Partners’ concurrency was significantly associated with younger age of the participant (ages 18 through 26 years, compared with age 27 years and older). Partners’ concurrency, similar to participants’ concurrency, was significantly associated with relationship status: compared with married women, those who had never married; or were divorced, separated widowed; or in other types of relationships were more likely to believe their partner had outside sexual partnerships. Cohabiting women were not significantly different from married women in reporting partners’ concurrency. Partners’ concurrency was also associated with history of substance abuse and STI during the past 6 months. There was no relationship between partners’ concurrency and race/ethnicity, education, or income. In multivariable analysis, the relationships between partners’ concurrency and all other covariates remained unchanged (Table 3).
Gaps and Overlaps in Sexual Partnerships
The mean and median overlaps in partnership dates among women who had concurrent partnerships were −17 and −5 months, respectively (Table 4). The mean and median gap in partnerships was about 1 month among women who reported only partners’ concurrency or no involvement with concurrent partnerships.
Sexual Behaviors: Frequency of Unprotected Intercourse and Partner Risk Characteristics
A substantial proportion of women in all concurrency categories reported frequent (more than 10 times) unprotected vaginal intercourse with their most recent partner during the 6 months before the interview (Table 4). Frequent unprotected vaginal intercourse was more likely to be reported by women who were involved with neither type of concurrency (53%) and those who had both concurrent partners and nonmonogamous partners (53%) than women who only had concurrent partners (participants’ concurrency only) (45%) and those who only had nonmonogamous partners (partners’ concurrency only) (42%) (P = 0.0036). Twenty-two percent of participants reported having had anal intercourse at least once with their most recent partner; 14% (235/1628) had anal sex with their most recent partner multiple times, but the distribution of this behavior did not vary by concurrency status.
A respondent was more likely to report either that her last partner had never undergone HIV testing or that she was unaware of whether or not he had been tested if she had both types of concurrent partnerships (45%), only nonmonogamous partners (47%), or only had concurrent partners herself (38%) compared with women who were involved with neither type of concurrency (29%) (P < 0.0001).
Only 2% women believed their most recent partner had sex with men; the prevalence of this belief did not vary by concurrency status (data not shown). There were no significant differences by concurrency status in the prevalence of women who believed that their last partner had injected drugs.
We evaluated frequency of vaginal intercourse with both partners among the 1193 women who reported 2 or more partners during the 6 months preceding the interview (Table 5). Substantial proportions of women reported unprotected intercourse with at least 2 of their most recent partners on more than 1 occasion. A woman with multiple partners was more likely to report multiple episodes of unprotected vaginal intercourse with 2 or more of these partners if she reported both types of concurrency (60%), participants’ concurrency only (50%), or partners’ concurrency only (33%) compared with a woman who was involved with neither type of concurrency (14%) (P < 0.0001). Of women with both types of concurrency, 16% reported unprotected vaginal intercourse with at least 2 partners on more than 10 occasions in the last 6 months. Similarly, 10% of women with only participants’ concurrency, 7% of those with only partners’ concurrency, and 3% of those of those who had neither type of concurrency reported more than 10 episodes of unprotected vaginal intercourse with at least 2 partners with both types of concurrency were most likely to report that both of their last 2 partners had not undergone HIV testing or were unaware that they had been tested (48%), followed by women with only participants’ concurrency (41%) or only partners’ concurrency (40%), whereas women who did not participate in any type of concurrency were least likely (17%) (P < 0.0001).
In this cohort of women at risk for HIV infection who were recruited from 10 communities in the United States, both participants’ and partners’ concurrency were frequently reported. During the 6 months before the baseline interview, 40% of participants had concurrent partnerships, and 36% believed their partners had concurrent partnerships; 24% of all respondents had concurrent partnerships themselves and strongly believed their partners did as well. Marital status, substance use, and history of STI were associated with participants’ and partners’ concurrency. Among the 47% of women who had neither concurrent nor nonmonogamous partners, the median gap between partnerships was 1 month, which is short enough to allow transmission of several STI pathogens, including acute HIV infection. Compared with women who had neither concurrent nor nonmonogamous partners, those with any type of concurrency were more likely to report multiple episodes of unprotected vaginal intercourse with at least 2 of their last 3 partners, and this was especially evident for women who had both concurrent and nonmonogamous partners. These findings suggest substantial opportunities for sexual transmission of HIV and other STIs among the women in this study.
