Correlates of Sexual HIV Risk Among African American Men Who Have Sex With Men

Objectives. We examined correlates of condomless anal intercourse with nonmain sexual partners among African American men who have sex with men (MSM).Methods. We recruited social networks composed of 445 Black MSM from 2012 to 2014 in Milwaukee, Wisconsin; Cleveland, Ohio; and Miami Beach, Florida. Participants reported past-3-month sexual behavior, substance use, and background, psychosocial, and HIV-related characteristics.Results. Condomless anal intercourse outside main concordant partnerships, reported by 34.4% of MSM, was less likely in the case of no alcohol and marijuana use in the past 30 days, and higher risk-reduction behavioral intentions. High frequency of condomless anal intercourse acts with nonmain partners was associated with high gay community participation, weak risk-reduction intentions, safer sex not being perceived as a peer norm, low condom-use self-efficacy, and longer time since most recent HIV testing.Conclusions. Condomless anal intercourse with nonmain partners among Black MSM was primarily associated with gay community participation, alcohol and marijuana use, and risk-reduction behavioral intentions.HIV infection in the United States falls along sharp lines of disparity related to sexual orientation and race. Every year since HIV surveillance began, men who have sex with men (MSM) have accounted for the majority of the country’s HIV cases.1 The disease also disproportionately affects African Americans, who constitute 12% of the American population but carry 44% of its HIV infection burden.1 Yet, the starkest disparity emerges from the combined impact of race and sexual orientation. Black MSM represent only a fraction of a percent of the American population but accounted for more than 25% of the country’s new HIV infections in 2010,1 with HIV rates much higher among Black than White MSM.2 HIV incidence among racial-minority MSM in some cities ranges from 24% to 29%.3,4 Considerable attention is being given to biomedical strategies such as early initiation of antiretroviral therapy (ART) and preexposure ART prophylaxis for HIV prevention.5,6 However, the impact of these promising strategies will depend upon ART coverage and adherence, neither of which is likely to be quickly attained or complete. For this reason, integrated HIV prevention approaches are needed, including improved interventions to reduce risk behavior among racial-minority MSM.Previous research has examined but has generally failed to establish differences in individual-level risk practices between Black and White MSM.7–10 However, sexual network characteristics, high rates of undiagnosed and untreated HIV infection, high sexually transmitted infection (STI) prevalence, and unsuppressed viral load among HIV-positive African American MSM are believed to contribute to HIV disparities.9–16Black MSM are not a monolithic population,17–20 and multiple factors may influence extent of HIV vulnerability within the community of racial-minority MSM. These include risk-related sexual behavior norms, attitudes, and intentions21–25; substance use12,26–30; poverty and disadvantage19,20; and psychosocial domains including internalized homonegativity or homophobia,31–34 self-perceived masculinity,35,36 HIV conspiracy beliefs or mistrust,37,38 religiosity,39 and resilience.40,41 It is important to ascertain the relative importance of these and other factors to properly tailor HIV prevention interventions for racial-minority MSM.In this study, we recruited social networks of African American MSM and sought to determine the relationships of 4 types of factors with the riskiness of men’s sexual behavior practices: (1) social, economic, and demographic background characteristics; (2) substance use; (3) HIV risk–specific knowledge, attitudes, beliefs, and intentions; and (4) psychosocial domains including internalized homonegativity, self-ascribed masculinity, AIDS conspiracy beliefs, resilience, religiosity, and gay community participation. We examined HIV risk–specific characteristics because they are proximal to adopting protective actions according to many behavioral science theories.42–44 We examined psychosocial domains because broader personal and contextual life experiences may also potentiate risk. We sought to identify characteristics related not only to some men’s high-risk behavior but also the adoption of very safe behavior by other African American MSM, a strengths-based question that has been insufficiently explored.     

Drug Use and High-Risk Sexual Behaviors Among African American Men Who Have Sex With Men and Men Who Have Sex With Women

