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Sexually Transmitted Diseases:
doi: 10.1097/OLQ.0b013e31820d5a77
Original Study

HIV/AIDS Complacency and HIV Infection Among Young Men Who Have Sex With Men, and the Race-Specific Influence of Underlying HAART Beliefs

MacKellar, Duncan A. DrPH, MA, MPH*; Hou, Su-I DrPH†; Whalen, Christopher C. MD†; Samuelsen, Karen PhD‡; Valleroy, Linda A. PhD*; Secura, Gina M. PhD, MPH*; Behel, Stephanie MPH*; Bingham, Trista PhD, MPH§; Celentano, David D. ScD¶; Koblin, Beryl A. PhD∥; LaLota, Marlene MPH**; Shehan, Douglas BA††; Thiede, Hanne DVM, MPH‡‡; Torian, Lucia V. PhD§§; for the Young Men's Survey Study Group

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Author Information

From the *Division of HIV/AIDS Prevention-Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA; †College of Public Health, University of Georgia, Athens, GA; ‡Department of Educational Psychology and Instructional Technology, University of Georgia, Athens, GA; §Los Angeles County Department of Health Services, Los Angeles, CA; ¶Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD; ∥The New York Blood Center, New York City, NY; **Florida Department of Health, Tallahassee, FL; ††University of Texas Southwestern Medical Center at Dallas, TX; ‡‡Public Health-Seattle & King County, Seattle, WA; and §§New York City Department of Health, New York City, NY

The authors are grateful to the young men who volunteered for this research project and to the dedicated staff who contributed to its success. They are especially grateful to the YMS Phase II coordinators: John Hylton and Karen Yen (Baltimore); Santiago Pedraza (Dallas); Denise Fearman-Johnson and Bobby Gatson (Los Angeles); David Forest and Henry Artiguez (Miami); Vincent Guilin (New York City); and Tom Perdue (Seattle).

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Correspondence: Duncan A. MacKellar, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS E-04, Atlanta, GA 30333. E-mail: dym4@cdc.gov.

Received for publication September 16, 2010, and accepted December 27, 2010.

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Abstract

Background: Among men who have sex with men (MSM) in the United States, the influence of HIV/AIDS complacency and beliefs about the efficacy of highly active antiretroviral therapy (HAART) on HIV-infection risk is unknown.

Methods: We analyzed data from a 1998–2000 cross-sectional 6-city survey of 1575 MSM aged 23 to 29 years who had never tested for HIV or had last tested HIV-negative to assess these plausible influences overall and by race/ethnicity.

Findings: Measured as strong endorsement for reduced HIV/AIDS concern due to HAART, HIV/AIDS complacency was associated with reporting ≥10 male sex partners (odds ratio [OR], 2.94; 95% confidence interval [CI], 2.12–4.07), unprotected anal intercourse with an HIV-positive or HIV-unknown-status male partner (OR, 2.06; 95% CI, 1.51–2.81), and testing HIV-positive (adjusted OR [AOR], 2.35; 95% CI, 1.38–3.98). Strong endorsement of the belief that HAART mitigates HIV/AIDS severity was more prevalent among black (21.8%) and Hispanic (21.3%) than white (9.6%) MSM (P < 0.001), and was more strongly associated with testing HIV-positive among black (AOR, 4.65; 95% CI, 1.97–10.99) and Hispanic (AOR, 4.12; 95% CI, 1.58–10.70) than white (AOR, 1.62; 95% CI, 0.64–4.11) MSM.

Conclusions: Young MSM who are complacent about HIV/AIDS because of HAART may be more likely to engage in risk behavior and acquire HIV. Programs that target HIV/AIDS complacency as a means to reduce HIV incidence among young MSM should consider that both the prevalence of strong HAART-efficacy beliefs and the effects of these beliefs on HIV-infection risk might differ considerably by race/ethnicity.

