Since the early 1980s, the HIV epidemic in the United States has exacted a severe toll on men who have sex with men (MSM). This HIV burden has most disproportionately impacted black men, who represent an increasingly large percentage of AIDS cases among MSM [1–4]. HIV prevalence and incidence are significantly higher among black MSM than other MSM and rival corresponding rates in the developing world [5–8]. Moreover, HIV prevalence and incidence are considerably higher both in younger (15–22 years) and older (18–49 years) US samples of black MSM than in MSM of all other racial or ethnic groups [9–10].
Explanations remain elusive for the racial disparity in HIV infection between black MSM and other racial/ethnic groups of MSM. Although unprotected anal intercourse (UAI), which is a leading risk factor for HIV infection among MSM , has been considered a prime candidate for the disparate rates of HIV infection between black and other MSM , several studies have found greater HIV prevalence among black MSM despite comparable or lower rates of UAI than MSM of other races or ethnicities [5,6,13–15].
Recent evidence suggests that racial differences in HIV infection rates among MSM may potentially depend on factors other than behavioral risks. A recently published literature review examined 12 hypotheses (Table 1) for the greater prevalence of HIV among black MSM . The authors of the qualitative review found that black MSM were no more likely than MSM of other races or ethnicities to engage in sexual risk behavior, nor were black MSM more likely than other MSM to report substance use. However, the investigators also found that black MSM were more likely to have had a sexually transmitted disease (STD). In addition, although black MSM were as likely as other MSM to ever be tested for HIV, black MSM tested less frequently and were more likely to have an unrecognized HIV infection than other MSM.
The qualitative nature of the literature review was one of its limitations. Accordingly, the current study extends the earlier review through a quantitative examination of possible explanations for the disparate rates of HIV infection by comparing the risk behaviors of black MSM and white MSM.
Article sources and selection
The search strategy used several sources for identifying relevant reports, replicating the search strategy described in the qualitative review. Using MEDLINE, ERIC, Sociofile and PsychInfo, articles were identified that had been published from the beginning of online indexing of scientific articles (1974) through December 2006. In addition, HIV-related online bibliographic resources (specifically, http://www.metrokc.gov/health/apu/newart/namenu.htm and http://www.medadvocates.org/marg/MSM/main.html), which contained indexed articles dating back to 2000, were searched and the reference lists of pertinent articles were checked for additional citations.
The initial search yielded a total of 1042 citations that referenced blacks and MSM. After eliminating articles that were not written in English, dissertation abstracts, conceptual papers, and review articles, 768 articles remained. Next articles unrelated to HIV or AIDS were eliminated, which reduced the sample to 457 articles. Last, qualitative articles, duplicate references, and articles that were not relevant to our hypotheses were removed, resulting in a sample of 117 articles.
To be included in the meta-analysis, articles needed to (a) be based in the United States, (b) recruit both black and white MSM, (c) be responsive to at least 1 of the 12 hypotheses, and (d) provide quantitative data for MSM stratified by race for an outcome relevant to one of the hypotheses. The comparison in HIV risk data was limited to black MSM and white MSM because data for other ethnic groups are less frequently given and their categorizations vary.
These criteria resulted in the selection of 53 peer-reviewed articles [5,13,14,17–66] for the meta-analyses, which allowed seven hypotheses from the qualitative review to be addressed (Table 1 hypotheses 1–5 and 8–9).
Data abstraction and preparation
Pairs of reviewers independently abstracted data from eligible articles. Abstracted data included the study authors, publication year, overall sample size, sample size of black MSM and white MSM, data collection methods (self-administered or interviewer administered), sampling methodology (random, nonrandom), data collection setting(s), data collection period, relevant hypotheses, types of analysis (univariate, multivariate), and findings. Any disagreements during the abstraction process were resolved by discussion.
Several decision rules guided the preparation of data for analyses.
- Only data from black MSM and white MSM were used to calculate effect sizes; data from other groups (e.g., women, heterosexuals, Latino MSM or Asian MSM, etc.) in eligible articles were not used.
- Given a zero cell, 0.5 was added to each cell before computing the odds ratio (OR) [67,68].
- Articles could contribute more than one effect size as data were analyzed separately for each outcome of interest to ensure independence.
- Multiple effect sizes that addressed the same outcome of interest in a given article were aggregated so that each article contributed only one effect size for each outcome of interest.
- When both univariate and multivariate results were provided, the univariate results were selected for the meta-analyses. Univariate results were more comparable across studies since covariates varied widely across multivariate models.
