Psychosocial Correlates of Unprotected Sex Without Disclosure of HIV-Positivity among African-American,Latino, and White Men Who Have Sex with Men and Women

African-American, Latino, and White men who have sex with men and women (MSMW) may be a bridge of HIV transmission from men to women. Very little research has directly compared culturally specific correlates of the likelihood of unprotected sex among MSMW. The present study examined psychosocial correlates of unprotected sex without disclosure of HIV status with male and female partners among 50 African American, 50 Latino, and 50 White HIV-positive MSMW recruited from AIDS service organizations in Los Angeles County. Multivariate logistic regressions were conducted to examine relationships of race/ethnicity and psychosocial variables (e.g., condom attitudes, self-efficacy for HIV disclosure, sexual identification) to unprotected sex without disclosure of HIV status, for male and female partners separately. For female partners, different effects emerged by race/ethnicity. Among African-Americans, less exclusively homosexual identification and low self-efficacy for disclosure of HIV status to female partners were associated with unprotected sex without disclosure; among Latinos, less exclusively homosexual identification and negative attitudes about condoms were significant. Participants who were more exclusively homosexually identified, who held less positive condom attitudes, and who had low self-efficacy for disclosure to female partners were more likely to have unprotected sex without disclosure of HIV status to male partners. Culturally tailored community-level interventions may help to raise awareness about HIV and bisexuality, and decrease HIV and sexual orientation stigma, thereby increasing African-American and Latino MSMW's comfort in communicating with their female partners about sexuality, HIV and condoms. Addressing norms for condom use and disclosure between male partners is recommended, especially for homosexually identified MSMW.     

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

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

Sexual Behaviors of Non-gay Identified Non-disclosing Men Who Have Sex with Men and Women

The sexual behaviors of non-gay identified men who have sex with men and women (MSMW) who do not disclose their same-sex behavior to their female partners (referred to by some as men "on the down low") were examined, including the potential for these men to serve as a "bisexual bridge" for HIV and STD acquisition and transmission. Self-reported sexual behavior data were collected as part of an exploratory study of an ethnically diverse (41% African American, 35% Latino, 22% White, and 2% Asian) sample of 46 non-gay identified, non-disclosing MSMW in New York City. Men reported significantly more male than female sexual partners, but more frequent sex with females. The prevalence and frequency of unprotected sex did not differ significantly between male and female partners in the past 3 months. Men reported risk behavior more often with steady female and steady male partners (e.g., wives, girlfriends, boyfriends) than with more casual male and female partners (regular uncommitted partners, one-night stands). Men, especially African American/Black men, were significantly less likely to report receptive sexual behaviors with men than insertive behaviors. Unprotected sex was common with male and female partners in the past 3 months (e.g., 35% of anal sex with men; 50% of vaginal sex). Indeed, 22% of the sample (38% of those who had both recent males and female partners) reported both unprotected vaginal sex and unprotected anal sex with a male partner during the past 3 months. Although the study was limited by a small convenience sample, the findings suggest that non-gay identified non-disclosing MSMW are at risk for the acquisition and transmission of HIV and STDs, and may serve as a potential bridge, suggesting the need for further research and intervention targeting this unique population.     

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

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

Differences in Sexual Identity, Risk Practices, and Sex Partners between Bisexual Men and Other Men among a Low-Income Drug-Using Sample

Men who have sex with men and women (MSMW) represent an important target population for understanding the spread of HIV because of the inherent bridging aspect of their sexual behavior. Despite their potential to spread HIV between gender groups, relatively little recent data have been reported about this population as a subgroup distinct from men who have sex with men only. This paper analyzes data from the Chicago site of Sexual Acquisition and Transmission of HIV Cooperative Agreement Program to characterize 343 MSMW in terms of their demographics, drug use, sexual risk behavior, sexual identity, and sex partners. Results show the MSMW sample to be extremely disadvantaged; to have high rates of drug use, including injection and crack use; to report more female than male sex partners; to not differ from gay and heterosexual men in rates of condom use; and, for the most part, to report sexual identities that are consistent with their sex behavior. MSMW represent an important subpopulation in the HIV epidemic and should be targeted for risk reduction interventions.     

