Chapter 5: Population-specific HIV/AIDS status report: Gay, bisexual, two-spirit and other men who have sex with men - Current research
Chapter 5 – Current Research on HIV/AIDS among Gay, Bisexual, Two-Spirit, and Other Men who have Sex with Men
This chapter provides an overview of research projects examining HIV/AIDS among gay, bisexual, two-spirit and other men who have sex with men (MSM) in Canada that were underway between 2006 and 2011, or under development at the end of this period. An analysis is provided of research on specific populations of gay and other MSM, as well as determinants of health related to HIV vulnerability and resilience. Potential areas for further research are outlined in the conclusion of the chapter.
The information in this chapter was gathered from national and selected provincial organizations that fund or track HIV/AIDS research. The national funders include the Canadian Association of HIV Research (CAHR), the Canadian Foundation for AIDS Research (CANFAR), the Canadian Institutes of Health Research (CIHR), and the Social Sciences and Humanities Research Council of Canada (SSHRC). Information was also gathered from the Ontario HIV Treatment Network (OHTN), Fonds de recherche du Québec – Société et culture (FQRSC), the Michael Smith Foundation for Health Research, and the British Columbia Centre for Excellence in HIV/AIDS.
Research projects were selected for inclusion in this chapter on the following criteria: were HIV/AIDS specific; conducted in Canada; focused on gay, bisexual, two-spirit, or other MSM; and underway or under development between 2006 and 2011. Community research capacity, research dissemination and knowledge transfer projects were also included if they sought funding for meetings, workshops and conferences on issues related to HIV/AIDS among gay and other MSM, or if their goal was to use research findings to inform program or policy development.
It was assumed that research completed prior to 2006 would have been published and therefore included in the academic and grey literature already reviewed in previous chapters of this report. Given the lag time between research and its publication, some material may not be included in either section. In addition, research funded by the private sector is not included in this report.
Exclusion criteria for this chapter were as follows:
- Research related to basic science, microbiology and/or clinical medicine was excluded.
- Research from international studies conducted abroad by Canadian researchers was excluded, unless the nature of the study provided additional insight into the lived experience of Canadian gay and other MSM.
Projects were coded according to HIV-related themes that emerged from abstracts. These themes were identified on the basis of the goals, objectives and purposes outlined in the abstracts.
A total of 48 current research projects met the criteria described above. Projects are identified in this chapter with a number (e.g., R1) corresponding to the project description listed in Appendix B.
A limitation of the selection strategy is that some projects received grants from more than one organization, or more than one grant in a different year from the same organization. Conversely, some funding was provided to support researcher salaries, student grants, knowledge translation or operating costs. Thus, the same funding source may support more than one project over a successive period of years, where only one project is outlined in the application to the funding source. Although efforts were made to develop a comprehensive list of current Canadian research on HIV/AIDS among gay and other MSM, it is possible that relevant research activities were missed or are duplicated under different project headings.
A second limitation in the selection process is that abstracts and full descriptors were not available for all projects. In some cases, summary information about the project may not have identified gay and other MSM as a population studied nor the subpopulations and priority areas discussed in this chapter and therefore were not included. Projects unaccompanied by abstracts were included in the chapter only when any of the search terms were used in the title or noted as project keywords. Some project descriptions required further information, and, where possible, the principal investigators were contacted to determine whether their projects were specifically related to gay and other MSM in Canada. Projects for which investigators could not be reached were coded according to themes that were indicated by the title. In short, some projects relevant to gay and other MSM may not have been uncovered in the search process due to the limitations of the search strategies, exclusion criteria and the scope of this report.
This section provides an analysis of current research by geographic distribution, major themes, specific subpopulations and vulnerabilities and resiliencies to HIV. It also examines community research capacity, research dissemination and knowledge transfer projects.
