HIV-Related Sexual Risk among African American Men Preceding Incarceration: Associations with Support from Significant Others,Family, and Friends

We evaluated the association between social support received from significant others, family, and friends and HIV-related sexual risk behaviors among African American men involved in the criminal justice system. Project DISRUPT is a cohort study among African American men released from prison in North Carolina (N?=?189). During the baseline (in-prison) survey, we assessed the amount of support men perceived they had received from significant others, family, and friends. We measured associations between low support from each source (<median value) and participants’ sex risk in the 6 months before incarceration. Low levels of social support from significant others, family, or friends were associated with poverty and homelessness, mental disorders, and substance use. Adjusting for age, poverty, and other sources of support, perceiving low support from significant others was strongly associated with multiple partnerships (fully adjusted odds ratio (OR) 2.64, 95% confidence interval (CI) 1.29–5.42). Low significant other support also was strongly associated with sex trade involvement when adjusting for age and poverty status (adjusted OR 3.51, 95% CI 1.25–9.85) but further adjustment for low family and friend support weakened the association (fully adjusted OR 2.81, 95% CI 0.92–8.55). Significant other support was not associated with other sex risk outcomes including concurrent partnerships, anal sex, or sex with an STI/HIV-infected partner. Low family support was associated with multiple partnerships in analyses adjusting for age and poverty (adjusted OR 1.98, 95% CI 1.05–3.76) but the association weakened and was no longer significant after adjusting for other sources of support (fully adjusted OR 1.40, 95% CI 0.65–3.00); family support was not correlated with other risk behaviors. Friend support was not significantly associated with sex risk outcomes. Indicators of overall support from any source were not associated with sex risk outcomes. Helping inmates maintain ties may improve economic security and well-being during community re-entry, while supporting and strengthening relationships with a significant other in particular may help reduce sex risk. Studies should evaluate the protective effects of distinct support sources to avoid masking effects of support and to best understand the influence of social support on health.     

Correlates of Concurrent Sexual Partnerships Among Young,Rural African American Men

ObjectiveWe investigated the social, behavioral, and psychological factors associated with concurrent (i.e., overlapping in time) sexual partnerships among rural African American young men with a primary female partner.MethodsWe recruited 505 men in rural areas of southern Georgia from January 2012 to August 2013 using respondent-driven sampling; 361 reported having a primary female partner and participating only in heterosexual sexual activity. Men provided data on their demographic characteristics and HIV-related risk behaviors, as well as social, behavioral, and psychological risk factors.ResultsOf the 361 men with a primary female partner, 164 (45.4%) reported concurrent sexual partners during the past three months. Among the 164 men with a concurrent sexual partner, 144 (92.9%) reported inconsistent condom use with their primary partners, and 68 (41.5%) reported using condoms inconsistently with their concurrent partners. Having concurrent sexual partnerships was associated with inconsistent condom use, substance use before sex, and self-reported sexually transmitted infections (STIs). Bivariate correlates of concurrent sexual partnerships included incarceration, substance use, early onset of sexual activity, impulsive decision-making, and masculinity attitudes (i.e., men''s adherence to culturally defined standards for male behavior). In a multivariate model, both masculinity ideology and impulsive decision-making independently predicted concurrent sexual partnerships independent of other risk factors.ConclusionMasculinity attitudes and impulsive decision-making are independent predictors of concurrent sexual partnerships among rural African American men and, consequently, the spread of HIV and other STIs. Developing programs that target masculinity attitudes and self-regulatory skills may help to reduce concurrent sexual partnerships.African American men who have sex with women (hereinafter referred to as heterosexual) are an understudied group that has experienced rising rates of human immunodeficiency virus (HIV) infection and high rates of other sexually transmitted infections (STIs).¹ Since 2004, HIV diagnoses among African American men who report heterosexual contact have been increasing by more than 9% annually,² and approximately 25% of African American men currently living with HIV/acquired immunodeficiency syndrome (AIDS) reported contracting the disease through heterosexual contact.³ Heterosexual transmission of HIV is facilitated by non-HIV STIs, both inflammatory and ulcerative, which increase HIV infectivity and susceptibility in both women and men.⁴ Thus, risk conferred by STIs acquired in heterosexual relationships affects the spread of HIV in a community and highlights the importance of investigating heterosexual men''s behavior.Engaging in concurrent sexual partnerships has been identified as a potential influence on the HIV/STI epidemics in African American communities.^5–7 Concurrent sexual partnerships describe situations in which an individual has overlapping sexual relationships with more than one person. They can be contrasted with serial monogamy, in which an individual has a sexual relationship with only one partner, with no overlap in time with subsequent partners. Population-based studies have linked concurrent sexual partnerships to male sex, younger age, and African American race.⁷ Structural drivers, such as community poverty and gender ratios, appear to play a key role in the prevalence of African American men''s concurrent sexual partnerships.^8,9 In multiethnic samples, associations also have emerged between concurrent sexual partnerships and a range of personal risk factors, including unemployment and economic distress, substance use, history of incarceration, early onset of sexual activity, and perception of partner infidelity.^5,10–12 Less is known, however, about individual differences in the social, behavioral, and psychological factors that predict concurrent sexual partnerships, specifically among African American men.The African American men in the present study live in small towns and rural communities in southern Georgia. In these communities, interconnected sexual networks increase the risks that concurrent sexual partnerships pose. In addition, this study focused on men with a primary sexual partner. Compared with men without a primary partner, men with a primary partner report more frequent intercourse and less consistency in condom use with their primary partners.^13,14 In the context of concurrent sexual partnerships, these factors amplify exposure to pathogens for men and their sexual partners. Little research, however, focuses on correlates of concurrent sexual partnerships specifically among African American men with a primary partner.We investigated previously identified personal risk factors, including incarceration history, early onset of sexual activity, and substance use.^6,10,15 We also considered two psychological processes, masculinity attitudes (i.e., men''s adherence to culturally defined standards for male behavior) and impulsive decision-making, that have been suggested as targets of study.^15–17 Little research addresses the influence of psychological processes associated with African American men''s concurrent sexual partnerships despite the important role psychological factors play in designing individual-, group-, and community-level interventions.The first psychological risk mechanism is masculinity attitudes. In his anthropological work with African American and Caribbean men, Whitehead¹⁸ described a set of reputation-based attributes that men may adopt to maintain masculine self-esteem. These attributes include sexual prowess, masculine “gamesmanship” skills (e.g., toughness and ability to seduce women), fathering numerous children, and street smarts. In contrast, masculine respectability attributes include marriage, economic provision for one''s family, and satisfactory possessions and accomplishments (e.g., a home, higher education, and economic independence). When men from economically disadvantaged backgrounds experience barriers to respect-based pathways to masculinity, they become more likely to express and identify with reputation-based attributes to achieve a sense of masculine self-esteem.^18,19 Masculinity attitudes characterized by endorsement of reputation-based assets are hypothesized to place men at risk for concurrent sexual partnerships.The second psychological risk mechanism is impulsive decision-making, which has been implicated in a range of sexual risk behaviors, including inconsistent condom use, casual sex, multiple sexual partners, and sex while intoxicated.^20–24 Impulsive behavior has been thought to result from personality factors that include sensation seeking, urgency, and a lack of premeditation and perseverance.²⁵ A number of possible pathways support the link between impulsive decision-making and concurrent sexual partnerships. Impulsive individuals lack the self-regulatory capacity needed to resist hedonistic impulses when opportunities for concurrent sexual activity arise.²² Impulsive decision-making also reduces men''s ability to deal with stresses in committed relationships that can undermine sexual fidelity.^24,26,27     