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

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

Racial Pride and Condom Use in Post-Incarcerated African-American Men Who Have Sex With Men and Women: Test of a Conceptual Model for the <Emphasis Type="Italic">Men in Life Environments Intervention</Emphasis>

African-American men who have sex with men and women (MSMW) are among those most heavily impacted by HIV in the United States, and those who have histories of incarceration are at further risk of infection. The Men in Life Environments (MILE) HIV prevention intervention was developed to provide culturally appropriate skills-based education and support for African-American MSMW with recent histories of incarceration. The MILE’s conceptual framework was informed by three theories: Theory of Reasoned Action and Planned Behavior, Critical Thinking and Cultural Affirmation Model, and Empowerment Theory. The theory-based framework posits that improving racial pride is crucial in building self-efficacy and intentions that in turn promote health-protective behaviors. Therefore, our study aimed to assess whether baseline associations between racial pride and condom use self-efficacy, intentions, and behaviors among African-American MSMW with histories of incarceration align with our conceptual model. We report data on 212 participants recruited from Los Angeles County Sheriff’s Department Men’s Central Jail and the local community. Using structural equation modeling, we tested two separate models: one with female sexual partners and one with male sexual partners, while stratifying by participant’s HIV status. Only among HIV-negative participants was greater racial pride associated with less condomless intercourse with men. In this group, greater self-efficacy and intentions—but not racial pride—predicted less condomless intercourse with women. Our findings suggest that racial pride is an important factor to address in HIV prevention interventions for post-incarcerated African-American MSMW.     

Men Who Report Recent Male and Female Sex Partners in Cape Town, South Africa: An Understudied and Underserved Population

The HIV/AIDS epidemic in South Africa has largely focused on the needs of heterosexual men and women. However, little is known about the sexual risk histories of men who have sex with both men and women (MSMW). Furthermore, we know very little about the psychosocial health needs or of the possibility of a syndemic (numerous interrelated epidemics) among MSMW. We surveyed 1,203 men attending drinking establishments in a township located in Cape Town, South Africa. We compared the behaviors and experiences of MSMW to men reporting only having sex with women (MSW). Twelve percent of the sample reported having sex with both men and women in the past 4 months. MSMW were twice as likely as MSW to report being HIV positive (10.5 vs. 4.6 %). MSW were more likely to be married than MSMW but reported similar numbers of female sex partners. MSMW were more likely to report a history of childhood sexual abuse, recent experienced and perpetrated physical and sexual partner violence, both receiving and giving sex for money, drugs, or shelter, and a recent STI. These factors were found to be interrelated among MSW but not MSMW. Although MSMW demonstrate considerable risk taking and report higher rates of HIV infection than MSW, their needs are largely unmet and underemphasized. Findings suggest the need to better understand factors contributing to sexual risk taking among MSMW. HIV prevention interventions should consider psychosocial health problems unique to MSMW residing in South African townships.     

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

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

Bridging Sexual Boundaries: Men Who Have Sex with Men and Women in a Street-Based Sample in Los Angeles

