Hughes getting in early 23.6 cp

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  • For those who don’t know much about New Zealand… population 4.2 million Make point about NZ being a low prevalence country eg. Around 21 locally-acquired diagnoses among MSM between 1997-2001, although it has been rising recently, particularly since 2002. Make point about NZ having a “condom programme” … elaborate e.g. 1987. Normative i.e. condoms for anal sex is expected Reflex i.e. it’s a reflex action, habitual, instinctive, like seatbelt wearing Universal i.e. applies in all contexts (positive/unknown/negative; casual / regular…) a population-wide “contract” Given the centrality of the condom programme in NZ, obviously we’re interested in whether condom use has changed over time, and we thought that the context of first anal sex is particularly interesting because it might tell us things about msm populational norms Because we’re interested in the concept of condom maintenance/stickiness, we also want to explore whether condom use at first sex predicted condom use at later sex.
  • The data comes from a self-completed regular behavioural surveillance programme among MSM, with an online component that was added in 2006. The same questionnaire was used both offline and online, total n=3369 My colleague Peter Saxton presented on this in the previous session.
  • Information on first anal sex was acquired through three basic questions in these studies - by asking the year that respondents first had anal sex, whether a condom was used on that occasion, and what the modality was.
  • Just before we get into the condom use findings, here’s what we found on the actual year of first anal sex, with the first bar representing respondents who had their first anal sex in 1975 or before. You can also see that a lot of people in the studies first had anal sex relatively recently, which probably reflects the current age of our sexually active respondents.
  • MORE TIME… Of particular interest is the observation that over half of our respondents had had their first experience of anal sex in the post-haart era, i.e. in the last ten years. As an aside, this has clear implications for prevention programme design… because it means a lot of msm had their first anal sex at a time when infection with HIV meant something clinically different, that is, first anal sex for these two groups has taken place in a different HIV context. Comparing condom use at first sex pre-haart and post-haart is interesting because it provides an alternative measure of whether the condom culture is “fracturing”. Possible reasons for this: Peer-based condom promotion has dropped off. Specific condom maintenance programmes have been neglected. Msm are less concerned about HIV risk post-haart. Non-condom use options are increasingly being “marketed” at MSM communities.
  • So, this paper today concentrates on 3 key questions …
  • MORE TIME… As this graph clearly shows, there’s been a substantial increase in condom use at first anal sex over time. This was especially marked during the 1980s, and appeared to level off somewhat post-1996. Overall, it moved from around 6% pre-1976 to 75% in 2005. Also marked on the slide is the year AIDS was first recognised in 1981 and HAART was introduced in 1996. Now this is an extremely good public health result
  • This is the same data presented in 5 year categories, and again you can see the sustained increase over time, which was statistically significant. You can see that this averaged from 29.2% in the 5 years after AIDS was discovered to 74.5% from 2001-2005. So again, the take out point from this is that it is possible to raise population-levels of condom use substantially, but that this doesn’t happen overnight and, speaking as someone who’s been involved in the practical side of HIV prevention for MSM for over 20 years, takes a lot of focussed and sustained effort.
  • Now moving on the second and third parts of the analysis, we want to look at what factors are associated with n on -condom use at first sex, and also whether non-condom use at first sex is related to current outcomes, such as recent condom use, STIs, and attitudes to condoms. Importantly, we’ll be looking at both of these questions in the two time periods we showed you on the earlier graph, i.e. whether first sex occurred pre-haart or post-haart. Note that the sample is different here…
  • So here, we’re looking at factors were associated with non-condom use at first anal sex, apart from of course year of first sex, which we’ve just covered…. (remember talking about 4 variables and time, i.e. down and across) Because this is retrospective study, there are only a limited number of variables that we can examine surrounding the context of first anal sex. They are: Age at first anal sex, ethnicity, modality of first anal sex, and we have also assumed that current sexual identity may also tell us something about sexual identity at first anal sex (p.s we know this last one is problematic) So here we’re looking at what is associated with non-condom use at first anal sex in the two eras mentioned, pre-Haart (1981-1995) and post-Haart (1996-2005). That is, men who had their first anal sex either pre-Haart or post-Haart.
  • And as we can see, non condom use at first sex was associated with younger age of first sex in both periods, ethnicity was marginally associated in both periods, and modality was associated post-HAART only.
