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Risk and protective factors related to HIV-risk
behavior: A comparison between HIV-positive and HIV-
negative young men who have sex with men
Jason C. Forney a , Robin L. Miller a & The City Project Study Team a
a Department of Psychology, Michigan State University, East Lansing, Ml, USA
Available online: 31 Jan 2012
To cite this article: Jason C. Forney, Robin L. Miller & The City Project Study Team (2012): Risk and protective factors
related to HIV-risk behavior: A comparison between HIV-positive and HIV-negative young men who have sex with men, AIDS
Care: Psychological and Socio-medical Aspects of AIDS/HIV, 24:5, 544-552
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Vol. 24, No. 5, May 2012, 544-552
~ '\. Taylor&Franci>Group
Risk and protective factors related to HIV -risk behavior: A comparison between HIV -positive
and HIV -negative young men who have sex with men
Jason C. Forney*, Robin L. Miller and The City Project Study Team
Department of Psychology, Michigan State University, East Lansing, Ml, USA
(Received 26 July 2010; final version received 28 September 2010)
The objective of this study was to assess and compare the prevalence of high-risk sexual behaviors among young
HIV-negative (n =8064) and HIV-positive (n = 171) men who have sex with men (MSM) on predictors of
unprotected anal intercourse (UAI). Using venue-based time-space sampling, 8235 MSM aged 15-25 were
anonymously surveyed as a part of the Community Intervention Trial for Youth (CITY). The Project was
conducted in 13 communities across the USA from 1999 to 2002. Forty percent of HIV-positive men and 34% of
HIV-negative men reported that they had UAI in the previous 3 months. HIV-positive MSM were more likely
than their uninfected peers to have traded sex within the previous year, to have had sex while high during their
last sexual encounter, and to have UAI with a greater number of partners. Multivariate analyses indicated that
for HIV-negative men, positive peer norms regarding safer sex and being Black or Latino predicted avoidance of
UAI. Among HIV-positive men, having social support for safer sex and positive peer norms predicted avoidance
of UAI. Young HIV-positive MSM are a relevant subgroup for prevention because they constitute a significant
source from which future infections could be generated.
Keywords: HIV seropositivity; MSM; sexual behaviors
Rates of HIV infection among young men who have
sex with men (MSM) aged 25 and younger have
steadily increased since 2001; men of this age
currently represent over 20% of new HIV diagnoses
(CDC, 2009). As young HIV -positive men live longer
and healthier lives due to advances in treatment, they
may also maintain active sex lives for years after
seroconverting, placing sexual partners at risk of
exposure to HIV if condoms are not used consis-
tently and properly. Assuring consistent condom use
among sexually active HIV-positive young men is
therefore an important public health priority to
eradicate the epidemic.
The reported rates of risky sexual behaviors among
HIV -positive and HIV -negative adult MSM have
varied across existing studies (Kral et al., 2005; Lauby
et al., 2008; Mansergh et al., 2010; Myers, Javanbakht,
Martinez, & Obediah, 2003; Ostrow, McKirnan,
Klein, & DiFranceisco, 1999; Williamson, Dodds,
Mercey, Hart, & Johnson, 2008). Among adolescent
and young adult MSM, few published studies have
examined differences in sexual risk-taking in relation
to serostatus. The Young Men's Survey (Valleroy
et al., 2000), the largest of these studies, found that
young seropositive MSM aged 15-22 years engaged in
similarly high rates of risky sex when compared with
their HIV -negative peers. In another study of 408
*Corresponding author. Email: Forneyja@msu.edu
ISSN 0954-0121 print/ISSN 1360-0451 online
© 2012 Taylor & Francis
http:f /dx.doi.org/10.1080/09540 121.2011.630341
http:f jwww .tandfonline.com
young adult MSM in San Francisco, men perceiving
themselves to be HIV -positive were more likely to
report unprotected anal sex when compared with their
uninfected counterparts (Hays et al., 1997). Other
studies of young men have found higher rates of risky
sexual behaviors among HIV -positive men when
compared with those who were HIV -negative (Hein,
Dell, Futterman, Rotheram-Borus, & Shaffer, 1995;
Stein, Rotheram-Borus, Swendeman, & Milburn,
2005). Overall, young HIV-positive MSM appear to
engage in higher rates of unprotected sex when
compared with their HIV-negative peers.