- Only the most recent and most generalizable study was selected when there were multiple publications from the same database for a given outcome of interest.
Abstracted data for black MSM and white MSM were converted into percentages that represented ‘yes’ versus ‘no’ responses for a given outcome of interest and placed into a summary table (available on request). For those few outcomes that only reported percentages, means, an F score or t statistic, a standardized mean difference was calculated and then converted into an OR value. Data were aggregated across studies for each outcome of interest to estimate an overall effect size. To estimate the overall effect size, the logarithm of each OR was weighted by the inverse of its variance, and the weighted log values were summed across samples and then divided by the sum of the weights. For the purpose of presenting the results, effect sizes and 95% confidence intervals (CI) were converted back to OR values.
A random-effects model for aggregating individual effect sizes was used because it provided a conservative estimate of the variance and generated more accurate inferences about a population of studies beyond those included in the review . An OR > 1 indicated an increased likelihood of an outcome of interest among black MSM compared with white MSM; while an OR < 1 indicated a decreased likelihood of a given outcome among black MSM compared with white MSM.
Of the 53 studies, 48 (91%) exclusively recruited MSM, four (8%) recruited men and women, and one (2%) recruited men of various sexual orientations. Most of the studies (68%) recruited participants through nonprobability methods. In addition, although 20 studies (38%) recruited a general sample of MSM from bars, clubs, and community organizations, the remaining studies targeted specific populations including HIV-positive participants (23%), young men [aged 15–29 years (15%)], STD clinic attendees (9%), drug-using men (4%), bisexual men (4%), HIV-negative men (4%), and incarcerated men (3%).
The meta-analysis results for the outcomes of interest are shown in Table 2. There were no significant differences between black MSM and white MSM across studies in reported UAI, commercial sex work activity, substance use by drug (except amyl nitrites), history of HIV testing, or sex with known HIV-positive partners. However, black MSM reported significantly fewer sex partners across studies than white MSM and were less likely than whites to identity as gay or to disclose their homosexuality to others. Among HIV-positive MSM, black MSM were less likely than white MSM to report taking antiretroviral therapy (ART). The only outcome of interest that was significantly greater among black MSM than white MSM was the occurrence of STD.
Several stratified analyses were performed to determine whether overall effects differed among subgroups of studies. For 17 studies addressing UAI, the effect sizes were recategorized based upon reporting timeframe, date of publication, and sample characteristics. There were no differences by race among MSM who reported UAI in the past year (OR, 1.12; 95% CI, 0.44–2.81; k = 3), past 6 months (OR, 0.89; 95% CI, 0.56–1.39; k = 5), past 3 months (OR, 1.75; 95% CI, 0.84–3.67; k = 2), or last sexual encounter (OR, 1.97; 95% CI, 0.28–14.05; k = 2). When the results were stratified by publication date, there were significantly higher rates of UAI among black MSM compared with white MSM (OR, 1.60; 95% CI, 1.38–1.86; k = 3) for studies published during the first decade of the epidemic (1981–1990). However, black MSM and white MSM reported comparable rates of UAI among studies published in the second (1991–2000) and third (2001–2006) decades of the epidemic (OR, 1.09; 95% CI, 0.62–1.93; k = 3 and OR, 0.92; 95% CI, 0.61–1.40; k = 11, respectively). There were also greater rates of UAI among black MSM for studies published before the availability of HAART (OR, 1.44; 95% CI, 1.11–1.87; k = 4) and comparable rates of UAI for studies published after HAART was introduced (OR, 0.95; 95% CI, 0.64–1.39; k = 13). There were no differences by race in receptive UAI (OR, 1.03; 95% CI, 0.55–1.93; k = 5). There were also comparable rates of UAI by race in studies that recruited a general sample of MSM (OR, 1.06; 95% CI, 0.59–1.91; k = 8), but young black MSM were significantly less likely than young white MSM to report engaging in UAI (OR, 0.66; 95% CI, 0.57–0.77; k = 4).
