AIDS and Behavior

, Volume 21, Issue 10, pp 3035–3046 | Cite as

Number of Psychosocial Strengths Predicts Reduced HIV Sexual Risk Behaviors Above and Beyond Syndemic Problems Among Gay and Bisexual Men

  • Trevor A. HartEmail author
  • Syed W. Noor
  • Barry D. Adam
  • Julia R. G. Vernon
  • David J. Brennan
  • Sandra Gardner
  • Winston Husbands
  • Ted Myers
Original Paper


Syndemics research shows the additive effect of psychosocial problems on high-risk sexual behavior among gay and bisexual men (GBM). Psychosocial strengths may predict less engagement in high-risk sexual behavior. In a study of 470 ethnically diverse HIV-negative GBM, regression models were computed using number of syndemic psychosocial problems, number of psychosocial strengths, and serodiscordant condomless anal sex (CAS). The number of syndemic psychosocial problems correlated with serodiscordant CAS (RR = 1.51, 95% CI 1.18–1.92; p = 0.001). When adding the number of psychosocial strengths to the model, the effect of syndemic psychosocial problems became non-significant, but the number of strengths-based factors remained significant (RR = 0.67, 95% CI 0.53–0.86; p = 0.002). Psychosocial strengths may operate additively in the same way as syndemic psychosocial problems, but in the opposite direction. Consistent with theories of resilience, psychosocial strengths may be an important set of variables predicting sexual risk behavior that is largely missing from the current HIV behavioral literature.


HIV Men who have sex with men Gay men Syndemics Psychosocial strengths 



The authors would like thank all the participants of the Gay Strengths Study for their participation.


This research was supported by a grant from the Canadian Institutes of Health Research (#CBR-112845) as well as by a Career Scientist Award (TH, #SCI G650) and an Applied HIV Research Chair Award (TH, #AHRC G937) from the Ontario HIV Treatment Network.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


  1. 1.
  2. 2.
    Paz-Bailey G, Mendoza MCB, Finlayson T, et al. Trends in condom use among MSM in the United States: the role of antiretroviral therapy and seroadaptive strategies. AIDS Lond Engl. 2016;30(12):1985–90.CrossRefGoogle Scholar
  3. 3.
  4. 4.
    Burchell AN, Gardner SL, Moravan V, et al. High incidence of diagnosis with syphilis co-infection among men who have sex with men in an HIV cohort in Ontario, Canada. BMC Infect Dis. 2015;15(1):356.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Kalichman SC, Pellowski J, Turner C. Prevalence of sexually transmitted co-infections in people living with HIV/AIDS: systematic review with implications for using HIV treatments for prevention. Sex Transm Infect. 2011;87(3):183–90.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Hagan H, Jordan AE, Neurer J, Cleland CM. Incidence of sexually transmitted hepatitis C virus infection in HIV-positive men who have sex with men. AIDS. 2015;29(17):2335–45.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    McFaul K, Maghlaoui A, Nzuruba M, et al. Acute hepatitis C infection in HIV-negative men who have sex with men. J Viral Hepat. 2015;22(6):535–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Singer M. A dose of drugs, a touch of violence, a case of AIDS: conceptualizing the SAVA syndemic. Free Inq Spec Issue Gangs Drugs Violence. 1996;24(2):99–110.Google Scholar
  9. 9.
    Singer M, Clair S. Syndemics and public health: reconceptualizing disease in bio-social context. Med Anthropol Q. 2003;17(4):423–41.CrossRefPubMedGoogle Scholar
  10. 10.
    Stall R, Catania JA, Mills TC, et al. Association of co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. Am J Public Health. 2003;93(6):939–42.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Herrick AL, Lim SH, Plankey MW, et al. Adversity and syndemic production among men participating in the Multicenter AIDS Cohort Study: a life-course approach. Am J Public Health. 2013;103(1):79–85.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Safren SA, Reisner SL, Herrick A, Mimiaga MJ, Stall RD. Mental health and HIV risk in men who have sex with men. J Acquir Immune Defic Syndr. 2010;55:S74–7.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Parsons JT, Grov C, Golub SA. Sexual compulsivity, co-occurring psychosocial health problems, and HIV risk among gay and bisexual men: further evidence of a syndemic. Am J Public Health. 2012;102(1):156–62.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Parsons JT, Rendina HJ, Moody RL, Ventuneac A, Grov C. Syndemic production and sexual compulsivity/hypersexuality in highly sexually active gay and bisexual men: further evidence for a three group conceptualization. Arch Sex Behav. 2015;44(7):1903–13.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Tulloch TG, Rotondi NK, Ing S, et al. Retrospective reports of developmental stressors, syndemics, and their association with sexual risk outcomes among gay men. Arch Sex Behav. 2015;44:1879–89.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Brennan DJ, Souleymanov R, George C, et al. Masculinity, muscularity, and HIV sexual risk among gay and bisexual men of color. Psychol Men Masc. 2015;16(4):393–403.CrossRefGoogle Scholar
  17. 17.
