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In the US, black men who have sex with men (BMSM) are diagnosed with HIV at a rate far exceeding other men. However, many studies report no substantial increase in risk behavior among BMSM. Here we examine a partner selection strategy as a potential risk factor for HIV among BMSM and white MSM (WMSM).
Cross-sectional surveys were collected from self-reported HIV negative BMSM and WMSM attending a gay pride festival in Atlanta, GA.
HIV negative WMSM were more likely to report having unprotected anal intercourse with HIV negative men, and HIV negative BMSM were more likely to report unprotected anal intercourse with HIV status unknown partners. Furthermore, WMSM were more likely to endorse serosorting (limiting unprotected partners to those who have the same HIV status) beliefs and favorable HIV disclosure beliefs than BMSM.
WMSM appear to be using risk reduction strategies to reduce the likelihood of HIV infection more so than BMSM. Partner selection strategies have serious limitations; however they may explain in part the disproportionate number of HIV infections among BMSM.
Men who have sex with men (MSM) continue to make up the vast majority of HIV infections in the US. About one-third of US HIV infections among MSM occur in black men.1 However, black men only account for 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 (BMSM) as compared to white MSM (WMSM).3,4 For example, BMSM on the whole report fewer sex partners and similar rates of unprotected anal intercourse when compared with WMSM. 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 BMSM have led this group to be among the foremost priority HIV prevention populations in the US.5 Thus, a comprehensive understanding of HIV risk factors relevant to this population is warranted.
Multiple contextual factors are potentially driving disparities in HIV/AIDS among BMSM and WMSM. Perceived HIV prevention strategies such as selecting unprotected sex partners thought to have the same HIV status, or serosorting, may play a role in explaining racial disparities in HIV infections. For many HIV infected and uninfected men, serosorting is believed to make HIV transmission less likely to occur and, thus, condom use unnecessary.6,7 This relationship may stem from the tendency for people to dislike using condoms8–10 and 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 serosorting is commonly used among MSM in general, but less is known about serosorting among MSM of different ethnicities.7,13–15
Data on the effectiveness of serosorting is 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.19,20
Within the practice of serosorting, there are two factors that directly influence motivations to serosort. First, individuals who serosort likely do so to lower their perceived risk for HIV infection, i.e., make them feel safe while not using condoms. In this sense, serosorting can reduce HIV transmission anxiety. Hence, the perception of serosorting as making unprotected sex safer is most likely driving sexual behavior risk taking. Notably, risk perceptions have been previously demonstrated as playing 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 In practicing serosorting, merely assuming the HIV status of a partner is often substituted for explicit disclosure,20 however, serosorting can not be effective under these conditions.
In the current study we sought to further examine partner selection practices that could potentially contribute to disparate HIV infection rates among MSM. First, we examined sexual behavior between BMSM and WMSM. Based on previous studies, we hypothesized that BMSM and WMSM would report similar rates of unprotected anal sex partners. However, because differences in HIV infection rates may be driven by the types of partners men are choosing, we hypothesized that BMSM would report more partners of unknown or positive HIV status and WMSM would report more partners of negative HIV status. In keeping with these hypotheses, BMSM would report less favorable beliefs about serosorting and HIV status disclosure. Finally, we predicted that BMSM would report higher HIV perceived risk due to their choosing serodiscordant partners.
Participants were 549 self reported HIV negative men surveyed at the Gay Pride Festival that occurred in June 2006 in Atlanta, GA and the Black Gay Pride Festival that occurred in September 2006 in Atlanta, GA. Surveys were collected using common venue intercept procedures.24,25 Participants were offered $4 for completing the survey and were given the option of donating their incentive payment to a local AIDS service organization. Approximately 80% of men approached agreed to complete a survey. This study was approved by the University of Connecticut Institutional Review Board.
For this study we asked participants to report on demographics, sex partners, last sexual experience, substance use, HIV status disclosure beliefs, serosorting beliefs, and perception of risk for HIV infection.
Participants were asked their age; years of education; income; ethnicity; employment status, relationship status, HIV status, and when they were last tested for HIV.