No differences by racial group were found when all illicit drugs were recategorized into ‘recreational drugs’ (marijuana, nitrites, and hallucinogens; OR, 0.60; 95% CI, 0.32–1.12; k = 10) or ‘hard drugs’ (crack/cocaine, injection drugs, amphetamines and opiates; OR, 0.82; 95% CI, 0.52–1.28; k = 20). However, black MSM were significantly less likely than white MSM (OR, 0.64; 95% CI, 0.43–0.94; k = 27) to use drugs associated with HIV infection (i.e., nitrites, injection drugs, crack/cocaine, opiates, and amphetamines). Given that most OR values for individual drugs and those for recreational and hard drugs suggested greater use by whites, all drugs were grouped together (Fig. 1). Blacks were significantly less likely than whites to report any substance use across studies (OR, 0.71; 95% CI, 0.53–0.97; k = 41). When stratified by reporting period, there were comparable rates of substance use in the past 3 months (OR, 1.02; 95% CI, 0.54–1.93; k = 8), past 6 months (OR, 0.67; 95% CI, 0.31–1.41; k = 10), past year (OR, 1.45; 95% CI, 0.50–4.19; k = 5), and past 5 years (OR, 0.87; 95% CI, 0.53–1.42; k = 7), but black MSM were significantly less likely than white MSM to report any substance use during their lifetime (OR, 0.34; 95% CI, 0.16–0.74; k = 8). Last, no differences were found in substance use by race for studies that recruited a general sample of MSM (OR, 0.96; 95% CI, 0.65–1.43; k = 12), HIV-positive MSM (OR, 1.12; 95% CI, 0.72–1.75; k = 10) or drug-using MSM (OR, 0.73; 95% CI, 0.32–1.66; k = 10); however, young black MSM were significantly less likely than young white MSM to report any substance use (OR, 0.25; 95% CI, 0.15–0.41; k = 8).
Reports of STD were recategorized as either ‘lifetime’ infections (based upon self-report) or ‘current’ infections (based upon laboratory tests). There were no statistically significant differences among MSM by race in reported lifetime STD infections (OR, 1.29; 95% CI, 0.63–2.66; k = 5). However, across studies, black MSM were 2.12 times more likely to be diagnosed with a current STD than white MSM (95% CI, 1.68–2.67; k = 5). The results remained consistent with the overall findings when studies were stratified by type of STD: Black MSM were significantly more likely than white MSM to report ever having had or to be currently diagnosed with gonorrhea (OR, 1.53; 95% CI, 1.25–1.87; k = 4), syphilis (OR, 2.14; 95% CI, 1.70–2.69; k = 4), or hepatitis B (OR, 2.48; 95% CI, 1.27–4.86; k = 4).
Individual risk behaviors do not appear to be driving the disparity in HIV/AIDS among black MSM (Fig. 2). Despite comparable rates of UAI and fewer sex partners, STD prevalence and HIV prevalence remained greater among black MSM than white MSM. Moreover, black MSM were significantly less likely than white MSM to report engaging in any substance use irrespective of drug type (Fig. 1), and significantly less likely to report using any drugs associated with HIV infection.
Previous studies have reported that nongay-identified or nondisclosing MSM have fewer male sex partners than gay-identified or ‘out’ MSM [22,54,70]. It is possible that black MSM have fewer sex partners across studies than white MSM because black MSM overall are less likely than white MSM to identify as gay or to disclose their sexual behavior . However, having fewer sex partners, being nongay-identified and nondisclosure of sexuality are also each associated with a lower likelihood of HIV infection [7,22,70]; yet HIV infection rates remain greater among black MSM than white MSM.
Our meta-analyses suggest several factors that may be contributing to the high HIV infection rates among black MSM. The first factor is the occurrence of STD, as infections of this type facilitate acquisition and transmission of HIV [72,73] and black MSM in our meta-analysis were more likely than white MSM to be diagnosed with a current STD and to have (or have had) gonorrhea, syphilis, or hepatitis B. Although gonorrhea and syphilis are both associated with HIV infection or transmission, hepatitis B is not. However, hepatitis B is transmitted through HIV risk behavior (i.e., unprotected sex or intravenous drug use), and black MSM across studies were more likely than white MSM to have hepatitis B in spite of comparable sexual and intravenous drug use behaviors.
The second factor is the high rates of UAI among black MSM early in the HIV/AIDS epidemic. Studies that solely recruited black MSM during the first decade of the epidemic also documented high rates of UAI [12,74], and high HIV prevalence among black gay and bisexual men were already being reported in Centers for Disease Control and prevention (CDC) surveillance data  and prospective studies  from that time period. Since black MSM tend to have sex with other black partners [18,76], greater rates of UAI early in the epidemic may have increased the background prevalence of HIV among black MSM, which has continued to rise to the disproportionately high HIV rates observed today in spite of comparable rates of UAI as white MSM since the 1990s.