Social Network Characteristics and HIV Sexual Risk Behavior among Urban African American Women

HIV/AIDS has emerged as a significant health threat for African American women with well-documented disparities. The purpose of this study was to assess the association between social network characteristics and high-risk sexual behaviors among a sample of urban African American women at risk of heterosexually acquired HIV/STIs. We performed a cross-sectional study of baseline data collected from the CHAT study, a randomized HIV-prevention trial targeting urban HIV-at-risk women in Baltimore, MD. Our primary outcomes were risky sexual behaviors defined as either (a) two or more sexual partners or (b) having a risky sex partner within the past 90 days. Bivariable and multivariable logistic regression examining the associations between individual and social network factors and our two outcomes of interest were conducted. The study population included 513 sexually active African American women with a mean age of 41.1 years. High levels of unemployment (89.5%), depressive symptoms (60.0%), and drug use (68.8%) were present among this high-risk urban cohort. Controlling for individual factors including participant drug use, age, and depression, having two or more sex partners within the past 90 days was associated with having a larger personal network (OR = 1.11; 95% CI, 1.06 and 1.17); more network members who pitched in to help (OR = 1.22; 95% CI, 1.04 and 1.44), provided financial support (OR = 1.33; 95% CI, 1.11 and 1.60), or used heroin or cocaine (OR = 1.26; 95% CI, 1.14 and 1.40). Having a risky sexual partner within the past 90 days was associated with having a larger social network (OR = 1.06; 95% CI, 1.00 and 1.12) and having more social networks who used heroin or cocaine (OR = 1.30; 95% CI, 1.14 and 1.49).In summary, social network characteristics are associated with HIV sexual risk behaviors among African American urban women. Social-network-based interventions that promote norms pertaining to HIV risk reduction and provide social support are needed for African American women at risk of heterosexually acquired HIV/STIs.     

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.     