As discussed in Chapter 2, available demographic data suggest that the majority of gay and other MSM are concentrated in Ontario, Quebec and British Columbia. As might be expected, more than three quarters of the projects (38 out of 48) identified for this study examine HIV among gay and other MSM in these provinces. Of the 48 projects identified, 18 focus on gay and other MSM in Ontario [R1, R2, R5, R11, R12, R13, R15, R21, R23, R26, R27, R28a/b, R37, R39, R40, R42, R45, R47], including those living in Toronto, Ottawa, London and Kingston. Thirteen focus on gay and other MSM in Quebec, mainly in Montréal [R3, R14, R15, R17, R18, R20, R31, R32, R33, R42, R43, R44, R47]. Seven focus on gay and other MSM in British Columbia [R4, R8, R10, R19, R22, R25, R48]. In addition, one project focuses on gay and other MSM in Manitoba, specifically those living in Winnipeg [R30]. Two of the remaining projects are national in scope [R6, R29]. Although information on the geographical focus of the remaining 10 projects was not available, seven are led by Ontario-based universities or organizations [R9, R16, R24, R35, R36, R41, R46], two in British Columbia [R7, R38] and one in Quebec [R34].
Access to care and treatment strategies, prevention and mental health emerged as major research themes in the projects examined.
As the MSM exposure category continues to account for the highest proportion of new HIV cases in Canada, prevention programs are a key element in the response to HIV/AIDS among gay and other MSM. Thirty-two of the 48 research projects identified focus on HIV prevention among gay and other MSM [R1, R2, R3, R4, R6, R7, R8, R10, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R24, R25, R28a/b, R31, R32, R33, R34, R37, R43, R44, R46, R47, R48].
Projects include those concentrated on vulnerabilities to HIV infection through psychosocial, socio-cognitive and behavioural factors [R1, R7, R15, R19, R21, R22, R25, R31, R37, R47]. Some projects focus on prevention of HIV transmission by examining unprotected anal sex [R47], virology of HIV in semen [R13], sexual networks [R8], and vaccine preparedness [R48]. Several projects examine secondary prevention by looking at HIV testing [R3, R10, R14, R20, R33, R44, R46], screening for anal cancer [R2] and co-infections [R2, R11]. Other projects examine HIV prevention through prevention programming [R1, R12, R16, R32, R33, R34], new methods in HIV prevention research [R4], the effects of the expansion of access to HAART among men in British Columbia [R19, R22] and analysis of HIV health promotion messaging [R24].
Much of the research identified addresses HIV prevention in the context of vulnerabilities and transmission. One project examined the views of MSM about potential HIV vaccines [R48]. None of the projects identified in this section examine new and emerging prevention technologies such as post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), and rectal microbicides.
Access to health care is a key determinant of health. As described in Chapter 4, gay and other MSM are less likely than heterosexuals to have their healthcare needs met. Of the 48 projects identified, nine look at access to care [R5, R6, R9, R10, R19, R23, R25, R35, R45] and three examine treatment [R2, R19, R22]. Most of these projects investigate access to and/or uptake of healthcare services [R5, R9, R10, R19, R23, R25, R35, R45], including barriers to accessing HIV testing [R5, R10, R25]. Four projects frame the issue of access to healthcare services in the context of homophobia, discrimination and social exclusion [R5, R9, R23, R45].
One project examines barriers to healthcare access among gay and other MSM in African and Caribbean communities [R9]; another examines follow-up strategies with partners of HIV-infected men [R10]. Four projects look at HIV infection clustering in the context of epidemiological surveillance [R17], treatment [R43] and the effects of increased access to HAART in British Columbia for gay and other MSM living with HIV in the province [R19, R22].
Mental health is a key determinant of HIV vulnerability for gay and other MSM. As discussed in Chapter 4, evidence suggests that gay and other MSM generally have poorer self-reported mental health outcomes than those of the general population. Five of the 48 research projects identified examine mental health among gay and other MSM [R5, R35, R37, R40, R41]. One project looks at the emotional well-being of lesbian, gay, bisexual, transgender and queer (LGBTQ) youth [R40]. Another includes the examination of access to mental health services, as well as other healthcare services, among gay, bisexual and other MSM in southwestern Ontario [R5]. Another project examines specific mental health issues among gay and other MSM, such as social anxiety, mood problems, alcohol and drug use, as precursors to HIV transmission risk behaviour [R37]. Two of the project abstracts do not specify an area of mental health focus: one focuses on social and structural issues affecting well-being [R41], while the second project examines the well-being of trans people and their access to health care [R35].