Since the early 1990s, the HIV epidemic has increasingly affected black and Hispanic men who have sex with men (MSM), particularly those who are young.1–5 MSM aged 13 to 29 years accounted for 38% of the estimated 30,000 new infections among MSM in 2006, and 52%, 43%, and 25% of the estimated new infections among black, Hispanic, and white MSM, respectively.6 Although subject to considerable research, few explanations for racial/ethnic HIV disparities among young MSM have been identified.7,8 One potential explanation that has not been adequately investigated is HIV/AIDS complacency attributed to beliefs about highly active antiretroviral therapy (HAART).

When used appropriately by persons with HIV, HAART substantially prolongs quality of life and reduces, but does not eliminate, sexual HIV transmission to uninfected partners.9–13 As hypothesized by several health-behavior theories, strong beliefs that HAART mitigates HIV/AIDS severity or susceptibility to HIV may increase HIV/AIDS complacency and reduce motivation to enact preventive behaviors.14,15 In support of this hypothesis, many studies suggest that MSM who hold optimistic beliefs or attitudes about HAART are more likely to engage in HIV risk behaviors.16–38 Interestingly, in 3 of these studies, MSM of black or Hispanic race/ethnicity were more likely than white MSM to hold optimistic HAART beliefs, suggesting the possibility that effects on HIV-infection risk might be different by race/ethnicity.24,25,33

With the exception of one study conducted in the Netherlands,38 however, none of these studies evaluated HIV infection as the outcome of interest.16–37 Thus, HIV-infection risk attributed to HAART-related complacency and efficacy beliefs is unknown among MSM in the United States overall, and by race/ethnicity. Evaluating the potential influence of HAART-related complacency and efficacy beliefs on HIV-infection risk, rather than behavior, is needed because behavioral measures can be inadequate proxies for risks in acquiring sexually transmitted diseases, including HIV.7,8,39,40 This need is paramount for studies of MSM because typical risk-behavior measures fail to explain considerable racial/ethnic HIV-infection disparities.8

To help address this need, this report uses data from the second phase of CDC's Young Men's Survey (YMS) to evaluate among young MSM whether acquiring HIV is associated with HIV/AIDS complacency and beliefs about the efficacy of HAART to mitigate HIV/AIDS severity and susceptibility to HIV, and whether the magnitude of these associations are similar among young MSM who are black, Hispanic, and white. In this article, “HAART” is used rather than “ART” (antiretroviral therapy) because at the time of our survey combination treatments were available that did not include protease inhibitors and that were not highly active.

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METHODS

YMS was a cross-sectional, venue-based survey of young MSM conducted in 2 phases in select metropolitan areas of the United States. The purpose of YMS was to evaluate the prevalence of HIV infection and associated risk behaviors among diverse samples of young men who attend MSM-identified venues. In Phase I (1994–1998), MSM aged 15 to 22 years were recruited in 7 metropolitan areas. In Phase II (1998–2000), MSM aged 23 to 29 years were recruited in 6 of the Phase I cities: Baltimore, Dallas, Los Angeles, Miami, NY, and Seattle. This report uses data from Phase II participants who were asked about their awareness, beliefs, and attitudes about HAART.

YMS methods have been described in detail.41 In brief, formative research was conducted to construct monthly sampling frames of the days, times, and venues attended by young MSM. From these sampling frames, 12 or more venues and their associated day/time periods were selected randomly and scheduled as recruitment events each month. During recruitment events, men were approached consecutively to assess their eligibility. Men aged 23 to 29 years who resided in a locally defined area and who had not previously participated in the second phase of YMS were eligible and encouraged to participate. Participants had blood drawn for HIV testing, and were interviewed using a standard questionnaire, provided counseling and referral for care, and reimbursed $50 for their time. Specimens were tested at local laboratories with FDA-approved assays. The YMS protocol was approved by institutional review boards at CDC, and at state and local institutions that conducted the survey.

