable because there is a significant interaction between the variable and age. JAIDS Journal of Acquired Immune Deficiency Syndromes, Vol. 23, No. 3, March 1, 2000
the influence of alcohol/drugs”; in younger men: “diffi-
behaviors. This may be explained by the fact that MSM
culties in getting condoms”) were associated to unpro-
who prefer risky practices also seek many partners (20)
tected anal sex with casual partners in the univariate
or because as the number of episodes of sex increases,
analysis (data not shown). However, they were not sig-
the likelihood of having unprotected sex also increases.
nificant in the multivariate model because they were
As reported elsewhere (4,5,20,25), frequent alcohol or
highly linked together and with the variable “difficulties
drug use before anal sex with casual partners (to be under
in handling safe sexual encounter.” In addition, among
the influence of alcohol or drugs during half or more of
men aged <30 years, very young age was associated with
anal intercourse) was strongly predictive of unprotected
risky behaviors. Indeed, among a small group of 32 men
anal sex. Whether this association between alcohol or
aged <20 years, 8 (25%) reported the practice of unpro-
drug intake is causal, this behavior could be used as a
tected anal sex with casual partners compared with 12%
marker for high-risk sexual activity to target MSM who
(38 of 316) among those aged 20 to 29 (p ס .05, Fisher’s
are more likely to practice unprotected anal sex (9,27).
Prevention strategies should be reinforced in locationswhere alcohol is sold, such as bars, clubs, and other
DISCUSSION
public venues. The link between alcohol use and unsafe
Overall, risk behaviors of Omega participants during
sex should also be made more explicitly in prevention
the previous 6 months did not differ according to age.
This is somewhat surprising because most North Ameri-
MSM who reported risky sex with casual partners also
can studies have reported that risk behaviors such as
reported more frequent difficulties in using safe sex. This
unprotected anal sex were associated with younger age
is related to a low perceived behavioral control toward
condom use. These MSM may feel emotional discomfort
MSM who were living with a male sexual partner at
using condoms, communicating openly about sex or be
the time of interview were less likely to have had unpro-
less confident about the negotiation of safe sex (7,9,28).
tected anal sex with casual partners. Some of these MSM
Prevention strategies should aim to help MSM in Mon-
may be monogamous or may have decided not to have
tre´al to improve the communication skills necessary for
risky sex outside their couple relationship to avoid con-
dom use with their regular partner. Many Omega partici-
Among young MSM, having lived in Montre´al for 1
pants reported that they and their regular partners are
year or less was a determinant of unprotected anal sex
getting tested for HIV before stopping condom use.
with casual partners. MSM who just arrived in Montre´al
However, it has been reported that some MSM who are
may be less aware of the prevention messages. Some of
practicing unprotected anal sex only with their regular
these young men may be willing to have new sexual
partners have serial or concomitant regular partners (22)
experiences without regard to the risks of HIV infection.
and/or do not know their own serostatus or that of their
This situation is also reflected by the fact that very young
MSM (<20 years) also reported more risky behaviors.
MSM who had ever had unprotected anal sex with
Organizations involved in HIV prevention should in-
regular partners were much more likely to report unpro-
crease prevention messages targeting young MSM living
tected anal sex with casual partners than MSM who
outside urban centers, such as in suburbs where there are
avoided this behavior. Many previous studies have found
fewer resources for MSM. Peer counselling strategies,
such an association between past risk behaviors and pre-
such as Montre´al’s “Project 10,” should be implemented
sent risk behaviors and with relapse of risk behaviors
in bars or in schools where a gay leader who endorses
(20–22,25). However, by targeting only MSM who re-
and recommends safe sex could serve as a role model and
port current unsafe behaviors, we may miss many men at
offers support to young MSM (27,29–31).
risk for future unsafe sex (22). Organizations involved in
Young MSM who had paid for sex were also more
HIV prevention should target MSM at the beginning of
likely to have had unprotected anal sex with casual part-
their sexual lives, that is, before they acquire risky habits.