某区男男性行为人群性伴网络特征与高危行为分析

[目的]了解男男性行为（MSM）人群性伴网络特征及该人群中高危性行为的发生情况,探讨性病（STDs）、人类免疫缺陷病毒（HIV）在该人群中传播及向普通人群传播的模式,为开展性病、艾滋病预防控制提供依据。[方法]通过艾滋病自愿咨询检测门诊、同性恋人群活动场所、同性恋QQ群内动员、＂滚雪球＂等途径寻找MSM人群,招募151人,采用面对面匿名问卷调查方式收集信息。[结果]151名被调查者中最近6个月有30人（19.9%）与异性发生过性行为,高危性行为的发生率为53.3%;与同性性活动情况,其中91人（60.3%）有同性固定性伴,76人（50.3%）与非固定同性性伴的人发生过多次男男性行为（简称有多次男性伴）,77人（51.0%）发生过偶遇性行为（简称有偶遇男性伴）,10人（6.6%）从事商业性行为。而在与固定性伴、多次男性伴、偶遇男性伴、商业性行为中高危性行为的发生率依次是69.2%、57.9%、50.6%、70.0%。与固定男性伴高危性行为的发生率高于与偶遇男性伴高危性行为的发生率（P=0.014）。最近6个月有2种及以上性伴类型占58.9%。30名已感染HIV者中有多次男性伴及偶遇男性伴类型的比例分别为53.3%和63.3%;有过多次男性伴、偶遇男性伴性行为者中发生高危性行为的比例分别为50.0%和63.2%。感染HIV者与固定男性伴发生高危性行为的率低于未感染HIV者（P=0.029）。[结论]MSM人群性伴网络复杂多样,高危性行为发生率高。不仅使HIV在该人群中容易传播,且该人群已成为向普通人群传播HIV的＂桥梁＂人群。     

Sexual Risk Behavior and Symptoms of Historical Loss in American Indian Men

Native Americans in the United States are not typically regarded as a most at-risk population for HIV or other sexually transmitted infections (STIs), despite emerging evidence which suggests otherwise. As a result, Native Americans lack access to key prevention services and programs. In planning prevention programs for this unique population, however, it is important to take into account the cultural factors that may be implicated in health risk behaviors. Historical Loss is a type of historical trauma that has been reported in Native Americans, and which may be related to health behaviors. We examined whether Historical Loss was associated with sexual risk behaviors in a sample of 120 American Indian men living in Fort Peck Reservation in northeastern Montana who completed questions regarding Historical Loss and sexual risk behaviors. Symptoms of Historical Loss that reflected Anxiety/Depression and Anger/Avoidance were associated with an increased likelihood of individuals’ having sex with multiple concurrent partners. Health interventions that aim to address HIV/STI prevention should take symptoms of Historical Loss into account, as Historical Loss could be a potential factor that will mitigate HIV, STI, and pregnancy prevention efforts in this population.     

The Urban Environment and Sexual Risk Behavior among Men who have Sex with Men

Increasingly, studies show that characteristics of the urban environment influence a wide variety of health behaviors and disease outcomes, yet few studies have focused on the sexual risk behaviors of men who have sex with men (MSM). This focus is important as many gay men reside in or move to urban areas, and sexual risk behaviors and associated outcomes have increased among some urban MSM in recent years. As interventions aimed at changing individual-level risk behaviors have shown mainly short-term effects, consideration of broader environmental influences is needed. Previous efforts to assess the influence of environmental characteristics on sexual behaviors and related health outcomes among the general population have generally applied three theories as explanatory models: physical disorder, social disorganization and social norms theories. In these models, the intervening mechanisms specified to link environmental characteristics to individual-level outcomes include stress, collective efficacy, and social influence processes, respectively. Whether these models can be empirically supported in generating inferences about the sexual behavior of urban MSM is underdeveloped. Conceptualizing sexual risk among MSM to include social and physical environmental characteristics provides a basis for generating novel and holistic disease prevention and health promotion interventions. Frye, Latka, Putnam, Galea, and Vlahov are with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, 1216 Fifth Avenue, New York, NY 10029, USA; Koblin is with the New York Blood Center, New York, NY, USA; Halkitis is with the Department of Applied Psychology, New York University, New York, NY, USA; Vlahov is with the Department of Epidemiology, Columbia University, New York, NY, USA; Galea is with the Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA.     

Early Onset of Sexual Intercourse and Parental Incarceration among African American Youth Living in Urban Public Housing

Mass incarceration, substance use, and adolescent early onset of sex (e.g., initiate sexual intercourse at 13 years of age or younger) are social problems with disparate impacts on low-income African American communities. Two out of every five inmates in state and federal prisons are African American and the vast majority of these inmates are from low-income communities. Furthermore, this population experiences more severe consequences of substance use and abuse compared to other populations. In sum, African American youth endure the lion share of problems that mass incarceration and substance use leave in their wake. It is likely that the early onset of sex reported by African American youth in national data is related to mass incarceration and substance use in their communities. Using a sample of 142 African American youth, this paper assesses whether parental incarceration or substance, or both, are related to the likelihood of early onset of sex. Analytic procedures included chi-square and sequential logistic regression. The sample reported a mean age of 19 and 36% reported early onset of sex. Being male, paternal incarcerated, and maternal alcohol problems were associated with an increased likelihood of early onset of sex. Results point to a need for supportive services for the children of incarcerated parents, particularly those living in urban public housing developments.     