Of the 48 projects identified, 24 focused on gay and other MSM who are also members of other vulnerable populations or groups. Specific populations studied include gay and other MSM living with HIV/AIDS [R2, R9, R10, R11, R13, R15, R16, R19, R22, R24, R37, R39, R43, R48]; gay and other MSM who use drugs [R30, R42, R48]; MSM from countries where HIV is endemic [R9, R11, R21, R27]; LGBTQ youth who are newcomers to Canada ; and transmen [R12, R35, R36, R40, R45]. One project examined condom use, HIV testing and risk behaviours among two-spirit First Nations men and women [R46]. None of the projects identified examine HIV/AIDS among gay and other MSM in prisons.
As discussed in Chapter 3, gay and other MSM who inject drugs are particularly vulnerable to HIV infection. Research in this area is important for tailoring response efforts to address risk behaviours among gay and other MSM who inject drugs. Of the 17 projects that focus on specific populations, three examine drug use among MSM [R30, R42, R48]. Two of these three specifically looked at injection drug use. The first study collected demographic information on injection drug use and sex trade involvement as part of a surveillance study [R30], while the second collected data on injection drug use to inform an HIV vaccine study [R48]. The third project is a qualitative study of drug use in the context of gay circuit parties [R42]. One additional project seeks to understand the motivations of gay and other MSM in the context of drug use [R22].
As discussed in Chapter 4, gay, bisexual, transgender and two-spirit youth are one of the key populations vulnerable to HIV infection. Research on this group is therefore important as they face challenges that are different from those faced by heterosexual youth, and may have an increased likelihood of engaging in risky sexual behaviour. Of the research projects identified that focus on specific populations, only one is focused on youth [R40]. This project examines the vulnerabilities of LGBTQ youth who are new to Canada.
Given that youth spend the majority of their time in school environments, projects examining school-based homophobic bullying and its impact on HIV vulnerability could help inform the development of appropriate school-based policies and programs for youth who are gay, bisexual, transgender, and two-spirit.
The MSM exposure category is the third most common route of HIV transmission among Aboriginal men after injection drug use and heterosexual contact. Research on this group is important since two-spirit, gay and bisexual Aboriginal men face several factors that make them more vulnerable to HIV infection and that are unique to Aboriginal people, such as the legacy of colonization and residential schools. Only one of the research projects that were identified addresses this population. This project examines behaviours and attitudes of two-spirit First Nations men and women about HIV testing, HIV status, condom use and other HIV risk behaviours [R46].
d) Gay and Other MSM from Countries Where HIV Is Endemic: Black Men of African and Caribbean Descent Living in Canada
The second highest proportion of HIV-positive tests among the Black population occurred in the MSM exposure category. Examining HIV among Black men is important since gay and other MSM from African and Caribbean countries face a specific combination of barriers, such as racism, homophobia, and typically lower socioeconomic status, which can increase their vulnerability to HIV infection. Analysis of current research projects that focus on specific populations identified four projects that examine issues related to HIV infection among this population [R9, R11, R21, R27]. One of these projects examines the risk behaviours of Black men who have sex with men [R21], while another project looks at the role of co-infections in HIV infection for this group [R11]. The remaining two projects aim to build ethnoracial community capacity to address HIV/AIDS. One project focuses on increasing the capacity of members of the African-Caribbean community who are HIV positive to undertake research [R9], while the second project, although not specific to African and Caribbean populations, focuses on improving capacity of the HIV sector to address HIV among ethnoracial minority MSM [R27]. More research examining the vulnerabilities and resiliencies of this group to HIV would assist in the development of appropriate interventions.
Chapter 3 relates how the MSM exposure category accounted for almost half of new infections in 2008 and represents over half of people already living with HIV/AIDS in Canada. Of the projects that focus on specific populations, 14 focused on gay and other MSM living with HIV/AIDS [R2, R9, R10, R11, R13, R15, R16, R19, R22, R24, R37, R39, R43, R48], with most of these examining HIV prevention (11) and/or service provision. (3) Projects focusing on prevention of HIV transmission include one project addressing gay and other MSM living with HIV/AIDS in the context of primary HIV infection clustering [R43]; one examining the connection between risk behaviour and social networking [R15]; one examining the effect of increasing access to antiretroviral therapy on the number of new HIV infections among gay and other MSM [R19]; one focusing on the physical transmission of HIV [R13]; one examining the role of co-infections on HIV transmission and progression [R11]; and one focusing on MSM living with HIV/AIDS to inform a vaccine preparedness study [R48]. Along with a prevention focus, three projects aim to inform service provision, including one that addresses the barriers to health and social services [R9]; one that investigates best practices for follow-up with sexual partners of those infected with HIV [R10]; and one that examines the mental health of those at risk for HIV and who are already living with the disease [R37]. Two projects focus on prevention of HIV/AIDS progression among those already living with HIV/AIDS [R2, R11].