A modest body of prior research has identified
factors that may be associated with risk-taking and
risk-avoidance among younger MSM. The use of
alcohol and drugs has been implicated in acts of
unprotected anal sex among both HIV -negative and
HIV-positive MSM (Barta, Tennen, & Kiene, 2010;
Forrest et al., 2010; Hirshfield, Remien, Humber-
stone, Walavalkar, & Chiasson, 2004; Hurt et al.,
2010; Shuper, Joharchi, Irving, & Rehm, 2009; Stall &
Purcell, 2000). Moreover, some research indicates that
young HIV -positive MSM are more likely to use
substances during sex when compared with those who
are HIV -negative (Harawa et al., 2004; Hein et al.,
Trading sex in exchange for money, food, shelter,
drugs, or other items is a well-documented risk factor
for HIV-risk behavior among young MSM (Bacon
et al., 2006; f; Greene, Ennett, & Ringwalt, 1999;
Halcaon & Lifson, 2004).) Although less is known
about trading sex and risky sexual behaviors among
HIV -positive young MSM, evidence suggests that
HIV -positive youth are significantly more likely to
engage in trading sex when compared with those who
are HIV-negative (Hein et al., 1995; Pfeifer & Oliver,
Social support has been theorized to serve as a
protective factor against negative health behaviors
(Cohen, 1988). However, researchers have failed to
find a significant relationship between general social
support and risky sexual behaviors among HIV-
negative and HIV-positive adults (Crepaz & Marks,
2002) and young HIV -positive and HIV -negative men
(Hays et al., 1997; Hein et al., 1995; Stein et al., 2005).
However, Naar-King et al. (2006) found that social
support for safer sex was associated with condom use
among 60 HIV -positive youth. More research is
needed to clarify the role that social support specific
to safer sex plays on rates of unprotected sex.
Individuals tend to practice safer sex to the degree
that it conforms to the norms of their reference group
(Fisher, 1988). An abundance of research underscores
the protective role of peer norms against risky sexual
behaviors among both adult and young MSM
(Kalichman, Kelly, & St Lawrence, 1990; Miner,
Peterson, Welles, Jacoby, & Simon Rosser, 2009;
Somlai, Kalichman, & Bagnall, 2001). However, the
research on the role of peer norms among young
HIV -positive MSM yields conflicting results on the
impact of norms on sexual behavior (Hays et al.,
1997; Stein et al., 2005).
In light of the small number of studies examining
sexual risk behaviors among young HIV -positive
MSM, the purpose of the present study is to: (1)
describe the sexual risk behaviors of HIV -infected
young MSM, (2) compare rates of engagement in
HIV -risk behaviors between HIV -negative and HIV-
positive young MSM, (3) identify risk and protective
factors associated with unprotected sex among HIV-
positive young MSM, and (4) explore the degree to
which risk and protective factors for unsafe sex
among HIV-positive young MSM explain unsafe
sex among HIV-negative young men.
Data are from the Community Intervention Trial for
Youth (CITY) Project, a 7-year randomized multi-
site control trial of interventions to reduce HIV -risk
behaviors among young MSM. To be eligible to
AIDS Care 545
participate in the CITY Project, men had to be
between the age of 15 and 25 years, and report that
they had engaged in sexual activity with another man
in the previous year. In addition, men had to meet
racial eligibility criteria applicable to the particular
study site at which they were recruited. The 13 sites
for the CITY Project were geographically diverse,
representative of most regions throughout the coun-
try, and had venues where it was possible to obtain a
multi-ethnic sample of young MSM. Cities were
divided into four strata based on racejethnicity (see
The study utilized a venue-based application of
time-space sampling (TSS) (Muhib et al., 2001).
CITY researchers at each site identified venues that
were likely to be frequented by young MSM and,
through a systematic process, identified venue-day-
time units that were optimal for collecting data. These
venue day-time units were randomly selected for data
collection (see Muhib et al., 2001 for a thorough
discussion of TSS). Randomization occurred once
each month. Data were collected in each site from
May through August in the years 1999-2002.
