Secondary Logo

Journal Logo

Differential Patterns of Risk and Vulnerability Suggest the Need for Novel Prevention Strategies for Black Bisexual Men in the HPTN 061 Study

Dyer, Typhanye V. PhD, MPH*; Khan, Maria R. PhD, MPH; Regan, Rotrease PhD, MPH, RN; Harawa, Nina T. PhD, MPH§; Nelson, LaRon E. PhD, RN, FNP, FNAP, FAAN║,¶; Wilton, Leo PhD#,**; Wang, Lei PhD††; Peng, Lili MS††; Ou, San San MS††; Shoptaw, Steve PhD‡‡

JAIDS Journal of Acquired Immune Deficiency Syndromes: August 15, 2018 - Volume 78 - Issue 5 - p 491–498
doi: 10.1097/QAI.0000000000001716
Epidemiology
Free

Background: Black men who have sex with men (BMSM) and some who also have sex with women (BMSMW) account for over 70% of new HIV infections in the United States representing an elevated HIV risk in this group, also informing risks of HIV transmission to other BMSM and female sexual partners.

Settings: We examined trajectories of self-reported substance use, HIV-related sexual risk behaviors, and psychosocial vulnerabilities among BMSMW versus BMSM over a 1-year study period.

Methods: We analyzed baseline, 6-, and 12-month follow-up data from the HIV Prevention Trials Network “BROTHERS” Study (HPTN 061; n = 1126). Categorizing participants by sexual partner type across 3 time points: (1) BMSMO: having male and no female partners across assessments and (2) BMSMW: having sex with male and one or more female partners at least at 1 time point. Using generalized estimating equations, we estimated associations between being BMSMW (versus BMSMO) and changes in psychosocial vulnerability, substance use, and HIV-related sexual risk behaviors.

Results: Generalized estimating equation models controlling for sociodemographics, time-varying effects, and intervention status showed that BMSMW versus BMSMO had 50% increased odds of crack use, 71% increased odds of alcohol use during condomless anal intercourse (CAI), 51% greater odds of using drugs at last CAI, and twice the odds of receiving goods at last CAI.

Conclusions: Findings show stable and comparatively elevated illicit drugs, alcohol, and exchange sex during last CAI among BMSMW. Future intervention research should focus on ways to address changes in substance-related HIV-transmission behaviors over time in this population of men.

*Department of Epidemiology and Biostatistics, University of Maryland, College Park, MD;

Population Health, New York University School of Medicine, New York, NY;

Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA;

§Charles R. Drew University of Medicine and Science, Los Angeles, CA;

University of Rochester, School of Nursing, Rochester, NY;

Centre for Urban Health Solutions, St. Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, ON;

#Department of Human Development, State University of New York at Binghamton, Binghamton, NY;

**Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa;

††Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA; and

‡‡Department of Family Medicine, University of California Los Angeles, Los Angeles, CA.

Correspondence to: Typhanye V. Dyer, PhD, MPH, Department of Epidemiology and Biostatistics, The University of Maryland, 2234FF School of Public Health College Park, MD 20742 (e-mail: typhanye@umd.edu).

Supported by NIAID, NIDA, and NIMH under cooperative agreement #UM1 AI068619 as part of the HPTN Scholars Program. T.V.D. additionally received funding from The UCLA HIV/AIDS Translational Training Program (R25 MH-080644), Johns Hopkins Drug Dependence Epidemiology Training Program (2-T32 DA-007292-17), Project DISRUPT (R01 DA-028766), and UCLA CHIPTS (P30 MH 058107). The HPTN 061 Manuscript Review Committee made the final decision to submit the manuscript for publication.

The authors have no conflicts of interest to disclose.

Received October 20, 2017

Accepted April 06, 2018

Back to Top | Article Outline

INTRODUCTION

HIV persists as a critical public health concern in the United States.1 HIV prevalence in certain subpopulations, such as black men who have sex with men (BMSM), is comparable with those observed in endemic regions such as sub-Saharan Africa.2 Preliminary incidence data from the HIV Prevention Trials Network 061 study (HPTN 061), a large multisite study to determine the feasibility and acceptability for an integrative HIV-prevention intervention among BMSM in 6 urban areas in the United States, highlighted the severe disproportionate risk of HIV in this population3; 3% of the men became newly infected over 12 months, with most of these infections occurring in young BMSM (ie, younger than 30 years).4

Sex with both men and women has been well substantiated as common in behavioral studies of black same-gender-loving men.5–8 At baseline, among participants in the HPTN 061 study, 46% were men who reported sex with both men and women (BMSMW) in the 6 months before enrollment.4 Although HIV incidence over the year was highest among black men who only had sex with men (BMSMO) (46.9 per 1000 PY), incidence among BMSMW also was high (17.5 per 1000 PY).4 These data highlight the potential for some BMSMW to transmit HIV to other BMSM and to their female sexual partners.5,8,9 The risk context among BMSMW is, therefore, worthy of exploration.

