Relation of Childhood Sexual Abuse,Intimate Partner Violence,and Depression to Risk Factors for HIV Among Black Men Who Have Sex With Men in 6 US Cities

Objectives. We assessed the relation of childhood sexual abuse (CSA), intimate partner violence (IPV), and depression to HIV sexual risk behaviors among Black men who have sex with men (MSM).Methods. Participants were 1522 Black MSM recruited from 6 US cities between July 2009 and December 2011. Univariate and multivariable logistic regression models were used.Results. Participants reported sex before age 12 years with someone at least 5 years older (31.1%), unwanted sex when aged 12 to 16 years (30%), IPV (51.8%), and depression (43.8%). Experiencing CSA when aged 12 to 16 years was inversely associated with any receptive condomless anal sex with a male partner (adjusted odds ratio [AOR] = 0.50; 95% confidence interval [CI] = 0.29, 0.86). Pressured or forced sex was positively associated with any receptive anal sex (AOR = 2.24; 95% CI = 1.57, 3.20). Experiencing CSA when younger than 12 years, physical abuse, emotional abuse, having been stalked, and pressured or forced sex were positively associated with having more than 3 male partners in the past 6 months. Among HIV-positive MSM (n = 337), CSA between ages 12 and 16 years was positively associated with having more than 3 male partners in the past 6 months.Conclusions. Rates of CSA, IPV, and depression were high, but associations with HIV sexual risk outcomes were modest.Despite significant medical advances, the HIV epidemic remains a health crisis in Black communities. The Black population represents only 14% of the total US population but accounted for 44% of all new HIV infection (68.9 of 100 000) in 2010.1 Black men who have sex with men (MSM) are disproportionately impacted by HIV compared with other racial/ethnic groups of MSM.1,2 Male-to-male sexual contact accounted for 72% of new infections among all Black men.1 Young Black MSM (aged 13–24 years) have a greater number of new infections than any other age or racial group among MSM.1 Researchers have been challenged with developing HIV prevention strategies for Black MSM.3–7 Higher frequencies of sexual risk behaviors, substance use, and nondisclosure of sexual identities do not adequately explain this disparity.8,9 High rates of sexually transmitted infections (STIs), which facilitate HIV transmission, and undetected or late diagnosis of HIV infection only partially explain disproportionate HIV rates.8Researchers have begun to examine a constellation of health factors that may contribute to HIV among MSM. For example, syndemic theory or the interaction of epidemics synergistically, such as intimate partner violence (IPV) and depression, may help explain HIV-related sexual risk behaviors among Black MSM.9 Childhood sexual abuse (CSA), IPV, and mental health disorders including depression may comprise such a constellation and warrant further exploration.Experiences of CSA have been identified as being associated with negative sexual health outcomes, with MSM reporting higher CSA rates than the general male population.10–12 Men with CSA experiences are more likely than men without CSA experiences to engage in high-risk sexual behaviors,13–21 have more lifetime sexual partners,13–16 use condoms less frequently,13,14,16 and have higher rates of STIs,13,14,17 exchanging sex for drugs or money,13,14,17 HIV,13,14 alcohol and substance use,13–21 and depression.13–15,18,21 Such findings suggest that sexual risk reduction counseling may need to be tailored for MSM with CSA experiences.15Childhood sexual abuse histories have also been correlated with sexual revictimization, including IPV.22–24 One study with population-based estimates of CSA found that gay and bisexually identified men had higher odds of reporting CSA (9.5 and 12.8, respectively) compared with heterosexual men.25 For sexual minority men, CSA histories were associated with higher HIV and STI incidence.25 However, research examining CSA, revictimization, and sexual risk behaviors is lacking among Black MSM.In one existing study, Black and Latino MSM with CSA histories identified their trauma experiences as influencing their adult sexual decision-making.26 Among Black MSM in 2 additional studies, emotional distress and substance use were attributed to having CSA experiences (Leo Wilton, PhD, written communication, October 2, 2013).27 In an ethnically diverse sample of 456 HIV-positive MSM, CSA was associated with insertive and receptive condomless anal sex.19Similar to CSA, IPV has not been extensively examined among MSM or Black MSM,28 but may be associated with sexual risk behaviors. Intimate partner violence is defined as a pattern of controlling, abusive behavior within an intimate relationship that may include physical, psychological or emotional, verbal, or sexual abuse.29 Little research exists on IPV among same-sex couples despite incidence rates being comparable to or greater than that of heterosexual women.28,30–34 Important IPV information comes from the National Intimate Partner and Sexual Violence Survey, a nationally representative survey for experiences of sexual violence, stalking, and IPV among men and women in the United States.28 Among men who experienced rape, physical violence, or stalking by an intimate partner, perpetrator differences by gender were found among gay, bisexual, and heterosexual men; 78% of bisexual and 99.5% of heterosexual men reported having only female perpetrators, and 90.7% of gay men reported having only male perpetrators.28 Being slapped, pushed, or shoved by an intimate partner during their lifetime was reported by gay (24%), bisexual (27%), and heterosexual (26.3%) men.28Intimate partner violence has been linked to condomless anal sex, HIV infection, substance use, CSA, and depression.35–37 Being an HIV-positive MSM has been linked with becoming a victim of IPV.38,39 Welles et al. found that being an African American MSM who initially disclosed having male partners and early life sexual abuse experiences was associated with IPV victimization.39 Wilton found that a high percentage of Black MSM reported IPV histories: emotional abuse (48.3%), physical abuse (28.3%), sexual abuse (21.7%), and stalking abuse (29.2%; Leo Wilton, PhD, written communication, October 2, 2013). Such findings lend to the importance of exploring, both independently and together, the association of CSA and IPV with sexual risk behaviors.Some studies have reported the influence of mental health (e.g., depression) on sexual risk behaviors among MSM,9,40,41 whereas others have not corroborated such findings.42 Greater rates of depression among MSM than among non-MSM samples43–45 and elevated rates of depression and anxiety among Black MSM have been reported.46 The Urban Men’s Health Study, a cross-sectional sample of MSM in 4 US cities, did not find a significant relationship between high depressive symptoms and condomless anal sex.42 However, the EXPLORE study, a randomized behavioral intervention for MSM in 6 US cities, supported the association between moderate depressive symptoms and an increased risk for HIV infection.47 Moderate levels of depression and higher rates of sexual risk were also reported for HIV-infected MSM over time.48 Another study conducted with 197 Black MSM found that moderate depressive symptoms were associated with having condomless anal sex with a serodiscordant casual partner.49 These mixed findings support the need to better understand the relationship between the severity of depression (i.e., moderate vs severe) and HIV risk behaviors.The HIV Prevention Trials Network 061 study, also known as the BROTHERS (Broadening the Reach of Testing, Health Education, Resources, and Services) Project, was a multisite study to determine the feasibility and acceptability of a multicomponent intervention for Black MSM. The current analysis aims to assess the prevalence of CSA, IPV, and depressive symptomology, and examine the relationships between these factors and insertive and receptive condomless anal sex and number of sexual partners in a large cohort of Black MSM.     