Data collection procedures and processes for obtain-
ing informed consent were reviewed and approved by
the relevant human subjects review committees. After
an initial screening, eligible men were asked to
participate in a 20-minute anonymous interview and
were paid $10-$20 (depending on the site) for their
participation. The current study uses data from the
8975 young MSM who reported they had been tested
for HIV and who knew their results.
The questionnaire assessed a wide range of constructs
and topics related to sexual risk behaviors.
Men were asked to provide their date of birth,
ethnicity, race, years of education completed, and
HIV status was assessed by first asking "Have you
been tested for HIV?" If the respondent replied
affirmatively, he was asked, "Would you be willing
to tell us the results of the last test?"
546 J.C. Forney et al.
Table I. Descriptive statistics of study variables among HIV-negative and HIV-positive young men who have sex with men.
Participants were asked if they had traded sex for
money, drugs, or anything valuable (i.e., food, or a
place to stay) in the past year. Participants were also
asked to report their number of partners and whether
they had engaged in unprotected insertive and
receptive anal and vaginal sex during the past 3
months. Men were asked whether they had used
condoms during insertive and receptive anal sex and
if they had sex under the influence of alcohol or drugs
with both main and non-main partners during their
last sexual encounter. Finally, participants were asked
whether they knew the HIV status of their most
recent main and/or non-main partners. Those who
reported a partner with either an unknown or
serostatus differing from their own were coded as
disconcordant while those men perceiving their part-
ners' serostatus to be similar to their own were coded
as concordant. To capture both main and non-main
partners in multivariate analysis, participants were
coded as "discordant" if they reported to have had
either a main or a non-main sexual partner with an
unknown or different HIV status from their own and
were categorized as concordant in instances when
their own serostatus matched both their main and
Participants were asked if they had heard about
combination drugs for HIV /AIDS treatment. Those
who replied "yes" were asked to report the degree to
which they felt HIV as a less serious threat than it
used to be and the extent that they practiced safe sex
less often because of treatment advances. Those who
agreed strongly or somewhat strongly to one or both
of these questions were coded 1 while all others were
coded as 0.
Peer norms about condoms
Participants were asked to rate how much they agreed
or disagreed with four questions about their friends'
beliefs about condom use. These items were adapted
from a longer scale developed by Choi, Coates,
Catania, Lew, & Chow (1995). Cronbach's internal
consistency alpha was adequate (ex =0.75).
Respondents rated the extent of available social
support regarding issues related to sex on a 5-point
scale ranging from 1 =none of the time to 5 =always
or all of the time. These items were adopted from
Miller (1995). Cronbach's internal consistency for this
sample was acceptable (ex= 0.83).
We examined differences pertammg to sociodemo-
graphics and HIV -risk behaviors between the two
serostatus groups using Pearson's x2 test of indepen-
dence for categorical variables and a dependent t-test
for continuous variables. Sequential logistic regres-
sion was employed to examine the impact of risk and
protective factors on engagement in unprotected anal
intercourse (UAI) in the prior 3 months. For the first
logistic regression analysis, only HIV -positive MSM
were included. In the first step of this analysis, we
controlled for the effects of age, race, education, and
employment. The second step included social norms,
social support, substance use, and trading sex. The x2
likelihood ratio determined the overall significance of
the model. In addition, the Wald statistic identified
which predictor variables made a significant impact
on the dependent variable after controlling for age
and race. To examine the potential differences
between the two serostatus groups, we tested an
identical model which included only those who
reported to be HIV -negative. Identical test statistics
used for the previous analyses were employed to
determine the significance of the model and the
impact of each individual predictor variable on the
dependent variable. In exploring the differences
between the two models, we analyzed the model fit
of the data, the direction of effects, and whether the
models had similar strength.
Table 1 displays characteristics of the study sample
and compares those who reported to be HIV -positive
to those who reported to be HIV -negative. HIV-
positive men were significantly more likely to be
older, to be African-American (41 %) or Hispanic
(35%), and to be unemployed when compared with
their HIV-negative peers (78% vs. 86%).