Objectives. We investigated covariates related to risky sexual behaviors among young African American men enrolled at historically Black colleges and universities (HBCUs).Methods. Analyses were based on data gathered from 1837 male freshmen enrolled at 34 HBCUs who participated in the 2001 HBCU Substance Use Survey. The covariates of risky sexual behavior assessed included condom nonuse, engaging in sexual activity with multiple partners, and history of a sexually transmitted disease.Results. Young Black men who had sex with men were more likely to engage in risky sexual behaviors than were young men who had sex with women. Two additional factors, early onset of sexual activity and consumption of alcohol or drugs before sexual activity, were independently associated with modestly higher odds of sexual risk behaviors.Conclusions. Services focusing on prevention of sexually transmitted diseases should be provided to all male college students, regardless of the gender of their sexual partners. Such a general approach should also address drug and alcohol use before sexual activity.Sexually transmitted diseases (STDs) threaten the sexual and reproductive health of adolescents and young adults, as indicated by the fact that an estimated half of the STD cases reported in 2000 occurred among those aged 15 to 24 years.¹ African Americans and men who have sex with men (MSM) are disproportionately affected by HIV/AIDS and other STDs. ^2–7 Moreover, although previous research indicates that Black MSM are no more likely than other MSM to engage in sexual risk behaviors,⁸ this group has been particularly affected by the HIV/AIDS epidemic.⁹Few studies have compared Black men who have same-gender and opposite-gender sexual partners. Thus, it is unclear whether Black MSM and Black men who have sex with women (MSW) differ in terms of their sexual risk behaviors. In addition, although a number of large studies have collected data from populations of young MSM,^10–14 few analyses have focused specifically on college populations.¹⁵In general, sexual risk-taking behaviors have received less attention among college students than among other groups; however, concerns regarding HIV/AIDS in this population were heightened by the rise in the number of HIV/AIDS diagnoses among male college students, particularly Black MSM, in North Carolina from 2001 to 2003.¹⁶ The majority of college students are sexually active, with prevalence estimates of lifetime sexual activity ranging from 74%¹⁵ to 86.1%.¹⁷ Less is known regarding students enrolled in historically Black colleges and universities (HBCUs). In one study of students enrolled at 8 HBCUs, 82% of the respondents reported a history of sexual intercourse and 59.6% reported that they had used a condom during their most recent intercourse.¹⁸Studies have identified risk and protective factors for sexual risk taking, including early onset of sexual activity,^19–21 substance use and early initiation of use,^22–25 and academic achievement.²⁶ Although the relation of other factors to risky sexual behaviors is less clear, some studies have shown that adolescents and college students with higher levels of religiosity are less likely to report a history of sexual activity.^27–29 However, findings regarding condom use are inconsistent,^28,30 and in 1 study individuals'' religiosity during adolescence was not related to their likelihood of contracting a sexually transmitted infection 6 years later.²⁶ Among college students, living situation may also be an important factor to consider, given previous research indicating that undergraduates who live with their parents are less likely than those who do not to use marijuana and alcohol.³¹We examined covariates of risky sexual behaviors, including inconsistent condom use, engaging in sexual activity with multiple partners, and history of STD infection (the latter as a proxy for risky behavior), among Black MSM and Black MSW attending HBCUs. In addition to the association between risky sexual behaviors and partner gender, we investigated relations between risky behaviors and early onset of sexual activity, substance use in conjunction with sexual activity, religiosity, and living situation.     

Sexual Risk Behaviors by Relationship Type and Trauma History Among HIV-Positive Men Who Have Sex with Men

The association of trauma exposure and coping style to sexual risk behavior has yet to be fully examined in the context of primary and casual sexual partnerships. The current study assessed a high risk sexual behavior—unprotected anal intercourse (UAI)—in a high risk population of HIV-positive men who have sex with men (MSM) with a history of trauma. Using audio computer-assisted self-interview technology, 132 HIV-positive MSM completed measures of trauma exposure, trauma symptoms, coping strategies, and sexual risk behavior. Hierarchical logistic regression analyses indicated that completing more years of education and having experienced sexual abuse were positively associated with UAI with casual partners. Additionally, use of active coping was negatively associated with UAI with casual partners and the final model significantly predicted variance in UAI with casual partners. However, no variables were significantly associated with UAI with primary partners, suggesting that sexual risk behavior with primary partners may be associated with factors not commonly assessed in risk prediction or prevention research. We discuss the results in the context of developing new or modifying existing interventions to address rates of sexual risk in the relationships of HIV-positive MSM.     

Sexual Marathons and Methamphetamine Use among HIV-Positive Men Who Have Sex with Men

A sexual marathon is defined as prolonged sexual activity over hours and even days. This exploratory study examined the phenomenon of sexual marathons in a sample of 341 HIV-positive methamphetamine-using men who have sex with men (MSM). Eighty-four percent of the men reported engaging in marathon sex while high on methamphetamine. MSM who engaged in sexual marathons and those who did not were compared in terms of background characteristics, methamphetamine use variables, alcohol and illicit drug use, sexual risk behaviors, and psychosocial factors. Men who engaged in marathon sex used significantly more illicit drugs, were more likely to use sildenafil (Viagra) and amyl nitrates, and scored higher on a sexual compulsivity scale compared to men who did not engage in marathon sex. In multivariate analyses, use of sildenafil in the past two months was significantly correlated with participation in sexual marathons. Findings are discussed in terms of their implications for HIV/STI prevention and intervention.     

Prospective Predictors of Multiple Sexual Partners Among African American Men Who Have Sex with Men

Studies show that having sex with multiple partners increases the risk of acquiring and transmitting sexually transmitted diseases, including HIV. The present article reports prospective predictors of having multiple sexual partners among 505 African American men in Philadelphia who have sex with men (MSM) who participated in an intervention trial and attended a 6-month follow-up. Participants completed audio computer-assisted surveys of demographics, sexual behavior, and Reasoned Action Approach and Social Cognitive Theory mediators concerning multiple partners. We analyzed the incidence of self-reported multiple partners at the 6-month follow-up, controlling for treatment condition and baseline levels of the theoretical variables. The odds of having multiple partners decreased with increasing age (p?<?.03). Participants who said they were HIV positive had lower odds of having multiple partners (p?<?.009). The more pride participants reported in their identities as black or African American men, the lower the odds that they reported having multiple partners (p?<?.02). Adverse outcome expectancies accruing to multiple partners fully mediated the effect of black pride and partially mediated the effects of age on the odds of having multiple partners. Modifiable factors such as perceived negative outcome expectancies regarding having multiple sex partners should be addressed in designing interventions and prevention programs with the goal of decreasing the number of sexual partners among African American MSM.     