Differences in the social networks of African American men who have sex with men only and those who have sex with men and women

Objectives. We compared social network characteristics of African American men who have sex with men only (MSMO) with social network characteristics of African American men who have sex with men and women (MSMW).Methods. Study participants were 234 African American men who have sex with men who completed a baseline social network assessment for a pilot behavioral HIV prevention intervention in Baltimore, Maryland, from 2006 through 2009. We surveyed the men to elicit the characteristics of their social networks, and we used logistic regression models to assess differences in network characteristics.Results. MSMO were significantly more likely than were MSMW to be HIV-positive (52% vs 31%). We found no differences between MSMO and MSMW in the size of kin networks or emotional and material support networks. MSMW had denser sexual networks, reported more concurrent and exchange partners, used condoms with more sexual partners, and reported interaction with a larger number of sexual partners at least once a week.Conclusions. Although there were many similarities in the social and sexual network characteristics of MSMO and MSMW, differences did exist. HIV prevention interventions should address the unique needs of African American MSMW.Recent epidemiological data suggest that the highest rates of HIV infection in the United States are found among African American men who have sex with men (MSM).¹ According to the National HIV Behavioral Surveillance survey in 2004–2005, among 5 cities studied, Baltimore, Maryland, had the highest HIV rates among African American MSM, with a prevalence of 51% and an estimated incidence rate of 8% per year.² African American MSM are also more likely than are MSM of other racial/ethnic groups to report bisexual identity.^3–9Some studies have focused on men who have sex with men and women (MSMW) as a potential bridge group to heterosexual transmission.^10,11 Several investigators have found that MSMW have lower HIV rates than do men who have sex with men only (MSMO).^11–13 Some studies have found that MSMW report more sexual partners than do MSMO,^11,14 although another has found that not to be true.¹⁵Social network factors have been linked to transmission of HIV and other sexually transmitted infections.^16–18 Indeed, there is evidence that network structural characteristics, such as network density (the extent to which social network members know one another) and partner concurrency, may lead to high rates of sexually transmitted infectious diseases.^19–21 Network dynamics have also been used to explain the greater burden of HIV and AIDS among African Americans compared with other racial groups in the United States.²² Network characteristics such as network size, composition, and density have been found to be associated with HIV risk behaviors, such as sharing injection equipment,^23–27 having multiple partners, engaging in unprotected sex, and exchanging sex for money or drugs.^28–31Social network analysis is a useful method to assess amounts, types, and sources of emotional and instrumental social support³² without assuming that social support is derived from specific role relationships, such as spouse, coworker, main sexual partner, or friend. In different populations, specific role relationships may not exist, or the same role may provide different types of social support. Few studies have examined the social networks of MSM,^33,34 and there is even less information on the social networks of African American MSM. Miller et al.³⁵ conducted in-depth interviews with 21 African American MSM and inquired about the composition of their social networks. They found that African American MSM listed twice as many non-MSM male friends as MSM friends. Few listed MSM friends with whom they did not have sex. A study of HIV-positive men and women reported that African American MSM received more social support from friends and health care providers than they did from family members.³⁶ It has been suggested that some African American MSM perceive that their community consists of their social network members rather than a physical location.³⁷We examined differences in social network composition between African American MSMO and African American MSMW. Examining social network composition is critical not only for assessing the dynamics of transmission of HIV but also for assessing the social and economic support available to people with HIV. Support issues are especially important among impoverished urban populations. Understanding social network composition is also critical for developing and sustaining appropriate HIV prevention and care programs. In these analyses we were specifically interested in examining the sources and functions of social support within participants'' social networks, the sexual risk behaviors participants engaged in with network members, and the overlap between social support networks and sexual networks. We anticipated that MSMO would report more dense social networks than MSMW but less social support.     

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.     

HIV Prevalence and Awareness of Positive Serostatus Among Men Who Have Sex With Men and Transgender Women in Bogotá, Colombia

Objectives. We estimated HIV prevalence among men who have sex with men (MSM) and transgender women in Bogotá, Colombia, and explored differences between HIV-positive individuals who are aware and unaware of their serostatus.Methods. In this cross-sectional 2011 study, we used respondent-driven sampling (RDS) to recruit 1000 MSM and transgender women, who completed a computerized questionnaire and received an HIV test.Results. The RDS-adjusted prevalence was 12.1% (95% confidence interval [CI] = 8.7, 15.8), comparable to a previous RDS-derived estimate. Among HIV-positive participants, 39.7% (95% CI = 25.0, 54.8) were aware of their serostatus and 60.3% (95% CI = 45.2, 75.5) were unaware before this study. HIV-positive–unaware individuals were more likely to report inadequate insurance coverage, exchange sex (i.e., sexual intercourse in exchange for money, goods, or services), and substance use than other participants. HIV-positive–aware participants were least likely to have had condomless anal intercourse in the previous 3 months. Regardless of awareness, HIV-positive participants reported more violence and forced relocation experiences than HIV-negative participants.Conclusions. There is an urgent need to increase HIV detection among MSM and transgender women in Bogotá. HIV-positive–unaware group characteristics suggest an important role for structural, social, and individual interventions.Colombia ranks second among countries in Latin America in HIV prevalence, with estimates ranging from 0.7% to 1.1% of the adult population.1 Men who have sex with men (MSM) represent the group most strongly affected, with prevalence of 18% to 20% based on venue-based convenience samples2,3 and 15% based on respondent-driven sampling (RDS).4 Colombia has a long history of armed conflict, and the pervasive conditions of violence, internal displacement, and poverty can be relevant to HIV transmission.5 “Social cleansing” by armed groups has been aimed at MSM and transgender women, as well as people living with HIV,5 and the stigma associated with homosexuality and HIV is widespread and inherent in structural inequalities in Colombia.6,7 Social epidemiological models posit that HIV is influenced by such structural (e.g., civil unrest, migration) and social factors (e.g., social networks, community attitudes), as well as individual characteristics (e.g., psychological characteristics, behavior).8Public health efforts emphasize the importance of detecting and treating undiagnosed HIV as a means of reducing HIV incidence.9–11 In the United States, approximately 20% of HIV-positive individuals are thought to be unaware of their infection, but this group is estimated to be responsible for nearly half of new transmissions.12 There is limited research concerning awareness of serostatus in Latin America. Undiagnosed infection was found to be 89% among HIV-positive MSM sampled in Peru in 2011,13 and rates are likely to be high in Colombia because of low levels of testing,6 including among MSM.4,14 Recent studies of MSM in France, Peru, and the United States have found associations between undiagnosed infection and demographic characteristics such as age, income, and education13,15,16; risk behaviors14,17,18; family or intimate partner violence19; and health insurance coverage.20 We also examined awareness in relation to violence and forced relocation, conditions specific to the Colombian context.Respondent-driven sampling was developed as a means of obtaining unbiased estimates from hidden populations,21–23 and it has been shown to capture a more diverse24,25 and hidden26 group of MSM than time–location or snowball sampling. Research has suggested, however, that biases can occur.27–29Our current study and a study conducted by the United Nations Population Fund and the Colombian Ministry of Health and Social Protection (UNFPA/MSPS) were independently funded at approximately the same time to address the limited information about behavioral risk and HIV prevalence among Colombian MSM. Comparison of findings from the 2 studies provides evidence concerning reliability of the RDS-derived prevalence estimates. We estimated HIV prevalence among MSM and transgender women in Bogotá, Colombia, examined reliability of RDS-derived estimates in relation to the UNFPA/MSPS study,4 and investigated the role of the social and structural context of Colombia in both prevalence and awareness of positive serostatus.     