As shown in Table 2, HIV -positive men were
more likely to have traded sex within the past year
when compared with HIV -negative MSM although
the relationship was only marginally significant
(p =0.056). In addition, having sex while intoxicated
was also more common among these men within
sexual encounters with main partners. HIV -positive
men were considerably more likely to report a main
and/or non-main partner with an unknown or
discordant HIV status when compared with the
HIV -negative group. HIV -positive men were also
more likely to report greater treatment optimism
and had UAI with a greater number of partners
when compared with their HIV -negative peers.
For the first logistic regression analysis, only HIV-
positive MSM were included. As seen in Table 3, the
predictors, as a set, reliably distinguished between
those HIV-positive men engaging in U AI and those
who did not report UAI. According to Wald criter-
ion, both peer norms and social support were
associated with avoidance of UAI. Young MSM
reporting positive peer norms for condom use were
1.13 times less likely to have engaged in UAI than
those who lacked positive peer norms. Also, those
who reported high levels of social support for safer
sex were 1.17 times more likely to have abstained
from UAI than those with low levels of social support
for safer sex.
As shown in Table 4, an identical logistic regres-
sion analysis with only the HIV -negative respondents
included 7270 sexually active men. As seen in Table 4,
the full model significantly predicted UAI. Being
Black or Hispanic was associated with avoiding UAI.
In addition, HIV -negative men who had sex with
either a serodiscordant main or non-main partner
were more likely to avoid UAI. HIV-negative men
who had positive peer norms for condom use were
1.12 times less likely to have UAI than men who had
less positive peer norms.
In comparing the results of two logistic regression
models the only common factor associated with UAI
between the HIV -positive and the HIV -negative
groups was peer norms for condom use. Those
reporting positive peer norms for condoms were less
likely to engage in UAI regardless of HIV status.
Lack of social support for safer sex was a significant
predictor of UAI only for the HIV -positive men. Not
being Black or Latino and having sex with a HIV
discordant partner was a significant predictor of UAI
for the HIV-negative men. Finally, in comparing the
N algelkerke R 2 statistics between the two logistic
regression analyses, the predictor variables better
explain the variance in UAI for the HIV -positive
group than for the HIV -negative group.
Findings from the current study suggest that young
HIV -positive MSM are an important target for
focused prevention interventions and may have
unique needs. Rates of UAI among the HIV -infected
men in our sample were similar to their HIV-negative
peers. In addition, HIV -positive men were signifi-
cantly more likely to have sex with a serodiscordant
partner; 88% of the positives had sex with someone
J.C. Forney et al.
Table 2. High risk sexual behaviors of HIV-negative young men who have sex with men vs. those are HIV-positive.
Within past year
Traded sex (N = 8375)
Past 3 months
Unprotected anal intercourse (UAI) with men (N =7538)
UAI or UVI with women (1003)
UAI with main partners (N = 6152)
UAI with non-main partners (N = 5969)
Sex while high wjmain partners (N =6167)
Sex while high wjnon-main partners (N = 5990)
Seroconcordance with main partners (N =6162)
Seroconcordance with non-main partners (N = 5978)
Seroconcordance with both main and non-main partner (N = 8341)
Number of male partners without a condom in past 3 months (N =8295)
alnsufficient cell size prohibited analysis on this variable.
*p <0.10; **p <0.05; ***p <0.01.
who they believed to be HIV-negative or of unknown
status while only 49% of the HIV -negatives had sex
with an HIV -positive or unknown status partner.
Furthermore, serodiscordance with sexual partners
did not impact condom use among the HIV -positive
men. These high rates of discordant relationships may
be attributed to the fact HIV -negative people far
outnumber those who are HIV -positive in any given
sub-group and HIV -infected young men therefore
draw from a smaller pool of sexual partners. None-
theless, these findings are alarming smce young
seropositive men are not only having unprotected
sex but they are also doing so with uninfected peers
thereby contributing to the epidemic within this
Although rates of UAI were unrelated to HIV
status, we found several differences between serosta-
tus groups with regard to other sexual risk behaviors.