Risk Reduction for HIV-Positive African American and Latino Men with Histories of Childhood Sexual Abuse

While the HIV epidemic has disproportionately affected African American and Latino men who have sex with men (MSM), few HIV prevention interventions have focused on African American and Latino men who have sex with both men and women (MSMW). Even fewer interventions target HIV-positive African American and Latino MSM and MSMW with histories of childhood sexual abuse (CSA), a population that may be vulnerable to high-risk sexual behaviors, having multiple sexual partners, and depression. The Men's Health Project, a small randomized clinical trial, compared the effects of two 6-session interventions, the Sexual Health Intervention for Men (S-HIM), guided by social learning theory and aimed at decreasing high-risk sexual behaviors, number of sexual partners, and depressive symptoms, and a standard health promotion control (SHP). A community sample of 137 HIV-positive gay and non-gay identifying African American and Latino MSM and MSMW with histories of CSA was recruited. Results were based on an "intent to treat" analyses of baseline to post, 3 and 6 month follow-ups. The sample as a whole reported reductions in sexual risk behaviors and number of sexual partners from baseline to post-test, and from the 3 to 6 month follow-ups, although the decrease in sexual risk behavior from baseline to post-test was significant only for S-HIM participants. No significant differences between conditions were reported for depressive symptoms, but the total sample reported a significant decrease at 6 months. These findings highlight the importance of addressing sexual decision-making and psychological adjustment for ethnic men, while being sensitive to CSA histories and sexual minority status, and suggest the need to develop additional strategies to heighten HIV risk reduction over time.     

Effects of Fear of Abuse and Possible STI Acquisition on the Sexual Behavior of Young African American Women

Objectives. We examined the interactive effects of fear of abuse and knowledge of sexually transmitted infections (STIs) on sexual risk behaviors in a sample of young African American women.Methods. We recruited 715 young African American women aged 15 to 21 years from a variety of health clinics and assessed them for fear of abuse because of negotiating condom use, knowledge of STIs, and several sexual risk behaviors.Results. Overall, 75% of young African American women reported inconsistent condom use in the past 60 days. Surprisingly, under relatively higher levels of fear, young women with high STI knowledge were more likely than were those with low STI knowledge to exhibit inconsistent condom use in the past 60 days (89% vs 80%; χ² = 4.32; P ≤ .04) and during the last sexual intercourse with a main sexual partner (76% vs 70%; χ² = 8.06; P ≤ .01).Conclusions. Most HIV prevention interventions focus on increasing knowledge about the transmission of STIs. However, other contextual factors such as fear of abuse because of negotiating condom use may heighten the risk of HIV infection. Our findings highlight the need for combining dating violence prevention activities with STI and HIV prevention programs targeting young African American women.Adolescence is a developmental period typically associated with risky and health-compromising behaviors. With the decrease in age at sexual initiation and the increase in sexual behaviors observed among adolescents,¹ attention to risk factors that may affect the sexual health of adolescents is critical. During adolescence, as girls develop and attempt to maintain dating and sexual relationships, some will experience abuse by a partner, which may adversely affect their ability to negotiate safer-sex practices, including condom use. Dating violence, a pervasive public health problem, affects between 12% and 43% of adolescents in the United States^2,3 and has the potential to increase the likelihood that adolescent girls will engage in sexual behaviors that increase their risk for HIV/AIDS.⁴At every phase of the HIV/AIDS epidemic in the United States, from HIV infection to death from AIDS-related complications, African Americans are disproportionately affected when compared with Whites and other racial/ethnic groups. This disparity is most glaring among African American women, whose rate of AIDS diagnosis is approximately 23 times that of White women in the United States.⁵ Furthermore, young African Americans in the United States are at increased risk of HIV infection. Among the 18 849 individuals younger than 25 years diagnosed with HIV or AIDS between 2001 and 2004, 64% were African American.⁶As a result of the HIV/AIDS crisis in the African American community, numerous studies have assessed factors associated with HIV risk behaviors among African Americans at the individual (e.g., knowledge, self-efficacy, risk perception), peer (e.g., peer norms for condom use), and societal (e.g., gender norms, gender and economic inequality) level.^7–9 These studies have led to programs to address these factors, with the intention of promoting change in HIV risk behaviors. Theories used to guide the development of HIV prevention interventions include the theory of reasoned action¹⁰ and the health belief model.¹¹ Based on these theories and subsequent prevention programs, behavioral change is more likely to occur with increased knowledge of HIV and other sexually transmitted infections (STIs) among high-risk individuals. There are, however, mixed findings for the effect of HIV/STI knowledge on promoting individuals'' behavior change, and the causal link has not been well established.¹² Hence, contextual factors between partners, such as dating violence, may explain sexual risk behaviors beyond increasing knowledge about how HIV and other STIs are transmitted.Social cognitive theory suggests that knowledge, though necessary, may not be sufficient to motivate people to adopt HIV-preventive behaviors; at best, knowledge is a prerequisite for behavior change.¹³ Social cognitive theory suggests that self-efficacy is also necessary when reducing risky sexual behavior and increasing safer sexual practices, such as condom use. Previous studies show that adolescents who feel confident in their ability to correctly use condoms,^13,14 to negotiate condom use with their partners,^14,15 to say “no” to unprotected intercourse,¹⁶ and to discuss their partner''s sexual history^15,17 are likely to use condoms more often and have lower rates of STIs than are those adolescents who are relatively less confident or self-efficacious. This positive association between self-efficacy and safer sexual practices is important in understanding an adolescent girl''s risk of HIV infection, particularly when attempting to negotiate condom use. Fear of an abusive partner might undermine an adolescent girl''s self-efficacy to encourage her sexual partner to use condoms.Because of the high rates of HIV infection observed in young women, the field of HIV prevention has seen a growing research interest in the intersection of gender-based violence and HIV infection. Specifically, there is mounting recognition of the effect of gender-based violence on young women''s perceived ability to engage in safer sexual practices.¹⁸ However, although most HIV prevention programs subscribe to the belief that knowledge of HIV/STI transmission is necessary to facilitate behavior change, programs often lack a substantial focus on gender-based factors that may compromise or threaten a woman''s self-efficacy to enact such change in light of newly acquired HIV/STI prevention knowledge.We focused on abuse—specifically, fear of abuse in adolescent and young-adult dating relationships—and its impact on HIV-related risk behaviors. We assessed the effect of fear of abuse because of attempted condom negotiation on the relation between STI knowledge and high-risk sexual behavior among African American women aged 15 to 21 years. We expected those with low STI knowledge and high fear of abuse because of condom negotiation to be more likely to engage in high-risk sexual behaviors than would those with high STI knowledge and low or no fear of abuse.     

