This study focused on the social and sexual networks of crack-using AA MSM, particularly older crack-using AA MSM, a potentially high-risk subgroup that has not been well-described in the literature. Findings reveal that sex networks of crack-using AA MSM were diverse, consisting of both male and female members and main and exchange partners. Moreover, crack use was independently associated with increased odds of having drug-using and sexual networks overlap. As Baltimore ranks among the most burdened city with gonorhea, syphilis, and chlamydia among African American women33
and HIV incidence among AA MSM,34
the present findings are a cause for concern. These sexual mixing patterns suggest a potential role that crack-using AA MSM have in bridging networks that may vary in prevalence of HIV and other STIs, and underscores the importance of sexual transmission of HIV even among drug users.35–38
Consistent with results from a study in Los Angeles where Gorbach et al.39
describes a “concentration of HIV risk” among a sample of low-income, minority drug-using men who have sex with men and women, our findings suggest potential capacity of these sexual networks to facilitate spread of HIV to other sexual and drug-using networks. Moreover, overlap of social ties (e.g., sex and drug ties) has been shown to increase risk of HIV.40
It is well established in the literature that crack use is associated with increased sexual risk behaviors, namely exchanging sex and decreased condom use. In the present study, we report that after controlling for sex exchange and main sex partners, condom use with fewer partners remained associated with crack use. Interventions that have been implemented for predominately white, methamphetamine-using MSM have focused on increasing condom use self-efficacy and lowering drug-and-alcohol-influenced sex.41,42
While these interventions would require tailoring for crack-using AA MSM, they may offer a future direction for decreasing sexual risk. For example, given that the sexual networks consisted of both male and female sex partners and multiple-risk partners, interventions tailored for drug-using AA MSM should include activities to develop proper male and female condom use skills in both drug-involved and non-involved contexts. Research on prevention norms about condom use among crack-using AA MSM may also suggest potential targets for intervention.25
AA MSM in this sample were older and two-fifths did not identify as gay. Although bisexual identity was strongly and independently associated with crack use, there were no differences in sizes of male and female sexual networks after adjusting for numerous network characteristics. We did not measure the level of social integration of CSs with other AA MSM within the larger community and how crack use may influence their identities.
It was surprising that the HIV rates did not vary by crack use. This lack of difference may be due to the high prevalence of HIV among AA MSM. Although no difference was observed between CS and NCS groups, it is also concerning that over half of the full sample reported sexual concurrency (53%; i.e., overlap in the time period of their sex partnerships). Concurrency is a significant factor associated with rapid transmission of HIV and STIs in sexual networks32,43
and has been hypothesized as a contributing factor to the disparity in HIV among African Americans compared to white samples.44
Promoting consistent and proper condom use in all sexual partnerships is a critical message in addition to encouraging frequent HIV and STI testing.
Limitations of this study should be noted. The sample is comprised of older men living in Baltimore who reported having unprotected sex in the prior 90 days. Generalizability of the findings to younger men and AA MSM in other areas of the country is limited. Additionally, analysis was conducted using cross-sectional data which limits our ability to draw causal inference from the results.
These limitations notwithstanding, findings suggest that crack use is an HIV risk factor among AA MSM and networks of crack-using AA MSM would be optimal targets for testing and behavioral interventions that focus on increasing skills for HIV risk reduction and HIV and STI testing. Crack-using AA MSM in this study was embedded within high-risk networks consisting of other drug users. Given these social contacts, crack-using MSM may be an ideal source to recruit other high-risk networks for HIV testing and risk-reduction interventions. Considerations for implementing these interventions should include a range of settings such as drug treatment centers and other venues where non-gay-identified AA MSM frequent.