The third factor is ART usage. It has been demonstrated that ART use decreases viral load, which lowers HIV infectivity . HIV-positive individuals who are not taking ART are more likely to transmit HIV to uninfected sex partners during unprotected episodes than are individuals who are taking therapy. However, despite markedly higher HIV prevalence and the widespread availability of ART, we found that HIV-positive black MSM were less likely than HIV-positive white MSM to be taking ART. This is concerning because studies report that black MSM are more likely to be diagnosed later in the progression of HIV infection, when ART is recommended, than white MSM [78,79].
Another possible factor for the disproportionately high rates of HIV infection among black MSM is undiagnosed HIV infection [21,43]. Although our meta-analyses showed that black MSM were just as likely as white MSM to report ever being tested for HIV across studies, an additional analysis (not reported in Table 2) found that black MSM were seven times more likely than white MSM to have an unrecognized HIV infection (OR, 7.67; 95% CI, 6.05–9.71; k = 2). High rates of unrecognized HIV infection among black MSM increase the odds of HIV transmission to sexual partners. Compared with MSM who know that they are HIV negative or MSM who do not know their HIV status, MSM who know that they are HIV positive engage in fewer sexual risk behaviors with partners at-risk for HIV infection [80,81]. Moreover, a recent CDC study estimated that most new HIV infections in the United States are attributable to HIV-positive individuals who are unaware of their infection . However, the contribution of unrecognized HIV infection to the disparate rates among black MSM must be interpreted cautiously since the meta-analysis was based on two studies and not eligible for our study. Nevertheless, the preliminary evidence for these data are strong given the large overall sample size in the analysis (1293 black and 2545 white), the similar direction of the outcome for each of the two studies, and the large overall effect size.
There are several limitations in the current study. First, the results in this paper cannot be generalized beyond black MSM and white MSM. It is not known whether the hypotheses examined would show similar effects if we compared black MSM with other MSM of color. Second, it is important to note that some findings are based on a small set of studies. These should be viewed as preliminary and need to be addressed when more data become available. Third, all of the studies of young MSM shared the same probability-based recruitment method and the meta-analysis results for young MSM may be a function of the recruitment methodology rather than actual behavioral differences by race. Fourth, there were too few studies to examine by meta-analysis the role of circumcision, genetics, incarceration, social networks, healthcare access, ART adherence or anorectal douching to disparate rates of HIV infection among MSM. These subject areas need to be addressed in subsequent studies and may provide further explanation for high rates of HIV infection among black MSM. Fifth, meta-analyses are subject to the biases of the selected studies and this must be considered in the interpretation of the results. Last, there is a possibility that our results reflect underreporting among black MSM. However, it is unlikely that reporting bias was evident only among black MSM and not white MSM across studies, years, regions, and demographic characteristics. Moreover, several other racial comparative studies have also reported greater HIV/STD prevalence despite low-risk behaviors among black adolescents [83–85], young black adults , and blacks generally .
The HIV/AIDS epidemic among black MSM is more complex and multifactorial than individual risk behavior . Future research should examine the degree to which other factors, such as social networks, in conjunction with high HIV/STD background prevalence impact HIV infection rates among black MSM.
The authors would like to thank Nicole Crepaz, Jeffrey Herbst, Richard Wolitski, Gary Marks, David Purcell and Adrian Liau for their careful review and helpful comments during an earlier draft of this manuscript.
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
1. Blair JM, Fleming PL, Karon JM. Trends in AIDS incidence and survival among racial/ethnic minority men who have sex with men, United States, 1990–1999. J Acquir Immune Defic Syndr 2002; 31:339–347.
2. Centers for Disease Control and Prevention. HIV/AIDS among racial/ethnic minority men who have sex with men–United States, 1989–1998.MMWR Morb Mortal Wkly Rep
3. Centers for Disease Control and Prevention. Cases of HIV infection and AIDS in the United States, by race/ethnicity, 1998–2002.HIV/AIDS Surv Rep
4. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2003
, Vol. 15. Atlanta, GA: Centers for Disease Control and Prevention; 2004. pp. 34–35.
5. Easterbrook PJ, Chmiel JS, Hoover DR, Saah AJ, Kaslow RA, Kingsley LA, Detels R. Racial and ethnic differences in human immunodeficiency virus type 1 (HIV-) seroprevalence among homosexual
and bisexual men. Am J Epidemiol 1993; 138:415–429.
6. Lemp G, Hirozawa AM, Givertz D, Nieri GN, Anderson L, Lindegren ML, et al
. Seroprevalence of HIV and risk behaviors among young homosexual
and bisexual men: The San Franciso/Berkeley Young Men's Survey. JAMA 1994; 272:449–454.