Participants were asked to report numbers of partners, separate for HIV statuses (HIV negative, HIV positive, and HIV unknown), with whom they had unprotected receptive and insertive anal intercourse. We assessed number of partners because partners are more reliably recalled than number of sexual acts,26 number of partners is closely linked to HIV transmission risk, 27–28 and we were interested in types of partners men select. In some cases, HIV status of sexual partner’s may have been assumed by participant. Finally, we asked participants to report the total number of partners from the past six months.
For some items, participants were asked to think about their last sexual experience when answering questions about their sexual risk behaviors. Participants were asked to report: whether they, their partner, or both of them were drinking or using drugs during this act, if they had anal sex with this person, if they used a condom, and if they knew the HIV status of their last partner.
Participants were asked if they had used alcohol, marijuana, nitrite inhalants, crack/cocaine, ecstasy, methamphetamine, Viagra or similar medication without a prescription, and any other drug in the past six months. These items were coded as a dichotomous response of yes/no. Alcohol was analyzed by itself and a composite score was created for drug use. Scores for drug use ranged from 0–7, with 0 representing no drug use and 7 representing having taken 7 different drugs in the past 6 months.
Participants were asked the following three items about discussing their HIV status: (a) I am comfortable telling my sex partners my HIV status before having sex, (b) I am confident that I can ask my sex partners if they have been tested for HIV before we have sex, (c) and I make sure I know what to say to a partner about my HIV status before we have sex. These three items were used to form a scale (cronbach’s alpha = .68). Responses ranged from 1 strongly disagree to 6 strongly agree.
Participants were asked the following three items about their serosorting beliefs: (a) If my sex partner tells me that his HIV status is the same as mine, I am more likely to have unprotected sex with him, (b) If my sex partner tells me his HIV status is the same as mine we don’t have to worry about using condoms, and (c) If my sex partner tells me his HIV status is the same as mine then I worry less about HIV. These three items were used to form a scale (cronbach’s alpha = .82). Responses ranged from 1 strongly disagree to 6 strongly agree.
To assess perceptions of risk, participants marked, along a 248-mm continuum visual analog scale (VAS) 29 how much risk they were taking for HIV transmission. Specifically, the question asked, “Think about your sex behaviors for the past 6 months. Based on your sex behaviors from the past 6 months, how much risk do you believe you are at for getting HIV or infecting someone with HIV? Mark a line showing how much risk you are at.” The VAS was anchored by No risk, abstinent, not having sex at all to Extremely high risk, having anal sex without a condom to ejaculation when the top partner is HIV-positive.
We conducted univariate and multivariate logistic regression analyses predicting WMSM and BMSM (WMSM were coded as 0 and BMSM were coded as 1) as the criterion variable. We used ethnicity as a criterion variable in order to identify sexual risk variables that are uniquely associated with being either BMSM or WMSM.
For this study we surveyed 1,051 men attending either Gay Pride Festival (N = 800) or Black Gay Pride Festival (N = 251) in Atlanta, GA. Of these men 50 (5%) identified as heterosexual, 88 (8%) were Hispanic, Asian, or other race, 178 (17%) had taken the survey at both events (one set of their responses was removed), 153 (15%) were HIV positive, 33 (3%) reported unknown HIV status, and thus were all excluded from analyses leaving 549 (52%) men included in all further analyses. Ninety six BMSM were recruited from Gay Pride Festival and 84 from Black Gay Pride Festival. Data analyses revealed no substantial difference between BMSM recruited from the two festivals. Remaining participants included 369 WMSM (67%) and 180 BMSM (33%).
Demographic characteristics were compared for BMSM and WMSM (see Table 1). BMSM were significantly younger in age, had less education, reported lower incomes, and were less likely to be in a committed relationship than WMSM. WMSM were significantly more likely to report alcohol use in the past 6 months and equally likely to report drug use in the past 6 months when compared to BMSM. Time since last HIV test was similar among groups, with the last test being on average more than a year ago.
In terms of sex partners, BMSM were significantly more likely to report unprotected insertive and receptive anal sex with a partner of unknown HIV status (number of partners variables were log10+1 transformed to correct for skewness, see Table 2). WMSM were significantly more likely to report unprotected insertive and receptive sex with an HIV negative partner. No differences emerged between groups in terms of numbers of unprotected receptive or insertive sex with HIV positive partners, and overall numbers of HIV positive partners reported were low. Total number of partners, both condom protected and unprotected, from the past six months was lower for WMSM (M = 3.58, SD = 5.182) than it was for BMSM (M = 5.06, SD = 7.72, t  = −2.325, p < .05)).