Consistent with prior studies, HIV -positive men were
more likely to have engaged in UAI and with more
partners in the prior 3 months when compared with
those who reported to be HIV-negative (Hays et al.,
AIDS Care 549
Table 3. Sequential logistic regression analysis predicting avoidance of unprotected anal intercourset among HIV-positive
young men who have sex with men (N = 146).
95% CI 95% CI
Wald Odds ratio Lower Upper
Wald Odds ratio Lower Upper
Model x2 ( df)
-2 Log likelihood
*p <0.05; **p <0.01.
1997; Valleroy et al., 2000). Also, similar to the
findings reported by Huba et al. (2000), those who
reported an HIV seropositive status were more likely
to have had sex while under the influence of alcohol
or drugs. HIV -positive men may use substances
during sex to increase sexual performance and
pleasure (Kalichman, Weinhardt, DiFonzo, Austin,
& Luke, 2002) or to facilitate avoidant coping
strategies (Malow, West, Corrigan, Pena, & Cunning-
Consistent with previous research, increased peer
norms for safer sex was associated with a decreased
likelihood of engaging in UAI among both the HIV-
positive and HIV -negative men (Stein et al., 2005). It
has been theorized that when a person's group norms
support HIV risk-reduction behavior, normative
processes work to decrease risky sexual behaviors
(Fisher, Misovich, & Fisher, 1992). Young MSM may
participate in UAI because individuals in this age
group are highly sensitive to peer influences (Fisher,
1988; Fisher & Misovich, 1990). Among the differ-
ences between the two groups, social support for safer
sex was predictive of lower rates of UAI among only
the HIV -positive men. Only one previous study has
explored the influence of HIV -specific social support
among young HIV-positive MSM (Naar-King et al.,
2006). Increased social support may play a role in
sexual behaviors for positive, but not negative men
for a number of reasons. First, men who have social
support for safer sex may receive informational
support concerning condom use and strategies for
negotiating safer sex. In turn, these individuals may
experience increased self-efficacy. For example, Naar-
King et al. (2006) found that social support leads to
greater self-efficacy, which resulted in safer sexual
behaviors among HIV-infected young men. Second,
having family and friends involved in the sexual
decision-making of these men may influence HIV-
positive men to take the personal responsibility to
protect the health of their sexual partners. Parsons,
Halkitis, Wolitski, Gomez, & the Seropsoitive Urban
Men's Study Team (2003) found that 25% of adult
HIV -positive men saw themselves as having little
personal responsibility for infecting others. Believing
that my partner is responsible for protecting himself
rather than believing it is my responsibility to protect
him is associated with engaging in sexual risk
behaviors (Wolitski, Flores, O'Leary, Bimbi, &
Gomez, 2007). Thus, social support may deter some
men from having unprotected sex because it makes
personal responsibility more salient.
Several limitations should be considered when inter-
preting the results of this study. First, our data on
HIV -status are self-reported rather than confirmed by
actual HIV test results. Second, our conclusions are
limited by the correlational nature of these data.
Third, the number of young men reporting them-
selves as HIV -positive is small relative to the number
of young men in the sample who are HIV -negative,
limiting power to detect differences between the two
550 J.C. Forney et al.
Table 4. Sequential logistic regression analysis predicting avoidance of unprotected anal intercourse among HIV-negative
young men who have sex with men (N =7270).
Step I Step 2
Model x2 ( df)
-2 Log likelihood
*p <0.05; **p <0.01.
Implications for prevention
In 2003, the CDC emphasized the need to target HIV-
infected individuals for prevention in their Advancing
HIV Prevention plan (CDC, 2003) and recently
developed evidence-based programs have made cru-
cial advances in helping HIV -positive individuals
adopt safer sexual practices (Crepaz et al., 2006).
However, preventative initiatives for young men have
not differentiated HIV -negative and HIV -positive
men. Interventions are needed for all age groups of
HIV -positive MSM, who may differ from adult
MSM, just as they do from their HIV -negative peers.
Future research on the developmental, cultural, and
social needs of this population reflects an urgent
The CITY Project was a multi-site cooperative agreement
funded by the Centers for Disease Control and Prevention.