The purpose of the study was to determine the potential contribution of bisexual men to the spread of HIV in Los Angeles. We compare the characteristics and behaviors of men who have sex with men and women (MSMW) to men who have sex with only women (MSW) and men who have sex with only men (MSM) in Los Angeles. Men (N?=?1,125) who participated in one of the two waves of data collection from 2005 to 2007 at the Los Angeles site for NIDA’s Sexual Acquisition and Transmission of HIV—Cooperative Agreement Program were recruited using Respondent Driven Sampling. Participants completed Audio Computer Assisted Self Interviews and received oral HIV rapid testing with confirmatory blood test by Western Blot and provided urine specimens for detection of recent powder cocaine, crack cocaine, methamphetamine, or heroin use. MSM, MSW, or MSMW were defined by the gender of whom they reported sex with in the past 6 months. Chi-square tests and ANOVAs were used to test independence between these groups and demographic characteristics, substance use, and sexual behaviors. We fit generalized linear random intercept models to predict sexual risk behaviors at the partner level. Men were mostly of low income, unemployed, and minority, with many being homeless; 66% had been to jail or prison, 29% had ever injected drugs, and 25% had used methamphetamine in the past 30 days. The sample had high HIV prevalence: 12% of MSMW, 65% of MSM, and 4% of MSW. MSMW were behaviorally between MSW and MSM, except that more MSMW practiced sex for trade (both receiving and giving), and more MSMW had partners who are drug users than MSW. Generalized linear random intercept models included a partner-level predictor with four partner groups: MSM, MSMW-male partners, MSMW-female partners, and MSW. The following were significantly associated with unprotected anal intercourse (UAI): MSW (AOR 0.15, 95% CI 0.08, 0.27), MSMW-female partners (AOR 0.4, 95% CI 0.27, 0.61), HIV-positive partners (AOR 2.03, 95% CI 1.31, 3.13), and being homeless (AOR 1.37, 95% CI 1.01, 1.86). The factors associated with giving money or drugs for sex were MSMW-female partners (AOR 1.70, 95% CI 1.09, 2.65), unknown HIV status partners (AOR 1.72, 95% CI 1.29, 2.30), being older (AOR 1.02, 95% CI 1.00, 1.04), history of incarceration (AOR 1.64, 95% CI 1.17, 2.29), and being homeless (AOR 1.73, 95% CI 1.27, 2.36). The following were associated with receiving money or drugs for sex: MSW (AOR 0.53, 95% CI 0.32, 0.89), African American (AOR 2.42, 95% CI 1.56, 3.76), Hispanic (AOR 1.85, 95% CI 1.12, 3.05), history of incarceration (AOR 1.44, 95% CI 1.04, 2.01), history of injecting drugs (AOR 1.57, 95% CI 1.13, 2.19), and had been recently homeless (AOR 2.14, 95% CI 1.57, 2.94). While overall HIV-positive MSM had more UAI with partners of any HIV status than MSMW with either partner gender, among HIV-positive MSMW, more had UAI with HIV-negative and HIV status unknown female partners than male partners. Findings highlight the interconnectedness of sexual and drug networks in this sample of men—as most have partners who use drugs and they use drugs themselves. We find a concentration of risk that occurs particularly among impoverished minorities—where many men use drugs, trade sex, and have sex with either gender. Findings also suggest an embedded core group of drug-using MSMW who may not so much contribute to spreading the HIV epidemic to the general population, but driven by their pressing need for drugs and money, concentrate the epidemic among men and women like themselves who have few resources.     

Reaching and engaging non-gay identified,non-disclosing Black men who have sex with both men and women

Non-gay identified (NGI) Black men who have sex with both men and women (MSMW) and who use substances are at risk of acquiring and transmitting HIV to their partners. Homophobic community norms can discourage such men from disclosing their risk behaviour to female partners and others, including service providers. It is important to understand the dynamics of risk in this vulnerable population, but research is challenged by the men's need for secrecy. In this paper we report on successful efforts to recruit 33 non-disclosing, NGI Black MSMW for in-depth interviews concerning substance use, HIV risk and attitudes toward disclosing their risk behaviour. We employed targeted and referral sampling, with initial contacts and/or key informants drawn from several types of settings in New York City, including known gay venues, community organisations, neighbourhood networks and the Internet. Key informant gatekeepers and the ability to establish rapport proved central to success. Perceived stigma is a source of social isolation, but men are willing to discuss their risk behaviour when they trust interviewers to protect their privacy and engage with them in a non-judgemental manner. Findings imply that the most effective prevention approaches for this population may be those that target risk behaviours without focusing on disclosure of sexual identities.     

Bridging Sexual Boundaries: Men Who Have Sex with Men and Women in a Street-Based Sample in Los Angeles