At the time of this review, there were no research projects identified that fell within the scope of this report that examined HIV among gay and other MSM in Canadian provincial/territorial or federal prisons. Accessing people in prison for research purposes can be challenging for a range of reasons, including the complexities of gaining research ethics approval, garnering support from prison administration and staff, losing research respondents over time, etc. Compounding these difficulties, population-specific factors which affect gay and other MSM, such as stigma, discrimination, and homophobia may also prevent individual gay and other MSM in prison from participating in such studies.
The Correctional Service of Canada (CSC) routinely conducts research on people in federal prisons. Recently, the National Inmate Infectious Disease and Risk Behaviours Survey asked questions regarding same sex behaviours in prison. Unfortunately, few data from this survey were collected to identify specifically the needs of gay and other MSM in prisons.
Transgender and transsexual men are a unique population, some of whom identify as gay or bisexual and others who identify as male and have sex with men. While HIV prevalence and incidence among transmen is not well understood, preliminary evidence suggests a potential for considerable vulnerability to HIV infection, given high rates of poverty, marginalization, and transphobic discrimination. Thus, there is a need to better understand the HIV vulnerabilities and resiliencies of transmen. Of the four projects identified in this section, three focus on transgender communities more broadly [R35, R40, R45] and one on transmen specifically [R36]. These projects examine the experiences of transmen in the context of HIV/AIDS [R36]; lack of access to health services among trans people [R35]; the impact of social exclusion, including transphobia, on HIV infection among newcomer LGBTQ youth [R40]; and the impact of social marginalization on HIV vulnerability among trans people [R45].
As discussed in Chapter 3, co-infections place significant health burdens on MSM. Research in this area is important as co-infections increase the likelihood of HIV transmission, acquisition, and disease progression. Two research projects address co-infection [R11] and co-morbidity [R2] among HIV-positive men. Project R11 addresses the role of co-infections, such as genital herpes, HPV, and gonorrhoea, in HIV transmission, acquisition, and disease progression. Project R2 examines techniques for screening for anal cancer among HIV-positive MSM. Understanding the relationship between HIV/AIDS and other infections is essential for developing comprehensive approaches to addressing co-infections.
As outlined in Chapter 4, a range of socioeconomic determinants of health affect the vulnerability and resilience of gay and other MSM to HIV/AIDS. Of the 48 projects identified, 32 examine determinants of health that impact HIV vulnerability [R1, R5, R6, R7, R8, R9, R14, R15, R17, R18, R19, R20, R21, R22, R23, R24, R26, R29, R30, R31, R32, R34, R35, R37, R39, R40, R41, R42, R43, R46, R47, R48]. Health determinants identified in this section include homophobia and related stigma and discrimination; mental health; income and social status; personal health practices and coping skills; culture; social and physical environments; and social networks.
Homophobia and related stigma and discrimination are key underlying factors that increase vulnerability to HIV/AIDS among gay and other MSM. Understanding the impact of homophobia on HIV vulnerability is critical to improving service provision and designing appropriate interventions. Ten projects examine homophobia, stigma, and discrimination [R5, R6, R9, R15, R23, R24, R26, R34, R40, R45]. Two of these projects aim to build capacity among key stakeholders and the gay and other MSM community to examine issues of homophobia, transphobia, stigma and discrimination [R9, R23]. Of these two, one later developed into a research study addressing homophobia and social exclusion [R5]. One project examines the needs and perspectives of youth regarding homophobia and transphobia and their impact on HIV vulnerability [R40]. One project addresses personal perceptions of stigma surrounding men who arrange sexual contacts via the Internet [R15]. Another project examines stigma as it relates to the social marginalization of trans communities [R45]. One project examines experiences of heterosexism and homophobia among gay and bisexual men as a determinant of HIV vulnerability and broader health [R26]. Developing a clearer understanding of the impact of homophobia, heterosexism and related stigma and discrimination on HIV vulnerability is key to effectively addressing HIV/AIDS among gay and other MSM over the long term.