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Measures

A standardized questionnaire was used in all cities to measure sociodemographic characteristics, sexual behaviors, perceived risk for HIV infection, and HAART-efficacy belief and HIV/AIDS complacency constructs. Sexual risk behaviors were assessed since sexual debut (lifetime) and in the 6 months preceding the survey interview (recent). Perceived HIV risk was measured with the following item: “Using this card, choose a number that best describes how likely it is that you are HIV-positive today.” The card included 6 possible responses (1, very unlikely; 2, unlikely; 3, somewhat likely; 4, likely; 5, very likely; 6, HIV-positive). Response values 1 to 2 were combined into one category labeled “low” and values 3 to 6 were combined into one category labeled “moderate-high.” Responses were dichotomized into these categories because of observed homogeneity of HIV-infection rates in response categories 1 and 2, and because very few MSM reported values ≥4. In this analysis, all participants except one reported values ≤5 for this risk-perception question. The one participant who perceived being “HIV-positive” also reported that his last HIV test result was negative, and was thus also included in the analysis.

Based in part from previous research, 11 items were used to measure the following 3 constructs: belief that HAART mitigates HIV susceptibility, belief that HAART mitigates HIV/AIDS severity, and reduced HIV/AIDS concern because of HAART (Appendix).28,32 Responses were measured on a 5-point scale ranging from (1) strongly disagree to (5) strongly agree. The 11 items were administered to MSM who had not previously tested positive for HIV and who answered yes to the following question: “Have you heard about the new combination-drug treatments for HIV and AIDS that include protease inhibitors? By combination-drug treatment, I mean a protease inhibitor taken with at least one other anti-HIV drug to treat HIV infection.” We defined HAART conditional on awareness of protease inhibitors because (1) of the availability of combination therapies at the time of our survey that did not include protease inhibitors and that were not “highly active,” and (2) the potential for bias in measuring beliefs and attitudes of men misclassified as HAART aware based on that availability.

Confirmatory factor analysis and Cronbach's coefficient α were used to assess the validity and reliability of the 3 posited constructs. For confirmatory factor analysis, all items were constrained to load on only hypothesized constructs (factors), error variances were not allowed to correlate, and all factors were free to correlate.42 Based on a sample size of 1575 MSM, the 3-factor model demonstrated adequate fit (root mean square residual, 0.045; root mean square error of approximation, 0.054 [90% confidence interval {CI}, 0.047–0.060]; comparative fit index, 0.964)42; all factor loadings were statistically significant with t values ≥21.4; and HAART belief and complacency constructs explained 34.6% to 61.1% of observed variance of respective items. Cronbach's coefficient α was 0.704 for the belief that HAART mitigates HIV/AIDS severity (items 1–4), 0.799 for the belief that HAART mitigates HIV susceptibility (items 5–7), and 0.804 for reduced HIV/AIDS concern because of HAART (items 8–11).

To evaluate associations with risk behavior and testing HIV-positive, responses to items corresponding to each construct were summed into a composite score. For each construct, composite scores were dichotomized into 2 endorsement levels labeled “weak-moderate” and “strong.” Strong endorsement represented approximately the 10th decile of the composite score response distribution for each construct. Composite scores were dichotomized to facilitate interpretation, and because behavioral and infection outcomes were similar within each category.

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Univariate and Bivariate Analyses

All data analyses were conducted using SAS version 9.1 (SAS Institute Inc, Cary, NC). The univariate distributions of recruitment outcomes, sociodemographic characteristics, and sexual behaviors were first evaluated overall and by survey city. Next, we evaluated bivariate associations between strong endorsement of each of the 3 HAART constructs and age group, race/ethnicity, testing HIV-positive, and the following 2 recent risk behaviors: reporting ≥10 male oral or anal sex partners and engaging in unprotected anal intercourse (UAI) with HIV-positive or unknown-status male partners. These behavioral outcomes were chosen because they had the highest adjusted hazards for incident HIV infection in a large contemporary cohort of MSM.43 Odds ratios (OR) and 95% CIs are reported for statistically significant associations with demographic variables, and for behavioral and HIV-infection outcomes regardless of statistical significance.