Uptake and Predictors of Anal Cancer Screening in Men Who Have Sex With Men

Objectives. We investigated attitudes about and acceptance of anal Papanicolaou (Pap) screening among men who have sex with men (MSM).Methods. Free anal Pap screening (cytology) was offered to 1742 MSM in the Multicenter AIDS Cohort Study, who reported history of, attitudes about, and experience with screening. We explored predictors of declining screening with multivariate logistic regression.Results. A history of anal Pap screening was uncommon among non–HIV-infected MSM, but more common among HIV-infected MSM (10% vs 39%; P < .001). Most participants expressed moderate or strong interest in screening (86%), no anxiety about screening (66%), and a strong belief in the utility of screening (65%). Acceptance of screening during this study was high (85%) across all 4 US sites. Among those screened, most reported it was “not a big deal” or “not as bad as expected,” and 3% reported that it was “scary.” Declining to have screening was associated with Black race, anxiety about screening, and low interest, but not age or HIV status.Conclusions. This study demonstrated high acceptance of anal Pap screening among both HIV-infected and non–HIV-infected MSM across 4 US sites.In the past 3 decades, anal cancer incidence has increased 39% in women and 96% in men in the United States.1–3 In the general US population, anal cancer incidence remains higher among women than men (1.8 vs 1.4 cases per 100 000 annually), but the incidence is especially high among men who have sex with men (MSM; 35 per 100 000).4–6 Indeed, data suggest that anal cancer incidence among MSM may be similar to or higher than incidence of cervical cancer among US women before the introduction of cervical cytology screening in the mid-1950s.1,7–13 Incidence estimates for HIV-infected MSM are even higher and vary from 45.9 per 100 000 person-years14 in meta-analyses to 78.2 per 100 000 person-years15 for US AIDS Surveillance Epidemiology and End Results data.Human papillomavirus (HPV) infection is the major cause of anal cancer.4,14,16,17 Consistent with the increased anal cancer incidence among MSM, anal HPV prevalence and incidence are elevated among MSM compared with the general population.18,19 HIV-infected MSM have even higher anal HPV prevalence, compared with non–HIV-infected MSM (98% vs 57%).20,21 As effective antiretroviral therapy (ART, also referred to as HAART) helps HIV-infected individuals live longer, more may now develop anal cancer.6,22,23 On the basis of initial studies, it is unclear whether ART use reduces risk of anal intraepithelial neoplasia (AIN2/3, precancer)24 or anal cancer,25,26 although low CD4-cell count does appear to increase risk of anal cancer.27Recent research suggests that anal Papanicolaou (Pap) screening may have utility in preventing anal cancer9,28–30 and is a cost-effective screening method for anal cancer prevention among MSM.31,32 Like cervical dysplasia, anal dysplasia is slow-growing and treatable, and studies suggest that anal Pap tests can detect dysplasia with similar sensitivity and specificity to cervical Pap tests.33–35 On the basis of these data and the success of cervical Pap screening in reducing cervical cancer incidence, some have proposed routine anal Pap cytology (referred to as anal Pap screening hereafter) among MSM.9,36 However, these guidelines remain preliminary as researchers have not yet conducted a randomized trial to establish whether anal Pap screening reduces anal cancer deaths. Furthermore, recent studies have suggested that anal precancers (AIN2+) are relatively common among unscreened non–HIV-infected (∼4%) and HIV-infected (15%–30%) MSM, much higher than anal cancer rates, so other researchers have suggested that closer examination of the relative harms and benefits of treating all AIN 2/3 in MSM is first needed.24,35,37–40Despite the high incidence of anal cancer among MSM and recommendations, by some, for screening, MSM currently have low awareness of, access to, and use of anal Pap screening.41,42 Indeed, in our previous research, we observed a low reported prevalence of ever having anal Pap screening among MSM.43 We have expanded on these previous findings by examining acceptance of screening when offered for free. We also examined attitudes about anal Pap screening, experience with screening, and reasons for declining to have an anal Pap test.     

The Role of Young Adults’ Pleasure Attitudes in Shaping Condom Use

Condoms can help young adults protect themselves from sexually transmitted infections and unintended pregnancy. We examined young people’s attitudes about whether condoms reduced pleasure and how these attitudes shape condom practices. We used a nationally representative sample of 2328 heterosexually active, unmarried 15- to 24-year-old young adults to document multivariate associations with condom nonuse at the last sexual episode. For both young men and women, pleasure-related attitudes were more strongly associated with lack of condom use than all sociodemographic or sexual history factors. Research and interventions should consistently assess and address young people’s attitudes about how condoms affect pleasure.Because of their unique ability to prevent both pregnancy and sexually transmitted infections (STIs), male condoms are a vital public health tool. For decades, researchers have worked to understand and promote young adults’ consistent condom use. Although 15- to 24-year-old young adults represent only 25% of the sexually experienced population in the United States, they account for 53% of all unintended pregnancies1 and nearly half of all new STI cases.2Many studies document the sociodemographic and sexual history factors most associated with young adults’ condom use,3–5 including age, education, and number of sexual partners.6 Research also explores psychosocial factors such as self-esteem7,8 and condom self-efficacy,9 as well as gender inequality that may render condom use especially difficult for young women.10 Relatively little research explores young people’s attitudes about condoms and sexual pleasure.Burgeoning research among samples of “older” adults11,12 and college students13,14 has suggested that attitudes about how condoms affected sexual pleasure might influence condom use practices, although this work has primarily focused on men.15,16 One exploratory mixed-gender study documented that both adult women and men who reported that condoms undermine arousal and enjoyment were least likely to use them.17 However, fewer studies have explored such pleasure attitudes among adolescents and young adults, especially among young women,18 and no nationally representative studies of this topic exist for any age group. We addressed these limitations using a nationally representative sample of young adult women and men to assess how attitudes about condoms and sexual pleasure might be related to condom practices.     

Network Mixing and Network Influences Most Linked to HIV Infection and Risk Behavior in the HIV Epidemic Among Black Men Who Have Sex With Men

Objectives. We evaluated network mixing and influences by network members upon Black men who have sex with men.Methods. We conducted separate social and sexual network mixing analyses to determine the degree of mixing on risk behaviors (e.g., unprotected anal intercourse [UAI]). We used logistic regression to assess the association between a network “enabler” (would not disapprove of the respondent’s behavior) and respondent behavior.Results. Across the sample (n = 1187) network mixing on risk behaviors was more assortative (like with like) in the sexual network (r_sex, 0.37–0.54) than in the social network (r_social, 0.21–0.24). Minimal assortativity (heterogeneous mixing) among HIV-infected men on UAI was evident. Black men who have sex with men reporting a social network enabler were more likely to practice UAI (adjusted odds ratio = 4.06; 95% confidence interval = 1.64, 10.05) a finding not observed in the sexual network (adjusted odds ratio = 1.31; 95% confidence interval = 0.44, 3.91).Conclusions. Different mixing on risk behavior was evident with more disassortativity among social than sexual networks. Enabling effects of social network members may affect risky behavior. Attention to of high-risk populations’ social networks is needed for effective and sustained HIV prevention.The HIV epidemic among men who have sex with men (MSM) has not only grown to alarming levels overall, but it also is one that demonstrates significant and marked racial disparities. In 2008, 28% of MSM with new HIV infection were Black, and among MSM aged 13 to 29 years, the number of new infections in Black MSM was nearly twice that of White MSM.1,2Traditional epidemiological approaches have made limited headway in explaining these findings because they tend to focus on the role of individual risk behaviors in shaping rates of HIV infection. The higher rates of HIV among Black MSM may not be explained by individual-level risk behaviors alone, and instead may be attributed in part to social and sexual network factors.3,4 But efforts to further illuminate these factors have been largely unsuccessful as they have often used sampling methodologies that can distort accurate measurement of existing networks of these MSM (e.g., lack of weighting and focus on most recent sexual partner).5,6 Furthermore, up until now, network analyses have not examined Black MSM’s nonsexual social networks; such networks may contribute to the disparities observed (e.g., lack of embedded social network members7) and might provide opportunities for future interventions.Some research has explained disparities in HIV rates by examining sexual network mixing patterns within and between racial subgroups.8,9 Previously, we demonstrated that higher rates of sexually transmitted infections (STIs) within the African American community were related to sexual network mixing patterns.10 Higher levels of disassortative mixing—core high-risk groups mixing with peripheral low-risk groups—within the African American community, combined with limited interracial mixing, was a major contributor for the disproportionately higher rates of STIs among Blacks than among Whites. Similar sexual network mixing explanations have been demonstrated among Blacks in the Southeastern United States.11 Drug use behavior was found to be highly assortative (like behavior with like), whereas sexual behavior in the form of concurrent (or simultaneous) partnerships was minimally assortative.In contrast to the attention devoted to sexual12–17 and drug-use networks,18–23 comparatively little research has been conducted on how nonrisk social networks comprising MSM’s close friends and family members can affect STI and HIV transmission, with a few notable exceptions.7,24,25 Social learning and differential association theories26,27 hold that risky behaviors, including rationalizations for them, diffuse through social networks of close ties. Furthermore, network members influence high-risk behavior by virtue of the behavioral examples they provide, the normative pressures they exert, and MSM’s perceptions of these influences.28–30 Research has shown in a variety of contexts that risky sexual and substance use behavior is affected by individuals’ perceptions of what their network members do, regardless of whether those perceptions are accurate.31–33 Studying Black MSM’s normative contexts may help researchers identify not only those social conditions that facilitate risky behavior, but also potential network influences that can be exploited or modified to encourage the spread of HIV prevention behavior through modification of a social network. To date, most work that has examined the indirect role of social networks on the spread of HIV has focused primarily on the role of having social network ties in general, but has not specified the mechanisms through which social network ties affect the risk behavior of MSM.34,35Formal social network analysis of high-risk populations has focused on MSM and injecting drug users in general and not specifically on Black MSM.25,36 One recent pilot study37 demonstrated that sexual partners of Black MSM were mostly introduced through friends. Known risk behaviors associated with HIV infection and that could be “transmitted” through a social network include sex-drug use38 and unprotected anal intercourse (UAI). Moreover, group sexual intercourse has also recently gained increased attention as an important risk practice39,40 that can complicate network analysis.41 Important influences and practices such as these, however, have not been previously explored through social network analysis within Black MSM despite this population’s position as a group with the highest risk of HIV infection in the United States. Furthermore, network patterns that potentially confer risk, such as disassortative social mixing, have also not been explored within this population as opposed to the larger Black community.10,11 We conducted a detailed analysis of close social and sexual networks of Black MSM to determine the salient properties and components of these networks that are most related to HIV risk and preventive behavior among these men.     