  • MORE TIME… Thirdly, we’re going to look at whether non-condom use at first sex is associated with some current health outcomes, the first of which is recent sexual practices. So, here we’re looking at condom use in the last 6 months, and the samples relate to men who had anal sex in these three partner contexts respectively, i.e. casual sex, boyfriend-type regular partners and fuckbuddy-type regular partners (i.e. down) So for example, in the pre-Haart group, 60.6% of respondents who did not use condoms at first sex reported any current unprotected sex with a casual partner in the last 6 months, compared to 35.5% of respondents who used a condom at first sex. That is, men who did not use condoms at first sex then were more likely to not be using condoms now. ( this covers off summary of frequency data ) Adjusting by current age as well did not significantly alter the findings for casual, BF or FB. These results also held for casual sex when looking at site of recruitment (offline/online) in the post-haart era. (Didn’t look at BF or FB). Adjusting by length of relationship did not significantly alter the findings for BF (I thought it might for those who first had anal sex pre-haart, since, being older, their BF-type regular relationships would be of longer duration, and this can be related to current non-use of condoms. Why are the odds ratios larger for post-haart than pre-haart? Probably for at least two reasons. (1) condom use at first anal sex was generally lower pre-haart than post-haart, meaning that those who did not use condoms at first sex post-haart are more likely to be men who were resistant to condoms/could not negotiate condom use. Thus we shouldn’t be surprised that this behaviour (non-condom use then) is more likely to be reflected in non-condom use now. (2) Relatedly, the non-condom use at first sex among the post-haart cohort is more proximal to current behaviour than for the pre-haart men, so again we shouldn’t be surprised to find a closer association between condoms at first sex and condoms at current sex.
  • We’ve highlighted here the odds ratio associated with each of these analyses, and we can see that the relationship between non-condom use at first sex and current non-condom use was statistically significant in all six contexts. That is, this association was maintained across all partnering contexts (i.e. down - casual, boyfriend and fuckbuddy), and also across time (i.e. across first anal sex pre-haart and first sex post-haart). (end of notes) A simple way of interpreting odds ratios is that if the odds ratio and the 95% confidence interval is above 1, that factor (e.g. non-condom use at first sex) is positively associated with the outcome (e.g. recent UAI with casual partner) (i.e. the outcome is more likely to occur if that factor is present), and if it is below 1, it is negatively associated with the outcome (i.e. the outcome is less likely to occur if that factor is present). It is basically a measure of both the direction and the magnitude of the association. Adjusting by current age as well did not significantly alter the findings for casual, BF or FB. These results also held for casual sex when looking at site of recruitment (offline/online) in the post-haart era. (Didn’t look at BF or FB). Adjusting by length of relationship did not significantly alter the findings for BF (I thought it might for those who first had anal sex pre-haart, since, being older, their BF-type regular relationships would be of longer duration, and this can be related to current non-use of condoms. Why are the odds ratios larger for post-haart than pre-haart? Probably for at least two reasons. (1) condom use at first anal sex was generally lower pre-haart than post-haart, meaning that those who did not use condoms at first sex post-haart are more likely to be men who were resistant to condoms/could not negotiate condom use. Thus we shouldn’t be surprised that this behaviour (non-condom use then) is more likely to be reflected in non-condom use now. (2) Relatedly, the non-condom use at first sex among the post-haart cohort is more proximal to current behaviour than for the pre-haart men, so again we shouldn’t be surprised to find a closer association between condoms at first sex and condoms at current sex.
  • And this shows the adjusted odds ratio, controlling for confounding by age of first sex, ethnicity, sexual identity and modality. And we see that the relationship holds when controlling for these factors in all but one of the contexts. (end of notes) Adjusting by current age as well did not significantly alter the findings for casual, BF or FB. These results also held for casual sex when looking at site of recruitment (offline/online) in the post-haart era. (Didn’t look at BF or FB). Adjusting by length of relationship did not significantly alter the findings for BF (I thought it might for those who first had anal sex pre-haart, since, being older, their BF-type regular relationships would be of longer duration, and this can be related to current non-use of condoms. Why are the odds ratios larger for post-haart than pre-haart? Probably for at least two reasons. (1) condom use at first anal sex was generally lower pre-haart than post-haart, meaning that those who did not use condoms at first sex post-haart are more likely to be men who were resistant to condoms/could not negotiate condom use. Thus we shouldn’t be surprised that this behaviour (non-condom use then) is more likely to be reflected in non-condom use now. (2) Relatedly, the non-condom use at first sex among the post-haart cohort is more proximal to current behaviour than for the pre-haart men, so again we shouldn’t be surprised to find a closer association between condoms at first sex and condoms at current sex.
