Sex marks the spot: Spatial variation of HIV risk and prevention behaviors among men who have sex with men Open Access

Vaughan, Adam Stephen (2016)

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Place is critical to our understanding of human immunodeficiency virus (HIV) among men who have sex with men (MSM) in the United States. However, within the scientific literature, place is typically represented by residential location, suggesting a fundamental assumption of equivalency between residential neighborhood, place of risk, and place of prevention. The concept of activity spaces, defined as a set of locations to which an individual is routinely exposed, seeks to address this imbalance. In the first study, we examined the completeness and reliability of detailed location data collected from an online sample of MSM. Using an online map tool, participants were generally willing and able to provide accurate data regarding home and non-residential locations. This tool may be used in more nuanced studies of place and behaviors of MSM. In the second study, we used latent class analysis to develop a measure of activity spaces and examined correlates of that measure. Classes were distinguished by the degree of spatial variation in routine and prevention behaviors (which were the same within each class) and in potential sexual risk behaviors (i.e., sex locations and locations of meeting sex partners). Reporting any casual sex partners represented a key correlate of activity space. These patterns of spatial behavior illustrate significant spatial variation in locations of routine, potential HIV sexual risk, and HIV prevention behaviors among MSM. In the third study, we explored associations between activity spaces and two HIV-related behaviors (recent HIV testing and unprotected anal intercourse) among MSM and examined differences in these associations by residential poverty. We found meaningful and significant differences in both behaviors by activity spaces among men living in high poverty areas, but not among men living in low poverty areas. Our findings reinforce the importance of incorporating activity spaces into contextual studies of HIV among MSM. They suggest the need for interventions targeted using more than residential locations, requiring behavioral and disease surveillance systems to collect additional place-based data. Future work should continue to explore the determinants of activity spaces and their relationships to HIV-related behaviors among MSM.

Table of Contents

Chapter 1. Background and Significance 1

HIV Prevalence and Incidence in the United States 1

HIV among MSM 2

Theories and Conceptual Frameworks 3

Associations between Place and Individual HIV-related Behaviors 5

Limitations of Place-Based Studies of HIV 9

Spatial Polygamy and Activity Spaces 11

Specific Dissertation Aims 17

Structure of this Dissertation 18

Chapter 2. Data Sources 19

Sex Marks the Spot Study 19

Area-Level Data 24

Chapter 3. Completeness and reliability of location data collected online: Assessing the quality of self-reported locations in an internet sample of MSM 25

Abstract 25

Publication 26

Introduction 27

Methods 29

Results 36

Discussion 44

Chapter 4. Measuring activity spaces: An analysis of geographic variation in locations of routine, potential sexual risk, and prevention behaviors among men who have sex with men 49

Abstract 49

Publication 50

Introduction 50

Methods 52

Results 58

Discussion 69

Chapter 5. Sex marks the spot: Residential poverty, activity spaces, and sexual risk and HIV testing behaviors among an online sample of men who have sex with men 74

Abstract 74

Publication 74

Background 74

Methods 76

Results 83

Discussion 96

Chapter 6. Conclusion and Future Directions 102

Review of Major Findings 102

Innovation 104

Relevance and Public Health Impact 105

Future Directions 109

References 111

Appendices 137

Appendix A: The Sex Marks the Spot Questionnaire 137

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