Acceptable Interventions to Reduce Syphilis Transmission Among High-Risk Men Who Have Sex With Men in Los Angeles

Objectives. We examined perceptions of and attitudes toward existing and potential syphilis interventions, including case management and Web-based programs, to increase syphilis testing among high-risk men who have sex with men (MSM).Methods. Between October 2010 and June 2011, we conducted in-depth interviews with 19 MSM in Los Angeles, California, with repeat early syphilis infections (primary, secondary, and early latent syphilis) within the previous 5 years. We analyzed the interviews inductively to determine the most acceptable potential interventions.Results. Experiences with health department and community-based standard of care case management were generally positive. The most popular interventions among respondents included a Web site providing information on syphilis and syphilis testing, automated Web reminders to test, being paid to test, free online home testing kits, and preexposure prophylactic medication. Respondents’ beliefs that they would continue to practice high-risk sexual behaviors reinforced their reasons for wanting increased accessibility and convenient testing strategies.Conclusions. Public health officials should consider participant responses to potential interventions for syphilis, which suggest that high-risk MSM would consider testing more often or using other interventions.Cases of primary and secondary syphilis among men who have sex with men (MSM) in the United States increased from approximately 6400 in 2009 to more than 8700 in 2012,1 with Los Angeles County reporting the highest number of cases in the country.2 In Los Angeles County as well as in other US metropolitan areas, the majority of cases occur among MSM,3–5 and incidence rates have increased dramatically in recent years.1,5–7 Syphilis is particularly common among MSM coinfected with HIV,8 and can increase the transmissibility of HIV among those who are HIV positive and the susceptibility to HIV among those who are HIV negative.9–11The Centers for Disease Control and Prevention recommends annual screening for syphilis among sexually active MSM and more frequent testing for MSM who have multiple or anonymous partners.12 It has also been suggested that additional testing and other intervention efforts focused on high-risk MSM,13–16 who may be core transmitters of syphilis, are needed to reduce the current syphilis epidemic.14 One potential group of core transmitters may be MSM who have repeated syphilis infections,17,18 because repeat infections suggest continued practice of risky sexual behaviors or riskier sexual networks. Indeed, in Los Angeles County and other jurisdictions, between 6% and 12% of MSM experience a repeat primary or secondary syphilis infection within 2 years.18–20Efforts to curtail the rising syphilis epidemic include increased community screening, enhanced case management and partner notification,21,22 and several wide-scale social marketing campaigns.23,24 One of the primary efforts currently in place in Los Angeles County is syphilis case management and partner notification services, which is provided by public health investigators (PHIs) who are located at the public health department or are embedded within a community-based organization. As the primary promoters of syphilis intervention strategies in the county, PHI duties include locating, counseling, and referring infected individuals to treatment and locating and notifying sexual partners potentially exposed to syphilis. In addition to these standard public health practices of enhanced testing and case management, recent research has indicated that antibiotic prophylaxis for syphilis is potentially an acceptable prevention method for high-risk individuals,25 although evidence is limited and concerns regarding risk compensation (i.e., being less careful because of feeling more protected) and the development of antibiotic resistance have been noted.26 Overall, syphilis rates have continued to rise despite current efforts, suggesting that new and improved approaches are needed.14Although targeting interventions to MSM repeatedly infected with syphilis may have the potential for significant individual and public health impact, little is known about the acceptability of potential interventions to this group of men. We have presented suggestions for improving current standard of care public health practices, such as case management. In addition, we explored attitudes about and responses to numerous potential interventions to increase syphilis testing and reduce transmission among MSM with repeat syphilis infection in Los Angeles County.     

Consistency and Change in Club Drug Use by Sexual Minority Men in New York City, 2002 to 2007

We used repeated cross-sectional data from intercept surveys conducted annually at lesbian, gay, and bisexual community events to investigate trends in club drug use in sexual minority men (N = 6489) in New York City from 2002 to 2007. Recent use of ecstasy, ketamine, and γ-hydroxybutyrate decreased significantly. Crystal methamphetamine use initially increased but then decreased. Use of cocaine and amyl nitrates remained consistent. A greater number of HIV-positive (vs HIV-negative) men reported recent drug use across years. Downward trends in drug use in this population mirror trends in other groups.“Club drugs” are illicit substances consumed in social or party situations¹ to increase social disinhibition and heighten sensual and sexual experiences.^2,3 This category typically includes ecstasy (3,4 methylenedioxymethamphetamine), γ-hydroxybutyrate (GHB), and ketamine,⁴ although recent reports also have included cocaine⁵ and crystal methamphetamine.⁶Concern about club drug use has increased because of consistent associations with unprotected sexual intercourse.^7–9 Given the high rates of use⁴ among men who have sex with men, most club drug research has focused on this population—and on identified gay and bisexual men specifically.^10,11 Published prevalence estimates are quite variable, ranging, for example, from 6% to 65% for crystal methamphetamine^9,12 and from 7% to 93% for ecstasy.^13,14 However, epidemiological trends remain unknown, and most studies contributing prevalence data have 1 or more significant limitations, including use of cross-sectional designs or small sample sizes, recruitment solely at bars or circuit parties, or investigation of some but not all club drugs.We used a repeated cross-sectional design¹⁵ to investigate trends in the prevalence of recent club drug use (and amyl nitrates or “poppers”) between 2002 and 2007 among urban sexual minority men. Given consistent differences in rates of use between HIV-positive and HIV-negative men, we reported differences by HIV serostatus.     