BMSMW have elevated risk of engaging in HIV-related sexual risk behaviors with both male partners compared with BMSMO, and female partners compared with BMSWO.10–12 A study exploring types of female partners among BMSMW and associated sexual risk behaviors found that BMSMW reported more than 3 times as many total and condomless sex acts with each primary female partner, as they did with each nonprimary female partner, heightening potential HIV risk to primary female partners.7

Psychosocial vulnerabilities, including depression, internalized homophobia, poor social support, and substance use, are key correlates of HIV-related sex-risk behaviors, such as engaging in condomless anal intercourse (CAI).13–17 Previous studies suggest a high burden of substance use within the BMSM community at risk of HIV transmission,18–21 further highlighting that HIV-prevention interventions should address substance-related factors. BMSMW may be substantially more likely to engage in high-risk sex with both male and female partners, particularly concomitant with alcohol use,6 with BMSMW being more likely to report substance use with their male sexual partners, particularly crack/cocaine and alcohol use compared with BMSMO.5 A growing number of studies have focused on correlates of substance use, particularly alcohol and HIV-risk behavior among BMSM, whereas others have indicated that drug use has often served as a central facilitating factor for black male same-sex activity;22,23 with alcohol, crack/cocaine, and crystal methamphetamine being common drugs used for this purpose.21,24,25 These findings underscore the heterogeneous nature and the fluidity of sexual orientation among BMSM,26–29 some of whom have female partners, as it relates to substance use and sexual risk when engaging same-sex activity, which may also change over time as can the sex of their partners.22 Examining and developing an understanding of changes in substance use patterns among BMSMO and BMSMW are critical to developing effective culturally relevant prevention–intervention strategies that are tailored to the specific needs of each group and take into account the stability of HIV-related risk behaviors.30

Cross-sectional study evidence has indicated that BMSMW experience differential structural and psychosocial vulnerabilities, with findings from several studies showing that these men were more likely to report elevated depression symptoms, poverty, unemployment, unstable housing, and incarceration compared with BMSMO—all of which describe contexts that are conducive to increased HIV-risk behaviors and potentially HIV transmission.5,6,31–35 Wheeler et al35 found that BMSMW were more likely to report an annual income of less than $5000, a limited education, 2 or more arrests during their lifetime, engaging exchange sex for money, food, or shelter, reporting illicit drug use during the past 3 months, and heavy alcohol use during the past 3 months, as compared to BMSM. Findings from a recent formative study on HIV testing and health perceptions demonstrated that BMSMW reported an annual household income of less than $10,000, inadequate health insurance coverage, and concerns about privacy, stigma, and HIV risk.36 What is not known is whether the disproportionate HIV-related sexual risk behavior and underlying psychosocial vulnerability and substance use observed cross-sectionally in BMSMW study populations remains stable over time.

In this study, we used a prospective cohort study design to assess substance use, HIV-related sexual risk behaviors, and psychosocial vulnerability among BMSMO and BMSMW repeatedly over a year with 2 follow-up visits (every 6 months). The aim of the study was to describe differences in psychosocial and HIV-related risk behaviors (both substance use and sexual) of BMSMW and BMSMO observed over a 1-year period in participants from HPTN 061. Based on previous research,6,25 we hypothesized that BMSMW would be more likely to continue engaging in high-risk behaviors (both substance use and sexual related) compared with BMSMO, and that BMSMW would remain more psychosocially vulnerable, even after accounting for time-varying effects, compared with BMSMO.