Sexual Risk Behaviors Among HIV-Positive Black Men Who Have Sex With Women, With Men, or With Men and Women: Implications for Intervention Development

Objectives. We compared demographics and sexual and drug risk behaviors among HIV-positive Black men who have sex with women only, with men only, or with men and women to assess differences among and between these groups.Methods. We analyzed cross-sectional data from the Supplement to HIV and AIDS Surveillance Project for 2038 HIV-positive Black men who reported being sexually active. We classified the participants by their reported sexual behaviors in the past year: intercourse with women (n = 1186), with men (n = 741), or with men and women (n = 111).Results. Respondents whose sexual partners were both men and women reported more noninjection drug use, sexual exchange, and sexual partners than did the other 2 groups. Bisexual respondents were also more likely than were heterosexuals to report unprotected intercourse with a steady female partner and were more likely than were both other groups to report having steady partners of unknown HIV serostatus and using drugs during their last sexual episode.Conclusions. HIV-positive Black men with both male and female sexual partners engaged in more sexual and drug risk behaviors than did their heterosexual and homosexual peers. More information concerning the prevention needs of behaviorally bisexual HIV-positive Black men is needed.Epidemiological studies consistently show that Black men are disproportionately affected by HIV/AIDS.¹ Although non-Hispanic Black men composed approximately 6% of the US population, they accounted for 29.2% of the estimated number of adults and adolescents living with HIV/AIDS at the end of 2005.^1,2 Surveillance data show that unprotected male–male sexual intercourse and injection drug use are the primary modes of HIV transmission among Black men. Behavioral studies examining sexual risk show that some HIV-positive persons, including HIV-positive Black men, continue to engage in unprotected sexual intercourse with male and female partners of negative and unknown HIV serostatus.^3–8Considerable research has examined sexual and drug risk behaviors, partner characteristics, and sociodemographics of HIV-positive men. Factors such as use of alcohol or drugs during last episode of sexual intercourse,^9–12 partnership status (steady or nonsteady),^13,14 number of partners,¹⁵ partner''s HIV status (negative, positive, or unknown),^16–18 poverty,¹⁹ and sexual exchange (paying or receiving goods or money for sexual intercourse)^20,21 have all been associated with high-risk sexual behaviors among HIV-positive persons. Many of these studies included relatively few Black men, or Black homosexual and bisexual men were combined into 1 group, or Black men were compared with high-risk men of other race/ethnicity. Although all of these studies have produced pieces of a puzzle for understanding issues associated with HIV transmission among Black men living with HIV/AIDS, they have not specifically focused on behaviorally different groups of HIV-positive Black men.Rates of HIV seropositivity are high among Black men, and HIV infections are spreading throughout Black communities. We therefore sought to examine differences in self-reported sexual behavior between HIV-positive Black men who have sex with men (MSM), with women (MSW), or with men and women (MSMW) without regard to self-reported sexual orientation. In particular, we examined differences in sexual risk behavior between MSW and MSMW and between MSM and MSMW in the past year. Our data may identify factors contributing to the spread of HIV in Black communities, assist researchers to develop interventions to reduce and eliminate high-risk behaviors in these populations, and ultimately help reduce and prevent the transmission of HIV.     

Gender Role Conflict Among African American Men Who Have Sex With Men and Women: Associations With Mental Health and Sexual Risk and Disclosure Behaviors