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Multivariate Analyses

Logistic regression analyses were next performed to assess independent associations between testing HIV-positive and the 3 HAART constructs. The effect of these constructs on HIV-infection risk is presumed to be mediated, at least partially, through behaviors that were not measured in our survey (e.g., partner-selection practices and partner-specific sexual behaviors). The following variables known to be associated with HIV infection among young MSM were also included in the full logistic regression model: YMS city, age group, race/ethnicity, education, previous incarceration, interval since last HIV-negative test result, ≥10 male oral or anal sex partners and engaging in UAI with HIV-positive or unknown-status male partners in the prior 6 months, and 2 behavioral proxies: ever diagnosed with a sexually transmitted disease (STD) and perceived risk for HIV.2,43,44

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Assessment of Moderation and Derivation of the Final Model

To assess potential race-specific effects, the full model included 2-way interaction terms between the HAART constructs and race/ethnicity. The fully adjusted model was then reduced by the manual stepwise elimination of interaction terms with P > 0.15 and all other variables with P > 0.05. A higher elimination threshold for interaction terms was used, given the lower power to detect statistically significant interactions.45 In order of highest to lowest P values, stepwise elimination proceeded first with interaction terms and then with variables not included in those interaction terms that were retained for the final model. Variables were only excluded from models after meaningful confounding of retained covariates was ruled out.

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RESULTS

Recruitment

At 181 venues in the 6 cities, staff enrolled 3137 (57.6%) men of 5443 identified as eligible. Proportionally more men aged 23 to 26 years enrolled compared with men 27 to 29 years (58.9% vs. 54.7%; P < 0.01). Statistically significant differences were not observed in the proportion of men enrolled by race/ethnicity. Of the 3137 participants, the following were removed from analyses: 53 (1.7%) duplicates; 13 (0.4%) who gave contradictory responses or who were impaired by alcohol or drugs; 11 (0.4%) who reported never having sex; 121 (3.9%) who reported never having sex with men; 199 (6.3%) who reported previously testing HIV-positive (n = 104), indeterminate (n = 5), or who either did not know their last HIV-test result (n = 89), or who refused to report their last result (n = 1); and 8 (0.3%) who had missing information on awareness of HAART.

Of the remaining 2732 MSM who had never tested or last tested negative for HIV, 1685 (61.7%) reported being aware of protease-inhibitor-based HAART. Awareness of HAART was associated with older age (23–25 vs. 26–29 years of age: 56.3% vs. 66.9%; P < 0.0001); being white/non-Hispanic (black, 46.7%; Hispanic, 47.4%; white, 73.7%; other race/ethnicity, 60.8%; P < 0.0001); and having more education (high school vs. at least some technical school or college: 41.3% vs. 67.4%; P < 0.0001). After controlling for age group and race/ethnicity, awareness of HAART was not associated with testing HIV-positive (adjusted OR 0.90; 95% CI, 0.68–1.20).

Of the 1685 MSM who reported being aware of HAART, the following were removed from analyses: 20 (1.2%) who were not tested for HIV at the time of their interview and 90 (5.3%) who either reported not knowing, had missing responses, or refused to respond to one or more construct items (n = 88) or to the measure on perceived risk for HIV (n = 2). All subsequent analyses were restricted to the 1575 HIV-tested MSM who (1) reported being aware of HAART, (2) had either never tested for HIV or last tested negative for HIV, and (3) had analyzable responses to risk perception and HAART attitude and belief measures.

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Participant Characteristics

Of the 1575 MSM, 876 (55.0%) were 26 to 29 years of age; and 100 (6.3%) were Asian, 197 (12.5%) black, 286 (18.2%) Hispanic, 935 (59.4%) white, and 57 (3.6%) were of other race/ethnicity. Most MSM reported receiving at least some technical or college education, being part- or full-time employed, and having previously tested for HIV. Although few MSM perceived themselves at risk for HIV, many reported having ≥20 lifetime and ≥10 recent male oral or anal sex partners, ever being diagnosed with an STD, and recently engaging in UAI with an HIV-positive or HIV-unknown-status male partner; 120 (7.6%) tested HIV-positive at the time of their YMS interview (Table 1).