  • Next, we move on to looking at associations between non-condom use at first sex and STI and HIV diagnoses. And you can see for example that in the post-haart first sex group, 11.5% of those who did not use condoms at first anal sex reported a recent STI compared to 7.6% of those who used a condom at first sex.
  • As we can see by the odds ratios, men who didn’t use condoms at first sex in the post-haart era were more likely to have acquired a recent STI and more likely to have acquired a lifetime STI, than men who used a condom at first sex. We also found that this was true for non-condom use pre-haart and lifetime STIs (although this was marginal) Non-condom use at first sex was not related to being diagnosed with HIV either pre-haart or post haart… different to abstract and small numbers (end of notes) (note FYI, the difference in proportion who were diagnosed positive who had their first anal sex pre-haart (both 4.7%) vs post-haart (0.4%-1.3%, the average being 0.6%). This must have implications for prevention – the fact that so few msm who had their first anal sex post-haart have been diagnosed HIV positive). Note this last result differs from the abstract due to a more refined pre-and post-haart analysis – but note also that the frequencies are still different e.g. post haart positive 0.4% vs 1.3%, though this relates to 4 and 5 individuals respectively).
  • These three findings held when adjusted for confounding (end of notes) Adjusting also by current age did not alter significant findings for recent stis or lifetime stis (somewhat surprisingly)
  • Finally, we’ve also looked to see if non-condom use at first sex was associated with later attitudes to condoms. Looking at 3 different attitude statements here. For example, focussing on the third one (I don’t like wearing condoms because they reduce sensitivity…), Just over 50% of those who didn’t use condoms at first anal sex post-Haart later agreed with this statement, compared to a third of those who used a condom at first sex. (End of notes) We didn’t ask about attitudes to condoms before first anal sex, and therefore can’t tell whether someone ALREADY had negative attitudes to condoms. However, the last point is interesting, because it is an attitude statement that relates to the experience of using a condom. i.e. it would seem to be difficult to have formed an opinion about the statement before using a condom. As with the current condom use analysis, the attitudes analysis is also likely to reflect the “proximity” phenomenon, i.e. we shouldn’t necessarily be that surprised to find that men who first had sex post-haart (in the last 10 years) and who didn’t use condoms, were more likely to report negative attitudes to condoms now … (pre-haart of course we hadn’t done as much condom promotion too)
  • Looking again at the odds ratios, we can see here that non-use of condoms at first sex was associated with more negative attitudes to condoms currently, for each of the condom attitude statements (down) and for both pre-haart and post-haart first sex (across).
  • These findings all remained significant when controlling for confounding. (End of notes) Obviously in the ideal world we would have data on other factors surrounding the context of first anal sex e.g. pressured sex, age disparity in partnering , sensation seeking etc but we don’t…
  • Main finding (bullet point 1) We also found that (bullet point 2) And interestingly, (bullet point 3) Finally, (bullet point 4)
  • MORE TIME… We think these findings have both prevention and research implications… Point 1 – As our first results on condom use at first sex over time demonstrate, lifting condom use in the MSM population takes a long time and requires action at many different levels. i.e it’s about building. Point 2 – Once raised, maintaining condom use takes specific effort and ground can easily be lost by neglect. What our data has also suggested is that there may be a habitual component to condom use, and from the point of view of prevention, condom maintenance requires specific dedicated programmes. This is important, it has been about making condom use the norm, instilling it as “habit”, and increasing msm’s familiarity with condoms. Concept of “stickiness”. Point 3 – In the context of research, the condom maintenance problem focussing research on condom use rather than non-use. i.e. it’s a different orientation to the problem. Point 4 - On its own , condom use at first sex is a useful alternative indicator of trends in safe sex norms … especially if your prevention programme is aiming to raise condom use up to a certain level and then maintain it over time. Point 5 - In conjunction with measures of later condom use, it provides additional capacity to examine patterns of condom maintenance. In other words, condom use at first anal sex is a useful tracking question – particularly in post-haart era (and online e.g. barebacking) when a variety of non-condom use approaches to prevention are being circulated. Basically, if we’re losing it at first sex, it may be that we’re well on the way to losing it big time elsewhere!