Objectives. We investigated whether high gender role conflict (GRC; internal conflict with traditional gender-role stereotypes and an individual’s perceived need to comply with these roles) is associated with psychological distress and HIV-related risk behaviors in a sample of African American men who have sex with men and women (MSMW).Methods. We analyzed baseline data collected from questionnaires completed by 400 MSMW participating in the Men of African American Legacy Empowering Self project in Los Angeles, California, in 2007 to 2010 for associations between participants’ GRC and experiences of poor mental health and HIV risk outcomes.Results. MSMW who reported higher levels of GRC than other participants also reported more psychological distress, lower self-esteem, greater internalized homophobia, less HIV knowledge, lower risk reduction skills, less disclosure of same-sex behaviors to others, and more unprotected vaginal or anal intercourse with female partners.Conclusions. Future research should consider how high GRC affects African American MSMW’s lives and identify specific approaches to help alleviate the psychological distress and other negative behavioral outcomes associated with internal conflict caused by rigid gender role socialization.Despite the heavy toll the HIV/AIDS epidemic has exerted on the lives of African American men who have sex with men (MSM), conspicuously few behavioral interventions have been developed to reduce HIV transmission in this population.1,2 Behavioral HIV prevention interventions designed specifically for men of any race/ethnicity who have sex with both men and women (MSMW) are practically nonexistent. In response to a 2005 report of HIV prevalence as high as 46% among African American MSM,3 the Centers for Disease Control and Prevention and other funding agencies began making resources available to adapt existing HIV prevention interventions, developed originally for gay White men, and to design and evaluate theory-driven HIV interventions to address the specific prevention needs of gay-, bisexual-, and heterosexual-identified African American MSM.The Men of African American Legacy Empowering Self (MAALES) project, conducted in Los Angeles, California, is an example of a collaborative academic–community effort to develop and rigorously test a culturally appropriate behavioral HIV intervention for African American MSMW.4 The critical thinking and cultural affirmation model, one of the behavioral theories underlying the MAALES small-group intervention, posits that a healthy integration of racial/ethnic pride, gender role, and sexual identity will allow African American MSMW to operate from a culturally rooted foundation to make healthier choices in their lives and relationships with sexual partners. This model recognizes that concerns regarding the preservation of African American masculinity underlie much of the conflict and discourse regarding male homosexuality and bisexuality in African American communities. A unique component of the MAALES intervention—aimed at reducing HIV acquisition and transmission risk behaviors—is its reliance on a culturally congruent framework that bolsters racial and cultural pride while reducing HIV stigma and gender role conflict (GRC).4GRC refers to negative consequences that can result from individuals'' socialization regarding the roles ascribed to their gender and the need to comply with these roles. According to O’Neil, such consequences for men can stem from “negative critiques of self or others when conforming to, deviating from, or violating stereotypic gender role norms of masculinity ideology.”5^(p363) Previous research on how males are socialized into traditional gender roles and the negative impacts of high GRC on mental health and other issues was conducted in samples primarily comprising heterosexual men.6–9 With the exception of a recent investigation of the impact of high GRC on condom use in a sample of African American MSM,10 most investigations of the impact of GRC on the lives of MSM have enrolled samples largely consisting of White gay-identified men.11–13In recent work to develop more effective HIV prevention programs for African American MSMW, Operario et al. conducted qualitative interviews with heterosexual-identified, behaviorally bisexual African American men to better understand the context of MSMW’s sexual behaviors with both male and female partners and the need for secrecy and confidentiality regarding same-sex behaviors.14 The study findings revealed a high level of internal conflict among participants stemming from their desire for male partners in the context of community norms that valued rigid male gender roles, namely, an explicit expectation that “real” men will only partner with women. The investigators also found that participants emphasized the need to conceal their same-sex behaviors from female partners and members of their broader social network because of their perceptions that the African American community viewed homosexuality as a weakness. Previous quantitative research in samples of heterosexual men also found higher levels of GRC to be associated with greater psychological distress.15,16 Similarly, among predominantly gay-identified White MSM, high GRC has been associated with higher levels of depression and anxiety and lower self-esteem.12,17We expanded on previous work by quantitatively investigating whether high GRC is associated with psychological distress as well as HIV-related risk behaviors in a sample of behaviorally bisexual African American men. Our theoretical rationale was that GRC may be related to African American men’s engagement in HIV risks through 2 mechanisms: indirectly, by influencing poor mental health outcomes such as psychological distress and lower self-esteem, which may reduce protective, safer-sex practices, and directly, because men with greater GRC may view vulnerability (either physical or emotional) as contrary to society’s expectation of masculinity. In other words, men may try to avoid the appearance of physical vulnerability by electing not to use condoms, an act that may be perceived as showing fear about health threats such as HIV. Men with greater GRC may also avoid the appearance of emotional vulnerability demonstrated by their use of condoms to protect their sexual partners’ health. Similarly, men struggling with GRC may see a need to have multiple female partners or to have more insertive anal intercourse with men to reinforce their masculinity.Consistent with observations in other populations, we hypothesized that high GRC contributes to increased psychological distress and reduced self-esteem in African American MSMW. In addition, we hypothesized that high GRC contributes to increased homophobia by heightening concerns over the implications of intercourse with other men for masculine status. These factors, in turn, may influence HIV risk by reducing African American MSMW’s motivation to acquire HIV knowledge and skills and to practice HIV preventive behaviors, thus increasing the likelihood that they will engage in risky behaviors such as drug use prior to intercourse with other men. We used baseline data collected from MAALES project participants to examine whether African American MSMW with higher levels of GRC than other participants also reported (1) higher levels of psychological distress and poorer self-concept, (2) greater secrecy regarding MSM behaviors, and (3) higher frequencies of engagement in HIV risk behaviors.     

