To the Editor:
Although African Americans are 13% of the US population, they constitute 49% of those living with HIV/AIDS.1 Although condom use is necessary to prevent sexual transmission of HIV, recent research with heterosexual African Americans in the rural south indicates that unprotected sex is not predictive of HIV for this population.2 Studies are documenting that riskier types of sex (sex trade and multiple and concurrent sex partners, including male sex partners), drug and alcohol misuse, and social-contextual factors (ie, poverty, lower education, incarceration history) rather than unprotected sex are significantly associated with higher rates of HIV among heterosexual African Americans.2-6 No research has directly examined whether such contextual issues remain linked to sexually transmitted disease (STD)/HIV diagnoses after accounting for the effects of individual risky sexual and substance use behaviors. Further, contextual factors such as street violence and gang involvement have largely been ignored in previous sexual risk research with heterosexual African American men, a notable concern given the established associations among gang involvement, violence and homicide, substance use, and incarceration.7,8 The purpose of this study was to assess whether incarceration, street violence, and gang involvement are independently associated with STD/HIV diagnosis among a sample of at-risk African American men who have sex with women, after accounting for risky sex and substance use behaviors and relevant demographic variables.
Study participants were from the Black and African American Men's Health Study (BAAMH), a cross-sectional study of black/African American men at sexual risk for HIV acquisition and/or transmission (N = 703). Participants were recruited from primary and urgent care clinics within Boston neighborhoods characterized by higher proportions of STD/HIV rates than that seen in Boston as a whole.9 The study involved a brief computerized survey (audio computer-assisted self-interview [ACASI]) of participants' sexual risk behaviors and related social and health concerns. Current analyses were restricted to men reporting sex with a woman in the past year (n = 672).
Measures for this study were obtained by means of self-report on ACASI and included incarceration history (ever and past year) and street and gang violence involvement (past 6 months and ever, respectively) as independent variables and STD/HIV diagnosis (past 6 months) as the dependent variable. Assessed covariates included sociodemographics (age, US born, completion of high school education or General Education Development [GED] degree, unemployment, and homelessness), risky sex variables (number of unprotected sex episodes with a female partner in the past 30 days, number of female sex partners in the past year, any male sex partners in the past year, and sex trade involvement in the past 6 months), and substance use (illicit drug use in the past 30 days and binge alcohol use [5+ drinks in 1 sitting] in the past 30 days).
Analyses involved simple logistic regression to assess significant associations between each independent variable and the dependent variable and a multivariate regression model to determine whether independent variables significantly associated with STD/HIV diagnosis in crude models remained significant after controlling for potentially confounding covariates. Covariates were included as potential confounders in the multivariate model if they altered the main effects regression coefficients by 10% or greater and if they were significant predictors of the dependent variable at P < 0.20 in the final model.10 Odds ratios (ORs) and 95% confidence intervals (CIs) were used to assess effect sizes and significance for variables in the final model.
Participants were aged 18 to 65 years (median age = 35 years), and 84.7% (n = 569) were US born. Approximately one quarter (28.1% [n = 189]) reported less than a high school education, 61.6% (n = 414) reported no current employment, and 24.4% (n = 164) were homeless (ie, in a shelter or on the streets) at the time of the study. More than half the sample (57.6% [n = 387]) had a history of incarceration, and 26.8% (n = 180) had been incarcerated in the past year. Additionally, 30.2% (n = 203) had been involved with street violence in the past 6 months, and 22.3% (n = 150) had a history of gang involvement. Almost half the sample (47.0% [n = 316]) reported past 30-day illicit drug use, and 35.6% (n = 239) reported past 30-day binge alcohol use.
Approximately 1 in 12 participants (8.8% [n = 59]) reported receipt of a diagnosis of HIV or another STD in the past 6 months (of these 59, 48 reported only STD diagnosis, 6 reported only HIV diagnosis, and 5 reported STD and HIV diagnosis). Sixty percent of participants (60.3% [n = 405]) reported unprotected sex with a female partner in the past 30 days; 8.2% (n = 55) reported sex with a man in the past year, and 17.8% (n = 120) reported sex trade involvement (selling or buying sex) in the past 6 months.