    Ferlatte O, Hottes TS, Trussler T, Marchand R. Evidence of a syndemic among young Canadian gay and bisexual men: Uncovering the associations between anti-gay experiences, psychosocial issues, and HIV risk. AIDS Behav. 2014;18(7):1256–63.CrossRefPubMedGoogle Scholar
  18. 18.
    Worth H, Rawstorne P. Crystallizing the HIV epidemic: methamphetamine, unsafe sex, and gay diseases of the will. Arch Sex Behav. 2005;34(5):483–6.CrossRefPubMedGoogle Scholar
  19. 19.
    Herrick AL, Stall R, Chmiel JS, et al. It gets better: resolution of internalized homophobia over time and associations with positive health outcomes among MSM. AIDS Behav. 2013;17(4):1423–30.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Myers T, Remis RS, Husbands W, et al. Technical report: Lambda survey: M-Track Ontario second generation surveillance. 2011.$file/lambda%20technical%20report%20FINAL.pdf.
  21. 21.
    Hart TA, James CA, Hagan CMP, Boucher E. HIV optimism and high-risk sexual behavior in two cohorts of men who have sex with men. J Assoc Nurses AIDS Care. 2010;21(5):439–43.CrossRefPubMedGoogle Scholar
  22. 22.
    Otis J, McFadyen A, Haig T, et al. Beyond condoms: risk reduction strategies among gay, bisexual, and other men who have sex with men receiving rapid HIV testing in Montreal, Canada. AIDS Behav. 2016;20(12):2812–26.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Card KG, Lachowsky NJ, Cui Z, et al. Seroadaptive strategies of gay and bisexual men (GBM) with the highest quartile number of sexual partners in Vancouver, Canada. AIDS Behav [journal on the internet]. 2016 [cited 29 Nov 2016].
  24. 24.
    Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–97.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Rofes E. Thriving: gay men’s health in the 21st century. Estate of Eric Rofes, 2007.Google Scholar
  26. 26.
    Meyer IH. Identity, stress, and resilience in lesbians, gay men, and bisexuals of color. Couns Psychol. 2010;8(3):442–54.CrossRefGoogle Scholar
  27. 27.
    Herrick AL, Lim SH, Wei C, et al. Resilience as an untapped resource in behavioral intervention design for gay men. AIDS Behav. 2011;15(S1):25–9.CrossRefGoogle Scholar
  28. 28.
    Aguinaldo JP. The social construction of gay oppression as a determinant of gay men’s health: “homophobia is killing us”. Crit Public Health. 2008;18(1):87–96.CrossRefGoogle Scholar
  29. 29.
    Race KD. Revaluation of risk among gay men. AIDS Educ Prev. 2003;15(4):369–81.CrossRefPubMedGoogle Scholar
  30. 30.
    Meyer IH. Minority stress and positive psychology: convergences and divergences to understanding LGBT health. Psychol Sex Orientat Gend Divers. 2014;1(4):348–9.CrossRefGoogle Scholar
  31. 31.
    Kurtz SP, Buttram ME, Surratt HL, Stall RD. Resilience, syndemic factors, and serosorting behaviors among HIV-positive and HIV-negative substance-using MSM. AIDS Educ Prev. 2012;24(3):193–205.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    De Santis J. Exploring the concepts of vulnerability and resilience in the context of HIV infection. Res Theory Nurs Pract. 2008;22(4):273–87.CrossRefPubMedGoogle Scholar
  33. 33.
    Antonovsky A. Unraveling the mystery of health: how people manage stress and stay well. San Francisco: Jossey-Bass; 1987.Google Scholar
  34. 34.