STD Prevalence, Risky Sexual Behaviors, and Sex With Women in a National Sample of Chinese Men Who Have Sex With Men

We describe the behavioral characteristics and sexually transmitted disease (STD) prevalence of Chinese men who have sex with men (MSM) (n = 41) from a national probability sample of men (n = 1861). Most MSM were partnered with females (97%) and had a low rate of consistent condom use (7%). More MSM than heterosexual men self-reported a prior STD and risky sexual behaviors. MSM may act as a bridge for HIV transmission to female partners. Targeted interventions may help prevent a generalized HIV epidemic in China.In some parts of China, HIV prevalence has exceeded 1% of the general population.^1,2 Men who have sex with men (MSM) accounted for 7.3% of HIV infections³ and 11% of new HIV infections in 2007.⁴ The proportion of HIV infections among MSM is likely to grow, as studies have documented increasing HIV prevalence and high prevalence of risky sexual behaviors and of sexually transmitted diseases (STDs) among this population.^5–12MSM may serve as a bridge population for transmitting HIV to the general population. Empirical data have shown that a large proportion of Chinese MSM are either married or have female sex partners.^5,13 High-risk sexual behaviors with both male and female partners among MSM are also common. Surveys have documented extremely high rates of inconsistent condom use with female partners.^13–15 We report the sociodemographic and sexual behavioral characteristics and the STD prevalence of a national probability sample of Chinese heterosexual men and men who had homosexual experiences.     

Trends in Sexual Orientation Missing Data Over a Decade of the California Health Interview Survey

Objectives. We explored changes in sexual orientation question item completion in a large statewide health survey.Methods. We used 2003 to 2011 California Health Interview Survey data to investigate sexual orientation item nonresponse and sexual minority self-identification trends in a cross-sectional sample representing the noninstitutionalized California household population aged 18 to 70 years (n = 182 812 adults).Results. Asians, Hispanics, limited-English-proficient respondents, and those interviewed in non-English languages showed the greatest declines in sexual orientation item nonresponse. Asian women, regardless of English-proficiency status, had the highest odds of item nonresponse. Spanish interviews produced more nonresponse than English interviews and Asian-language interviews produced less nonresponse when we controlled for demographic factors and survey cycle. Sexual minority self-identification increased in concert with the item nonresponse decline.Conclusions. Sexual orientation nonresponse declines and the increase in sexual minority identification suggest greater acceptability of sexual orientation assessment in surveys. Item nonresponse rate convergence among races/ethnicities, language proficiency groups, and interview languages shows that sexual orientation can be measured in surveys of diverse populations.Measuring sexual orientation in health surveys facilitates comprehensive public health surveillance. Accumulating evidence suggests that some lesbians, gay men, and bisexual individuals, compared with heterosexual persons, have higher smoking rates,1,2 greater second-hand smoke exposure,3 more psychological distress4–6 and depression,7 higher suicide attempt rates,8 worse general health status9 and higher disability rates,10 and lower preventive care use.11 As a reflection on these emerging findings, calls for greater collection of sexual orientation data abound,12–17 but the validity of sexual-minority research is threatened if survey respondents cannot or will not provide these data.Several large health surveys now routinely measure sexual orientation. Since 2001, the California Health Interview Survey (CHIS) has included questions assessing self-identified sexual orientation.18 Twelve Behavioral Risk Factor Surveillance System state surveys also asked sexual orientation questions at least once between 2000 and 2014.19 Other large-scale surveys currently asking sexual orientation include the Los Angeles County Health Survey,20 National Health Interview Survey (NHIS),21 National Health and Nutrition Examination Survey,22 and General Social Survey.23Results from these surveys indicate that most respondents provide a codeable sexual orientation response. One percent of NHIS respondents in 2013 did not respond when asked their sexual orientation. “Don’t know” responses comprised 0.4% and refusals made up 0.6%.24 In 2003 to 2010 Washington State Behavioral Risk Factor Surveillance System data, 0.74% responded “don’t know” or “not sure,” and 1.12% refused.25 Yet, African Americans, Asian Americans, and Hispanics in that study had higher odds of nonresponse than Whites. This raises questions about possible sociodemographic differences in sexual orientation measurement, but there have been few assessments of the combined roles of race/ethnicity and language in sexual orientation item nonresponse, and changes in those effects over time.25,26 The independent effects of English proficiency and interview language remain largely unexplored as well. Linguistic and ethnic minorities who are also sexual minorities may be underrepresented in routine public health surveillance efforts if they are differentially likely to answer sexual orientation questions.25 Understanding the relationship among sexual orientation item nonresponse, race/ethnicity, and language proficiency is important because these sociodemographic domains correlate with health disparities.27-29Sexual orientation nonresponse is likely attributable to social stigma of identification and a lack of understanding of the terminology used to discuss the topic.30 Secular trends in lesbian, gay, and bisexual (LGB) social and legal recognition31 may increase LGB individuals’ willingness to disclose their sexual orientation in surveys. The non-LGB public may also become more comfortable with and knowledgeable about the topic as a result. Public opinion surveys now show majority support for gay marriage and LGB people in general.32,33 Sexual orientation item nonresponse should decline, and the percentage of respondents identifying as LGB may increase as stigma recedes and familiarity grows. These potential effects may be more pronounced among racial, ethnic, and linguistic minorities.25,26Two primary research questions guided this study:

• (1) Does the sexual orientation item nonresponse rate change over time?
• a. If so, is this change constant across races/ethnicities, English proficiency levels, and interview languages?
• b. How strongly do race/ethnicity, English proficiency, and interview language predict sexual orientation nonresponse?
• (2) Does LGB identification vary over the same time period?

     

Project HOPE: Online Social Network Changes in an HIV Prevention Randomized Controlled Trial for African American and Latino Men Who Have Sex With Men

Objectives. We examined whether and how an HIV prevention diffusion-based intervention spread throughout participants’ online social networks and whether changes in social network ties were associated with increased HIV prevention and testing behaviors.Methods. We randomly assigned 112 primarily racial/ethnic minority men who have sex with men (MSM) to receive peer-delivered HIV (intervention) or general health (control) information over 12 weeks through closed Facebook groups. We recorded participants’ public Facebook friend networks at baseline (September 2010) and follow-up (February 2011), and assessed whether changes in network growth were associated with changes in health engagement and HIV testing.Results. Within-group ties increased in both conditions from baseline to follow-up. Among the intervention group, we found a significant positive relation between increased network ties and using social media to discuss sexual behaviors. We found a positive trending relationship between increased network ties and likelihood of HIV testing, follow-up for test results, and participation in online community discussions. No significant differences were seen within control groups.Conclusions. Among high-risk MSM, peer-led social media HIV prevention interventions can increase community cohesion. These changes appear to be associated with increased HIV prevention and testing behaviors.African American and Latino individuals are at high risk for contracting HIV.1 In Los Angeles County, California, most of these cases are attributable to men who have sex with men (MSM), who currently account for more than 75% of all HIV cases.2,3 Researchers, and MSM themselves, have suggested use of novel approaches to increase HIV prevention and testing among at-risk populations.4,5Peer leader interventions, based on diffusion theories, are community-based interventions that train community peers to spread HIV prevention information and change HIV prevention-related social norms.6–9 Successful peer-led interventions have resulted in decreasing anal intercourse up to 25% and increasing condom use up to 16%, with sustained behavior change up to 3 years later.10–12 Peer-delivered interventions have been found to be acceptable among MSM populations.13 Social network interventions have shown that information can rapidly diffuse throughout social networks to change health behaviors,14,15 suggesting that peer-delivered HIV interventions also might diffuse throughout social networks.Growth in social media allows these technologies to be used for peer-led HIV testing interventions,4 and research supports that peer-led interventions delivered via social media can increase HIV testing.16 Social networking technologies, such as Facebook, allow users to connect and communicate with other network users by sharing pictures, messages, Web site links, and other multimedia information.17 High rates of online social networking, especially among groups disproportionately affected by HIV (e.g., MSM),18 make it important to evaluate whether and how interventions might diffuse throughout online social networks. Although social media can be used to increase HIV prevention,16,19,20a and health behaviors of (offline) social ties influence our own health behaviors20b, no known research has studied changes in social network ties during the course of an online social media community HIV intervention or whether and how HIV prevention information and behaviors might spread among group participants in a social media–based HIV testing intervention that is designed for network diffusion.The Harnessing Online Peer Education (HOPE) intervention was a 12-week randomized controlled HIV prevention intervention designed to use peer-led Facebook groups to diffuse HIV information to increase testing among African American and Latino MSM. The study found that participants in the HIV intervention groups were more likely to request an HIV test than were those in the control groups,16 but whether changes in social network ties (i.e., participants within each group becoming Facebook friends with one another) played a role in these effects among intervention group participants is unknown. The current study used data from the HOPE study and was designed to evaluate the association between changes in online social network structure and HIV prevention and testing among HOPE network participants. Specifically, we have (1) described the change from baseline to follow-up in network ties among HOPE participants as a result of the intervention, (2) presented network visualizations to illustrate changes in network connections among intervention and control group participants, and (3) determined whether changes in social network ties from baseline to follow-up were associated with online community engagement, discussions about HIV prevention, and rates of HIV testing.     