The purpose of the study was to determine the potential contribution of bisexual men to the spread of HIV in Los Angeles. We compare the characteristics and behaviors of men who have sex with men and women (MSMW) to men who have sex with only women (MSW) and men who have sex with only men (MSM) in Los Angeles. Men (N = 1,125) who participated in one of the two waves of data collection from 2005 to 2007 at the Los Angeles site for NIDA’s Sexual Acquisition and Transmission of HIV—Cooperative Agreement Program were recruited using Respondent Driven Sampling. Participants completed Audio Computer Assisted Self Interviews and received oral HIV rapid testing with confirmatory blood test by Western Blot and provided urine specimens for detection of recent powder cocaine, crack cocaine, methamphetamine, or heroin use. MSM, MSW, or MSMW were defined by the gender of whom they reported sex with in the past 6 months. Chi-square tests and ANOVAs were used to test independence between these groups and demographic characteristics, substance use, and sexual behaviors. We fit generalized linear random intercept models to predict sexual risk behaviors at the partner level. Men were mostly of low income, unemployed, and minority, with many being homeless; 66% had been to jail or prison, 29% had ever injected drugs, and 25% had used methamphetamine in the past 30 days. The sample had high HIV prevalence: 12% of MSMW, 65% of MSM, and 4% of MSW. MSMW were behaviorally between MSW and MSM, except that more MSMW practiced sex for trade (both receiving and giving), and more MSMW had partners who are drug users than MSW. Generalized linear random intercept models included a partner-level predictor with four partner groups: MSM, MSMW-male partners, MSMW-female partners, and MSW. The following were significantly associated with unprotected anal intercourse (UAI): MSW (AOR 0.15, 95% CI 0.08, 0.27), MSMW-female partners (AOR 0.4, 95% CI 0.27, 0.61), HIV-positive partners (AOR 2.03, 95% CI 1.31, 3.13), and being homeless (AOR 1.37, 95% CI 1.01, 1.86). The factors associated with giving money or drugs for sex were MSMW-female partners (AOR 1.70, 95% CI 1.09, 2.65), unknown HIV status partners (AOR 1.72, 95% CI 1.29, 2.30), being older (AOR 1.02, 95% CI 1.00, 1.04), history of incarceration (AOR 1.64, 95% CI 1.17, 2.29), and being homeless (AOR 1.73, 95% CI 1.27, 2.36). The following were associated with receiving money or drugs for sex: MSW (AOR 0.53, 95% CI 0.32, 0.89), African American (AOR 2.42, 95% CI 1.56, 3.76), Hispanic (AOR 1.85, 95% CI 1.12, 3.05), history of incarceration (AOR 1.44, 95% CI 1.04, 2.01), history of injecting drugs (AOR 1.57, 95% CI 1.13, 2.19), and had been recently homeless (AOR 2.14, 95% CI 1.57, 2.94). While overall HIV-positive MSM had more UAI with partners of any HIV status than MSMW with either partner gender, among HIV-positive MSMW, more had UAI with HIV-negative and HIV status unknown female partners than male partners. Findings highlight the interconnectedness of sexual and drug networks in this sample of men—as most have partners who use drugs and they use drugs themselves. We find a concentration of risk that occurs particularly among impoverished minorities—where many men use drugs, trade sex, and have sex with either gender. Findings also suggest an embedded core group of drug-using MSMW who may not so much contribute to spreading the HIV epidemic to the general population, but driven by their pressing need for drugs and money, concentrate the epidemic among men and women like themselves who have few resources.     

Sexual behavior and HIV risk among age-discrepant,same-sex male couples

Research has suggested that men who have sex with men and who have older sexual partners are at increased risk of HIV infection. However, while several studies have explored risk among men in age-discrepant non-primary partnerships, only two have explored age discrepancy and risk in primary same-sex male relationships. We used data from semi-structured in-depth interviews to explore sexual behaviour and HIV risk among 14 Black, white and interracial (Black/white) same-sex male couples with an age difference of 10 or more years. Most couples regularly used condoms, and sexual positioning tended to lead to lower risk for younger partners. Some serodiscordant couples abstained from anal sex, while others used seropositioning to avoid transmission within the relationship. Within some couples, older partners acted as mentors on HIV prevention and broader life lessons. Future studies should further explore the potential risks and benefits of large age differences in same-sex male primary relationships.     

HIV Acquisition and Transmission Potential Among African American Men Who Have Sex with Men and Women in Three U.S. Cities