    Ouellette S. Inquiries into hardiness. In: Goldberger L, Breznitz S, editors. Handbook of stress: theoretical and clinical aspects. New York: The Free Press; 1993.Google Scholar
  35. 35.
    Peterson JL, Folkman S, Bakeman R. Stress, coping, HIV status, psychosocial resources, and depressive mood in African American gay, bisexual, and heterosexual men. Am J Community Psychol. 1996;24(4):461–87.CrossRefPubMedGoogle Scholar
  36. 36.
    Herrick AL, Stall R, Goldhammer H, Egan JE, Mayer KH. Resilience as a research framework and as a cornerstone of prevention research for gay and bisexual men: theory and evidence. AIDS Behav. 2014;18(1):1–9.CrossRefPubMedGoogle Scholar
  37. 37.
    Fergus S, Zimmerman MA. Adolescent resilience: a framework for understanding healthy development in the face of risk. Annu Rev Public Health. 2005;26(1):399–419.CrossRefPubMedGoogle Scholar
  38. 38.
    Buttram ME, Kurtz SP. Risk and protective factors associated with gay neighborhood residence. Am J Mens Health. 2012;7(2):110–8.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Hays RB, Turner H, Coates TJ. Social support, AIDS-related symptoms, and depression among gay men. J Consult Clin Psychol. 1992;60(3):463–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Hall VP. The relationship between social support and health in gay men with HIV/AIDS: an integrative review. J Assoc Nurses AIDS Care. 1999;10(3):74–86.CrossRefPubMedGoogle Scholar
  41. 41.
    Safren SA, Heimberg RG. Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents. J Consult Clin Psychol. 1999;67(6):859–66.CrossRefPubMedGoogle Scholar
  42. 42.
    Hatzenbuehler ML. How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychol Bull. 2009;135(5):707–30.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Li R, Cai Y, Wang Y, et al. Psychosocial syndemic associated with increased suicidal ideation among men who have sex with men in Shanghai, China. Health Psychol. 2016;35(2):148–56.CrossRefPubMedGoogle Scholar
  44. 44.
    Hatzenbuehler ML, Nolen-Hoeksema S, Dovidio J. How does stigma “get under the skin”?: The mediating role of emotion regulation. Psychol Sci. 2009;20(10):1282–9.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Mustanski B, Liu RT. A longitudinal study of predictors of suicide attempts among lesbian, gay, bisexual, and transgender youth. Arch Sex Behav. 2013;42(3):437–48.CrossRefPubMedGoogle Scholar
  46. 46.
    Lorenzi G, Miscioscia M, Ronconi L, Pasquali C, Simonelli A. internalized stigma and psychological well-being in gay men and lesbians in Italy and Belgium. Soc Sci. 2015;4(4):1229–42.CrossRefGoogle Scholar
  47. 47.
    Graham JM, Barnow ZB. Stress and social support in gay, lesbian, and heterosexual couples: direct effects and buffering models. J Fam Psychol. 2013;27(4):569–78.CrossRefPubMedGoogle Scholar
  48. 48.
    Golub SA, Walker JJ, Longmire-Avital B, Bimbi DS, Parsons JT. The role of religiosity, social support, and stress-related growth in protecting against HIV risk among transgender women. J Health Psychol. 2010;15(8):1135–44.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Qiao S, Li X, Stanton B. Social support and HIV-related risk behaviors: a systematic review of the global literature. AIDS Behav. 2014;18(2):419–41.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Kimberly JA, Serovich JM. The role of family and friend social support in reducing risk behaviors among HIV-positive gay men. AIDS Educ Prev. 1999;11(6):465–75.PubMedGoogle Scholar
  51. 51.
    Darbes LA, Lewis MA. HIV-specific social support predicts less sexual risk behavior in gay male couples. Health Psychol. 2005;24(6):617–22.CrossRefPubMedGoogle Scholar
  52. 52.
    Fergus S, Lewis MA, Darbes LA, Kral AH. Social Support moderates the relationship between gay community integration and sexual risk behavior among gay male couples. Health Educ Behav. 2009;36(5):846–59.CrossRefPubMedGoogle Scholar
  53. 53.
    Campbell C. Letting them die: why HIV/AIDS intervention programmes fail. Bloomington: Indiana University Press; 2003.Google Scholar
  54. 54.