  • Hughes getting in early 23.6 cp

    1. 1. Getting in early: Condom use at first anal sex between males is associated with better current health outcomes Tony Hughes ¹ Peter Saxton ¹ ² Nigel Dickson ² Katrina Sharples ² ¹ Research, Analysis and Information Unit, New Zealand AIDS Foundation. ² Department of Preventive and Social Medicine, University of Otago, Dunedin. AIDS Impact Conference 1-4 July 2007 Marseille, France
    2. 2. <ul><li>NZ low prevalence of HIV diagnoses among MSM </li></ul><ul><li>Condom-centred programme for MSM from 1987 </li></ul><ul><ul><li>Normative </li></ul></ul><ul><ul><li>Reflex </li></ul></ul><ul><ul><li>Universal </li></ul></ul><ul><li>Has condom use for first anal sex changed over time? </li></ul><ul><li>Does condom use at first sex predict condom use at later sex? </li></ul>New Zealand
    3. 3. Behavioural surveillance studies <ul><li>Offline </li></ul><ul><ul><li>Gay Auckland Periodic Sex Survey (GAPSS) </li></ul></ul><ul><ul><li>Every 2 years (n=1228 in 2006) </li></ul></ul><ul><ul><li>Fair day, saunas/sex-on-site, bars </li></ul></ul><ul><ul><li>Response rate ~70% </li></ul></ul><ul><li>Online </li></ul><ul><ul><li>Gay men’s Online Sex Survey (GOSS) </li></ul></ul><ul><ul><li>Added in 2006 (n=2141 in 2006) </li></ul></ul><ul><ul><li>Internet dating sites </li></ul></ul><ul><li>Same questionnaire (total n=3369) </li></ul>
    4. 4. Questions on first anal sex <ul><li>Asked the year of first anal sex (92.5% had anal sex) </li></ul><ul><li>Whether condom used? (Y/N) </li></ul><ul><li>Modality of first anal sex? (I/R/Both) </li></ul>
    5. 5. Year of first anal sex n=2989
    6. 6. Year of first anal sex Pre-HAART Post-HAART 54.5% of sample 45.5% of sample n=2989
    7. 7. Key questions: <ul><li>Has condom use at first anal sex changed over time? </li></ul><ul><li>What is associated with non-condom use at first anal sex? </li></ul><ul><li>Whether non-condom use at first anal sex is related to current outcomes? </li></ul>
    8. 8. 1. Has condom use at first anal sex changed over time? AIDS identified % used condom at first anal sex HAART n=2834
    9. 9. 1. Has condom use at first anal sex changed over time? * p<0.001 * 25.5 28.8 33.1 48.1 70.8 81.9 93.5 No 74.5 71.2 66.9 51.9 29.2 18.1 6.5 Yes 2001-2005 (n=815) 1996-2000 (n=701) 1991-1995 (n=335) 1986-1990 (n=289) 1981-1985 (n=226) 1976-1980 (n=188) < 1976 (n=232) Condom used at first sex (%) Period during which first anal sex occurred
    10. 10. Next two parts of the analysis: <ul><li>What is associated with non-condom use at first sex </li></ul><ul><ul><li>( Pre-HAART 1981-1995 vs Post-HAART 1996-2005 ) </li></ul></ul><ul><li>Whether non-condom use at first sex is related to current outcomes </li></ul><ul><ul><li>( Pre-HAART 1981-1995 vs Post-HAART 1996-2005 ) </li></ul></ul>
    11. 11. Sample reduced to MSM for whom: <ul><li>First anal sex occurred between 1981 and 2005 (HIV era) </li></ul><ul><li>Age at first anal sex was ≥ 12yrs old </li></ul><ul><li>n=2266 </li></ul>