Table 1
Table 1
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Associations With Race/Ethnicity and Risk Behavior

Strong endorsements of the 3 HAART constructs did not vary by age. The 2 HAART-efficacy beliefs, but not reduced HIV/AIDS concern, did vary by race/ethnicity (Fig. 1). Compared with white MSM, black (OR, 2.62; 95% CI, 1.75–3.92) and Hispanic (OR, 2.55; 95% CI, 1.78–3.64) MSM were more likely to strongly endorse the belief that HAART mitigates HIV/AIDS severity. Compared with black MSM, white MSM were more likely to strongly endorse the belief that HAART mitigates HIV susceptibility (OR, 2.17; 95% CI, 1.22–3.85). Strong endorsement of the belief that HAART mitigates HIV susceptibility did not vary between Hispanic and white MSM (white vs. Hispanic: OR, 1.36; 95% CI, 0.90–2.07) (Fig. 1). Strong endorsements of the 3 HAART constructs were associated with reporting ≥10 male sex partners; strong endorsements of the belief that HAART mitigates HIV/AIDS severity and reduced HIV/AIDS concern were also associated with engaging in UAI with an HIV-positive or HIV-unknown-status male partner (Table 2).

Figure 1
Figure 1
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Table 2
Table 2
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Association With Testing HIV-Positive

In bivariate analyses, testing HIV-positive was associated with strong endorsements for the belief that HAART mitigates HIV/AIDS severity and reduced HIV/AIDS concern (Table 3). In logistic regression analyses, these associations remained statistically significant after adjustment for YMS city, age group, education, having tested HIV-negative within the past year, and perceived HIV risk (Table 3). Testing HIV-positive was not associated with strong endorsement of the belief that HAART mitigates HIV susceptibility (Table 3), and this nonsignificant association was not moderated by race/ethnicity (P = 0.92).

Table 3
Table 3
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In the full model, the association between strong endorsement for reduced HIV/AIDS concern and testing HIV-positive also was not moderated by race/ethnicity (P = 0.61). The association between strong endorsement of the belief that HAART mitigates HIV/AIDS severity and testing HIV-positive was moderated by race/ethnicity (P = 0.14). In the final reduced model, the adjusted HIV-infection odds for strong endorsement of this belief was approximately 2.9 (4.65/1.62) and 2.5 (4.12/1.62) fold higher among black and Hispanic MSM, respectively, compared with white MSM (Table 4).

Table 4
Table 4
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DISCUSSION

In a 6-city survey of MSM who had not tested or had last tested negative for HIV, we found that HIV/AIDS complacency, measured as reduced HIV/AIDS concern because of HAART, was associated with both recent sexual risk behavior and testing positive for HIV. We also found important racial/ethnic differences in one HAART-efficacy belief: young black and Hispanic MSM were more likely than young white MSM to endorse strongly the belief that HAART mitigates HIV/AIDS severity, and that the association between this belief and testing HIV-positive among young black and Hispanic MSM was very strong (adjusted OR ∼4.0) and over twice that observed among young white MSM.

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HIV/AIDS Complacency

In accordance with theoretical expectations, our findings suggest that young MSM who are complacent about HIV/AIDS because of HAART may be less motivated to consistently enact protective sexual behavior, and as a result, may be more likely to acquire HIV.14,15 Our findings are supported by 11 of 13 studies that found similar reduced HIV/AIDS concern constructs were associated with HIV-acquisition behavior,27–37 and by the only study found of its kind, with subsequent STD/HIV infection among MSM in the Netherlands.38 The 2 studies that did not observe associations were either conducted in the year following first availability of HAART17 or included only MSM ≤25 years of age.26

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Belief That HAART Mitigates HIV/AIDS Severity

Our finding on racial/ethnic differences in endorsing the belief that HAART mitigates HIV/AIDS severity is supported by 3 previous studies that also found that MSM of minority race/ethnicity were more likely than white MSM to endorse HAART-optimism beliefs,24,25,33 including the belief that HAART is a cure for AIDS.33 Our findings that strong endorsement of the belief that HAART mitigates HIV/AIDS severity is associated with both risk behavior and testing HIV-positive, however, stands in contrast to 6 studies that did not observe associations between similarly measured constructs and acquisition behavior among MSM.17,22,27,33,36,37

Two reasons might explain these differences. First, our measures required subjects to appraise their personal likelihood of a quality life taking HAART, assuming they had acquired HIV. In contrast, all 6 studies assessed how subjects perceived HAART in curing or reducing the severity of HIV/AIDS, specifically in other persons or without regard to self. It is possible that our personalized items were able to measure a belief construct more salient to reduced personal concern about HIV/AIDS and risk behavior.