Other studies have also revealed short gaps, but differences in study design make it difficult to directly compare results. Our study examined partnerships that occurred during the last 6 months. Therefore, the maximum possible gap is 6 months, which may not be comparable with other studies that measured partnerships over shorter or longer intervals. In a representative sample of the U.S. population, among women aged 15–44 years with multiple consecutive partners, the mean gap varied with age from as short as 8 months among the youngest women to 18 months among women aged 30–44 years and was longer among non-Hispanic black women (15 months) than non-Hispanic white women (12 months). Of note, roughly 11%–14% women had gaps less than 1.8 months.10 The 18- to 39-year-old male and female Seattle respondents in a random digit dial survey reported a mean gap length of 60.8 days.11 Gap lengths among male and female patients with consecutive partners in a Malawi STI clinic averaged 21 days.14 These short gaps would especially facilitate HIV transmission during acute infection when HIV viral load is extremely high.15
The duration of overlap in concurrent partnerships varied considerably among respondents in our study, as evidenced by the marked differences between the median of 5 months and the mean of 17 months, indicating that a small proportion of women had partnerships that overlapped by at least 17 months. Variation in duration of overlap has been observed in other study populations.11,14,16 Long-term concurrency can provide increased opportunities for HIV transmission.17
Estimates of per contact risk of HIV acquisition through vaginal intercourse vary from 0.001 to as high as 0.1; risk is especially high if the HIV-uninfected individual has an STI (as did 11% of our participants) or if the index contact has early or late stage HIV infection with high viral load.18 Anal intercourse further heightens HIV transmission risk.18 A substantial minority (14%) of all participants in this study had anal intercourse multiple times with their most recent partner. Moreover, women who had both concurrent and nonmonogamous partners were especially likely to have had unprotected vaginal intercourse with multiple partners and to report unknown HIV status of those partners. Unprotected intercourse during the course of concurrent partnerships has been previously reported. More than one third (35%) of men with concurrent partners in a representative sample of the U.S. population did not use condoms during last intercourse with either of their partners.16 These findings suggest a need for increased availability, promotion, and acceptability of condom use; increased diagnosis and treatment of STIs, other HIV prevention strategies such as preexposure HIV prophylaxis; and expansion of HIV testing, as recommended by the U.S. National HIV/AIDS Strategy.19
A key strength of this study is its collection of extensive details concerning sexual partnerships among women at high risk for HIV infection. We believe these findings may be generalizable to women with similar characteristics in the United States. However, it is important to note that our study population is not representative of any racial/ethnic or demographic group. Rather, participants were recruited because of their high-risk characteristics. Although they may be representative of women at high risk for HIV infection, they are not representative of poor women in general.
These results share the limitations of studies that rely on self-reported data, including those involving social desirability, recall, understanding, and communication,20,21 and we used a relatively insensitive measure of coital frequency. In addition, concurrency—particularly partners’ concurrency—is difficult to measure. Because our survey only queried women about their last 3 partners, we may have missed concurrency among women who had 4 or more partners. In addition, our concurrency definition (which we adopted to avoid misclassifying respondents with short gaps between consecutive partnerships) may have missed concurrent partnerships whose overlap only occurred within 1 calendar month.
Our comparison of first and last dates of sexual intercourse is considered one of the more robust strategies for measuring concurrency.22 The UNAIDS Reference Group on Estimates, Modeling, and Projections recommends determination of the 6-month point prevalence of concurrency (ie, the prevalence of concurrency exactly 6 months before the interview).23,24 This definition is useful as a standard for comparison of concurrency rates across populations. However, our goal was not to evaluate population prevalence of concurrency; we evaluated the cumulative proportion of concurrency to fully capture the characteristics of concurrent partnerships.
Determination of partners’ concurrency is problematic, as people are reporting the usually unobserved behavior of others. Although some studies have noted poor agreement between individuals’ reports of their partners’ concurrency and the partners’ reports of their own concurrent partnerships,25–27 the poor agreement stems largely from respondents’ failure to identify their partners’ lack of monogamy and not from overreports of the partners’ concurrency.28
In contrast to previous nationally representative studies, in which the crude and adjusted prevalence of concurrency among black women exceeded that among whites and Hispanics,6,8 there were no racial differences in concurrency among our respondents. Our study is notable for the exceptional poverty of the participants. Almost half survived on an annual income of less than $10,000, and all resided in an area with high rates of poverty. Given the importance of contextual factors in sexual network patterns,29,30 it is likely that the adverse economic context shared by participants of all race/ethnicities may have contributed to the distribution of the observed network patterns.
This study identified several sexual partnership characteristics that contribute to HIV and STI acquisition and transmission, including short time gaps between consecutive partnerships, partners’ concurrency, long-term participants’ concurrency, unprotected intercourse with concurrent partners, and lack of awareness of partner HIV serostatus among individuals whose network position placed them at high risk of acquiring or transmitting STIs, including HIV. These findings can improve our understanding of partnership dynamics and help target behavioral and biomedical interventions to prevent HIV infection.
The authors thank the study participants, community stakeholders, and staff from each study site. In particular, they acknowledge Lynda Emel, Jonathan Lucas, Nirupama Sista, Kathy Hinson, Elizabeth DiNenno, Ann O’Leary, Lisa Diane White, Waheedah Shabaaz-El, Quarraisha Abdool-Karim, Sten Vermund, Edward E. Telzak, Rita Sondengam, Cheryl Guity, Tracy Hunt, Khadijah Abass, Eileen Rios, Irene Kuo, Christopher Chauncey Watson, Christopher Walker, Oluwakemi Amola, and LeTanya Johnson-Lewis.
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Keywords:© 2014 by Lippincott Williams & Wilkins
HIV; epidemiology; concurrent partnerships; perceived partner concurrency; sexual networks; indirect concurrency