    Cullen M, Whiteford H. The interrelations of social capital with health and mental health. 2001.
  55. 55.
    Woolcock M. The place of social capital in understanding social and economic outcomes. Can J Policy Res. 2001;2(1):11–7.Google Scholar
  56. 56.
    Thomas-Slayter BP, Fisher WF. Social capital and AIDS-resilient communities: strengthening the AIDS response. Glob Public Health. 2011;6:S323–43.CrossRefPubMedGoogle Scholar
  57. 57.
    Afzali M, Shahhosseini Z, Hamzeghardeshi Z. Social capital role in managing high risk behavior: a narrative review. Mater Socio Med. 2015;27(4):280.CrossRefGoogle Scholar
  58. 58.
    Holtgrave DR, Crosby RA. Social capital, poverty, and income inequality as predictors of gonorrhoea, syphilis, chlamydia and AIDS case rates in the United States. Sex Transm Infect. 2003;79(1):62–4.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Pronyk PM, Harpham T, Morison LA, et al. Is social capital associated with HIV risk in rural South Africa? Soc Sci Med. 2008;66(9):1999–2010.CrossRefPubMedGoogle Scholar
  60. 60.
    Sivaram S, Zelaya C, Srikrishnan AK, et al. Associations between social capital and HIV stigma in Chennai, India: considerations for prevention intervention design. AIDS Educ Prev. 2009;21(3):233–50.CrossRefPubMedGoogle Scholar
  61. 61.
    O’Leary A, Jemmott JB, Stevens R, Rutledge SE, Icard LD. Optimism and education buffer the effects of syndemic conditions on hiv status among African American men who have sex with men. AIDS Behav. 2014;18(11):2080–8.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Halkitis PN, Kapadia F, Bub KL, Barton S, Moreira AD, Stults CB. A longitudinal investigation of syndemic conditions among young gay, bisexual, and other MSM: the P18 Cohort Study. AIDS Behav. 2015;19(6):970–80.CrossRefPubMedPubMedCentralGoogle Scholar
  63. 63.
    City of Toronto. Immigration, Citizenship, Place of Birth, Ethnicity, Visible Minorities, Religion and Aboriginal Peoples. 2013.
  64. 64.
    Radloff LS. The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385–401.CrossRefGoogle Scholar
  65. 65.
    Lewinsohn PM, Seeley JR, Roberts RE, Allen NB. Centre for Epidemiologic Studies Depression Scale (CES-D) as a screening instrument for depression among community-residing older adults. Psychol Aging. 1997;12(2):277–87.CrossRefPubMedGoogle Scholar
  66. 66.
    Lyness JM, Noel TK, Cox C, King DA, Conwell Y, Caine ED. Screening for depression in elderly primary care patients: a comparison of the Centre for Epemiologic Studies-Depression Scale and the Geriatric Depression Scale. Arch Intern Med. 1997;157:449–54.CrossRefPubMedGoogle Scholar
  67. 67.
    Roberts RE, Lewinsohn PM, Seeley JR. Screening for adolescent depression: a comparison of depression scales. J Acad Child Adolesc Psychiatry. 1991;30:58–66.CrossRefGoogle Scholar
  68. 68.
    Axelrod SR, Perepletchikova F, Holtzman K, Sinha R. Emotion regulation and substance use frequency in women with substance dependence and borderline personality disorder receiving dialectical behavior therapy. Am J Drug Alcohol Abuse. 2011;37(1):37–42.CrossRefPubMedGoogle Scholar
  69. 69.
    Newcomb MD, Harlow LL. Life events and substance use among adolescents: mediating effects of perceived loss of control and meaninglessness in life. J Pers Soc Psychol. 1986;51(3):564.CrossRefPubMedGoogle Scholar
  70. 70.
    Bernstein DP, Stein JA, Newcomb MD, Walker E, Pogge D, Ahluvalia T, et al. Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse Negl. 2003;27(2):169–90.CrossRefPubMedGoogle Scholar
  71. 71.
    Szymanski DM. Does internalized heterosexism moderate the link between heterosexist events and lesbians’ psychological distress? Sex Roles. 2006;54(3–4):227–34.CrossRefGoogle Scholar
  72. 72.
    De Silva MJ, Huttly SR, Harpham T, Kenward MG. Social capital and mental health: a comparative analysis of four low income countries. Soc Sci Med. 2007;64(1):5–20.CrossRefPubMedGoogle Scholar
  73. 73.
    Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. J Pers Assess. 1988;52:30–41.CrossRefGoogle Scholar
  74. 74.
    O’Leary A, Horvath KJ, Simon Rosser BR. Associations between partner-venue specific personal responsibility beliefs and transmission risk behavior by HIV-positive men who have sex with men (MSM). AIDS Behav. 2013;17(5):1855–61.CrossRefPubMedPubMedCentralGoogle Scholar
  75. 75.
    Noor SWB, Rampalli K, Rosser BRS. Factors influencing HIV serodisclosure among men who have sex with men in the US: an examination of online versus offline meeting environments and risk behaviors. AIDS Behav. 2014;18(9):1638–50.CrossRefPubMedPubMedCentralGoogle Scholar
  76. 76.
    Pantalone DW, Tomassilli JC, Starks TJ, Golub SA, Parsons JT. Unprotected anal intercourse with casual male partners in urban gay, bisexual, and other men who have sex with men. Am J Public Health. 2015;105(1):103–10.CrossRefPubMedPubMedCentralGoogle Scholar
  77. 77.
    Wilkerson JM, Noor SW, Galos DL, Rosser BRS. Correlates of a single-item indicator versus a multi-item scale of outness about same-sex attraction. Arch Sex Behav. 2016;45(5):1269–77.CrossRefPubMedGoogle Scholar
  78. 78.
    Mimiaga MJ, Reisner SL, Pantalone DW, O’Cleirigh C, Mayer KH, Safren SA. A pilot trial of integrated behavioral activation and sexual risk reduction counseling for HIV-uninfected men who have sex with men abusing crystal methamphetamine. AIDS Patient Care STDs. 2012;26(11):681–93.CrossRefPubMedPubMedCentralGoogle Scholar
  79. 79.
    Tjur T. Coefficients of determination in logistic regression models—a new proposal: the coefficient of discrimination. Am Stat. 2009;63(4):366–72.CrossRefGoogle Scholar
  80. 80.
    Statacorp LP. STATA-IC, version 13.1. College Station, TX, 2013. Accessed 30 June 2016.
  81. 81.
    Lewis RJ, Derlega VJ, Griffin JL, Krowinski AC. Stressors for gay men and lesbians: life stress, gay-related stress, stigma consciousness, and depressive symptoms. J Soc Clin Psychol. 2003;22(6):716–29.CrossRefGoogle Scholar
  82. 82.
    Newcomb ME, Mustanski B. Internalized homophobia and internalizing mental health problems: a meta-analytic review. Clin Psychol Rev. 2010;30(8):1019–29.CrossRefPubMedGoogle Scholar
  83. 83.
    Hatzenbuehler ML, Nolen-Hoeksema S, Erickson SJ. Minority stress predictors of HIV risk behavior, substance use, and depressive symptoms: results from a prospective study of bereaved gay men. Health Psychol. 2008;27(4):455–62.CrossRefPubMedGoogle Scholar
  84. 84.
    Schwartz DR, Stratton N, Hart TA. Minority stress and mental and sexual health: Examining the psychological mediation framework among gay and bisexual men. Psychol Sex Orientat Gend Divers 2016, advance online.
  85. 85.
    Pachankis JE. A transdiagnostic minority stress treatment approach for gay and bisexual men’s syndemic health conditions. Arch Sex Behav. 2015;44(7):1843–60.CrossRefPubMedPubMedCentralGoogle Scholar
  86. 86.
    Pachankis JE. Uncovering clinical principles and techniques to address minority stress, mental health, and related health risks among gay and bisexual men. Clin Psychol Sci Pract. 2014;21(4):313–30.CrossRefGoogle Scholar
  87. 87.
    Pachankis JE, Hatzenbuehler ML, Rendina HJ, Safren SA, Parsons JT. LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: a randomized controlled trial of a transdiagnostic minority stress approach. J Consult Clin Psychol. 2015;83(5):875–89.CrossRefPubMedPubMedCentralGoogle Scholar
  88. 88.
    Rutter PA. Sex therapy with gay male couples using affirmative therapy. Sex Relatsh Ther. 2012;27(1):35–45.CrossRefGoogle Scholar
  89. 89.