No differences emerged in terms of drinking at last sexual encounter. About 43% of the total sample reported either they, their partner, or both had been drinking before sex. BMSM were significantly more likely to report that their partner had been using drugs before sex. A majority of the total sample reported no drug use before sex. BMSM and WMSM were equally likely to report having anal sex during their last sex act, but WMSM were less likely to report condom use. Consistent with overall partner findings, BMSM were significantly more likely to report that the HIV status of their last partner was unknown (see Table 3).
WMSM were significantly more likely to report being better able to discuss HIV status with sex partners than BMSM. WMSM were significantly more likely to have favorable beliefs about the HIV related protective benefits of serosorting (See Table 4).
BMSM were significantly more likely to report that they perceived themselves as having taken greater risk for HIV transmission in the past 6 months than WMSM (See Table 4). Overall, both BMSM and WMSM perceived themselves to be at little to moderate risk for HIV with scores on average falling below the center point of the scale.
For the multivariate model we sought to identify unique predictors of WMSM and BMSM. Inclusion in the model resulted from significant prediction of ethnicity during univariate analyses (with the exception of last sex items which were not included due to overlap with both the general substance use items and sex partners items). The following variables were included in the model: age, education, income, relationship status, alcohol use, serosorting beliefs, HIV disclosure beliefs, HIV risk perception, unprotected insertive and receptive anal sex with negative partners, and unprotected insertive and receptive anal sex with unknown partners. Results of this model demonstrate that age (WMSM were older), relationship status (WMSM reported more committed relationships), alcohol use (WMSM reported more alcohol use), serosorting beliefs (WMSM reported more favorable serosorting beliefs), HIV risk perception (BMSM reported higher perceived risk for HIV), unprotected insertive sex with negative partners (WMSM reported more of these partners), and unprotected insertive sex with unknown partners (BMSM reported more of these partners) all remained significant and thus unique predictors of WMSM and BMSM.
In the current study we found that a substantial number of both WMSM and BMSM reported unprotected anal sex partners. However, a difference lies in the partners that were chosen by these men; BMSM were more likely to report having unprotected anal intercourse with a partner of unknown HIV status. Similarly, BMSM were more likely to report not knowing the HIV status of their last sexual partner, however, BMSM were also more likely to have used condoms during this act. The types of unprotected anal sex partners reported were consistent with our measures of prevention beliefs, risk perceptions, and partner selection strategies. WMSM reported more unprotected HIV negative partners, were more likely to believe that serosorting offers protection from HIV, and were more likely to endorse favorable HIV status disclosure beliefs. Perception of risk reported by BMSM and WMSM was also consistent with the types of partners men reported. Furthermore, in the multivariate model controlling for key variables, number of unprotected insertive HIV status unknown partners and unprotected insertive HIV negative partners remained significant predictors.
Understanding the types of sex partners BMSM chose may help explain, in part, the higher rates of HIV infection among this group. Data from the current study suggest that a further understanding of serostatus of sex partners among BMSM is warranted. The elevated rates of unknown sexual partners may explain differences in HIV infection rates between BMSM and WMSM. However, it is important to stress that serosorting should not be promoted as an HIV prevention strategy as it can lead to HIV infection.16 HIV infection occurs during serosorting due to factors such as acute HIV infection, the difficulty of being certain of one’s HIV status during periods of engagement in risk behavior, and lack of overt HIV status disclosure. Finally, in looking at protected sex acts among BMSM and WMSM, BMSM were more likely to report condoms at last sex act. This finding, taken on the whole, suggests that BMSM do take critical steps to protect themselves, yet when they do not use condoms appear to engage in considerable risk (i.e., have more partners of unknown HIV status).