A Randomized Controlled Trial to Reduce HIV-Related Risk in African American Men Who Have Sex with Men and Women: the Bruthas Project

Prevention Science - African American men who have sex with men and women (MSMW) are among the populations with the highest need for HIV prevention programs in the USA. We tested a theory-based,...     

Experiences of Racial Discrimination and Relation to Sexual Risk for HIV among a Sample of Urban Black and African American Men

This study aimed to examine racial discrimination and relation to sexual risk for HIV among a sample of urban Black and African American men. Participants of this cross-sectional study were Black and African American men (N = 703) between the ages of 18 and 65 years, recruited from four urban clinical sites in the northeast. Multivariate logistic regression models were used to analyze the relation of reported racial discrimination to the following: (1) sex trade involvement, (2) recent unprotected sex, and (3) reporting a number of sex partners in the past 12 months greater than the sample average. The majority of the sample (96 %) reported racial discrimination. In adjusted analyses, men reporting high levels of discrimination were significantly more likely to report recent sex trade involvement (buying and/or selling) (adjusted odds ratio (AOR) range = 1.7–2.3), having recent unprotected vaginal sex with a female partner (AOR = 1.4, 95 % confidence interval (CI), 1.1–2.0), and reporting more than four sex partners in the past year (AOR = 1.4, 95 % CI, 1.1–1.9). Findings highlight the link between experiences of racial discrimination and men''s sexual risk for HIV.     

A Sexual Risk and Stress Reduction Intervention Designed for HIV-Positive Bisexual African American Men With Childhood Sexual Abuse Histories