Back to Top | Article Outline

MATERIAL AND METHODS

Study Design and Study Participants

The current study was part of the HPTN 061 study, also known as the Broadening the Reach of Testing, Health Education, Resources, and Services (BROTHERS) Project. HPTN 061 used a cohort study design including 1 baseline and 2 follow-up visits at 6 and 12 months, which was conducted between July 2009 and December 2011. The overall objective of HPTN 061 was to determine the feasibility and acceptability of a multicomponent intervention to reduce HIV infection among BMSM in the United States in 6 cities including Atlanta, Boston, Los Angeles, New York City, San Francisco, and Washington, DC. The institutional review boards at the participating institutions approved the study. A detailed description of the recruitment methods for the study has been described in detail elsewhere.6

A total of 1553 participants were enrolled in the study at baseline. Of those enrolled, 1371 cis-men (identified as male at birth and currently identify as men) participants who had at least 1 male partner at any visit were included in the analysis. Because the sample of cis-men reported varying or no sex partner genders across multiple time points, only men for whom sex partner type data were present at a minimum of 2 time points and who did not indicate that their sex partners were transgender or trans-sexual were included (n = 1126). Therefore, the analytic cohort for this study included cis-men participants who reported at least 1 partner who was a cis-man at any of the 3 visits. At each follow-up visit, we asked the same questions regarding the men's substance use, psychosocial vulnerability, and HIV-related sexual risk in the 6 months before the assessment.

Back to Top | Article Outline

Measures

Sociodemographic Variables

Sociodemographic variables included age, education, income, employment status, housing stability, incarceration history, study site location, and intervention assignment.

Back to Top | Article Outline

Exposure Variable

Defining BMSMW and BMSMO Status

At each study visit (baseline, 6, and 12 months), a participant was asked to report the number of cis-man and cis-woman partners he had in the previous 6 months. Participants were categorized into 2 groups: (1) having male partner(s) exclusively and (2) having both male and female partners at any time during the study.4

Back to Top | Article Outline

Outcome Variables

Substance-Use Variables

A screening question asked participants whether they had used marijuana, crack cocaine, powder cocaine, or methamphetamine in the past 6 months.6 Individual items then asked participants to report the frequency of use (eg, daily use) of specific drugs reported. Those who denied drug use in the past 6 months were coded “0 = None” for each type of drug. Participants who answered “Yes” to the screener were then asked, “How many days did you use “x” “drug” in the past 6 months?” Response categories were “1 = Daily,” “2 = Several times a week,” “3 = Weekly,” “4 = Several times a month,” “5 = Monthly,” “6 = A few times,” and “7 = Once.” These categories then were collapsed to create a 3-level variable reflecting frequency of substance use. The categories were “0 = None,” “1 = Rarely or Occasionally (Several times a month, Monthly, A few times, or Once),” and “2 = Frequently (Daily, Several times a week, or Weekly).”

At each study visit (baseline, 6, and 12 months), participants were also asked “In the past 6 months, how many drinks containing alcohol did you have on a typical day when you were drinking?” Response categories were “1 = 1 or 2,” “2 = 3 or 4,” “3 = 4,” and “4 = 5 or more.” These categories then were collapsed to create a dichotomous variable reflecting participants who drank 5 or more drinks versus those who drank less than 5 drinks.37

Back to Top | Article Outline

Psychosocial Vulnerability Variables

Depression Symptoms

The Center for Epidemiologic Studies Depression (CES-D) Scale38 was used to measure symptoms of depression. The CES-D is a 20-item, 4-point Likert-type scale ranging from (0 = rarely or none of the time, 1 = some or little of the time, 2 = moderately or much of the time, and 3 = most or almost all the time). The sum of all the scores was computed for participants who answered all 20 questions on the CES-D. A score of 16 or higher was considered to denote moderate depression symptoms. The Cronbach alpha coefficient indicated high internal consistency (α = 0.94).

Back to Top | Article Outline
Internalized Homophobia

A 7-item, 5-point Likert-type scale from 1 (strongly disagree) to 5 (strongly agree), adapted from Herek et al39 was used to measure internalized homophobia. Sample items included: “I have tried to stop being attracted to men,” “If someone offered me the chance to be completely heterosexual, I would accept the chance,” “I wish I were not attracted to men,” and “I feel bad about being attracted to men because my community looks down on men who are attracted to other men.” Possible scores ranged from 7 to 35. The mean was calculated for participants who answered at least 5 of the 6 items in the scale. The alpha coefficient showed high internal consistency for both subpopulations of men (α = 0.90 for BMSMW and α = 0.88 for BMSM).