    Hart TA, Stratton N, Coleman TA, et al. A pilot trial of a sexual health counseling intervention for HIV-positive gay and bisexual men who report anal sex without condoms. PLoS ONE. 2016;11(4):e0152762.CrossRefPubMedPubMedCentralGoogle Scholar
  90. 90.
    Golin CE, Earp JA, Grodensky CA, et al. Longitudinal effects of SafeTalk, a motivational interviewing-based program to improve safer sex practices among people living with HIV/AIDS. AIDS Behav. 2012;16(5):1182–91.CrossRefPubMedPubMedCentralGoogle Scholar
  91. 91.
    Kegeles SM, Hays RB, Coates TJ. The Mpowerment Project: a community-level HIV prevention intervention for young gay men. Am J Public Health. 1996;86(8):1129–36.CrossRefPubMedPubMedCentralGoogle Scholar
  92. 92.
    Adam BD, Betancourt G, Serrano-Sanchez A. Development of an HIV prevention and life skills program for Spanish-speaking gay and bisexual newcomers to Canada. Can J Hum Sex. 2011;20:11–7.Google Scholar
  93. 93.
    Hermanos de Luna y Sol. A Model for HIV Prevention with Latino Gay Men. In: Diaz RM, ed. Latino Gay Men and HIV: Culture, sexuality, and risk behavior. New York, NY: Routledge; 1998.Google Scholar
  94. 94.
    Statistics Canada. Immigration and ethnocultural diversity in Canada 2013.
  95. 95.
    Mayer KH, Krakower DS. If PrEP decreases HIV transmission, what is impeding its uptake? Clin Infect Dis 2015, advance online.
  96. 96.
    Parsons JT, Rendina HJ, Whitfield THF, Grov C. Familiarity with and preferences for oral and long-acting injectable HIV Pre-exposure Prophylaxis (PrEP) in a national sample of gay and bisexual men in the U.S. AIDS Behav. 2016;20(7):1390–9.CrossRefPubMedPubMedCentralGoogle Scholar
  97. 97.
  98. 98.
    Palmer HM, Young H, Winter A, Dave J. Emergence and spread of azithromycin-resistant Neisseria gonorrhoeae in Scotland. J Antimicrob Chemother. 2008;62(3):490–4.CrossRefPubMedGoogle Scholar
  99. 99.
    Kirkcaldy RD, Zaidi A, Hook EW, et al. Neisseria gonorrhoeae antimicrobial resistance among men who have sex with men and men who have sex exclusively with women: the Gonococcal Isolate Surveillance Project, 2005–2010. Ann Intern Med. 2013;158:321–8.CrossRefPubMedGoogle Scholar
  100. 100.
    Rodger CV, Bruun T, Vernazza P, et al. HIV transmission risk through condomless sex if the HIV positive partner is on suppressive ART: PARTNER study. Conference on Retroviruses and Opportunistic Infections Boston, 2014. [abstract 153LB].Google Scholar
  101. 101.
    Montaner JS, Daly P, Kendall P, et al. Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study. Lancet. 2010;376(9740):532–9.CrossRefPubMedPubMedCentralGoogle Scholar
  102. 102.
    Starks TJ, Tuck AN, Millar BM, Parsons JT. Linking syndemic stress and behavioral indicators of main partner HIV transmission risk in gay male couples. AIDS Behav. 2016;20(2):439–48.CrossRefPubMedPubMedCentralGoogle Scholar
  103. 103.
    Stall R, Paul JP, Greenwood G, et al. Alcohol use, drug use and alcohol-related problems among men who have sex with men: the Urban Men’s Health Study. Addiction. 2001;96(11):1589–601.CrossRefPubMedGoogle Scholar
  104. 104.
    Welles SL, Baker AC, Miner MH, Brennan DJ, Jacoby S, Rosser BS. History of childhood sexual abuse and unsafe anal intercourse in a 6-city study of HIV-positive men who have sex with men. Am J Public Health. 2009;99(6):1079–86.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  1. 1.Department of PsychologyRyerson UniversityTorontoCanada
  2. 2.Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
  3. 3.Department of Sociology, Anthropology and CriminologyUniversity of WindsorWindsorCanada
  4. 4.Ontario HIV Treatment NetworkTorontoCanada
  5. 5.Factor-Inwentash Faculty of Social WorkUniversity of TorontoTorontoCanada
  6. 6.AIDS Committee of TorontoTorontoCanada

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