Sexual Risk Behaviors of HIV-Positive,HIV-Negative,and Serostatus-Unknown Black Men Who Have Sex with Men and Women

Black men who have sex with men and women (MSMW) are at high risk for HIV infection and transmission. This study compared the sexual risk behaviors of Black MSMW who self-reported being HIV-positive with those who reported being HIV-negative and those who did not know their HIV status. Respondent-driven sampling (RDS) was used to recruit 1,154 Black MSM in Philadelphia and New York who completed an audio computer-assisted self-interview (ACASI). Of these men, 212 had engaged in anal sex with male partners and vaginal or anal sex with female partners in the past 3 months. A quarter (23.6%; n = 50) of MSMW self-reported testing positive for HIV at their last test, 59.4% (n = 126) reported testing negative for HIV at their last test, and 17.0% (n = 36) reported never having an HIV test. Multivariate logistic regression analysis revealed that HIV-positive MSMW were much less likely than HIV-negative men and never-tested men to have engaged in unprotected intercourse with main male and main female partners perceived to be HIV-negative or of unknown serostatus. However, HIV-positive men were equally as likely as HIV-negative men to have unprotected intercourse with non-main male and non-main female partners perceived as HIV-negative or of unknown serostatus. Our findings indicate that some HIV-positive MSMW engage in unprotected sex that places female and male partners at risk for HIV infection. However, MSMW who have never taken an HIV test, or who have not been recently tested, may be a greater source of HIV transmission to their female and male partners.     

Examining the Correspondence Between Relationship Identity and Actual Sexual Risk Behavior Among HIV-Positive Men Who Have Sex with Men

Sexual behavior of men who have sex with men (MSM), within and outside of one’s primary relationship, may contribute to increased risk of HIV transmission among those living with HIV. The current study sought to understand how HIV-infected MSM report their relationship status and the degree to which this corresponds with their sexual behavior. Further, we examined rates and psychosocial associations with sexual HIV transmission risk behavior (TRB) across relationship categories. In a sample of 503 HIV-infected MSM in HIV care, 200 (39.8 %) reported having a primary partner. Of these, 115 reported that their relationship was open and 85 reported that it was monogamous. Of the 85 who reported a monogamous relationship, 23 (27 %) reported more than one sexual partner in the prior 3 months, 53 (62 %) reported only one partner, and nine did not report on the number of partners in the past 3 months. Hence, there were three categories of relationships: (1) “monogamous with one sexual partner,” (2) “monogamous with more than one sexual partner,” and (3) “open relationship.” The “monogamous with more than one sexual partner” group reported higher TRB and crystal methamphetamine use compared to the “monogamous with one sexual partner” group and different patterns of relationships with TRB emerged across the three groups. Couples-based HIV prevention interventions for MSM may be enhanced by considering that there may be different definitions of monogamy among MSM, and that the context of relationship status may require tailoring interventions to meet the needs of specific subgroups of MSM couples.     

Methamphetamine Use,Attitudes About Condoms,and Sexual Risk Behavior Among HIV-Positive Men Who Have Sex with Men

This study examined attitudes about condoms as a moderator of the relationship between methamphetamine use and sexual risk behavior in a sample of 297 HIV-positive, methamphetamine-using men who have sex with men (MSM). To test for a moderating effect of attitudes towards condoms, an interaction term was included in multiple regression analysis along with age, income, negative condom attitudes, frequency of methamphetamine use, and Beck depression score. A post hoc analysis was conducted to determine the relations between methamphetamine use and unprotected sex for persons with more vs. less negative attitudes toward condoms. These analyses indicated that when individuals had more negative attitudes toward condoms, the relation between methamphetamine frequency and unprotected sex was significant, while among participants with less negative attitudes toward condoms, no significant association was found. Addressing methamphetamine-using MSM’s attitudes about condoms can serve as a form of harm reduction for those who are not yet ready or willing to discontinue methamphetamine use.     

Crystal Methamphetamine Use and Sexual Risk Behaviors among HIV-Positive and HIV-Negative Men Who Have Sex with Men in South Florida

Using data collected through venue-based sampling in South Florida from 2004 to 2005 as part of the Centers for Disease Control and Prevention-funded National HIV Behavioral Surveillance Among Men Who Have Sex with Men, we estimate the prevalence of crystal methamphetamine use and its association with high-risk sexual behaviors among a large and diverse sample of men who have sex with men (MSM) residing in South Florida. We also examine how these associations differ between HIV-positive and HIV-negative men. Bivariate analyses were used to assess the characteristics of study participants and their sexual risk behaviors by drug use and self-reported HIV status group. Of 946 MSM participants in South Florida, 18% reported crystal methamphetamine use in the past 12 months. Regardless of self-reported HIV status, crystal methamphetamine users were more likely to report high-risk sexual behaviors, an increased number of non-main sex partners, and being high on drugs and/or alcohol at last sex act with a non-main partner. Our findings indicate that crystal methamphetamine use is prevalent among the MSM population in South Florida, and this prevalence rate is similar, if not higher, than that found in US cities that have been long recognized for having a high rate of crystal methamphetamine use among their MSM populations. Notably, the use of crystal methamphetamine among both HIV-positive and HIV-negative MSM is associated with increased HIV-related risk behaviors.     