    12. 12. 2. What is associated with non-condom use at first sex? 24.6 48.8 Both receptive and insertive 23.2 42.9 Insertive only 0.036 29.8 0.505 46.1 Modality Receptive only 38.0 62.1 Other 34.8 54.2 Asian 36.8 66.7 Pacific 27.7 37.8 Maori 0.054 25.1 0.053 45.3 Ethnicity NZ European 25.3 42.6 Bisexual 0.668 27.1 0.421 46.7 Sexual identity Gay 24.8 41.4 40+ 21.6 38.9 35-39 17.9 34.6 30-34 20.8 36.7 25-29 28.5 44.2 20-24 26.4 43.9 16-19 0.006 35.4 <0.001 66.7 Age at first sex 12-15 X 2 p-value % X 2 p-value % Post-HAART Pre-HAART
    13. 13. 2. What is associated with non-condom use at first sex? 24.6 48.8 Both receptive and insertive 23.2 42.9 Insertive only 0.036 29.8 0.505 46.1 Modality Receptive only 38.0 62.1 Other 34.8 54.2 Asian 36.8 66.7 Pacific 27.7 37.8 Maori 0.054 25.1 0.053 45.3 Ethnicity NZ European 25.3 42.6 Bisexual 0.668 27.1 0.421 46.7 Sexual identity Gay 24.8 41.4 40+ 21.6 38.9 35-39 17.9 34.6 30-34 20.8 36.7 25-29 28.5 44.2 20-24 26.4 43.9 16-19 0.006 35.4 <0.001 66.7 Age at first sex 12-15 X 2 p-value % X 2 p-value % Post-HAART Pre-HAART
    14. 14. 3. Is non-condom use at first sex associated with non-condom use now? 1 Adjusted for age at first anal sex, ethnicity, identity, modality 3.7 (1.9-7.2) 2.8 (1.2-6.5) Adj 1 3.8 (2.0-7.1) 69.2 2.3 (1.1-4.9) 61.9 Did not use condom at first sex 1 37.2 1 41.1 Used condom at first sex Any unprotected sex with regular “fuckbuddy” <6 mths 2.9 (1.5-5.6) 2.1 (0.9-4.6) Adj 1 2.8 (1.5-5.2) 87.3 2.0 (1.01-4.1) 85.0 Did not use condom at first sex 1 71.3 1 73.5 Used condom at first sex Any unprotected sex with regular “boyfriend” <6 mths 3.9 (2.8-5.5) 2.9 (1.9-4.3) Adj 1 3.9 (2.8-5.4) 67.1 2.8 (1.9-4.1) 60.6 Did not use condom at first sex 1 34.3 1 35.5 Used condom at first sex Any unprotected sex with casual partner < 6 mths Odds ratio % Odds ratio % Post-HAART Pre-HAART
    15. 15. 3. Is non-condom use at first sex associated with non-condom use now? 1 Adjusted for age at first anal sex, ethnicity, identity, modality 3.7 (1.9-7.2) 2.8 (1.2-6.5) Adj 1 3.8 (2.0-7.1) 69.2 2.3 (1.1-4.9) 61.9 Did not use condom at first sex 1 37.2 1 41.1 Used condom at first sex Any unprotected sex with regular “fuckbuddy” <6 mths 2.9 (1.5-5.6) 2.1 (0.9-4.6) Adj 1 2.8 (1.5-5.2) 87.3 2.0 (1.01-4.1) 85.0 Did not use condom at first sex 1 71.3 1 73.5 Used condom at first sex Any unprotected sex with regular “boyfriend” <6 mths 3.9 (2.8-5.5) 2.9 (1.9-4.3) Adj 1 3.9 (2.8-5.4) 67.1 2.8 (1.9-4.1) 60.6 Did not use condom at first sex 1 34.3 1 35.5 Used condom at first sex Any unprotected sex with casual partner < 6 mths Odds ratio % Odds ratio % Post-HAART Pre-HAART
    16. 16. 3. Is non-condom use at first sex associated with non-condom use now? 1 Adjusted for age at first anal sex, ethnicity, identity, modality 3.7 (1.9-7.2) 2.8 (1.2-6.5) Adj 1 3.8 (2.0-7.1) 69.2 2.3 (1.1-4.9) 61.9 Did not use condom at first sex 1 37.2 1 41.1 Used condom at first sex Any unprotected sex with regular “fuckbuddy” <6 mths 2.9 (1.5-5.6) 2.1 (0.9-4.6) Adj 1 2.8 (1.5-5.2) 87.3 2.0 (1.01-4.1) 85.0 Did not use condom at first sex 1 71.3 1 73.5 Used condom at first sex Any unprotected sex with regular “boyfriend” <6 mths 3.9 (2.8-5.5) 2.9 (1.9-4.3) Adj 1 3.9 (2.8-5.4) 67.1 2.8 (1.9-4.1) 60.6 Did not use condom at first sex 1 34.3 1 35.5 Used condom at first sex Any unprotected sex with casual partner < 6 mths Odds ratio % Odds ratio % Post-HAART Pre-HAART