Objectives. HIV transmission risk is high among men who have sex with men and women (MSMW), and it is further heightened by a history of childhood sexual abuse (CSA) and current traumatic stress or depression. Yet, traumatic stress is rarely addressed in HIV interventions. We tested a stress-focused sexual risk reduction intervention for African American MSMW with CSA histories.Methods. This randomized controlled trial compared a stress-focused sexual risk reduction intervention with a general health promotion intervention. Sexual risk behaviors, psychological symptoms, stress biomarkers (urinary cortisol and catecholamines), and neopterin (an indicator of HIV progression) were assessed at baseline and at 3- and 6-month follow-ups.Results. Both interventions decreased and sustained reductions in sexual risk and psychological symptoms. The stress-focused intervention was more efficacious than the general health promotion intervention in decreasing unprotected anal insertive sex and reducing depression symptoms. Despite randomization, baseline group differences in CSA severity, psychological symptoms, and biomarkers were found and linked to subsequent intervention outcomes.Conclusions. Although interventions designed specifically for HIV-positive African American MSMW can lead to improvements in health outcomes, future research is needed to examine factors that influence intervention effects.HIV/AIDS continues to disproportionately affect African Americans relative to other racial/ethnic groups.1,2 In 2009, for example, African Americans represented only 14% of the US population but accounted for 44% of all new HIV diagnoses.1 Male-to-male sexual contact is the greatest category of risk among Blacks, accounting for 73% of new infections among Black men.1 HIV infection rates are higher among Black men who have sex with men (MSM) than in any other racial/ethnic MSM group.1,2 Despite this disparity, few interventions have been designed specifically for African American MSM3–6 or for men who have sex with men and women (MSMW).Prevention strategies that emphasize HIV education and access to condoms may be inadequate in effecting sexual risk reduction in these populations. Preexisting risk factors and mediational mechanisms may operate differently among African American MSMW, who may also be less likely to respond to interventions that are developed for gay men3,7–9 or to those that are not contextualized for African American experiences. Intervention strategies that focus on less commonly examined mediators may influence sexual behavior changes and HIV transmission and serve as new modalities for addressing the HIV epidemic among African American MSMW.Individual behavior change is complicated by personal, environmental, historical, and institutional factors.10 Trauma exposure, a social determinant operating at multiple ecological levels, may be contributing to the HIV epidemic. Childhood sexual abuse (CSA) is a significant predictor of generalized emotional distress, anxiety, and posttraumatic stress disorder (PTSD) in adulthood,11–15 and it has also been associated with an increased risk of sexual revictimization.16–22 Experiencing CSA not only affects people’s health, but it may also have an impact on their interpersonal relationships in adulthood (e.g., how they select and interact with their intimate sexual partners). Societal and environmental factors such as the stigma associated with sexual abuse may also contribute to negative psychosocial health outcomes.23Acute traumatic and chronic stress is also known to disrupt neurobiological mechanisms essential for survival. Preclinical research demonstrates that all vertebrates share a similar threat system.24 Stimuli identified as potentially challenging to the basic state of equilibrium (i.e., stressors) trigger immediate release of catecholamines and subsequent release of glucocorticoids (e.g., cortisol). These regulatory systems have feedback loops that ensure a return to homeostasis when the threat subsides. However, when chronic or excessive demands are placed on these systems, long-term changes occur in the areas of growth, reproduction, and immune activity.24 These well-known effects are embodied in the allostatic load model,25 which reflects the cumulative burden of stress disruptions on primary mediators such as cortisol and catecholamines. Over time, primary mediator disruptions compromise efficient and effective responses to new demands, secondary downstream mediators (e.g., blood pressure and body mass index) are dysregulated, and ultimately an increased risk of tertiary disease outcomes results.26,27Major life events, including trauma and abuse experiences, and common but chronic challenges such as problems at work and home or relationship issues may all contribute to cumulative stress burdens.28 Among members of ethnic minority groups, racially discriminatory experiences may also be perceived as threatening and precipitate a stress response.29–31 Such chronic stress is thought to contribute to health disparities in racial/ethnic minority groups in a framework referred to as the weathering hypothesis.32,33 In the case of African Americans, racial, sociocultural, and political inequities, as well as trauma experiences such as CSA, may contribute to increased disease risk.Associations between CSA and increased HIV sexual risk behaviors34–38 and mental health symptoms have been reported among men with abuse histories.38,39 However, these relationships are complex. For example, PTSD with co-occurring depression has been shown to act as both a moderating and a mediating variable in the relationship between CSA and number of lifetime sexual partners.38,39 One recent study suggested that the associations of sexual risk behaviors with CSA trauma and with mental health symptoms were influenced by trauma and symptom severity.40 Severe CSA (e.g., forcible penetration over multiple incidents) and an increased number of PTSD symptoms were linked to more sexual risk behaviors among HIV-infected African American men. Also, mixed linear regression models showed that clinically meaningful levels of PTSD symptoms predicted a composite indicator of primary neurohormones (cortisol, norepinephrine, epinephrine, and dopamine) reflecting physical health risks.Although researchers have attempted to identify racial/ethnic differences in risk behaviors to explain disproportionate HIV rates,41 characteristics of trauma and subsequent mental and physical health stress burden have not been adequately examined. Research exploring whether stress reduction intervention components can reduce sexual risk behaviors and improve mental and physical health is still in its infancy. Evidence from HIV interventions links social cognitive models emphasizing relaxation skills, cognitive coping strategies, and social support to the mediation of mood effects and stress-related neurohormones.42–45 Decreased urinary cortisol levels with corresponding decreases in depressive symptoms and decreased urinary norepinephrine levels with reduced anxiety symptoms have been reported.42,46Two meta-analyses showed that cognitive–behavioral interventions decreased psychological symptoms such as depression, anxiety, anger, and stress among people living with HIV/AIDS.43,44 Unfortunately, immune functioning, as evidenced by CD4^43,44 and viral load,43 showed little improvement. A study involving a 15-session individual stress management intervention for people with HIV reported a decreased frequency of unprotected sexual acts but no effect on depression and anxiety symptoms.47 Another intervention, employing cognitive and stress management strategies with people who had HIV/AIDS and a history of CSA, reported decreases in both traumatic stress symptoms48 and unprotected sex acts.49 Comprehensive interventions designed to reduce sexual risk behaviors, psychological difficulties, and stress-related neurohormones are lacking.We conducted a small, randomized clinical trial to develop and test the Enhanced Sexual Health Intervention for Men (ES-HIM) that targeted HIV-positive African American MSMW who did not self-identify as gay and who had histories of CSA. We compared ES-HIM with an attention-matched health promotion intervention (HP) with respect to their efficacy in reducing sexual risk behaviors (i.e., unprotected anal and vaginal sex), numbers of sexual partners, psychological symptoms of PTSD and depression, and primary neurohormonal mediators (cortisol and catecholamines). We also explored the intervention’s effects on neopterin, which is produced primarily in monocytes and macrophages. Because neopterin is responsive to immune-inflammatory stimuli, it can serve as an indicator of HIV disease progression (i.e., deterioration of one’s health status as a result of stress).     