Second, because behavioral measures do not typically include partner risks, absence of observed behavioral associations does not rule out associations with sexually transmitted infections including HIV, particularly among MSM.7,8,39,40 Measured behaviors have proven inadequate to explain exceptional HIV-infection differences between black and white MSM.8 Notably, our measures of risk behavior also did not predict HIV infection when evaluated in the presence of perceived HIV risk, a measure that may have taken both behavior and partner risks into account.

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Belief That HAART Mitigates HIV Susceptibility

Similar to other studies, we also observed that strong endorsement of the belief that HAART mitigates HIV susceptibility was associated with acquisition behavior (≥10 recent male sex partners).17,22–24,27,28,37 The lack of association between this belief and testing HIV-positive could be attributed, in part, to the fact that white MSM, at substantially lower HIV-infection risk in our sample, were more likely to strongly endorse this belief than black MSM, who were at substantially higher infection risk (only 14 black MSM strongly endorsed this belief). Although proportionally more white MSM who strongly endorsed this belief (n = 133) tested HIV-positive compared with weak-moderate endorsers (n = 803), our survey lacked sufficient power to detect differences between these 2 groups (white MSM: % HIV-positive strong vs. weak-moderate, 5.3% vs. 3.4%; OR, 1.59; 95% CI, 0.68–3.74).

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Limitations

The findings in this report are subject to several important limitations. First, because this survey was restricted to 23 to 29 year-old men who attended MSM-identified venues in 6 cities, our findings may not generalize to MSM who are younger or older, who reside in other cities, and who do not attend MSM-identified venues. Also, because our survey was conducted 2 to 4 years after HAART became available, the relevance of our findings in contemporary populations of young MSM is unknown. This may be particularly true for black and Hispanic MSM because compared with white MSM, significantly fewer reported being aware of HAART at the time of our survey.

Second, because our definition of HAART required participants to recognize the term “protease inhibitors,” our analyses may have excluded some MSM who had formulated beliefs about the new combination therapies even though they were unaware of the “highly active” component of these therapies. We were not surprised that many men reported being unaware of protease inhibitors considering that our survey was conducted of young MSM shortly after protease inhibitors became widely available. Notably, of identified HAART-optimism studies, only 2 assessed awareness of protease-inhibitor-based HAART.18,33 Our finding among 23- to 29-year-old MSM who had never tested or had last tested negative for HIV (61.7% aware of protease inhibitors) is consistent with findings from these 2 surveys composed of younger MSM 15 to 22 years of age (45% aware of protease inhibitors) and older MSM (mean age, 35.1 years; 86% aware of protease inhibitors).18,33

Third, because YMS was cross-sectional, we could not assess the directionality of observed associations: whether strong endorsement of HAART-efficacy beliefs or attitudes presumably caused, or were caused by, increased risk behavior. Some MSM who engaged in risk behavior, for example, could have subsequently adopted or strengthened HAART-efficacy beliefs to rationalize the behavior and reduce the stress from knowingly placing themselves at risk for HIV.30,31,34,35,46 Prospective studies are required to confirm the presumed causal path that strong HAART-efficacy beliefs and HIV/AIDS complacency reduce protection motivation, which in turn increases risk behavior and HIV-acquisition risk.14,15

Fourth, it is unknown whether observed associations with HAART-efficacy belief and HIV/AIDS complacency constructs would attenuate when evaluated in the presence of other theoretically important determinants (e.g., stigma, depression, homophobia, etc). The importance of other potential determinants is notable because both racial disparities and resurgence in HIV incidence among MSM preceded the availability of HAART.1,2,5 Finally, although the items used to measure HAART-efficacy belief and HIV/AIDS complacency constructs demonstrated acceptable internal consistency, the language and content of these items developed in the late 1990s should be reevaluated before use in future studies.