7. Valleroy LA, MacKellar DA, Karon JM, Rosen D, McFarland W, Shehan DA, et al
. HIV prevalence and associated risks in young men who have sex with men. JAMA 2000; 284:198–204.
8. Torian LV, Makki HA, Menzies IB, Murrill CS, Weisfuse IB. HIV infection in men who have sex with men, New York city Department of Health sexually transmitted disease clinics, 1990–1999: a decade of serosurveillance finds that racial disparities and associations between HIV and gonorrhea persist. Sex Transm Dis 2002; 31:339–347.
9. Centers for Disease Control and Prevention. HIV incidence among young men who have sex with men- seven US cities, 1994–2000.MMWR Morb Mortal Wkly Rep
10. Centers for Disease Control and Prevention. Percentage of persons aged 18–49 years with HIV infection, by age group and race/ethnicity: United States 1999–2002.MMWR Morb Mortal Wkly Rep
11. Vittinghoff E, Douglas J, Judson F, McKirnan D, MacQueen K, Buchbinder S. Per-contact risk of HIV transmission between male sexual partners. Am J Epidemiol 1999; 150:306–311.
12. Reid A. Many gay
blacks say they shun ‘safe sex’. Boston Globe
June 4, 1990. p. 15.
13. Harawa NT, Greenland S, Bingham TA, Johnson DF, Cochran SD, Cunningham WE, et al
. Associations of race/ethnicity with HIV prevalence and HIV-related behaviors among young men who have sex with men in 7 urban centers in the United States. J Acquir Immune Defic Syndr 2004; 35:526–536.
14. Ruiz J, Facer M, Sun RK. Risk factors for human immunodeficiency virus infection and unprotected anal intercourse among young men who have sex with men. Sex Trans Dis 1998; 25:100–107.
15. Koblin BA, Husnik MJ, Colfax G, Huang Y, Madison M, Mayer K, et al
. Risk factors for HIV infection among men who have sex with men. AIDS 2006; 20:731–739.
16. Millett GA, Peterson JL, Wolitski R, Stall R. Greater risk for HIV infection of black
men who have sex with men. A critical literature review. Am J Public Health 2006; 96:1007–1019.
17. Bartholow BN, Buchbinder S, Celum C, Goli V, Koblin B, Para M, et al
. HIV sexual risk behavior
over 36 months of follow-up in the world's first HIV vaccine efficacy trial. J Acquir Immune Defic Syndr 2005; 39:90–101.
18. Bingham TA, Harawa NT, Johnson DF, Secura GM, MacKellar DA, Valleroy L. The effect of partner characteristics on HIV infection among African American men who have sex with men in the Young Men's Survey, Los Angeles, 1999–2000. AIDS Educ Prev 2003; 15:39–52.
19. Bingman CR, Marks G, Crepaz N. Attributions about one's HIV infection and unsafe sex in seropositive men who have sex with men. AIDS Behav 2001; 5:283–289.
20. Centers for Disease Control and Prevention. Human immunodeficiency virus (HIV) Risk, prevention, and testing behaviors – United States, National HIV Behavioral Surveillance System: Men Who Have Sex with Men, November 2003–April 2005.MMWR Morb Mortal Wkly Rep
21. Centers for Disease Control and Prevention. HIVprevalence, unrecognized infection, and HIV testing among men who have sex with men (MSM): five US cities, June 2004–April 2005.MMWR Morb Mortal Wkly Rep
22. Centers for Disease Control and Prevention. HIV/STD risks in young men who have sex with men who do not disclose their sexual orientation: six US cities,1994–2000.MMWR Morb Mortal Wkly Rep
23. Chen JL, Callahan DB, Kerndt PR. Syphilis control among incarcerated men who have sex with men: Public health response to an outbreak. Am J PublicHealth 2002; 92:1473–1475.
24. Chu SY, Peterman TA, Doll LS, Buehler JW, Curran JW. AIDS in bisexual men in the United States: epidemiology and transmission to women. Am J PublicHealth 1992; 82:220–224.
25. Denning PH, Campsmith ML. Unprotected anal intercourse among HIV-positive men who have a steady male sex partner with negative or unknown HIV serostatus. Am J Public Health 2005; 95:152–158.
26. Doll LS, Judson FN, Ostrow DG, O'Malley PM, Darrow WW, Hadler SC, et al
. Sexual behavior before AIDS: the hepatitis B studies of homosexual
and bisexual men. AIDS 1990; 4:1067–1073.