Association of Discrimination-Related Trauma With Sexual Risk Among HIV-Positive African American Men Who Have Sex With Men

Objectives. We investigated whether 1 form of traumatic stress, discrimination-related trauma (e.g., physical assault because of race), was associated with unprotected anal intercourse, especially when compared with non–discrimination-related trauma, among African American men who have sex with men.Methods. A convenience sample of 131 HIV-positive African American men who have sex with men receiving antiretroviral treatment completed audio computer-assisted self-interviews that covered unprotected anal intercourse, interpersonal trauma, and whether trauma was because of discrimination on the basis of race/ethnicity, HIV serostatus, or sexual orientation.Results. Sixty percent reported at least 1 interpersonal trauma; they attributed at least 1 trauma to being gay (47%), African American (17%), or HIV positive (9%). In a multivariate regression, experiencing discrimination-related trauma was significantly associated with unprotected anal intercourse (adjusted odds ratio [AOR] = 2.4; 95% confidence interval [CI] = 1.0, 5.7; P = .04), whereas experiencing non–discrimination-related trauma was not (AOR = 1.3; 95% CI = 0.6, 3.1; P = .53).Conclusions. HIV-positive African American men who have sex with men experience high levels of discrimination-related trauma, a stressor associated with greater risk taking. HIV prevention interventions should consider the potential damaging effects of discrimination in the context of trauma.HIV disproportionately affects African American men who have sex with men (MSM). Twenty-eight percent of African American MSM are estimated to be HIV positive, compared with 16% of White MSM1 and 2% of the general African American male population.2 Young African American males (aged 13–29 years) who have sex with males have had a higher increase in HIV incidence in recent years than has any other racial/ethnic subgroup in the United States.3 Rates of unprotected anal intercourse (UAI) fail to account for racial/ethnic disparities in HIV prevalence.4 However, UAI remains the highest risk factor for HIV transmission among MSM. Understanding the sociocultural variables associated with UAI among African American MSM is likely to be important for developing appropriate HIV prevention strategies for this population. One such sociocultural variable is interpersonal trauma, including childhood sexual abuse (CSA),5 intimate partner violence,6 forced sex,7 and other physical assault. Interpersonal violence disproportionately affects African Americans in general8 as well as MSM.9,10 Although few studies have examined forced sex and physical assault among African American MSM, several have reported a higher prevalence of CSA among African American MSM than among White MSM.9,11 Furthermore, MSM who experience trauma may be more likely to engage in sexual risk behaviors. For example, 1 study reported that MSM with a history of CSA had more sexual contacts and acts of UAI than did MSM who had no history of CSA.11Other research suggests that African American MSM are faced with multiple forms of discrimination associated with their HIV serostatus, race, and sexual orientation12 and that such discrimination may sometimes be experienced as interpersonal trauma. A qualitative study of 87 African American MSM reported that victims may perceive experiences of CSA to be related to their sexual orientation.13 A small quantitative study of a convenience sample of 56 HIV-positive patients recruited from an AIDS treatment clinic reported that of HIV-positive men of color and MSM who reported intimate partner violence, slightly more than one quarter believed that their abuse was related to their HIV serostatus.14The minority stress model posits that social discrimination leads to excess stress among minority persons, which may be more damaging than are other types of stressors because discrimination on the basis of one’s social group may threaten individuals’ core sense of identity.15–18 Consistent with this model, a survey of lesbians and gays found that those who had experienced a bias-related crime showed worse mental health consequences (e.g., symptoms of depression, anxiety, anger, and posttraumatic stress) than did those who had experienced non–bias-related crimes.19 The effect of social discrimination on mental health outcomes has been well documented across various populations, including people living with HIV.12,20 Furthermore, some research indicates an association of perceived social discrimination with sexual risk among MSM,21–28 but none has included an examination of the distinct association of discrimination-related trauma with sexual risk behavior, beyond the effects of other types of trauma. The minority stress model suggests that social discrimination–related trauma would have a greater association with sexual risk than would trauma alone. Although previous research has indicated an association of sexual risk with both trauma5–7 and chronic discrimination,21–28 the effects of trauma resulting from discrimination on sexual risk do not appear to have been investigated in the literature.We examined the association of prior trauma with sexual risk among African American MSM living with HIV. In multivariate models, we examined the distinct effects of discrimination-related and -unrelated interpersonal trauma on sexual risk. We were especially interested in assessing whether experiences of discrimination-related interpersonal trauma had a unique association with UAI beyond variables related to sexual risk in previous research. We were also interested in whether there was a distinct association of UAI with discrimination-related interpersonal trauma beyond any association with interpersonal trauma in general (including discrimination-related and -unrelated interpersonal trauma). Such findings would suggest a need to focus on the added effects of discrimination from interpersonal trauma in both research and secondary HIV prevention interventions targeting this population.     