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Implications for Research and Prevention

Although the subject of considerable speculation, the determinants of both racial disparities and increasing HIV incidence among MSM in the United States remain unknown.5,8 One study in Amsterdam suggests that only 8% to 13% of new risk behavior among MSM might be attributed to HAART optimism, and thus, some have argued that prevention efforts should address more important determinants.36,47 The relevance of this population-attributable behavioral risk to population-attributable infection risk, however, is unknown.

Our findings suggest that HAART-related HIV/AIDS complacency and efficacy beliefs may be important determinants for acquiring HIV among young MSM in the United States, particularly those who are black and Hispanic. Programs that target HIV/AIDS complacency as a means to reduce HIV incidence among young MSM should consider that both the prevalence of strong HAART-efficacy beliefs and the effects of these beliefs on HIV-infection risk might differ considerably by race/ethnicity.48 HIV prevention and care providers should consider assessing HAART-efficacy beliefs of their MSM clients, and the potential role of these beliefs as motivations or rationale for risk behavior. When needed, providers should clarify that transmission from HIV-infected persons on HAART occurs, that HIV/AIDS remains a disabling, costly, and fatal disease, and that MSM should consistently use condoms with all partners unless they are in a mutually monogamous relationship in which both partners have tested negative at least 3 months since their last potential HIV exposure.9,11–13

Although we found that many young men in our sample were not yet aware of HAART, because of widespread media and direct-to-consumer drug advertisements, HAART awareness has probably increased considerably since the time of our survey.49,50 The prevalence of HAART-efficacy beliefs and corresponding complacent attitudes may also have increased, as has been suggested in 2 recent reports.24,37 Therefore, new research is needed to evaluate the current prevalence of HAART-efficacy beliefs and HIV/AIDS complacency among contemporary samples of MSM, and whether these beliefs and attitudes increase HIV-acquisition risk equally by race/ethnicity. Given continued improvements in the safety and efficacy of HAART to prolong quality life,9 compelling evidence that HAART reduces sexual HIV transmission,10–13 and the growing HIV epidemic among MSM in the United States, particularly among men who are young, black, and Hispanic,5,6 our findings suggest this research may be particularly important for HIV prevention.

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APPENDIX

Measures of HAART-efficacy belief and HIV/AIDS complacency constructs (response range for each measure: 1 [strongly disagree] to 5 [strongly agree]).

HAART mitigates HIV susceptibility belief:

1. I would be less likely to get infected by an HIV-positive partner with undetectable virus than a HIV-positive partner with detectable virus.

2. If I were having anal sex with an HIV-positive man and his condom broke, it would be less risky for me if he had no detectable virus.

3. If my partner had a low viral load it would be less risky for me to have receptive anal sex with him than if he had a high viral load.

HAART mitigates HIV/AIDS severity belief:

1. If I became infected with HIV today, I probably wouldn't get AIDS given the combination drug treatments that are available.

2. If I got infected with HIV today, I could live a long and healthy life by taking the combination drug treatments that are available.

3. HIV is now a manageable disease much like diabetes.

4. If I became HIV infected today, the combination drug treatments would prevent me from getting AIDS for many years.

Reduced HIV/AIDS concern (HIV/AIDS complacency):

1. Because of the combination drugs available for HIV, I am less concerned about becoming infected.

2. Because of the combination drugs available for HIV, I am not as concerned about slipping and having unsafe sex.

3. With the good news about combination drugs for HIV, I worry less about having sex with partners that might be HIV-positive.

4. I am not as concerned about HIV infection now that there are combination drugs available for HIV.

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Cited By:

This article has been cited 1 time(s).

Journal of Homosexuality
HIV/AIDS, Social Capital, and Online Social Networks
Drushel, BE
Journal of Homosexuality, 60(8): 1230-1249.
10.1080/00918369.2013.784114
CrossRef
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