The CITY Project Study Team is: John L. Peterson, Ph.D.
and Derrick Reese, M.P.H. (Georgia State University,
Atlanta); Leslie Clark, Ph.D., (now at University of South-
ern California, Los Angeles) Patrick Packer, and Charles
Collins, Ph.D., (now at Centers for Disease Control and
Prevention) (University of Alabama at Birmingham);
Robin Lin Miller, Ph.D. (now at Michigan State Univer-
sity) and Joseph P. Stokes, Ph.D. (University of Illinois at
Chicago); Wesley Ford, M.P.H. (Los Angeles County
Department of Health Services), Ellen Iverson, M.P.H.,
George Weiss, and Arthur Durazo (Children's Hospital,
Wald Lower Upper
Los Angeles); David W. Seal, Ph.D., Jeffrey A. Kelly,
Ph.D., Anton Somlai, Ed.D., Yvonne Stevenson, and Mike
Brondino (Medical College of Wisconsin, Milwaukee);
Gary Remafedi, M.D. (University of Minnesota, Minnea-
polis); Lydia O'Donnell, Ed.D., Ann Stueve, Ph.D., Alexi
San Doval, M.P.H. and Richard Duran, M.S.W. (Educa-
tion Development Center, Newton, Massachusetts);
Kyung-Hee Choi, Ph.D. and Eugene Kumekawa, Ph.D.
(University of California, San Francisco); Esther Sumarto-
jo, Ph.D., Carolyn Guenther-Grey, Sandra Wright-Fofa-
nah, M.P.H., Lillian S. Lin, Ph.D., Joan Kraft, Ph.D.,
Sherri Varnell, Ph.D., and DeMarc Hickson, Ph.D. (Cen-
ters for Disease Control and Prevention).
Bacon, 0., Lum, P., Hahn, J., Evans, J., Davidson, P.,
Moss, A., & Page-Shafer, K. (2006). Commercial sex
work and risk of HIV infection among young drug-
injecting men who have sex with men in San Francisco.
Sexually Transmitted Diseases, 33(4), 228-234.
Bailey, S.L., Camlin, C.S., & Ennett, S.T. (1998). Substance
use and risky sexual behavior among homeless and
runaway youth. Journal of Adolescent Health, 23(6),
Barta, W.D., Tennen, H., & Kiene, S.M. (2010). Alcohol-
involved sexual risk behavior among heavy drinkers
living with HIV /AIDS: Negative affect, self-efficacy,
and sexual craving. Psychology of Addictive Behaviors,
Centers for Disease Control and Prevention [CDC]. (2003).
Advancing HIV prevention: New strategies for a
changing epidemic - United States, 2003. Journal of
the American Medical Association, 289(19), 2493-2495.
Centers for Disease Control and Prevention [CDC] (2009).
HIV /AIDS surveillance report: Diagnoses of HIV
infection and AIDS in the United States and depen-
dent Areas, 2009, 21.
Choi, K.H., Coates, T.J., Catania, J.A., Lew, S., &
Chow, P. (1995). High HIV risk among gay and Asian
and Pacific Islander men in San Francisco. AIDS, 9(3),
Cohen, S. ( 1988). Psychosocial models of the role of social
support in the etiology of physical disease. Health
Psychology, 7(3), 269-297.
Crepaz, N., Lyles, C.M., Wolitski, R.J., Passin, W.F.,
Rama, S.M., Herbst, J.H., ... Team, H.A.P. (2006).
Do prevention interventions reduce HIV risk beha-
viours among people living with HIV? A meta-analytic
review of controlled trials. AIDS, 20(2), 143-157.
Crepaz, N., & Marks, G. (2002). Towards an understanding
of sexual risk behavior in people living with HIV: A
review of social, psychological, and medical findings.
AIDS, 16(2), 135-149.
Fisher, J.D. (1988). Possible effects of reference group-
based social influence on AIDS-risk behavior and
Fisher, J.D., & Misovich, S.J. (1990). Social influence
and AIDS-preventive behavior. In J. Edwards, R.S.
Tindale, L. Heath, & E.J. Posavac (Eds.), Social
influence processes and prevention (pp. 39-70). New
Fisher, J.D., Misovich, S., & Fisher, W. (1992). Impact of
perceived social norms on adolescents' AIDS-risk
behavior and prevention. In R.J. DiClemente (Ed.),
Adolescents and AIDS: A Generation in Jeopardy
(pp. 117-136). Newbury Park, CA: Sage.
