In this analysis of combined data from two online surveys of MSM, we found significant differences between white, black, and Hispanic participants in demographic characteristics and sexual risk behaviors. These data support the argument that racial/ethnic behavioral differences must be taken into account when designing initiatives to reduce HIV risk, even if some data suggest that prevention message preferences, in terms of content, identification of credible sources, and level of sexual explicitness, are similar by race/ethnicity [22
Of particular concern is the finding that black MSM respondents were significantly less likely to report HIV testing or to answer the question about their HIV status. Although most studies have not found significant differences in rates of HIV testing for black MSM vs. white MSM [3
], the difference in testing rates observed in this study has also been seen in at least one other recent investigation [23
]. Although data on HIV testing rates are mixed, black MSM are more likely to have undiagnosed HIV infection compared to white MSM [14
]. This prior finding and the present results suggest that more HIV-positive black men surveyed were unaware of their status or unwilling to provide this information. Data show that HIV-positive men of color who are unaware of their HIV infection are more likely to engage in UAI than men who know they are HIV-infected [24
]. Mathematical models, not limited to MSM of color, demonstrate that those unaware of their HIV infection may be responsible for a higher proportion of new HIV infections than those aware of their serostatus [15
]. A recent investigation found that HIV-negative black MSM were more likely than white MSM to report UAI with partners of unknown HIV status [11
]. Lower rates of HIV testing and diagnosis of HIV infection among black MSM in this sample may be secondary to lack of access to testing and health care [25
]. The ability of the online recruitment strategy used in this investigation to reach significant numbers of untested MSM of color highlights its potential utility in future prevention and testing initiatives and underscores the need to find better ways to engage these men online.
A previously published analysis from one of the internet studies presented in this paper found that men who screened positive for recent depressive symptoms and did not report treatment from a mental health provider were significantly more likely to have less education, be black or Hispanic, and were less likely to have a primary care provider, compared to men who screened positive and reported mental health treatment [27
]. These findings indicate socioeconomic differences in access to care among MSM online. Men of color and men with low socioeconomic status who use the Internet may not otherwise have access to these types of services. Further, the Internet is an underutilized tool for providing HIV education and prevention materials and referrals to services, such as HIV testing and treatment [28
Contrary to some prior studies of MSM, Hispanic men participating in these online studies were more similar to white men than black men in terms of sexual orientation, with more Hispanic men self-identifying as gay, and fewer reporting sex with women [31
]. A recent community-based survey lends support to these findings, reporting that Hispanic and white MSM scored higher on a scale that measured comfort with and attitudes towards homosexuality than black men scored [33
], but other data show that Hispanics who experience “homonegativity” engage in riskier sexual behaviors than those who do not [34
]. Hispanic men were also more similar to white men in HIV risk behavior, including multiple partners in the last sexual encounter and use of drugs before sex, both of which correlate with HIV transmission risk [3
In this study, black and Hispanic MSM were more likely than white MSM to report anal intercourse in the last sexual encounter, though frequency of UAI was lower in these race/ethnic groups than in whites. This finding is consistent with some of the data from existing literature [2
]. However, racial/ethnic concordance between partners in the last sexual encounter was much more common among white MSM, than black or Hispanic, which differs from some literature suggesting that black MSM were more likely to have black partners than white men were likely to have white partners [9
]. It is possible that the online sampling undertaken in this investigation reached a different population than prior studies due to recruitment sites or other factors. In addition, a single sexual encounter may not be representative of participants’ usual sexual behavior.
The observation that risk for UAI was lower for MSM having sex with non-main partners argues that men may engage in lower risk behavior with people they do not know as well, and higher risk behavior with trusted partners. This has been seen in other groups of MSM [4
]. Of note, the self-reported prevalence found in this investigation (13.5% of those who reported HIV testing) was similar to self report results in another study which recruited MSM both on- and off-line: 16.3% for the sample recruited on-line and 11.6% for the sample recruited offline [40
]. These self-reported prevalence estimates are higher than that found in a recent serosurvey of MSM participating in the National Health and Nutrition Examination Survey (9.1%)[41
], and lower than that from a recent HIV surveillance report of MSM from 21 cities (19%) [42
Online research has the advantage of collecting data from large and diverse samples of respondents in a confidential or anonymous manner, and may allow participants to disclose stigmatized practices more easily than in-person interviews [43
]. This investigation includes data from over 10,000 MSM, most of whom were white. The proportion of black and Hispanic respondents was low relative to white participants; however, 530 black and 900 Hispanic MSM were included in the analysis, making the absolute sample size robust. Some limitations of this analysis stem from the online nature of the survey itself, which limits the investigator’s ability to ensure complete and accurate responses.
Limitations of the surveys used for this analysis include our inability to examine either the frequency of serodiscordant UAI or the prevalence of concurrent sexual partnerships by race/ethnicity. Although the high rates of UAI reported by HIV-infected study participants lead to questions regarding the HIV infection status of their partners, the statistical power to detect differences between racial/ethnic groups was limited by small subgroup sample size in the analysis of predictors of UAI stratified by sex partner HIV status. In addition, information about partner concurrency was not collected in either study. Since these were cross-sectional studies, we were unable to determine changes in patterns of sexual behavior over time, specifically regarding partner race and relationship status, disclosure and specific sexual acts. Since the completion of these two Internet studies, community-based studies have found higher rates of concurrent partnerships in networks of black MSM compared with non-black MSM, suggesting that this behavior pattern deserves further exploration in online and offline surveys [10
]. Finally, the fact that the surveys were not offered in Spanish may limit the generalizability of the findings to English-speaking Hispanic men.
This analysis provides insights into necessary components of target interventions for risk reduction in MSM seeking sex online. Reaching MSM of color online who have not been HIV tested is a potential new strategy for intervention in this hard-to-reach population. MSM who have had more than 100 lifetime sex partners, who have had sex with women, and who are HIV-positive should also be a priority for reducing HIV transmission risk. MSM who do not self-identify as gay, a phenomenon that was more prevalent amongst black MSM surveyed, may require different outreach techniques and prevention messages. Finally, interventions that address the need for protection even when having sex with a main partner are critical.
Our findings highlight the need to target HIV prevention efforts to MSM who visit social and sexual networking sites online. Data from the studies analyzed here can be used to design online HIV prevention interventions, which will make best use of this novel and important venue for delivering the next generation of behavioral interventions. The advantages of conducting online interventions include engaging untested, not recently tested, and HIV-positive MSM of color where they meet sex partners [30
], reducing the stigma associated with HIV by enabling men to participate anonymously, and being cost-effective because of the ability to reach and potentially change HIV risk behaviors among a large population at relatively low cost [43
]. This investigation included a large number of untested MSM of color, and underscores the unique power of an online recruitment strategy to reach this lower income, at risk population, which may not be regularly accessing HIV testing or care.