27. Doll LS, Petersen LR, White CR, Johnson ES, Ward JW. Homosexually and nonhomosexually identified men who have sex with men: a behavioral comparison. J Sex Res 1992; 29:1–14.
28. Geisler WM, Whittington WLH, Suchland RJ, Stamm WE. Epidemiology of anorectal chlamydial and gonococcal infections among men who have sex with men in Seattle: utilizing serovar and auxotype strain typing. Sex Transm Dis 2002; 29:189–195.
29. Goldbaum G, Perdue T, Wolitski R, Rietmeijer C, Hedrich A, Wood R, et al
. Differences in risk behavior
and sources of AIDS information among gay
, bisexual, and straight-identified men who have sex with men. AIDS Behav 1998; 2:13–21.
30. Grov C, Bimbi DS, Nanin JE, Parsons JT. Race, ethnicity, gender and generational factors associated with the coming-out process among gay
, lesbian, and bisexual individuals. J Sex Res 2006; 43:115–121.
31. Greenwood GL, White EW, Page-Shafer K, Bein E, Osmond DH, Paul J, et al
. Correlates of heavy substance use among young gay
and bisexual men: the San Francisco Young Men's Health Study. Drug Alcohol Depend 2001; 61:105–112.
32. Halkitis PN, Parsons JT, Wolitski RJ, Remien RH. Characteristics of HIV antiretroviral treatments, access and adherence in an ethnically diverse sample of men who have sex with men. AIDS Care 2003; 15:89–102.
33. Halkitis PN, Green KA, Mourgues P. Longitudinal investigation of methamphetamine use among gay
and bisexual men in New York City: findings from Project BUMPS. J Urban Health 2005; 82(suppl 1):i18–i25.
34. Halkitis PN, Zade DD, Shrem M, Marmor M. Beliefs about HIV noninfection and risky sexual behavior among MSM
. AIDS Ed Prev 2004; 16:448–458.
35. Heckman TG, Kelly JA, Bogart LM, Kalichman SC, Rompa DJ. HIV risk differences between African-American and white men who have sex with men. J Natl Med Assoc 1999; 91:92–100.
36. Irwin TW, Morgenstern J. Drug-use patterns among men who have sex with men presenting for alcohol treatment: differences in ethnic and sexual identity. J Urban Health 2005; 82(suppl 1):i127–i133.
37. Jacobson LP, Gore ME, Strathdee SA, Phair JP, Riddler S, Detels R. Therapy naivete in the era of potent antiretroviral therapy. J Clin Epidemiol 2001; 54:149–156.
38. Kass N, Flynn C, Jacobson L, Chmiel JS, Bing EG. Effect of race on insurance coverage and health service use for HIV-infected gay
men. J Acquir Immune Defic Syndr Human Retroviruses 1999; 20:85–92.
39. Kennamer JD, Honnold J, Bradford J, Hendricks M. Differences in disclosure of sexuality among African American and White gay
/bisexual men: implications for HIV/AIDS
prevention. AIDS Educ Prev 2000; 12:519–531.
40. Kim AA, Kent CK, Klausner JD. Risk factors for rectal gonococcal infection amidst resurgence in HIVtransmission. Sex Transm Dis 2003; 30:813–817.
41. Kramer MA, Aral SO, Curran JW. Self-reported behavior patterns of patients attending a sexually transmitted disease clinic. Am J Public Health 1980; 70:997–1000.
42. Linn LS, Spiegel JS, Mathews WC, Leake B, Lien R, Brooks S. Recent sexual behaviors among homosexual
men seeking primary medical care. Arch Intern Med 1989; 149:2685–2690.
43. MacKellar DA, Valleroy LA, Secura GM, Behel S, Bingham T, Celentano DD, et al
. Unrecognized HIV infection, risk behaviors, and perceptions of risk among young men who have sex with men. J Acquir Immune Defic Syndr 2005; 38:603–614.
44. Mackellar DA, Valleroy LA, Secura GM, McFarland W, Shehan D, Ford W, et al
. Two decades after vaccine license: hepatitis B immunization and infection among young men who have sex with men. Am J Public Health 2001; 91:965–971.
45. Mansergh G, Marks G, Colfax GN, Guzman R, Rader M, Buchbinder S. “Barebacking” in a diverse sample of men who have sex with men. AIDS 2002; 14:653–659.