Sexual Risk Behavior of HIV-Positive Methamphetamine-Using Men Who Have Sex with Men: The Role of Partner Serostatus and Partner Type

This study examined the role of partner serostatus and partner type in relation to the sexual risk behaviors and disclosure practices of HIV-positive methamphetamine (meth)-using men who have sex with men (MSM). The sample consisted of 132 HIV-positive meth-using MSM who reported having both serodiscordant (i.e., HIV-negative and unknown serostatus) and seroconcordant (i.e., HIV-positive) partners. HIV-positive meth-using MSM engaged in significantly fewer acts of anal sex with serodiscordant partners as compared to seroconcordant partners. However, mean levels of unprotected anal and oral sex were high, and mean levels of protected sex were low for both seroconcordant and serodiscordant partners. Oral sex was practiced twice as often as anal sex; however, both types of sex were primarily unprotected. This pattern of risky sexual behavior was reported for steady, casual, and anonymous partners, regardless of partner serostatus. Despite high rates of unprotected sex, rates of HIV serostatus disclosure were consistently high for HIV-positive and HIV-negative steady, casual, and anonymous partners. However, rates of disclosure to unknown serostatus partners were low, particularly in relation to anonymous partners. Future research should address the reasons why HIV-positive meth-using MSM engage in risky sexual activity with serodiscordant partners, and HIV prevention programs for this population should emphasize the risks associated with unprotected sex with seroconcordant partners.     

Sexual Partner Selection and HIV Risk Reduction Among Black and White Men Who Have Sex With Men

Objectives. We examined differences in sexual partner selection between Black and White men who have sex with men (MSM) to better understand how HIV status of participants'' sexual partners and related psychosocial measures influence risk taking among these men.Methods. We collected cross-sectional surveys from self-reported HIV-negative Black MSM and White MSM attending a gay pride festival in Atlanta, Georgia.Results. HIV-negative White MSM were more likely than were HIV-negative Black MSM to report having unprotected anal intercourse with HIV-negative men, and HIV-negative Black MSM were more likely than were HIV-negative White MSM to report having unprotected anal intercourse with HIV status unknown partners. Furthermore, White MSM were more likely to endorse serosorting (limiting unprotected partners to those who have the same HIV status) beliefs and favorable HIV disclosure beliefs than were Black MSM.Conclusions. White MSM appear to use sexual partner–related risk reduction strategies to reduce the likelihood of HIV infection more than do Black MSM. Partner selection strategies have serious limitations; however, they may explain in part the disproportionate number of HIV infections among Black MSM.Men who have sex with men (MSM) continue to make up the majority of people who are HIV infected in the United States. About one third of US HIV infections among MSM occur in Black men¹; however, Black men account for only 13% of the US male population.² Several published reports of HIV risks that stratify risk behavior by race do not demonstrate elevated risk behavior among Black MSM as compared with White MSM.^3,4 For example, Black MSM overall report fewer sexual partners and similar rates of unprotected anal intercourse when compared with White MSM. Because rates of risk behaviors fail to explain the racial disparities in HIV infections, contextual factors may offer important information for explaining the disproportionate HIV infections. Alarming rates of HIV among Black MSM have led this group to be among the top priority HIV prevention populations in the United States.⁵ Thus, a comprehensive understanding of HIV risk factors relevant to this population is warranted.Multiple contextual factors potentially drive disparities in HIV/AIDS between Black MSM and White MSM. Perceived HIV prevention strategies such as selecting unprotected sexual partners thought to have the same HIV status, or serosorting, may play a role in explaining racial disparities in HIV infections. Many HIV-infected and non–HIV-infected men believe serosorting makes HIV transmission less likely and, thus, condom use unnecessary.^6,7 This relationship may stem from the tendency for people to dislike using condoms^8–10 and to practice alternative behaviors they believe are protective, such as serosorting. As a result, partner HIV serostatus is often a determining factor in sexual risk decision making.^11,12 Several studies have found that MSM commonly use serosorting in general, but less is known about serosorting among MSM of various ethnicities.^7,13–15Data on the effectiveness of serosorting are somewhat mixed, but it is known that serosorting can lead to HIV exposure.¹⁶ Although some studies have noted the potential for serosorting to reduce overall HIV rates,^17,18 limitations of this practice, including infrequent HIV testing, lack of open communication about HIV status, and acute HIV infection place MSM who serosort at risk for HIV transmission.^19,20There are at least 2 factors that directly influence whether or not an individual is motivated to serosort. First, individuals who serosort likely do so to lower their perceived risk for HIV infection, that is, to make them feel safe while not using condoms. In this sense, serosorting can reduce HIV transmission anxiety. Hence, the perception that serosorting makes unprotected sex safer is most likely driving sexual behavior risk taking. Notably, risk perceptions have been previously demonstrated to play an important role in predicting other health-related behaviors.^21–23 Second, serosorting requires explicit verbal discussion about HIV status. As such, those who engage in serosorting need to be capable of discussing their own and their partners'' HIV status.⁷ When serosorting, merely assuming the HIV status of a partner is often substituted for explicit disclosure²⁰; however, serosorting cannot be effective under these conditions.We sought to examine partner selection practices that potentially contribute to disparate HIV infection rates among Black MSM and White MSM. First, we examined the sexual behavior of Black MSM versus that of White MSM. On the basis of previous studies, we hypothesized that Black MSM and White MSM would report similar numbers of unprotected anal intercourse partners. However, because the HIV status of partners men choose may drive the differences in HIV infection rates, we hypothesized that Black MSM would report more partners of unknown or positive HIV status than would White MSM and that White MSM would report more partners of negative HIV status than would Black MSM. In keeping with these hypotheses, we also predicted that Black MSM would report less favorable beliefs about serosorting and HIV status disclosure. Finally, we predicted that Black MSM would report higher HIV perceived risk because of their choosing serodiscordant partners.     