Black men who have sex with men and women (BMSMW) are at increased HIV risk, but few efficacious interventions meet their unique needs. Three HIV prevention interventions were evaluated with a common protocol. Baseline data were pooled to describe sexual behavior involving transmission risk with male, female, and male-to-female transgender partners and identify factors associated with transmission risk. BMSMW from Los Angeles, Philadelphia, and Chicago who reported sexual risk and bisexual behavior in the past year were recruited via modified chain referral sampling and community recruitment. Baseline assessments were conducted via audio computer-assisted interview and sexual behaviors assessed over the past 3 months. From December 2010 to November 2012, 584 BMSMW were enrolled across the three cities. More than half (55%) were recruited by other participants. Overall, the mean age was 43 years. Seventy-five percent reported an annual income <$10,000 and selling sex was prevalent (31%). Three-quarters identified as bisexual. Thirty-nine percent were HIV-positive. Among HIV-positive participants, 46% reported sex without condoms with HIV-negative or unknown male partners and 45% with HIV-negative or unknown female partners. Overall, factors associated with sex without condoms included network size, education, income, sexual orientation identification, HIV status, exchange sex, homonegativity, and social support. Findings support the need for enhanced HIV prevention efforts for this population. Future studies should examine contextual factors in addition to individual risk behaviors to inform the development and implementation of promising strategies to prevent HIV and promote the overall health and wellness of BMSMW and their sexual partners.     

Mutual HIV Disclosure among HIV-Negative Men Who have Sex with Men in Beijing, China, 2010

HIV is rising rapidly among Chinese men who have sex with men (MSM). Discussion of HIV status between sexual partners is potentially a key prevention behavior. It is unclear if HIV-negative Chinese MSM talk about HIV and disclose their HIV status with sexual partners. Understanding the correlates of disclosure among this population could provide insight into developing disclosure-based interventions. We conducted a respondent driven sampling based study of 500 MSM in Beijing. A total of 332 men had a previous HIV-negative test result and thus considered themselves to be HIV-negative and were included in our analysis of disclosure. Equal numbers of these men reported talking about HIV and disclosing their HIV status to at least one sexual partner. MSM who disclosed were more likely to be living with a main partner. No other demographic characteristics were associated with disclosure in bivariate analysis. We also used data on up to three sexual partners per participant to examine disclosure on the partnership level. Main partnerships, meeting partners at bars/clubs, sometimes using alcohol before sex in a partnership, and usually having sex at home compared to other venues were associated with disclosure. Using generalized estimating equation analysis to characterize individuals from their partnership data, we found only having at least one main partnership and knowing people who were infected with HIV to be associated with a participant being a discloser. Interventions that wish to harness discussion of HIV and HIV status among Chinese MSM will need to focus on moving these discussions towards having them with casual partners.     

Gender Matters: Condom Use and Nonuse Among Behaviorally Bisexual Men

Although frequently cited as being at high risk for HIV/STI transmission, little is known about behaviorally bisexual men’s patterns and experiences of condom use and nonuse with male and female sexual partners. Using a variety of recruitment techniques informed by a Community Advisory Committee, a total of 77 behaviorally bisexual men were recruited from Indianapolis, Indiana to participate in semi-structured interviews focused on sexual health. Qualitative data were collected containing detailed information on their patterns and experiences of condom use and nonuse with both male and female partners. Participants described numerous commonly reported barriers for consistent condom use, as well as distinct bisexual-specific barriers. The majority reported consistent condom use with male and female casual partners, but many who did not use condoms described doing so in the context of ongoing relationships. In addition, participants provided reasons for condom use and nonuse that varied based on the gender of the partner and the type of relationship with the partner. Future interventions focused on increasing condom use among behaviorally bisexual men should take into account the unique complexities of gender and relationship configurations in this distinct population.     

Behaviorally Bisexual Men and their Risk Behaviors with Men and Women

Gay and bisexual men are often treated as a homogenous group; however, there may be important differences between them. In addition, behaviorally bisexual men are a potential source of HIV infection for heterosexual women. In this study, we compared 97 men who have sex with men only (MSM) to 175 men who have sex with men and women (MSMW). We also compared the 175 MSMW to 772 men who have sex with women only (MSW). Bivariate and multiple logistic regression analyses were performed to assess correlates of MSMW risk behaviors with men and with women as well as whether MSMW, compared with MSW, engaged in more risky behaviors with women. Compared with MSM, MSMW were less likely to be HIV-positive or to engage in unprotected receptive anal intercourse. In contrast, MSMW were more likely than MSW to be HIV-positive and to engage in anal intercourse with their female partners; however, rates of unprotected anal intercourse were similar. The study findings suggest that there may be important differences in HIV risk behaviors and HIV prevalence between MSM and MSMW as well as between MSMW and MSW.