46. Mason HR, Simoni JM, Marks G, Johnson CJ, Richardson JL. Missed opportunities? Disclosure of HIVinfection and support seeking among HIV+ African-American and European-American men. AIDS Behav 1997; 1:155–162.
47. McKirnan D, Houston E, Tolou-Shams M. Is the web the culprit? Cognitive escape and internet sexual risk among gay
and bisexual men. AIDS Behav 2007; 11:151–160.
48. McKirnan D, Stokes J, Doll L, Burzette R. Bisexually active men: social characteristics and sexual behavior. J Sex Res 1995; 32:65–76.
49. McKirnan DJ, Vanable PA, Ostrow DG, Hope B. Expectancies of sexual “escape” and sexual risk among drug and alcohol-involved gay
and bisexual men. J Subst Abuse 2001; 13:137–154.
50. McNall M, Remafedi G. Relationship of amphetamine and other substance use to unprotected intercourse among young men who have sex with men. Arch Pediatr Adolesc Med 1999; 153:137–154.
51. Montgomery JP, Mokotoff ED, Gentry AC, Blair JM. The extent of bisexual behaviour in HIV-infected men and implications for transmission to their female sex partners. AIDS Care 2003; 15:829–837.
52. Newman PA, Rhodes F, Weiss RE. Correlates of sex trading among drug-using men who have sex with men. Am J Public Health 2004; 94:1998–2003.
53. Ostrow DG, Vanable PA, McKirnan DJ, Brown L. Hepatitis and HIV risk among drug-using men who have sex with men: demonstration of Hart's law of inverse access and application to HIV. J Gay
Lesbian Med Assoc 1999; 3:127–136.
54. Pathela P, Hajat A, Schillinger J, Black
S, Sell R, Mostashari F. Discordance between sexual behavior and self-reported sexual identity: a population-based survey of New York City men. Ann Intern Med 2006; 145:416–426.
55. Paz-Bailey G, Meyers A, Black
S, Brown J, Rubin S, Braxton J, et al
. A case-control study of syphilis among men who have sex with men in New York City: association with HIV Infection. Sex Transm Dis 2004; 31:581–587.
56. Peterson JL, Bakeman R, Stokes J, Community Intervention Trial for Youth Study Team. Racial/ethnic patterns of HIV sexual risk behaviors among young men who have sex with men. J Gay
Lesbian Med Assoc 2001; 5:155–162.
57. Rhodes SD, Yee LJ, Hergenrather KC. A community-based rapid assessment of HIV behavioural risk disparities within a large sample of gay
men in southeaster USA: A comparison of African American. AIDS Care 2006; 18:1018–1024.
58. Rietmeijer CA, Wolitski RJ, Fishbein M, Corby NH, Cohn DL. Sex hustling, injection drug use, and nongay identification by men who have sex with men: associations with high-risk sexual behaviors and condom use. Sex Transm Dis 1998; 25:353–360.
59. Samuel M, Winkelstein W Jr. Prevalence of human immunodeficiency virus infection in ethnic minority homosexual
/bisexual men. JAMA 1987; 257:1901–1902.
60. Siegel K, Scrimshaw EW, Karus D. Racial disparities in sexual risk behaviors and drug use among older gay
/bisexual and heterosexual men living with HIV/AIDS
. J Natl Med Assoc 2004; 96:215–223.
61. Simoni JM, Mason HR, Marks G. Disclosing HIV status and sexual orientation to employers. AIDS Care 1997; 9:589–599.
62. Stokes JP, McKirnan DJ, Doll L, Burzette RG. Female partners of bisexual men: what they don't know might hurt them. Psychol Women Q 1996; 20:267–284.
63. Stokes JP, Vanable PA, McKirnan DJ. Ethnic differences in sexual behavior, condom use, and psychosocial variables among black
and white men who have sex with men. J Sex Res 1996; 33:373–381.
64. Sullivan PS, Nakashima AK, Purcell DW, Ward JW. Geographic differences in noninjection and injection substance use among HIV-seropositive men who have sex with men: western United States versus other regions. J Acquir Immune Defic Syndr Hum Retrovirol 1998; 19:266–273.
65. Thiede H, Valleroy LA, MacKellar DA, Celentano DD, Ford WL, Hagan H, et al
. Regional patterns of correlates of substance use among young men who have ex with men in 7 US urban areas. Am J Pub Health 2003; 93:1915–1921.