As discussed in Chapter 4, culture affects resiliency against, and vulnerability to, HIV infection. Understanding the cultural contexts of gay and other MSM may provide insight into the ways in which risk behaviours are influenced by cultural norms and values, and in turn can be used to inform the development of culturally-sensitive HIV prevention strategies.
Six projects examine ethnocultural MSM communities [R9, R21, R25, R27, R40, R46]. Two of these projects seek to build capacity for research on ethnocultural minority gay and other MSM [R9, R27]. One of these aims to inform the development of targeted prevention activities [R21], while the other focuses on newcomer LGBTQ youth [R40], Asian Canadian MSM [R25], and two-spirit First Nations men and women [R46].
Four projects were identified that examine the unique subcultures among gay and bisexual men, and how membership in these communities may impact HIV vulnerability and resilience [R15, R39, R42, R47]. All three projects address culture through the examination of socio-cultural dimensions of different risky sexual practices: gay bathhouses [R47]; circuit parties [R42]; and using gay-cruising sites on the Internet [R13, R39].
Given the importance of cultural connectedness to HIV resilience in other key populations, such as Aboriginal peoples, a stronger understanding of the roles played by culture (including cultures specific to gay and bisexual male communities) in HIV vulnerability and resilience would inform broader efforts to address HIV among gay and other MSM.
As discussed in Chapter 4, support from families, friends and communities is associated with better health. Use of the Internet by gay and other MSM to access support has also increased. Among the projects identified, one examines the Internet as an intervention tool [R18], while two others examine it as a means for arranging sex [R13, R39]. At the time of this review, however, no current research was identified that addressed key social support networks, such as family, friends, lovers, casual sexual relationships and chosen family as either risk or protective factors in HIV vulnerability and resilience.
Chapter 4 discusses in more detail how income and social status are key determinants of health for gay and other MSM, just as they are for the broader population. Three projects examine social issues—including income, housing instability and homelessness—as factors contributing to HIV vulnerability among gay and other MSM [R9, R41, R45]. Of these, one aims to increase community capacity for conducting research on housing instability among African and Caribbean communities [R9], while another aims to increase capacity for research on factors such as employment, income, and housing instabilities on HIV vulnerability among transgender communities [R45].
The health of gay and other MSM is affected by the social and physical environments in which they live. As discussed in Chapter 4, physical and social environments, such as bathhouses and circuit parties, have been associated with increased risk behaviours, suggesting a need for research that addresses social and physical environments and their link to HIV vulnerability or resiliency. Among the projects identified, one addresses circuit parties [R42] and the other bathhouses [R47] as physical environments associated with HIV risk behaviours. No current research was found that focused on other physical and social environments, such as schools, gay neighbourhoods, parks, and rural areas, as places contributing to HIV vulnerability and resilience.
Unprotected anal intercourse and multiple sexual partners are key risk factors for HIV transmission. Of the 48 projects identified, 20 examine sexual behaviours as risk factors for HIV infection [R1, R7, R14, R15, R18, R19, R21, R22, R29, R30, R31, R32, R34, R37, R39, R42, R43, R46, R47, R48].
Of these projects, more than half examine risk behaviours among gay and other MSM to inform the development of HIV prevention programs. Two projects address risk behaviours in the context of social and physical environments: one examines circuit parties, crystal meth use and risky sexual practices through an ethnographic lens [R42] and the other examines barebacking in bathhouses [R47]. Another two projects examine risk behaviours in the context of social networks, specifically gay men's use of the Internet to arrange sexual contacts [R15, R39]. One project addresses the relationship between mental health and risky sexual behaviour [R37]. Two projects involve the collection of epidemiological information on HIV and STI prevalence among gay and other MSM, as well as information on risk behaviours [R14, R30]. Two projects examine the potential effects on sexual risk behaviour of expanded access to HAART among gay and other MSM living with HIV in British Columbia [R19, R22].
Of the 48 projects identified, 19 sought to enhance capacity for HIV research or programming, and/or support knowledge translation and policy development [R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R15, R18, R26, R27, R28a/b, R31, R32, R44].