Crude logistic regression analyses demonstrated significantly greater likelihood of STD/HIV diagnoses among participants reporting a history of incarceration (OR = 5.3, 95% CI: 2.5 to 11.3) and gang involvement (OR = 2.9, 95% CI: 1.7 to 5.0) (Table 1). Findings remained significant in the final multivariate model.
Findings from the current study indicate that among African American men reporting sex with multiple female partners, those with a history of incarceration and gang involvement were more likely to report recent STD/HIV diagnosis compared with men with no such exposures. These findings are consistent with recent research involving African Americans in the southeastern United States, which also found that social context (eg, poverty, incarceration history) is linked to HIV.2 The current study is the first to document that observed associations between incarceration history and STD/HIV diagnosis among African American men persist after controlling for risky sexual and substance use behaviors. Similar findings for gang involvement further emphasize that risky sexual and substance use behaviors are insufficient to explain heightened STD/HIV risk for African American men.
Additional study is needed to clarify mechanisms responsible for observed associations. Previous studies document that contextual factors of racism, specifically poverty and lack of social capital, are linked with higher rates of STD/HIV among US African Americans.2,5,6 These effects are likely exacerbated among men with a history of incarceration, because they have greater difficulty in obtaining jobs, housing, or legal economic security.11,12 STD/HIV rates may be higher among men incarcerated or with a history of gang involvement as a result of higher proportions of STD/HIV-positive individuals within the sexual networks of these men. Recent research has found high seropositivity among HIV testers whose networks include those who are HIV-positive.13 The current study builds on recent research documenting the link between STD/HIV and poverty by means of neighborhood level analyses14,15 by demonstrating that marginalization (incarceration and gang involvement) may compound STD/HIV risk for individuals residing within such neighborhoods.
Although current study findings offer important insight into the risk for STD/HIV among US African American men who have sex with women, these results must be considered in light of several study limitations. Findings have limited generalizability because of the use of a northeastern United States clinic-based sample of African American men reporting 2 or more sex partners in the past year. This research was cross-sectional; hence, causality cannot be assumed. Time frames used to assess key research variables were not always consistent, ranging from 90 days to 1 year and ever. Reliance on self-report subject these data to social desirability and recall biases, although such biases would more likely result in conservative estimates of these sensitive indicators. Nonetheless, ideally, biologic markers of STD/HIV diagnosis and court records of incarceration histories would have better supported this study. Longitudinal study of these issues among a more representative sample of African American men and with more direct rather than self-report measurements is needed to improve examinations of these issues. Additionally, qualitative research to explore the mechanisms of observed associations is needed to support development of STD/HIV prevention and intervention programs for this population.
Consistent with previous studies,2,5,6,14,15 the current study demonstrates that the social context of risk among African American men who have sex with women is at least as important as individual behavioral risk in predicting the likelihood of STD/HIV infection. Future studies should include multilevel modeling to assess the role of neighborhood levels of such factors (neighborhood levels of drug use, gang violence, street crime, and incarceration) on individual STD/HIV acquisition as well to confirm findings. Nonetheless, these findings do demonstrate that efforts to address STD/HIV in African American communities must go beyond individual risk reduction approaches (eg, condom education, skills building) and include programs to reduce incarceration and gang involvement among African American men. Primary prevention efforts could include policy changes that provide drug treatment rather than incarceration for more minor drug possession crimes. Secondary efforts could include STD/HIV prevention integrated with social integration skills building and resource provision (eg, housing support) for incarcerated individuals and releasees; such efforts have been developed and seem promising.16-18 More research is needed to understand mechanisms linking incarceration and gang involvement with STI, however, because such research could better support creation of more effective primary and secondary prevention efforts.
Anita Raj, PhD*
Elizabeth Reed, MPH*†
M. Christina Santana, MPH*
Seth L. Welles, ScD, PhD‡
C. Robert Horsburgh, MD‡
Stephen A. Flores, PhD§
Jay G. Silverman, PhD‡
*Social Behavioral Sciences Department Boston University School of Public Health Boston, MA
†Department for Society, Human Development, and Health Harvard University School of Public Health Boston, MA
‡Department of Epidemiology Boston University School of Public Health Boston, MA
§Centers for Disease Control and Prevention Atlanta, GA
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