Social, structural and behavioral factors influenced concurrent sexual partnerships among these low-income African American men, suggesting that social determinants of HIV risk may be equally important as individual behavioral factors in influencing concurrent partnerships. Most participants had main and non-main partners and indicated they relied on their main partner for emotional support and companionship while relying on other partners for housing, economic support, or sex. This finding is supported by another study that found concurrent partners played different roles in men's lives (Carey, Senn, Seward, & Vanable, 2008
Structural factors such as poverty, unemployment and economic dependence on women for housing and food strongly impacted concurrent relationships. Philadelphia has the highest poverty rate among the nation's ten largest cities (Butkovitz, 2010
; “Philadelphia: The State of the City,” 2010), and most participants are from poor inner-city communities that had unemployment levels above 10% prior to the 2008 economic downturn (BLS, 2004
). Other literature associates living below the poverty line with concurrent partnerships among men and women (Adimora, et al., 2002
; Adimora, et al., 2007
). However, little research explores how economic dependence on partners contributes to concurrency; our findings linking concurrency to unemployment and unstable housing represent novel contributions to the concurrency literature.
Most participants (17/24) had a history of incarceration; numerous men noted incarceration interrupted their partnerships and influenced their partners’ concurrency. Philadelphia has the nation's 4th
highest incarceration rate; 5.7 of every 1,000 residents are behind bars (Eichel, 2010
). Our findings noting incarceration's impact on concurrency add to a growing body of research documenting associations between incarceration of African American men, concurrency and interruption of sexual partnerships (Adimora, et al., 2004
; Adimora et al., 2001
; Aral, et al., 2008
; Khan et al., 2009b
; Khan, Miller, et al., 2008
; Khan, Wohl, et al., 2008
Marital status and social norms were important social factors influencing concurrent sexual partnerships. Nearly 45% of African Americans in Philadelphia have never been married; (BLS, 2004
) fewer than 10% of individuals living below the poverty line in Philadelphia are married (BLS, 2004
). Engaging in concurrent sexual relationships when one is unmarried was socially acceptable, expected, and associated with masculine identity among this population. Notably, many respondents commented they expected their female partners to engage in concurrent relationships. Taken together, our findings suggest concurrency has been normalized in this community with low marriage rates; this is a novel contribution of this study.
The most common reason participants cited for engaging in concurrency was trusting neither main nor non-main partners. This phenomenon has not been explored elsewhere in the concurrency literature. Notably, many respondents believed their partners had other partners, and noted this affected their own decisions to pursue concurrent relationships, often in spite of perceived health risks. Participants generally reported trusting main partners more than non-main partners. Participants also noted that trust impacted condom use practices; most men in our sample rarely, if ever, used condoms with their main partners and only sometimes used condoms with non-main partners. Other studies also report more consistent condom use with non-main than main partners (Fortenberry, Tu, Harezlak, Katz, & Orr, 2002
; Howard, Fortenberry, Blythe, Zimet, & Orr, 1999
; Misovich, Fisher, & Fisher, 1997
; Rosengard et al., 2001
). Inconsistent condom use among concurrent partners likely increases HIV transmission.
Many also reported that distrusting their community affected marital decisions and concurrent partnerships. Low levels of trust of sexual partners and of the community at large may reflect low levels of trust and social capital in this community. Social capital is defined as levels of “community trust, community participation and civicness” (Putnam, 1993
). High crime rates, low marriage rates, and high poverty rates are frequently associated with low levels of neighborhood social capital, low socioeconomic status (SES) and poor health outcomes (Berkman & Kawachi, 2000
; Kawachi, Kim, Coutts, & Subramanian, 2004
; Saegert, Thompson, & Warren, 2001
; Subramanian & Kawachi, 2006
). Not trusting others, including sexual partners, suggests low levels of social capital may have important impacts on concurrent sexual partnerships; these important phenomena are fertile ground for ongoing research about social determinants of concurrent sexual relationships.
Additionally, substance use, and cocaine use in particular, was cited as a contributing factor to concurrency. This supports other research associating drug and alcohol use with increased HIV risk behaviors (Donovan & McEwan, 1995
; Leigh, 2002
; Leigh et al., 2008
; Sheth, Moore, & Gebo, 2006
; Woolf & Maisto, 2009
Although addressing concurrency's social determinants presents formidable challenges, one prime opportunity for interventions to address concurrent partnerships may be reducing drug-related incarceration. African American men are incarcerated for drug offenses at disproportionately higher rates (Western, 2005
), and racial disparities in incarceration have been correlated with HIV/AIDS prevalence among African Americans (Johnson & Raphael, 2009
). Policies to reduce prison sentences for drug-related crimes, drug-related recidivism, parole violations and harm reduction policies could be less socially disruptive than incarceration, and may ultimately reduce concurrency and communal HIV risks.
Our study is subject to several limitations. We interviewed small sample of African American men in Philadelphia who reported engaging in concurrent sexual partnerships, and did not recruit men of other races from similar socioeconomic strata. Findings may not represent broader trends among heterosexual men or even heterosexual African American men; rather, these findings reflect the experiences of a group of African American men of low SES engaged in concurrency.
However, this study underscores the importance of social determinants of HIV risks and concurrent partnerships among low-income African American men. Individual-level behavioral interventions may overlook the important role of social networks in potentiating health disparities in HIV/AIDS and may fail to address the critical roles of social and structural factors that contribute to concurrent sexual partnerships.