Five projects focus on increasing capacity for HIV prevention research [R4, R6, R8, R9, R27]. Of these, two projects aim to increase capacity around factors impacting HIV vulnerability, such as stigma, discrimination, access to health care, and housing and income instability [R6, R9]. Two projects seek to enhance capacity for research or to respond to HIV among ethnoracial minority gay and other MSM [R9, R27]. Two projects aim to develop new survey tools for HIV prevention research [R4, R8]. None of the projects, however, address research capacity development for other specific subpopulations of gay and other MSM, such as those in prison or in Aboriginal communities.
Many of the projects seek to use research findings to inform the development of HIV/AIDS policy, program, and interventions [R1, R2, R3, R7, R10, R11, R15, R18, R26]. Seven of these aim to provide strategies for preventing HIV transmission [R1, R2, R3, R7, R10, R15, R18], including projects understanding HIV risk and testing behaviours [R7, R10, R15], evaluating interventions for HIV prevention and testing [R1, R3, R18], informing anal cancer screening programs [R2], and improving research [R8].
Though the following list should not be considered exhaustive, this report has revealed a number of knowledge gaps pertaining to HIV/AIDS among gay, bisexual, two-spirit and other MSM which require further study. These knowledge gaps have been identified through an analysis of chapters 2 through 4 of this report and with the assistance of the national expert working group for this report. These areas for further research include the following:
- Factors that promote resilience against HIV among gay and other MSM
- The impact of homophobia, heterosexism and related stigma and discrimination on the HIV vulnerability and resilience of gay and other MSM
- The impact of homophobic bullying on the HIV vulnerability and resilience over the life-course of gay male youth and other young MSM
- The ways in which physical and social environments (such as rural areas, schools and gay neighbourhoods) affect HIV vulnerability and resilience
- The impact of social support networks, such as family (biological and chosen), friends, lovers, casual sexual relationships, and broader communities as both risk and protective factors against HIV infection among gay and other MSM
- The impact of the Internet, including social networks, chatrooms, other social support networks and sexual health promotion websites as social support networks, on HIV resilience among gay and other MSM
- Canadian research examining the concept of syndemics, which refers to multiple, interacting epidemics in communities of gay and bisexual men (1)
- Demographics, HIV and co-infection epidemiology, and factors affecting the HIV vulnerability and resiliency of gay and other MSM, including research on particular sub-populations, such as the following:
- older gay men
- ethnocultural minority gay men, including two-spirit, gay, bisexual and other Aboriginal MSM
- gay men living in rural areas
- gay and other MSM in prison
- gay and other MSM engaged in the sex trade
- MSM who do not identify as gay or bisexual
- Demographics, HIV and co-infection epidemiology, risk behaviours and factors affecting HIV vulnerability and resilience for transmen who have sex with men, including factors such as the following:
- the impact of transphobia and genderism on HIV vulnerability and resilience
- HIV risk associated with female-to-male (FTM) sex reassignment surgeries
- access to appropriate health care and support services for trans men
- Unique sub-communities of gay and other MSM (such as leather, kink, bear and newcomer communities) and how identification with these communities impacts HIV vulnerability and resilience.
- Health outcomes of long-term use of HAART on gay and other MSM
- Cultural competency of health professionals providing care to gay and other MSM
- How to integrate new prevention technologies, such as post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP), as well as rectal microbicides (once available) into the overall HIV prevention toolkit for gay and other MSM
- HIV co-infection, particularly HCV, and co-morbidity (e.g., anal cancer, tuberculosis) and the challenges of dealing with multiple conditions for gay and other MSM living with HIV/AIDS
The national expert working group for this report identified a need for further research on gay men's health, both in the context of HIV prevention, care, treatment and support, as well as research on gay men's health not specifically tied to HIV vulnerability and resiliency. This knowledge gap includes:
- Understanding the impact of a broader, holistic approach to gay men’s health on HIV vulnerability and resiliency, prevention, care, treatment and support
- Understanding the effects of tailored healthcare services for gay men
- Examining the links between a broader, holistic approach to gay men’s health and addressing syndemics (1)
 Stall R, Friedman M, Catania JA. Interacting epidemics and gay men's health: a theory of syndemic production among urban gay men. In: Wolitski RJ, Stall R, Valdiserri RO, editors. Unequal opportunity: health disparities affecting gay and bisexual men in the United States. New York: Oxford University Press; 2008. p. 251-74.
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