    17. 17. 3. Is non-condom use at first sex associated with later STI and HIV acquisition? 1 Adjusted for age at first anal sex, ethnicity, identity, modality - - Adj 1 3.5 (0.9-13.0) 1.3 1.0 (0.5-2.0) 4.7 Did not use condom at first sex 1 0.4 1 4.7 Used condom at first sex Was later diagnosed with HIV 1.6 (1.2-2.0) 1.4 (1.1-1.9) Adj 1 1.5 (1.2-1.9) 34.6 1.3 (0.99-1.8) 54.8 Did not use condom at first sex 1 26.3 1 47.8 Used condom at first sex Reported STI in lifetime 1.7 (1.1-2.5) 1.5 (0.9-2.6) Adj 1 1.5 (1.04-2.3) 11.5 1.3 (0.8-2.2) 9.6 Did not use condom at first sex 1 7.6 1 7.3 Used condom at first sex Reported STI in previous 12 mths Odds ratio % Odds ratio % Post-HAART Pre-HAART
    18. 18. 3. Is non-condom use at first sex associated with later STI and HIV acquisition? 1 Adjusted for age at first anal sex, ethnicity, identity, modality - - Adj 1 3.5 (0.9-13.0) 1.3 1.0 (0.5-2.0) 4.7 Did not use condom at first sex 1 0.4 1 4.7 Used condom at first sex Was later diagnosed with HIV 1.6 (1.2-2.0) 1.4 (1.1-1.9) Adj 1 1.5 (1.2-1.9) 34.6 1.3 (0.99-1.8) 54.8 Did not use condom at first sex 1 26.3 1 47.8 Used condom at first sex Reported STI in lifetime 1.7 (1.1-2.5) 1.5 (0.9-2.6) Adj 1 1.5 (1.04-2.3) 11.5 1.3 (0.8-2.2) 9.6 Did not use condom at first sex 1 7.6 1 7.3 Used condom at first sex Reported STI in previous 12 mths Odds ratio % Odds ratio % Post-HAART Pre-HAART
    19. 19. 3. Is non-condom use at first sex associated with later STI and HIV acquisition? 1 Adjusted for age at first anal sex, ethnicity, identity, modality - - Adj 1 3.5 (0.9-13.0) 1.3 1.0 (0.5-2.0) 4.7 Did not use condom at first sex 1 0.4 1 4.7 Used condom at first sex Was later diagnosed with HIV 1.6 (1.2-2.0) 1.4 (1.1-1.9) Adj 1 1.5 (1.2-1.9) 34.6 1.3 (0.99-1.8) 54.8 Did not use condom at first sex 1 26.3 1 47.8 Used condom at first sex Reported STI in lifetime 1.7 (1.1-2.5) 1.5 (0.9-2.6) Adj 1 1.5 (1.04-2.3) 11.5 1.3 (0.8-2.2) 9.6 Did not use condom at first sex 1 7.6 1 7.3 Used condom at first sex Reported STI in previous 12 mths Odds ratio % Odds ratio % Post-HAART Pre-HAART
    20. 20. 3. Is non-condom use at first sex associated with later attitudes to condoms? 1 Adjusted for age at first anal sex, ethnicity, identity, modality 2.2 (1.7-2.8) 2.5 (1.8-3.4) Adj 1 2.0 (1.6-2.6) 50.3 2.3 (1.7-3.0) 54.0 Did not use condom at first sex 1 33.3 1 34.3 Used condom at first sex AGREE that “ I don’t like wearing condoms because they reduce sensitivity” 3.7 (2.6-5.1) 2.8 (1.8-4.3) Adj 1 3.6 (2.6-4.9) 23.0 2.8 (1.8-4.3) 21.4 Did not use condom at first sex 1 7.7 1 8.9 Used condom at first sex AGREE that “I’d sometimes rather risk HIV transmission than use a condom during anal sex” 4.4 (2.5-7.5) 3.2 (1.6-6.4) Adj 1 4.2 (2.5-7.0) 9.2 3.0 (1.6-5.6) 9.4 Did not use condom at first sex 1 2.4 1 3.4 Used condom at first sex DISAGREE that “ condoms are ok as part of sex” Odds ratio % Odds ratio % Post-HAART Pre-HAART