The Interaction of Sexual Identity With Sexual Behavior and Its Influence on HIV Risk Among Latino Men: Results of a Community Survey in Northern San Diego County,California

Objectives. We examined the sexual behavior, sexual identities, and HIV risk factors of a community sample of Latino men to inform efforts to reduce Latinos'' HIV risk.Methods. In 2005 and 2006, 680 Latino men in San Diego County, California, in randomly selected, targeted community venues, completed an anonymous, self-administered survey.Results. Most (92.3%) respondents self-identified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. Overall, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. Compared with behaviorally heterosexual men, heterosexually identified men who had sex with both men and women were more likely to have had a sexually transmitted infection, to have unprotected sexual intercourse with female partners, and to report having sex while under the influence of alcohol or other drugs. Bisexually identified men who had sex with men and women did not differ from behaviorally heterosexual men in these risk factors.Conclusions. Latino men who have a heterosexual identity and bisexual practices are at greater risk of HIV infection, and efforts to reduce HIV risk among Latinos should target this group.Latinos and sexual minorities are disproportionately affected by HIV/AIDS. Latinos represented 14% of the US population in 2005,¹ but they accounted for 18% of HIV/AIDS cases diagnosed in 2006.² Although an estimated 6% to 9% of the US population has a lifetime history of homosexual sex,^3,4 men who have sex with men accounted for 49% of all HIV/AIDS cases diagnosed in the United States in 2006.² Sexual risk for HIV varies considerably by sexual orientation, with gay-identified and bisexually identified men generally at greater risk.^5,6 However, a person''s self-identified sexual orientation frequently does not correspond to his or her sexual behavior.^7–9Within Latino culture, it is possible for a man to have sex with men while maintaining a heterosexual identity and protecting his sense of masculinity.^10–13 For Latino men, sexual identity appears to be contingent upon certain behavioral and contextual factors, such as whether they have female sexual partners, are primarily attracted to women, adopt an insertive role in sexual practices, have sex with effeminate men, or have sex with men when under the influence of alcohol or drugs. Homophobia, social stigma attached to same-sex practices, and sexual conservatism are commonly found throughout Latino culture and may inhibit Latino men who have sex with men from self-identifying as gay or bisexual.^9,10,14–16 Research suggests that Latino men are more likely than are White men to engage in bisexual behavior (i.e., to have sex with both men and women)^8,17,18 but are less likely than are White men to disclose a nonheterosexual orientation.^16,19,20Among men, bisexual behavior appears to be more prevalent than bisexual identity. Although approximately 1% to 2% of the US male population identifies as bisexual,^3,4 rates of male bisexual behavior in national samples have ranged from 1% to 5%.^4,21,22 However, these estimates are questionable because of differences in sampling methods and varying definitions of bisexuality.²³ Recent research conducted in the United States suggests that men who have sex with men and women (MSMW) are at greater risk of HIV infection than men who have sex with men (MSM) exclusively and men who have sex with women (MSW) exclusively.^24–26 By contrast, investigators in Mexico have found that MSMW who self-identify as bisexual practice less risky sexual behaviors with their male partners than do exclusively gay men.⁶It has been difficult to quantify the population of heterosexually identified Latino MSMW because of the secretive nature of their sexual practices. In a homophobic cultural context, the fear of social rejection encourages people to hide their same-sex sexual behavior and lead a double life.¹⁰ A study involving a large population of HIV-positive MSM found that 15% of the Latino sample identified as heterosexual had a history of same-sex intercourse,²⁷ whereas a survey of 455 men recruited from gay-oriented publications and venues in 12 US cities found that 17% (n = 26) of Hispanic respondents (as per terminology used in the original survey) reported being “on the down low”.⁹ Although these results may not generalize to community-based US samples of Latino men, they suggest that a substantial proportion of heterosexually identified Latino men have a history of sex with men. Similarly, a household probability survey in Mexico City found that 73% of men with a lifetime history of bisexual practices identified as heterosexual, as did 29% of those with a lifetime history of having sex only with men.⁶Men''s nondisclosure of sexual practices with men has implications for the health of their female sexual partners.^8,17 In the United States in 2006, Latinas accounted for 23.7% of HIV infections among Hispanics; of these, an estimated 51.7% were infected through heterosexual contact.² Although most cases of heterosexual transmission to Latinas are related to sex with injection drug users,²⁸ women who have unprotected sex with heterosexually identified MSMW are also at risk and are likely a subset of this population.Although there is some evidence of greater HIV risk among MSMW than among MSM or MSW,^24–26 previous research has not examined the roles that both sexual behavior and sexual identity play in HIV risk among Latino men in particular. Sexual identity may influence HIV risk among Latino MSMW because a man who identifies as heterosexual may perceive that he is at lower risk of sexually transmitted infections (STIs) than are gay or bisexual men and may thus take fewer measures to protect himself or his partner. MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.²⁹Our goal was to learn more about the sexual practices of Latino men and to better understand the interactions among sexual behaviors and sexual identities in this population so as to inform efforts to reduce HIV risk among Latinos. Using survey data, we examined the sexual behavior of a community sample of Latino men; determined the proportions of MSM, MSW, and MSMW among them; elicited any discrepancies between their sexual behavior and their sexual identity; and searched for differences in HIV risk by sexual orientation.     

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 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.     