Forrest, D.W., Metsch, L.R., LaLota, M., Cardenas, G.,
Beck, D.W., & Jeanty, Y. (2010). Crystal methamphe-
tamine use and sexual risk behaviors among HIV-
positive and HIV-negative men who have sex with men
in south Florida. Journal of Urban Health-Bulletin of
the New York Academy of Medicine, 87(3), 480-485.
doi: 10.1007 jsll524-009-9422-z
Greene, J.M., Ennett, S.T., & Ringwalt, C.L. (1999).
Prevalence and correlates of survival sex among run-
away and homeless youth. American Journal of Public
Health, 89(9), 1406-1409.
Halcaon, L.L., & Lifson, A.R. (2004). Prevalence and
predictors of sexual risks among homeless youth.
Journal of Youth and Adolescence, 33(1), 71-80.
Harawa, N.T., Greenland, S., Bingham, T.A., Johnson,
D.F., Cochran, S.D., Cunningham, W.E., ... Valleroy,
L.A. (2004). Associations of racejethnicity with HIV
prevalence and HIV-related behaviors among young
men who have sex with men in 7 urban centers in the
United States. ]aids-Journal of Acquired Immune
Deficiency Syndromes, 35(5), 526-536.
Hays, R.B., Paul, J., Ekstrand, M., Kegeles, S.M., Stall, R.,
& Coates, T.J. (1997). Actual versus perceived HIV
status, sexual behaviors and predictors of unprotected
AIDS Care 551
sex among young gay and bisexual men who identify as
HIV-negative, HIV-positive and untested. AIDS,
Hein, K., Dell, R., Futterman, D., Rotheram-Borus, M.J.,
& Shaffer, N. (1995). Comparison of HIV positive and
HIV negative adolescents: Risk factors and psychoso-
cial determinants. Pediatrics, 95(1), 96-104.
Hirshfield, S., Remien, R.H., Humberstone, M., Walavalk-
ar, 1., & Chiasson, M.A. (2004). Substance use and
high-risk sex among men who have sex with men: A
national online study in the USA. AIDS Care, 16(8),
Huba, G.J., Melchior, L.A., Panter, A.T., Trevithick, L.,
Woods, E.R., Wright, E., ... Singer, B. (2000). Risk
factors and characteristics of youth living with, or at
high risk for, HIV. Aids Education and Prevention,
Hurt, C.B., Torrone, E., Green, K., Foust, E., Leone, P., &
Hightow-Weidman, L. (2010). Methamphetamine use
among newly diagnosed HIV-positive young men in
North Carolina, United States, from 2000 to 2005.
PloS one, 5(6), 273-277.
Kalichman, S.C., Kelly, J.A., & St Lawrence, J.S. (1990).
Factors influencing reduction of sexual risk behaviors
for human immunodeficiency virus infection: A review.
Annals of Sex Research, 3(2), 129-148.
Kalichman, S.C., Weinhardt, L., DiFonzo, K., Austin, J.,
& Luke, W. (2002). Sensation seeking and alcohol use
as markers of sexual transmission risk behavior in
HIV-positive men. Annals of Behavioral Medicine,
Kral, A.H., Lorvick, J., Ciccarone, D., Wenger, L., Gee, L.,
Martinez, A., & Edlin, B.R. (2005). HIV prevalence
and risk behaviors among men who have sex with men
and inject drugs in San Francisco. Journal of Urban
Health-Bulletin of the New York Academy of Medicine,
Lauby, J.L., Millett, G.A., LaPollo, A.B., Bond, L.,
Murrill, C.S., & Marks, G. (2008). Sexual risk beha-
viors of HIV-positive, HIV-negative, and serostatus-
unknown Black men who have sex with men and
women. Archives of Sexual Behavior, 37(5), 708-719.
Malow, R.M., West, J.A., Corrigan, S.A., Perra, J.M., &
Cunningham, S.C. (1994). Outcome of psychoeduca-
tion for HIV risk reduction. AIDS Education &
Prevention, 6(2), 113-125.