ners than MSM who avoided this behavior. These men
Prevention strategies should be implemented in schools,
may represent a group of MSM who take risks in general
particularly those located outside downtown Montre´al, to
and thus are willing to have unprotected anal sex with
increase the awareness of youth about safe sex guidelines
Among older men, unprotected anal sex with casual
As reported elsewhere (26), MSM who reported un-
partners was also associated with unprotected anal sex
protected anal sex with casual partners also reported
with an HIV-positive partner. These MSM may take
more casual partners than MSM who avoided such risk
risks in general or feel somewhat invulnerable to HIV
JAIDS Journal of Acquired Immune Deficiency Syndromes, Vol. 23, No. 3, March 1, 2000CORRELATES OF RISK BEHAVIORS AMONG MEN WHO HAVE SEX WITH MEN
because they did not become infected in spite of previous
APPENDIX
behaviors. This is supported by the fact that feeling in-
The Omega Study Group is composed of Michel Bouchard, Michel
vulnerable to AIDS was also a predictor of unprotected
Chaˆteauvert, Andre´ Desmarais, Fre´de´ric Doutrelepont, Micheline Du-
anal sex with casual partners among older Omega par-
puis, Yves Jalbert, Pierre Junod, Ralf Ju¨rgens, Roger Leblanc, E
ticipants. These men may also incorrectly underestimate
Lefebvre, Rene´ Le´gare´, Catherine Lowndes, Eva Nonn, Sylvie Savard,
their personal vulnerability to AIDS (21). Some MSM
Robert Steinman, Re´jean Thomas, and Anne Vassal.
could correctly identify practices risky for HIV transmis-
Acknowledgments: This research was supported by the Na-
sion but are unable to interpret the implications of their
tional Health Research and Development Program (NHRDP),
own risky sexual behaviors (27). It could be an indication
Health Canada (grant no. R6605-4639-AIDS). Additional fund-
that these MSM have not reached the first step required
ing was also provided by the Centre Que´be´cois de Coordination
for the adoption of safe sexual practices, which is the
sur le Sida and through the AIDS Research Network of theFonds de la Recherche en Sante´ du Que´bec (grant no.
recognition of one’s sexual behaviors as being at risk
960071.06). Dufour was recipient of a training award from
(15). Among Omega participants, at risk MSM perceived
NHRDP (grant no. 6605-4857-47A). Alary is a research
wrongly their sexual activities as relatively safe.
scholar of the Fonds de la Recherche en Sante´ du Que´bec (grant
Among older men, to have had sex with a woman
no. 970097). We would like to thank Omega participants,
during the previous year was a predictor of unprotected
Omega employees, collaborators, gay and HIV-related commu-nity organizations who have collaborated since the study’s in-
anal sex with casual partners. Some of these men may
ception and the Montre´al Regional Public Health Department
have just have begun homosexual activity and have poor
that provided hepatitis B vaccine without charge.
safe sex negotiation skills, fewer social norms, or lesssupport for safe sex (21). According to Fisher (32), “the
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In retrospect, we believe that Stefania Paolucci and Fausto Baldanti, Servizio id Virologia, IRCCS Poli-clinico San Matteo, Pavia, Italy, should be listed as coauthors of the paper entitled “Efavirenz, Nelfiniavir,and Stavudine Rescue Combination Therapy in HIV-1–Positive Patients Heavily Pretreated With Nucleo-side Analogues and Protease Inhibitors,” published in the December 15, 1999 issue (volume 22, issue 5,pages 453–460). By developing a new sequencing assay and using samples which were stored in theirlaboratory, they made possible the drug resistance analysis described in the article. In addition, theyperformed this analysis using their own research grants (IRCCS Policlinico San Matteo, Ricerca Corrente1998, and Ministero della Sanita´, Istituto Superiore di Sanita´, Il Programma Nazionale AIDS, contract no. 30B.33). Thus, we ask that the article’s authorship now be listed as: Elena Seminar, Franco Maggiolo, PaolaVillani, Fredy Suter, Angelo Pan, Mario B. Regazzi, Stefania Paolucci, Fausto Baldanti, Carmine Tinelli,and Renato Maserati. JAIDS Journal of Acquired Immune Deficiency Syndromes, Vol. 23, No. 3, March 1, 2000
The instruction on use of medicinal product METROGYL® PLUS vaginal gel International non-proprietary name: Metronidazole + Clotrimazole Composition Active ingredients: One gram of gel contains: Metronidazole 10 mg, Clotrimazole 20 mg. Auxiliary substances: methylhydroxy benzoate, propylhydroxy benzoate, disodium edetate, carbomer-940, benzyl alcohol, sodium hydroxide, puri
PRE PROCEDURE INSTRUCTIONS 1. Please arrive a half hour before your scheduled procedure time. 2. Please bring with you the following:• Your insurance card(s)• Some type of I.D. (i.e. driver’s license, work I.D., etc.)3. You will need someone to drive you home. 4. *There is no eating or drinking 8 hrs before your procedure. * • You may take you regular medications, such as pain