Community Influences on Young People's Sexual Behavior in 3 African Countries

Objectives. I examined the role of community-level factors in the reporting of risky sexual behaviors among young people aged 15 to 24 years in 3 African countries with varying HIV prevalence rates.Methods. I analyzed demographic and health survey data from Burkina Faso, Ghana, and Zambia during the period 2001 through 2003 to identify individual, household, and community factors associated with reports of risky sexual behaviors.Results. The mechanisms through which the community environment shaped sexual behaviors varied among young men and young women. Community demographic profiles were not associated with reports of risky sexual behavior among young women but were influential in shaping the behavior of young men. Prevailing economic conditions and the behaviors and attitudes of adults in the community were strong influences on young people''s sexual behaviors.Conclusions. These results provide strong support for a focus on community-level influences as an intervention point for behavioral change. Such interventions, however, should recognize specific cultural settings and the different pathways through which the community can shape the sexual behaviors of young men and women.Countries in sub-Saharan Africa are home to only 10% of the world''s population but account for approximately 85% of AIDS deaths worldwide.^1,2 Previous studies have highlighted high levels of sexual activity among young people (i.e., those aged 15–24 years) in many sub-Saharan African countries,^3–7 paralleled by increasing rates of HIV infection among young people.^1,8,9 Although young people in these countries have been shown to have high levels of knowledge regarding HIV/AIDS, studies have demonstrated significant deviation between such knowledge and reported sexual behaviors,^10–12 with high levels of risky sexual activity reported (e.g., failing to use a condom,¹³ engaging in transactional sex,^13,14 having multiple partners.^3,6,15).The health hazards associated with sexual risk taking among young people are well documented, but little is known about the factors associated with sexual behaviors among adolescents in developing countries.^13,15–20 In the few studies that have examined young people''s sexual behavior in these countries, a micro-level approach has been adopted, with a focus on individual characteristics as predictors of behavior²¹ and little consideration of the potential pathways through which the wider community may shape behavior.Condom use has often been the outcome of interest in studies of adolescent sexual behavior,^7,22–25 which is not surprising given the emphasis of many HIV prevention strategies on promoting condom use; other studies have examined factors associated with sexual activity or sexual debut.^1,15,17,26 Higher levels of risky sexual activity have been shown among young people (both male and female) and adult men^24,26 than among adult women.^4,6,27 In many sub-Saharan African countries, young women''s lack of negotiating power in sexual relationships is influenced by the large age differences common in many relationships,^3,14,27,28 the presence of violence or coercion,²⁵ and economic incentives to participate in risky sexual activities.¹⁴Educational attainment has been shown to be associated with young people''s sexual behaviors.^5–7,29 This relationship is more than simply a function of increased knowledge leading to positive health behaviors; the type of educational institution attended and the place of residence of the student have been shown to be influential in determining sexual behaviors,⁵ suggesting that these behaviors are also influenced by the degree of freedom afforded to the young person.Young women from poor households have been shown to be at particular risk of sexual risk taking, with their economic status motivating them to partake in transactional sex and serving as another limitation in their negotiating power with respect to condom use.^6,14 In terms of the influence of knowledge on behavior, some studies have demonstrated a disparity between knowledge regarding HIV risk and sexual behavior^12,22,30 such that many young people, despite knowing the risks associated with unprotected sexual activities, still engage in these activities. There is a limited amount of evidence suggesting that risk knowledge is a more protective factor against risky sexual activity among women than among men,³¹ with fear of unplanned pregnancy providing a greater deterrent for women than for men.Although much is known about the individual characteristics associated with sexual risk taking among young people, the role of the community in shaping such behaviors has been largely overlooked. In a study of adolescents residing in the United States, Billy et al.²¹ suggested that young people''s sexual behavior is strongly influenced by a community''s opportunity structure (i.e., presence of social and economic opportunities), which is composed of 3 key elements. The first element is the presence in the community of reproductive and sexual health services, which determines a young person''s access to information and services. The second element is the demographic profile of the community, which determines the presence of potential sexual partners. The final element is the presence or absence of economic or social opportunities, which influences young people''s perceptions regarding the opportunity costs of sexual behavior.Studies testing the theory of Billy et al. have largely been restricted to developed countries.^21,32 Although some studies have addressed the influence of community factors on young people''s sexual behavior in developing countries, these investigations have focused primarily on indicators of the presence of economic opportunities for young people,^33,34 failing to examine the roles of the cultural and social environments in shaping behavior.I examined community-level factors associated with risky sexual behaviors among young people in the African countries of Burkina Faso, Ghana, and Zambia. The goal of the study was to advance understanding of how the community environment shapes young people''s sexual behavior by considering a broad range of potential community influences, including social, behavioral, and demographic dimensions of the community environment.     

Pleasure, power, and inequality: incorporating sexuality into research on contraceptive use

We know surprisingly little about how contraception affects sexual enjoyment and functioning (and vice versa), particularly for women. What do people seek from sex, and how do sexual experiences shape contraceptive use? We draw on qualitative data to make 3 points. First, pleasure varies. Both women and men reported multiple aspects of enjoyment, of which physical pleasure was only one.Second, pleasure matters. Clear links exist between the forms of pleasure respondents seek and their contraceptive practices. Third, pleasure intersects with power and social inequality. Both gender and social class shape sexual preferences and contraceptive use patterns. These findings call for a reframing of behavioral models that explain why people use (or do not use) contraception.Despite the addition of “sexual” to the sexual and reproductive health agenda^1,2 and the increasing attention paid to how gendered power differentials influence sexual behaviors, public health research has yet to adequately explore the needs and purposes that sex fulfills. Research with both heterosexual and homosexual men has taken into account how the goal of physical pleasure shapes risk taking,^3–8 and a parallel body of work for heterosexual women has explored the relative importance of economic need and the desire for intimacy to risk taking.^9–11 Each of these bodies of work, however, are themselves bound by gender stereotypes—specifically by the assumptions that women do not have sex for pleasure and that men do not have sex for intimacy. Unintended pregnancy, sexually transmitted infections (STIs), and HIV are among the most pressing issues in public health both in the United States and abroad. It is more important than ever to understand the array of factors contributing to sexual risk taking and risk reduction, including sexual goals and sexual pleasure.Sexual health research within public health has largely failed to explore how pleasure and positive sexual functioning affect sexual risk and risk-reduction practices,^12,13 particularly for women.^14,15 This void is especially evident in the field''s approach to male condoms and women. Public health programs target women to carry out sexual risk reduction through condom use (even though women do not “use” or “wear” male condoms) despite research showing that women may lack the power to press their partners to use condoms^16–20 and that even when women are able to negotiate for condom use, they may refrain from doing so out of the desire for sex that is “close,” loving, and monogamous.^{10,11,21–23} We still know little, however, about women''s sexual experiences with male condoms and how their perceptions of the way condoms feel physically affect their risk behaviors (for 2 exceptions, see Holland et al.²⁴ and Ehrhardt et al.²⁵). There is a critical need for research that examines how a desire for sexual pleasure—or more broadly, the full range of reasons women have sex—shapes women''s willingness to encourage condom use.Many studies of hormonal contraceptives also fail to systematically assess how these methods affect sexual functioning or pleasure or how women''s sexual goals shape their patterns of use.^26–28 However, several recent studies have suggested that a desire for sexual enjoyment can play a role in women''s contraceptive behaviors. US women and men ranked pleasure as equally important in evaluating a contraceptive''s acceptability in one study.²⁹ Other research associates method continuation to the reductions in or enhancement of sexual experience caused by oral contraceptives,²⁶ injectables,³⁰ tubal ligation,³¹ and especially, the female condom^32–34 and microbicides.^35–39These studies suggest that the initiation and continuation of contraceptive methods (including male and female condoms) is influenced by how they make sex feel and that sexual experience and contraceptive experience may shape each other reciprocally. However, few of these studies have explored multiple forms of contraception simultaneously, and none has gone beyond individual experience to situate pleasure more broadly within social processes. Furthermore, as evident in the data we present, “pleasure” contains multiple overlapping categories. Work to date has not adequately explored variation in people''s ideas about what makes sex feel good or the varying weight given to this “feeling good” relative to other valued qualities in the sexual encounter.We used an ethnographic, inductive approach to explore the range of sexual motivations and goals—that is, what sex is for or what needs it fulfills—expressed by a sample of individuals in urban Atlanta, Georgia, and we analyzed the relationship between these sexual goals and contraceptive practices. We had 3 research questions: (1) What do people seek from and experience within their sexual encounters and relationships? (2) How do these expectations and experiences shape contraceptive use? and (3) How are sexual goals shaped by gender, social class, and other forms of structural social inequality?     