Although both WMSM and BMSM reported risks for HIV/STI, future research on how BMSM choose sexual partners who they consider risky or less risky for HIV/STI and what steps they may take to reduce risks for HIV/STI is warranted. Research should focus on the role of homophobia, discrimination, and stigma as possible impediments to having open discussions with sexual partners about HIV testing and HIV status.30 Internalized homophobia, particularly among BMSM, is an important factor to consider when examining sexual decision making among these men.31 It is possible that these pervasive contextual factors lead to negative expectations about discussions of sexual decision making, and thus discourage its likelihood. Also, race of sexual partners and sexual networks are important considerations for future research in this area. Specifically, cultural norms that dictate sexual decision making discussions may vary between sexual networks. As such, further research on what discussions are acceptable during sexual decision making may explain differences between WMSM and BMSM and their partner selection. Moreover, research suggests that black MSM may become part of tightly interconnected sexual networks where HIV can more rapidly spread.32 The use of focus groups to collect qualitative data on how men assess risk for HIV/STI and what steps they take to protect themselves could provide valuable information on this topic. Finally, it is important to point out that research generally relies on condom usage in order to determine the risk a person is taking. However, data from the current study suggests that it is more complicated than condom use and that strategies outside of condom use, such as serosorting, may offer considerable insight into risk taking and thus HIV incidence.
Demographic data from BMSM suggest that they may have less access to important health care related services. Mainly, less education and lower incomes reported among BMSM may result in larger societal level racial disparities, although these factors were non-significant in the multivariate model. With health disparities being prevalent from birth: blacks have 2.4 times the infant mortality rates; to adolescence: blacks are somewhat less likely to be immunized; through adulthood: blacks are 50% more likely to die from a stroke and have lower 5-year cancer survival rates when compared to whites,33 higher rates of HIV infection among BMSM are fitting to the larger racial health disparity context. Reasons for these disparities include multiple factors such as poor/no health insurance, perceiving health care as inadequate, and differential treatment from providers.34
As for limitations, due to the nature of convenience samples our findings may not be generalizable to other communities of gay/bisexual men. It is likely that our sample under-represents gay/bisexual men who are not open about their sexual orientation. Moreover, our study used a cross-sectional survey method, precluding any inferences of causation regarding HIV serostatus, sexual risk beliefs, and sex partners. Study measures relied on self-report of sensitive and often stigmatized experiences and behaviors. This information is prone to cognitive and motivational processes that can bias responses. In particular, emotional and personal events, such as risky sexual behavior are susceptible to social biases.35 The significant rates of sex partners reported by this sample may therefore actually be underestimates of risk behaviors. Nevertheless, surveys such as the one reported here can yield biased information which must be considered when interpreting study findings.
Our sexual risk measures posed limitations. We assessed the number of unprotected sex partners rather than frequencies of sexual acts because our study focused on serosorting. This approach allowed us to estimate unprotected sex partners but did not allow for estimating frequencies of potential exposure to HIV. Alternatively, we could have assessed frequencies of sexual acts. Sexual acts outside of the index relationship would have required a partner-by-partner assessment methodology which is difficult to achieve in a self-administered anonymous survey. From a measurement perspective, number of sexual acts is necessary to estimate potential exposure,26 whereas numbers of sex partners allows estimating risks for HIV transmission at the partner level, in keeping with partner selection strategies.28 Major limitations for number of sexual acts include not specifying if all acts are with one partner and poorer recall, while limitations of number of partners include not having a measure of the number of potential exposures within partners. Likewise, specifying partner type such as steady or casual is an important factor in making sexual decisions and thus should be distinguished in future research. Given that the aim of the study was a focus on serosorting sex partners, number of partners with whom participants engaged in sexual acts was most consistent with our goals. Moreover, some measures used in the survey lack psychometric testing and would benefit from reliability and validity testing. With these limitations in mind, we believe that the current study findings offer new information about HIV risks among BMSM and WMSM.
The issue of increased risk for HIV infection among BMSM requires a closer look at partner selection strategies among these men. Gathering more information on how BMSM strategically protect themselves (or do not protect themselves) from HIV can help inform interventions. Understanding why BMSM report less favorable beliefs towards discussions of HIV status with sex partners is also as area that warrants greater understanding. Future research in this area should identify specific ways in which to improve sexual health options for BMSM.
National Institute of Mental Health (NIMH) Grants RO1-MH71164 and T32- MH074387 supported this research.
ContributorsAll authors participated in the design and implementation of the study materials and protocol. L. Eaton provided data analysis and drafted article. S. Kalichman reviewed final draft of article.
Human Participation Protection
This study was approved by University of Connecticut’s institutional review board.