Mansergh, G., McKirnan, D.J., Flores, S.A., Hudson,
S.M., Koblin, B.A., Purcell, D.W., & Colfax, G.N.
(2010). HIV-related attitudes and intentions for high-
risk, substance-using men who have sex with men:
Associations and clinical implications for HIV-Positive
and HIV-Negative MSM. Journal of Cognitive
Psychotherapy, 24( 4), 281-293.
Miller, R.L. (1995). Assisting gay men to maintain safer
sex: An evaluation of an AIDS service organization's
safer sex maintenance program. AIDS Education and
Prevention, 7(5), 48-63.
Miner, M.H., Peterson, J.L., Welles, S.L., Jacoby, S.M., &
Rosser, B.R.S. (2009). How do social norms impact
HIV sexual risk behavior in HIV-positive men who
552 J.C. Forney et al. Download full-text
have sex with men? Multiple mediator effects. Journal
of Health Psychology, 14(6), 761-770.
Muhib, F.B., Lin, L.S., Stueve, A., Miller, R.L., Ford,
W.L., Johnson, W.D., ... Community Intervention
Trial (2001). A venue-based method for sampling hard-
to-reach populations. Public Health Reports, 116, 216-
Myers, H.F., Javanbakht, M., Martinez, M., & Obediah, S.
(2003). Psychosocial predictors of risky sexual beha-
viors in African American men: Implications for
prevention. AIDS Education and Prevention, 15( I),
Naar-King, S., Wright, K., Parsons, J., Frey, M., Templin,
T., & Ondersma, S. (2006). Transtheoretical model
and condom use in HIV-positive youths. Health
Psychology, 25(5), 648-652.
Ostrow, D.-G., McKirnan, D., Klein, C., & DiFranceisco,
W. (1999). Patterns and correlates of risky behavior
among HIV positive gay men: Are they really different
from HIV negative men? AIDS and Behavior, 3(2), 99-
Parsons, J.T., Halkitis, P.N., Wolitski, R.J., Gomez, C.A.,
& Seropositive Urban Men's Study (2003). Correlates
of sexual risk behaviors among HIV-positive men who
have sex with men. AIDS Education & Prevention,
Pfeifer, R.W., & Oliver, J. (1997). A study of HIV
seroprevalence in a group of homeless youth in Holly-
wood, California. Journal of Adolescent Health, 20(5),
Shuper, P.A., Joharchi, N., Irving, H., & Rehm, J. (2009).
Alcohol as a correlate of unprotected sexual behavior
among people living with HIV /AIDS: Review and
meta-analysis. AIDS and Behavior, 13(6), 1021-1036.
Somlai, A.M., Kalichman, S.C., & Bagnall, A. (2001). HIV
risk behaviour among men who have sex with men in
public sex environments: An ecological evaluation.
AIDS Care, 13(4), 503-514.
Stall, R., & Purcell, D.W. (2000). Intertwining epidemics: A
review of research on substance use among men who
have sex with men and its connection to the AIDS
epidemic. AIDS and Behavior, 4(2), 181-192.
Stein, J.A., Rotheram-Borus, M.J., Swendeman, D., &
Milburn, N.G. (2005). Predictors of sexual transmis-
sion risk behaviors among HIV-positive young men.
AIDS Care, 17(4), 433-442.
Valleroy, L.A., MacKellar, D.A., Karon, J.M., Rosen,
D.H., McFarland, W., Shehan, D.A., ... Young Mens
Survey Study (2000). HIV prevalence and associated
risks in young men who have sex with men. lAMA-
Journal of the American Medical Association, 284(2),
Williamson, L.M., Dodds, J.P., Mercey, D.E., Hart, G.J.,
& Johnson, A.M. (2008). Sexual risk behaviour and
knowledge of HIV status among community samples
of gay men in the UK. AIDS, 22(9), 1063.
Wolitski, R.J., Flores, S.A., O'Leary, A., Bimbi, D.S., &
Gomez, C.A. (2007). Beliefs about personal and
partner responsibility among HIV-seropositive men
who have sex with men: Measurement and association
with transmission risk behavior. AIDS & Behavior,