The association of sexual orientation measures with young adults' health-related outcomes

Objectives. We examined associations among 3 dimensions of sexual orientation (identity, behavior, and attraction) and key health-related indicators commonly studied among sexual minority populations: depressive symptoms, perceived stress, smoking, binge drinking, and victimization.Methods. We analyzed data from the National Longitudinal Study of Adolescent Health, Wave IV (2007–2008) when respondents were aged 24 to 32 years (n = 14 412). We used multivariate linear and logistic regressions to examine consistency of associations between sexual orientation measures and health-related indicators.Results. Strength of associations differed by gender and sexual orientation measure. Among women, being attracted to both sexes, identifying as “mostly straight” or “bisexual,” and having mostly opposite-sex sexual partners was associated with greater risk for all indicators. Among men, sexual attraction was unrelated to health indicators. Men who were “mostly straight” were at greater risk for some, but not all, indicators. Men who had sexual partners of the same-sex or both sexes were at lower risk for binge drinking.Conclusions. Using all 3 dimensions of sexual orientation provides a more complete picture of the association between sexual orientation and health among young adults than does using any 1 dimension alone.Sexual orientation is composed of at least 3 dimensions—sexual identity, sexual behavior, and sexual attraction.^1–4 Yet, not until the Williams Institute released its report outlining best practices for asking questions about sexual orientation on surveys did a consensus exist among researchers regarding the best ways to measure these dimensions.⁵ This previous lack of consensus, coupled with the evidence that data sources commonly used to investigate the association between sexual orientation and health do not measure all 3 dimensions, has left the field with an incomplete understanding of health differences not only between heterosexual and sexual minority (nonheterosexual) populations but also within sexual minority populations themselves.Sexual identity is one of the most commonly assessed dimensions of sexual orientation in health research. However, items used to measure sexual identity have been the most difficult for respondents to answer,^1,6–8 not only because some feel discomfort admitting to a nonheterosexual identity but also because sexual minorities increasingly use diverse labels (e.g., two-spirited, same-gender loving, queer), have multiple identities (bilesbian, gay-curious heterosexual, pan-sexual), or use no labels at all when referring to their sexual identity.^9–11 Most measures of sexual identity force individuals to choose among a “heterosexual/straight,” “gay or lesbian,” “bisexual,” or “unsure” identity^1,4–8; whereas others include intermediate options such as “mostly heterosexual/straight” and “mostly homosexual/gay,” which are preferred because they better reflect personal experiences and some view “heterosexual/straight,” “gay or lesbian,” and “bisexual” as static states or permanent identities.^1,4–8Sexual orientation has also been measured by identifying the gender of respondents’ sexual partners. However, terminology used to define “sex” varies considerably, as do respondents’ interpretations of sexual behaviors. For example, the terms “sex” and “sexual intercourse” are often perceived as implicitly heterosexual, referring only to penile penetration. Using these terms may therefore exclude a range of sexual behaviors in which many sexual minorities have engaged.^1,8,12 Moreover, using sexual behavior as the sole measure of sexual orientation is uninformative for individuals who have never had any sexual experience and may misrepresent the sexual orientation of others who have had “sex” with partners of 1 gender but have sexual attractions to the other or both genders.^1,8,12Sexual attraction, or desire for sexual intimacy, is typically considered the defining feature of sexual orientation^13–16 but is the least studied of the 3 sexual dimensions with regard to health outcomes.^17,18 This fact is particularly perplexing given that women show greater variability than do men in the age at which they (1) first become aware of same-gender attractions, (2) consciously question their sexuality, and (3) pursue their first same-gender sexual contact—all of which women tend to experience later in life than do men.^19–25 Moreover, women are more likely than are men to say they become attracted to or fall in love with the person as opposed to the person''s gender^21,26 and to report that their sexuality is fluid over time.^24,26–30Decades of research have documented health disparities between heterosexual and lesbian, gay, and bisexual (LGB) populations,^4,31–46 with minority stress theory frequently used to explain these disparities.⁴⁷ However, Meyer''s minority stress theory conceptualized the LGB population as homogenous; distinctions were not made on the basis of gender or dimension of sexual orientation.⁴⁷ Moreover, few studies have used nationally representative samples or examined all 3 dimensions of sexual orientation.^48–50 Among those that assessed all 3 dimensions, health disparities between LGB populations and heterosexuals differed by dimension of sexual orientation.^17,18For example, Bostwick et al. used nationally representative data to compare clinical measures of mental health among adults aged 20 years and older across all 3 dimensions of sexual orientation and found that adults with an LGB identity had higher odds of having any mood or anxiety disorder than did adults who self-identified as straight.¹⁷ However, women who had only same-sex sexual partners and exclusive same-sex attractions had the lowest rates for most disorders, whereas men who had any same-sex attraction had the highest rates.¹⁷McCabe et al. examined the prevalence of substance use and dependence across all 3 dimensions of sexual orientation using nationally representative data and found that substance use outcomes varied considerably across sexual orientation dimensions and were more pronounced among women than among men.¹⁸ Unlike previous research, the authors found substance use to be less prominent among men and women who identified as bisexual than among those who identified as gay or lesbian.¹⁸ Alternatively, they found greater risk for substance use and dependence among men and women who engaged in bisexual behavior but not among those who engaged in same-sex behavior.¹⁸Few studies using nationally representative samples have assessed associations between health-related outcomes and all 3 dimensions of sexual orientation, and fewer, if any, have explored these associations within an exclusively young adult population—although early adulthood is often accompanied by greater anxiety and uncertainty because of transitions, career entry, and role formations.⁵¹ We examined associations between several health-related indicators commonly used to investigate sexual minority health (i.e., depressive symptoms, perceived stress, smoking, binge drinking, and victimization) and 3 dimensions of sexual orientation (i.e., identity, attraction, and behavior) using a nationally representative sample of young adults. We hypothesized that significant differences would be reported in these health indicators among young adults by gender and the dimension of sexual orientation measured.     

Utilizing Screening,Brief Intervention,and Referral to Treatment: Teaching Assessment of Substance Abuse

Although social workers regularly encounter clients with substance use problems, social work education rarely addresses addictions with any depth. This pilot study explored the use of screening, brief intervention, and referral to treatment (SBIRT) with 74 social work students. Students completed SBIRT training with pre- and post-questionnaires that assessed attitudes, knowledge, and skills concerning substance misuse. Statistically significant differences were demonstrated with students reporting more confidence in their ability to successfully assess for alcohol misuse and subsequently intervene.Substance misuse in the United States is high; 30% of adults engage in at-risk drinking.1 At-risk drinking (typically categorized as “misuse”) does not meet diagnostic criteria for abuse or dependence and is inconsistently identified. Because approximately 70% of the US adult population sees a primary care physician at least once every 2 years,2 a screening and brief intervention model for substance misuse was developed for primary care settings.Screening, brief intervention, and referral to treatment (SBIRT)3 is based on the transtheoretical model of change,4 incorporating motivational interviewing to “briefly intervene” with patients who are at-risk drinkers. The transtheoretical model presents 5 stages of client readiness to change: precontemplation (change is not considered); contemplation (some awareness of consequences but ambivalence to change); preparation (change is planned); action (change begins); and maintenance (change is managed).4 The idea is to “meet the patient where they are.” SBIRT is efficacious with assessing and intervening with at-risk drinkers in primary care settings5–7 and emergency departments8,9; however, SBIRT has not been integrated into social work education or practice.Social workers are employed in a variety of venues. Like other health care professionals, they are not necessarily trained to identify or treat misuse. Less than 10% of accredited social work programs offer a graduate certificate specific to substance abuse.10 Research shows similar barriers to screening among health care providers: lack of training to assess alcohol misuse, how to or when to screen for it, and what to do if the client indicates a need for treatment.11 Training practitioners can be effective in increasing confidence in screening and intervention as well as improving attitudes toward people with alcohol problems.12–15This pilot study assessed social work students’ attitudes, perceived skills, and knowledge of alcohol misuse before and after receiving training on SBIRT. We hypothesized that students would improve skills and knowledge of substance misuse as well as improve attitudes toward people who misuse alcohol.