HIV-positive black men who have sex with both men and women engage in more high-risk behaviors than do those who have sex only with men or only with women, according to a U.S. multisite study.1 For example, in the past year, higher proportions of these men than of the other two groups have paid for sex, received payment for sex and used noninjection drugs. While high-risk behaviors have been well documented in research on HIV-positive individuals, the investigators point out that few studies have concentrated on black men, even though they account for three in 10 HIV-positive adults and adolescents in the United States.
To examine the relationships between high-risk behaviors and choice of sexual partners among HIV-positive black men, the researchers analyzed data reported to the Centers for Disease Control and Prevention by 19 health departments (located in 18 states) between June 2000 and January 2004. The analytic sample consisted of 2,038 black men who had been sexually active in the past year. Respondents were interviewed about their social and demographic characteristics and medical history, in addition to their sexual behaviors and related risk behaviors. The partner that the respondent felt most committed to was considered "steady," while any other partners were "nonsteady." The researchers assessed differences in men’s characteristics and behaviors by partner type using chi-square tests and analyses of variance.
Men were, on average, 40 years old, and 26% had less than a high school education. Six in 10 were unemployed, and about half had a yearly household income of less than $10,000. On average, men had known that they were HIV-positive for about five years; 63% had AIDS. In the past year, four in 10 reported only a steady partner or only nonsteady partners, and 19% had had both types of partners. Some 58% of men had had sex only with women, 36% only with men and 5% with at least one man and one woman.
Men in this last group had had an average of eight partners, roughly double the number reported by men who had had only male or female partners. Compared with these two groups, men who had had partners of both genders were more likely to report having used noninjection drugs (50–64% vs. 75%), having paid for sex (30–37% vs. 72%) and having been paid for sex (15–33% vs. 56%).
Sixty-five percent of men who had had sex only with women had had a steady female partner, compared with 25% of men reporting partners of both genders. Among those reporting a steady female partner, significantly higher proportions of men who had had partners of both genders than of those who had had only female partners reported that they did not know their partner’s HIV serostatus (43% vs. 14%) and that their most recent sexual encounter with this partner had included anal intercourse (21% vs. 4%) or unprotected vaginal intercourse (46% vs. 28%). In contrast, a lower proportion of the former than of the latter reported that this partner was HIV-positive (14% vs. 31%).
Nonsteady female partners were reported by 78% of men who had had partners of both genders and by 52% of men who had had sex only with women. More than four in 10 in each group reported not knowing their most recent partner’s HIV serostatus. Smaller proportions of men reporting only female partners than of men reporting male and female sex partners had used drugs at last sex (25% vs. 46%) and had had anal intercourse on that occasion (6% vs. 13%).
A higher proportion of men who had had sex only with men than of men who had had partners of both genders reported having a steady male partner in the last year (62% vs. 44%). These two groups did not differ significantly in their sexual behaviors. However, men who had had only male partners were less likely than those who had had both male and female partners to report substance use at last sex (13% vs. 25–27%) and to not know their partner’s HIV status (15% vs. 27%); they were more likely to say that their steady partner was HIV-positive (52% vs. 25%).
As in the analysis focusing on female partners, men who had had sex with both men and women were more likely to have had a nonsteady male partner than were men who had had sex only with men (78% vs. 61%). Among those with nonsteady male partners, a higher proportion of men who had had male and female partners than of men who had had only male partners reported drug use at last sex (36% vs. 23%). Two-thirds of men reporting partners of both genders had had insertive anal intercourse with their nonsteady male partner, compared with four in 10 men who had had sex only with men; 41% and 55%, respectively, reported having had receptive anal intercourse with this type of partner.
The researchers acknowledge that these findings, which may not hold true for all HIV-positive black men in the United States, may have been influenced by social desirability bias. They note, however, that the high-risk behavior of men with male and female partners may be "contributing to new infections and fueling the epidemic" in black communities. The investigators add that since HIV-positive black men often face unemployment, poverty and stigma related to HIV and same-gender sexual behavior, among other issues, interventions that go beyond reducing sexual risk behaviors may best meet the "urgent need for prevention interventions for this population."—S. Ramashwar
1. Spikes PS et al., Sexual risk behaviors among HIV-positive black men who have sex with women, with men, or with men and women: implications for intervention development, American Journal of Public Health, 2009, 99(6):1072–1078.