This unique sample of men recruited by their peers provides insight into how drugs and sex weave into the relationships of men on the streets in the large, diverse city of Los Angeles. Our sample is unusual because it captured many poor, homeless men who use drugs and in doing so, also mix sexually with those of both genders. Almost half our sample were men who have sex with men and women (MSMW) in the past six months—a very high proportion of the sample given that in the US general population only about 1% of men 15–44 years of age have had both male and female sexual partners in the last 12 months.16
This enables us to describe the behavior of these men that are often difficult to capture using more standard methods of sampling. Moreover, our sample contained partner specific data on recent partners, enabling us to analyze within men differences in behavior by the gender of their partners. The men in our sample shared many demographic and behavioral characteristics regardless of the gender of their sex partners, but there were important distinctions in the contexts in which sex occurred. It is where and how the sexual networks of these men mix that could account for spread of HIV or alternatively entrench it within certain subgroups.
MSMW have been shown to reside behaviorally between MSM and MSW for key risk behaviors such as numbers of sexual partners and frequency of sex.17
In our sample, MSMW also occupied the middle on most risk variables, yet what distinguished them from the other men is that about twice as many reported receiving drugs or money for sex as MSM or MSW. More of the MSMW we studied were also in the lowest income and education categories and more were homeless than either MSM or MSW, suggesting that the extreme poverty and social marginalization interact with these men’s lives to drive commercial sex activities—to facilitate either survival or desired sexual expression. Our multivariate analysis further illustrates that those reporting receipt of drugs or money for sex were more likely to report histories of incarceration and of injection drug use, further emphasizing associations between social marginalization and trading of sex. Finally, men who reported being paid for sex were more likely to be African American, findings consistent with a qualitative study of African American MSM in Los Angeles in which exchange of sex or drugs, money, or basic needs were reported to be common.18
The frequent experiences of incarceration and homelessness in this sample imply that these men spend much time in jails and on the streets—places at which sexual networks can be connected. Such locales, however, have barriers that affect the practice of safe sex. For example, African American men in Los Angeles have reported a lack of availability of condoms in jails and homeless shelters as a barrier to protected sex.18
This suggests that when in jail or on the streets, those who may not normally practice risky behavior are faced with structural barriers to being safe and therefore engage greater risk in these settings.
The MSMW in our study appear to be sexually bridging geographic as well as gender networks. Many MSM and about one-half MSMW-male partners reported sexual partners from other neighborhoods, which contrasts with MSW and the MSMW-female partners, many of whom reported partners from their own neighborhood. For these MSM and MSMW, concerns about same-sex behaviors being found out by acquaintances, friends, or family members may contribute to looking outside one’s social network to encounter male sex partners. There would be few similar concerns when seeking female partners, as most of these were reported from the men’s neighborhoods. Such neighborhood differences suggest that heterosexual networks may be more localized, whereas sexual networks of MSM and MSMW may be more far reaching. This suggests more disassortative mixing by location among men with male partners than with female partners. As such, MSMW can function as potential bridges for HIV to cross, as the men travel for some sexual partners while maintaining others in their own neighborhood, thereby connecting two distinct neighborhoods. We also observed in our data high rates of both dissasortative mixing and concurrent sexual partnerships, which enhances the efficiency of HIV spread throughout populations.
In this sample, potential for transmitting HIV from MSMW to either men or women results largely from a lower use of condoms and because MSMW are having sex with both a very high HIV prevalence (MSM) and low HIV prevalence group (women). We found that the MSMW did report relatively little condom use with female partners, especially during vaginal intercourse, but many more reported condom use during sex with men. Other studies have shown minority MSMW use condoms as much as, if not more than MSMW of other races/ethnicities.19,20
Furthermore, African American and “other” race men who have both male and female partners tend to have less
UAI with males than those men who have only male partners. However, MSMW who do not disclose their same-sex behaviors report more unprotected intercourse with female partners than those who do disclose.13
What is of concern in our study is that when we examine the practice of UAI among HIV-positive men (Figure ), we observed MSMW reporting significant UAI with females partners of HIV-negative and of unknown HIV status. Given that UAI is the highest transmitting sexual risk behavior, possible transmission to these female partners is of great concern. This finding is surprising because the other HIV-positive men in the sample appear to “serosorting” by having UAI mostly with HIV-positive partners. Nevertheless, substantial proportions of the HIV-positive men in all groups report UAI with HIV negative and status unknown partner, demonstrating that risks for transmission is occurring between men as well as between men and women.
MSMW were predominantly African American in this sample, and most of the partners also were African American. This suggests a highly assortative sexual networking pattern that describes MSMW as a “core group” who largely mix with other minority men and women. The higher numbers of sexual partners, especially male partners, reported by MSMW compared to either MSM or MSW also confirms that these MSMW may function like a core group. A core group is defined as a group of individuals characterized by high rates of partner change (often with each other), longer duration of infection often related to poor access to health care, and highly efficient transmission of infection per exposure, all contributing to high rates of STIs.21
While such a dynamic has been noted before among African American MSM and been suggested to be a contributing factor to their higher prevalence of HIV,22
it has also been shown that these men are also likely to be have disassortative mixing with regard to age, with many partnerships that have a difference of 10 years of age or greater.23
In our sample, we observe such assortative mixing by race/ethnicity among African American participants; however, we see no evidence of pronounced disassortative age mixing. We do see evidence of mixing by HIV status, and this is a great cause for concern.
Drug use is an important dynamic that pervades the sexual choices of the men in this study. While MSMW reported methamphetamine use rates between MSM and MSW, they were more likely to have recently injected methamphetamine than even MSM. Clearly, when sex occurs in the context of drug use, it is usually higher risk. For example, IDU MSM are more likely than non-IDU MSM to report unprotected receptive anal intercourse (UAI) with casual partners, which was found to be strongly associated with HIV seroconversion in a prospective analysis of a cohort of MSM.24
In our study, we also show that UAI was associated with a history of injecting drug use, suggesting the ability to practice safe sex is a particular challenge for drug users.
Using RDS produced a sample of very poor, minority, drug-using men; very few men were employed, well-educated, White, or young. This limits the generalizability of our findings to other MSMW in Los Angeles. Patterns of risk may be very different for MSMW that are not as marginalized as those in our sample. Another limitation is that it was beyond the scope of this manuscript for us to examine differences in sexual position among MSMW, a factor that affects the transmission probability. Future analyses of this dataset will address these research questions and shed further light on the potential contributions for transmission and dynamics of that risk among the men in our sample.
This study provides a rare look into the interconnectedness of sexual and drug behaviors in this sample of men—most of whom have sex partners who use drugs. The findings raise a flag of concern for the HIV-negative female sexual partners of MSMW who we show to be at considerable risk for HIV acquisition because of the proportion of HIV-positive MSMW who report UAI with them. Such risky sexual behavior likely occurs in the context of drug use or commercial sex, as we also found many MSMW reporting trading money or drugs for sex with female partners. What is borne out is that a concentration of risk occurs among impoverished minorities—where men, many of whom are HIV positive, commonly use drugs, trade sex, and have sex with either gender. These data provide support for the hypothesis that such “compound risk” enhances the frequency and variety of exposures, increasing the cumulative probability of transmission and, therefore, plays a major role in maintaining the endemicity of HIV in the settings where it occurs.25
Our findings suggest an embedded core group of minority 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, may concentrate the epidemic among men and women like themselves who have few resources. What remains to be found is whether such dynamics also hold in younger groups of urban MSMW.