Perceptions Towards Condom Use, Sexual Activity, and HIV Disclosure among HIV-Positive African American Men Who Have Sex with Men: Implications for Heterosexual Transmission

Disproportionately high HIV/AIDS rates and frequent non-gay identification (NGI) among African American men who have sex with men or with both men and women (MSM/W) highlight the importance of understanding how HIV-positive African American MSM/W perceive safer sex, experience living with HIV, and decide to disclose their HIV status. Thirty predominately seropositive and non-gay identifying African American MSM/W in Los Angeles participated in three semi-structured focus group interviews, and a constant comparison method was used to analyze responses regarding condom use, sexual activity after an HIV diagnosis, and HIV serostatus disclosure. Condom use themes included its protective role against disease and pregnancy, acceptability concerns pertaining to aesthetic factors and effectiveness, and situational influences such as exchange sex, substance use, and suspicions from female partners. Themes regarding the impact of HIV on sexual activity included rejection, decreased partner seeking, and isolation. Serostatus disclosure themes included disclosure to selective partners and personal responsibility. Comprehensive HIV risk-reduction strategies that build social support networks, condom self-efficacy, communication skills, and a sense of collective responsibility among NGI African American MSM/W while addressing HIV stigma in the African American community as a whole are suggested.Harawa is with the Charles B. Drew University of Medicine and Sciences, University of California, Los Angeles, CA, USA. Williams is with the Semel Institute of Neuroscience & Human Behavior, Suite C8-871C, 760 Westwood Plaza, Los Angeles, CA 90024-1759, USA. Williams and Ramamurthi are with the Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles, CA, USA; Bingham is with the Los Angeles Department of Health Services, HIV Epidemiology Program, Los Angeles, CA, USA.     

HIV Risk Profiles Among HIV-Positive,Methamphetamine-Using Men Who Have Sex with Both Men and Women

This study examined demographic characteristics, sexual risk behaviors, sexual beliefs, and substance use patterns in HIV-positive, methamphetamine-using men who have sex with both men and women (MSMW) (n = 50) as compared to men who have sex with men only (MSM) (n = 150). Separate logistic regressions were conducted to predict group membership. In the final model, of 12 variables, eight were independently associated with group membership. Factors independently associated with MSMW were acquiring HIV through injection drug use, being an injection drug user, using hallucinogens, using crack, being less likely to have sex at a bathhouse, being less likely to be the receptive partner when high on methamphetamine, having greater intentions to use condoms for oral sex, and having more negative attitudes about HIV disclosure. These results suggest that, among HIV-positive methamphetamine users, MSMW differ significantly from MSM in terms of their HIV risk behaviors. Studies of gay men and HIV often also include bisexual men, grouping them all together as MSM, which may obscure important differences between MSMW and MSM. It is important that future studies consider MSM and MSMW separately in order to expand our knowledge about differential HIV prevention needs for both groups. This study showed that there were important differences in primary and secondary prevention needs of MSM and MSMW. These findings have implications for both primary and secondary HIV prevention among these high-risk populations.     

Transition to Adulthood and Antiretroviral Adherence Among HIV-Positive Young Black Men Who Have Sex With Men