    21. 21. 3. Is non-condom use at first sex associated with later attitudes to condoms? 1 Adjusted for age at first anal sex, ethnicity, identity, modality 2.2 (1.7-2.8) 2.5 (1.8-3.4) Adj 1 2.0 (1.6-2.6) 50.3 2.3 (1.7-3.0) 54.0 Did not use condom at first sex 1 33.3 1 34.3 Used condom at first sex AGREE that “ I don’t like wearing condoms because they reduce sensitivity” 3.7 (2.6-5.1) 2.8 (1.8-4.3) Adj 1 3.6 (2.6-4.9) 23.0 2.8 (1.8-4.3) 21.4 Did not use condom at first sex 1 7.7 1 8.9 Used condom at first sex AGREE that “I’d sometimes rather risk HIV transmission than use a condom during anal sex” 4.4 (2.5-7.5) 3.2 (1.6-6.4) Adj 1 4.2 (2.5-7.0) 9.2 3.0 (1.6-5.6) 9.4 Did not use condom at first sex 1 2.4 1 3.4 Used condom at first sex DISAGREE that “ condoms are ok as part of sex” Odds ratio % Odds ratio % Post-HAART Pre-HAART
    22. 22. 3. Is non-condom use at first sex associated with later attitudes to condoms? 1 Adjusted for age at first anal sex, ethnicity, identity, modality 2.2 (1.7-2.8) 2.5 (1.8-3.4) Adj 1 2.0 (1.6-2.6) 50.3 2.3 (1.7-3.0) 54.0 Did not use condom at first sex 1 33.3 1 34.3 Used condom at first sex AGREE that “ I don’t like wearing condoms because they reduce sensitivity” 3.7 (2.6-5.1) 2.8 (1.8-4.3) Adj 1 3.6 (2.6-4.9) 23.0 2.8 (1.8-4.3) 21.4 Did not use condom at first sex 1 7.7 1 8.9 Used condom at first sex AGREE that “I’d sometimes rather risk HIV transmission than use a condom during anal sex” 4.4 (2.5-7.5) 3.2 (1.6-6.4) Adj 1 4.2 (2.5-7.0) 9.2 3.0 (1.6-5.6) 9.4 Did not use condom at first sex 1 2.4 1 3.4 Used condom at first sex DISAGREE that “ condoms are ok as part of sex” Odds ratio % Odds ratio % Post-HAART Pre-HAART
    23. 23. Summary <ul><li>Condom use at first anal sex increased substantially until mid-to-late 1990s then levelled off </li></ul><ul><li>Non-condom use at first sex clearly associated with younger age at first anal sex, both in pre-HAART and post-HAART first sex periods </li></ul><ul><li>Non-condom use at first sex associated with recent non-use of condoms, both in pre-HAART and post-HAART first sex periods </li></ul><ul><li>Non-condom use at first sex also associated with increased STI risk and current negative attitudes towards condoms </li></ul>
    24. 24. Discussion <ul><li>Lifting condom use in the MSM population takes a long time and requires action at many different levels </li></ul><ul><li>Once raised, maintaining condom use takes specific effort and ground can easily be lost by neglect </li></ul><ul><li>Important to examine reasons for condom use, not just reasons for non -condom use </li></ul><ul><li>On its own, condom use at first sex is a useful alternative indicator of trends in safe sex norms </li></ul><ul><li>In conjunction with measures of later condom use, it provides additional capacity to examine patterns of condom maintenance </li></ul>Prevention Research
    25. 25. Potential limitations <ul><li>Self-report </li></ul><ul><li>Short questionnaire </li></ul><ul><li>Retrospective – lack data surrounding context of first anal sex </li></ul><ul><li>Recall error – though expect less because first anal sex is unique experience </li></ul>
    26. 26. Acknowledgements <ul><li>All offline and online participants (n=3369) </li></ul><ul><li>Co-authors Peter Saxton, Nigel Dickson, Katrina Sharples </li></ul><ul><li>NZ Ministry of Health (funding) </li></ul><ul><li>New Zealand AIDS Foundation (funding and support) </li></ul><ul><li>University of Otago (funding and support) </li></ul>

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