66. Xia Q, Osmond DH, Tholandi M, Pollack LM, Zhou W, Ruiz JD, et al
. HIV prevalence and sexual risk behaviors among men who have sex with men: results from a statewide population-based survey in California. J Acquir Immune Defic Syndr 2006; 41:238–245.
67. Cooper H, Hedges LV. The Handbook of Research Synthesis. New York: Russell Sage Foundation; 1994.
68. Wickens TD. Multiway contingency tables analysis for the social sciences. Hillsdale, NJ: Erlbaum; 1989.
69. Hedges LV, Vevea JL. Fixed and random effects models in meta-analysis. Psychol Meth 1998; 3:486–504.
70. Wood RW, Krueger LE, Pearlman TC, Goldbaum G. HIV transmission: women's risk from bisexual men. Am J Pub Health 1993; 83:1757–1759.
71. Millett G, Malebranche D, Mason B, Spikes P. Focusing “down low”: bisexual black
men. HIV risk and heterosexual transmission. J Natl Med Assoc 2005; 97:52S–59S.
72. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999; 75:3–17.
73. Rothenberg RB, Wasserheit JN, St Louis ME, Douglas JM. The effect of treating sexually transmitted diseases on the transmission of HIV in dually infected persons: a clinic-based estimate. Sex Transm Dis 2000; 27:411–416.
74. Peterson JL, Coates TJ, Catania JA, Middleton L, Hilliard B, Hearst N. High-risk sexual behavior and condom use among gay
and bisexual African-American men. Am J Public Health 1992; 82:1490–1494.
75. Bakeman R, Lumb JR, Jackson RE, Smith DW. AIDS risk-group profiles in whites and members of minority groups. N Engl J Med 1986; 315:191–192.
76. Centers for Disease Control and Prevention. HIV transmission among black college student and nonstudent men who have sex with men–North Carolina, 2003.MMWR Morb Mortal Wkly Rep
77. Porco TC, Martin JN, Page-Shafer KA, Charlebois E, Cheng A, Osmond DH. Decline in HIV infectivity following the introduction of highly active antiretroviral treatment. AIDS 2004; 18:81–88.
78. Hall I, Byers RH, Ling Q, Espinoza L. Racial/ethnic and age disparities in HIV prevalence and disease progression among men who have sex with men in the United States. Am J Public Health 2007; 97:1060–1066.
79. Wortley PM, Chu SY, Diaz T, Ward JW, Doyle B, Davidson AJ, et al
. HIV testing patterns: where, why, and when were persons with AIDS tested for HIV? AIDS 1995; 9:487–492.
80. Colfax GN, Buchbinder SP, Cornelisse PGA, Vittinghoff E, Mayer K, Celum C. Sexual risk behaviors and implications for secondary HIV transmission during and after HIV seroconversion. AIDS 2002; 16:1529–1535.
81. Centers for Disease Control and Prevention. Adoption of protective behaviors among persons with recent HIV infection and diagnosis: Alabama, New Jersey, and Tennessee, 1997–1998.MMWR Morb Mortal Wkly Rep
82. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS 2006; 20:1447–1450.
83. Romero EG, Teplin LA, McClelland GM, Abram KM, Welty LJ, Washburn JJ. A longitudinal study of the prevalence, development, and persistence of HIV/sexually transmitted infection risk behaviors in delinquent youth: Implications for healthcare in the community. Pediatrics 2007; 119:e1126–e1141.
84. Ellen JM, Aral SO, Madger LS. Do differences in sexual behaviors account for the racial/ethnic differences in adolescents' self-reported history of a sexually transmitted disease? Sex Transm Dis 1998; 25:125–129.
85. Hallfors DD, Iritani BJ, Miller WC, Bauer DJ. Sexual and drug behavior patterns and HIV/STD racial disparities: The need for new directions. Am J Public Health 2007; 97:125–132.
86. Harawa NT, Greenland S, Cochran SD, Cunningham WE, Visscher B. Do differences in relationship and partnership attributes explain disparities in sexually transmitted disease among young white and black
women? J Adol Health 2003; 32:187–191.
87. Pepin J. From the Old World to the New World: an ecologic study of population susceptibility to HIV infection. Trop Med Int Health 2005; 10:627–639.
88. Millett GA, Malebranche D, Peterson JL. HIV/AIDS
Prevention Research among Black
Men who have Sex with Men: Current Progress and Future Directions. In: Meyer IH, Northridge ME, editors. The Health of Sexual Minorities: Public Health Perspectives on Lesbian, Gay
, Bisexual and Transgender Populations. New York: Springer; 2007. pp. 539–565.