Objectives. We conducted a qualitative study of HIV-positive young Black men who have sex with men (YBMSM) to explore their experiences of living with HIV and adhering to antiretroviral medications (ARVs) within the developmental context of their transition to adulthood.Methods. We conducted life history interviews with 20 HIV-positive YBMSM in Atlanta, Georgia, engaged in outpatient HIV care. We addressed these questions: (1) How do YBMSM living with HIV experience the transition to adulthood? and (2) What are the important sociocontextual influences on ARV adherence for YBMSM?Results. Successful transition to adulthood and optimal ARV adherence were inextricably linked. HIV’s detrimental impact on development was moderated by the degree of physical illness at diagnosis. Many participants described resilient trajectories while coping with HIV. Adherence problems occurred primarily among participants who were not meeting their developmental goals.Conclusions. Our findings support the need for early diagnosis and linkage to care, as well as the need to develop holistic, resilience-based interventions focusing on transition to adulthood. These findings have implications for individual clinical outcomes as well as ARV-based prevention efforts among YBMSM.Young Black men who have sex with men (YBMSM) aged 13 to 24 years are acquiring HIV infection at increasing rates, more than any other demographic group in the United States.1 Between 2006 and 2009, HIV incidence among YBMSM increased by 48%.2 These disparities are particularly prominent in the southern United States, which represents an increasing proportion of HIV incidence and prevalence.3,4 Effective interventions to improve treatment and prevention of HIV among YBMSM in the South are urgently needed.5,6 Significant public health benefit has been demonstrated from the use of antiretroviral medications (ARVs) to treat both people living with HIV (treatment as prevention) and uninfected high-risk individuals (preexposure prophylaxis).7,8 Given the rising HIV rates among YBMSM and the recent shift in focus toward ARV-based prevention approaches, we can anticipate that ARVs will be prescribed to YBMSM with increasing frequency in the near future. However, the efficacy of ARV-based interventions depends on optimal medication adherence,9,10 leading to concerns about the feasibility of implementing these strategies with youths.11 Adolescence and emerging adulthood are high-risk periods for medication nonadherence because of cognitive and developmental immaturity as well as structural barriers (e.g., housing and financial instability) that often manifest during the transition to independent adulthood.12,13 In addition to these youth-related obstacles, Black men who have sex with men of all ages frequently experience significant cultural and logistical barriers to obtaining appropriate medical care,14 including discrimination and mistrust at the community, institutional, and patient–provider relationship levels.15–20Developmentally and culturally appropriate support interventions must therefore be developed for YBMSM to maximize ARV adherence and the consequent individual and public health benefits. However, there is limited research focusing on sociocontextual factors in the lives of HIV-positive YBMSM to guide development of such programming. Extrapolation of prevention and treatment strategies designed for perinatally infected youths, older adults, or nonminority individuals is likely inadequate to address the unique circumstances of infected YBMSM as they learn to cope with a newly diagnosed chronic illness, manage intersecting stigmatized minority identities, and survive the normal developmental turbulence of adolescence and emerging adulthood.21,22 Formative research is needed to fill these gaps in the literature and maximize the likelihood of successfully implementing ARV-based prevention strategies in this growing population. We conducted a qualitative study to explore developmental and health-related experiences of HIV-positive YBMSM and to answer the following questions: (1) How do YBMSM experience the transition to adulthood while living with HIV? and (2) What are the important sociocontextual influences on ARV adherence for YBMSM?     

History of Childhood Sexual Abuse and Unsafe Anal Intercourse in a 6-City Study of HIV-Positive Men Who Have Sex With Men

Objectives. We assessed rates of childhood sexual abuse and its demographic and mental health correlates among HIV-positive men who reported unsafe anal intercourse with other men in the past year.Methods. We conducted a cross-sectional analysis of baseline data from 593 HIV-positive men who have sex with men enrolled in the Positive Connections intervention.Results. Childhood sexual abuse was reported by 47% of participants; 32% reported frequency as often or sometimes. Men reporting abuse were more likely to be Latino (odds ratio [OR] = 2.6; 95% confidence interval [CI] = 1.6, 4.2; P < .001) or African American (OR = 1.8; 95% CI = 1.2, 2.7; P = .005) than White. Among those who were abused, more frequent abuse was associated with more sexual contacts (for each, rate ratio [RR] = 1.3; P < .001) and unsafe anal intercourse (often, RR = 1.5; sometimes, RR = 2.0; P < .001) compared with men who were not abused.Conclusions. History of childhood sexual abuse is highly prevalent among HIV-positive men who engage in risky sexual behavior with other men and appears to be more common among men of color. Our findings suggest that abuse is associated with a significantly increased risk of sexually transmitted infections.Considerable evidence suggests that men who have sex with men (MSM) and who experienced childhood sexual abuse are at heightened risk for HIV infection and sexually transmitted infections (STIs) and associated sexual risk behaviors. Several publications have indicated that self-reported history of sexual abuse is indirectly associated with high-risk sexual behaviors among diverse samples of MSM, such as attendees at targeted events and members of support organizations for lesbian, gay, bisexual, and transgender adolescents.^1–4These reports corroborate earlier studies that found that MSM who reported childhood sexual abuse were at higher risk of becoming HIV positive and engaged in higher rates of unprotected anal intercourse. Few of these studies have focused on whether a history of childhood sexual abuse among HIV-positive MSM is associated with unprotected anal intercourse with partners who are HIV negative.^5–8 In a study of HIV-positive MSM recruited at gay venues in San Francisco and New York City, O''Leary et al. found an association between a history of childhood sexual abuse and unprotected anal intercourse with partners who were HIV negative or of unknown infection status.⁹ With little other research published on the effect of childhood sexual abuse on unsafe sexual behavior among HIV-positive MSM, the generalizability of this report is unknown.Few studies have had an adequate overall sample size to address differences in reported rates of childhood sexual abuse by race/ethnicity with precision. In a study of more than 1000 predominantly HIV-negative MSM, Doll et al. reported higher rates of childhood sexual abuse among African American and Latino than White MSM.¹⁰ Surveillance reports reveal very high rates of diagnosed and undiagnosed HIV infection among MSM of color^11,12; therefore it is critical to identify risk factors that may contribute to higher rates of unsafe sex among racial/ethnic subgroups of HIV-positive MSM.We examined the prevalence of self-reported history of childhood sexual abuse and the demographic and behavioral correlates of such abuse in a group of racially diverse HIV-positive MSM who reported anal intercourse with other men in the past year and who were enrolled in a weekend sexual health intervention to reduce unsafe sexual behavior. We hypothesized that men who reported childhood sexual abuse would also report higher rates of unprotected anal intercourse with men of HIV serodiscordant or unknown HIV infection status.