Substance Use and HIV Risk Behavior among Men Who Have Sex with Men: The Role of Sexual Compulsivity

The relationship between substance use, sexual compulsivity and sexual risk behavior was assessed with a probability-based sample of men who have sex with men (MSM). Stimulant, poppers, erectile dysfunction medication (EDM), alcohol use, and sexual compulsivity were independently associated with higher odds of engaging in any serodiscordant unprotected anal intercourse (SDUAI). The association of sexual compulsivity with SDUAI was moderated by poppers and EDM use. Behavioral interventions are needed to optimize biomedical prevention of HIV among substance using MSM.     

Perceived HIV-Related Sexual Risks and Prevention Practices of African American Women in the Southeastern United States

African American women in the southeastern United States constitute the fastest growing segment of those infected with the human immunodeficiency virus (HIV). Little data exist about the relationships between HIV infection risks and preventive practices. In this article, we describe a focus group investigation of how HIV-related sexual risks are perceived by 19 heterosexual African American women, ages 18 to 44. Data were analyzed and interpreted using content analysis, where key ideas, words, and phrases were grouped based on their relation to the purpose of the study. Four themes were revealed: ''a man will be a man,'' inconsistent and/or no condom use, safe relationships, and racism and discrimination. Perceived safety within relationships mediated both perceptions of HIV-related risks and sexual practices. In light of beliefs about the riskiness of sex with high-risk partners, fear of HIV, and the importance of self love in minimizing HIV infection risks, the women continued to practice unsafe sexual behaviors. Results indicate that women perceive themselves as victims in society and that this perception limits their propensity to take action to protect themselves from HIV. Successful HIV infection prevention interventions need to address negative social and economic factors that define the context of many women's lives.     

Patterns of Drug Use and HIV-Related Risk Behaviors among Incarcerated People in a Prison in Iran

Previous research indicates that prisoners in Iran are at risk of drug-related harm, including acquisition of blood-borne infections. In response, several prevention interventions have been introduced into prisons in Iran, such as methadone maintenance treatment (MMT). MMT is now provided to opioid-dependent prisoners in 142 of the 230 prisons and correctional settings in Iran. A baseline behavioral survey was conducted in Karaj Central prison which mainly holds prisoners with drug-related charges. Overall, 203 male prisoners from randomly selected rooms in two prison blocks were interviewed using a structured questionnaire in 2007, just before the introduction of MMT program in this prison. Among participants, 7% reported never having used illicit drugs in their lifetime, but 51% had used non-injecting illicit drugs, and as high as 42% reported having injected an illicit drug. Up to 79% (160/203) of all participants reported using drugs, and about 6% (12/203) reported drug injecting during their current incarceration term. Same-gender sexual practice during current incarceration term was reported by 2.5% (5/203) of all male prisoners. Comparison between injecting and non-injecting drug-using prisoners indicated that drug injectors had higher rates of previous incarcerations, commenced drug use at a younger age, were more likely to have used illicit drugs in the previous week, were more likely to have been treated by a physician for drug addiction, had higher rates of registration for methadone treatment inside prison, and were more likely to have been tested for HIV infection. These study findings provide a behavioral profile of prisoners in regard to drug-related harm and can be considered in any plan to introduce or improve provision of MMT in prisons in Iran or other countries with similar features.     

History of Sexual Abuse and Development of Sexual Risk Behavior in Low-Income,Urban African American Girls Seeking Mental Health Treatment

Objective: This study examined relationships between sexual abuse and patterns of sexual risk-taking among low-income, urban African American adolescent girls seeking mental health treatment. Method: Participants (N = 158) were 12- to 16-year-old African American girls recruited from outpatient mental health clinics serving urban, mostly low-socioeconomic status communities in Chicago, Illinois and followed for two years between 2003 and 2010. This study included self-reports of sexual abuse and four waves (T2–T5) of self-reported data on sexual experience and sexual risk-taking (number of partners, inconsistent condom use, and sex with a risky partner). Latent curve modeling was used to examine patterns of sexual behavior over the four time points with sexual abuse and mental health symptoms as covariates. Results: Sexual abuse was significantly associated with T2 sexual experience, T2–T4 number of partners, T3 inconsistent condom use, and T2–T3 having a risky partner. These relationships decreased when mental health symptoms were controlled. Conclusions: This longitudinal study revealed a complex relationship between sexual abuse and sexual risk that would be missed if sexual risk were assessed at a single time point. Findings supported early intervention to delay onset of sexual risk behavior among low-income African American girls with mental health concerns and histories of sexual abuse.