Back to Top | Article Outline

HIV-Related Sexual Risk Behavior Variables

Any Drug Use Within 2 Hours of Last CAI

At each study visit, respondents were asked whether they had used marijuana, crack cocaine, powder cocaine (ie, coke), or methamphetamine in the past 6 months. The “any drug use” score proximal to CAI was derived if any of the abovementioned substances were reported used within 2 hours of last CAI.6

Back to Top | Article Outline
Alcohol Use Within 2 Hours of Last CAI

Similarly, at each study visit (month 0, 6, and 12), respondents were also asked “In the past 6 months, how many drinks containing alcohol did you have on a typical day when you were drinking?” Response categories were “1 = 1 or 2,” “2 = 3 or 4,” “3 = 4,” and “4= 5 or more.” The “any alcohol use” proximal to CAI was derived from participants' responses to whether alcohol was ever used within 2 hours of CAI.6

Back to Top | Article Outline
Involvement in Sex Exchange

Two items asked whether participants either received or gave money, drugs, other goods, or a place to stay the last time they had CAI. Each question was coded as a dichotomous (yes/no) outcome, indicating whether participants engaged in exchange sex.

Back to Top | Article Outline

STATISTICAL ANALYSES

Baseline, 6-, and 12-month demographics, substance use, sex risks, and psychosocial characteristics were summarized for BMSMW and BMSMO.

For categorical variables, χ2 tests were used to compare differences in characteristics between the 2 groups of men, whereas for continuous variables, Wilcoxon rank-sum tests were used. Next, as both exposure and outcome variables were repeated measures, we used logistic regression using generalized estimating equations (GEEs) to estimate associations between being BMSMW (versus BMSMO) and substance use, psychosocial vulnerability (internalized homophobia and depression), and HIV-related sexual risk behaviors at baseline, 6, and 12 months. Each respondent constituted a cluster to be accounted for, and we specified an exchangeable working correlation matrix. We then fit GEE models for binomial outcomes including drug use within 2 hours or during the last CAI with men in the past 6 months, alcohol use within 2 hours of last CAI with men in the past 6 months, and exchange sex, depression, and internalized homophobia. Each GEE model included the sexual behavioral category (ie, BMSMW and BMSMO), 1-year change, and the interaction of the 2. If the interaction term was not statistically significant, we fit a second model without the interaction and reported the odds ratio estimates from the second model. For all adjusted models, we controlled for age, education, incarceration, housing status, income, and study site.6 We additionally adjusted each model for the key confounder and intervention group assignment. All analyses were conducted using SAS 9.2.40

Back to Top | Article Outline

RESULTS

Fifty-four percent of men in the study were BMSMO and another 46% were BMSMW. Compared with BMSMO, BMSMW were significantly older, less educated, had lower income and were more likely to be unemployed, less stably housed, and more likely to have been incarcerated before enrollment. Additional baseline characteristics have been summarized elsewhere.6

Table 1 illustrates baseline, 6-, and 12-month comparisons of substance use, psychosocial characteristics, and HIV-related sexual risk of BMSMW and BMSMO. At baseline, compared with BMSMO, BMSMW were significantly more likely to report elevated levels of marijuana use (41.3% vs. 29.5%, P < 0.0001). These differences were no longer significant at 6- and 12-month follow-up, with BMSMW reporting similar levels of marijuana use at 6- (25.5% vs. 21.4%, P = 0.14) and 12-month follow-up (24.9% vs. 21.3%, P = 0.19). At baseline, compared with BMSMO, BMSMW were significantly more likely to report elevated levels of cocaine use (29.3% vs. 7.9%, P < 0.0001) within 2 hours of CAI. These differences remained significantly elevated for BMSMW at 6- (16.8% vs. 5.5%, P < 0.0001) and 12-month follow-up (12.0% vs. 5.1%, P < 0.0001). BMSMW also reported more crack use at baseline compared with BMSMO (14.4% vs. 5.6%, P < 0.0001), and these differences remained at 6- (9.3% vs. 4.6%, P < 0.01) and 12-month follow-up (6.5% vs. 2.0%, P < 0.001). At baseline, BMSMW were also more likely to report alcohol use within 2 hours of CAI (60.4% vs. 52.7%, P = 0.012) compared with BMSMO; however, these differences were no longer significant at 6- and 12-month follow-up. BMSMW were also significantly more likely to report that they received drugs, money, or goods for sex (34.8% vs. 7.7%, P < 0.0001), as well as being more likely to give drugs, money, or goods for sex (13.3% vs. 6.9%, P = 0.0005), and these differences remained at 6- and 12-month follow-up.

TABLE 1-a

TABLE 1-a

TABLE 1-b

TABLE 1-b

Results of the unadjusted and adjusted models estimating group differences over time in psychosocial, substance use, and HIV-related sexual risk behaviors are shown in Table 2. Adjusting for sociodemographic covariates, time, study site, and intervention status compared with BMSMO, BMSMW reported 50% increased odds of crack use, 71% increased odds of alcohol use at last CAI, a 51% increased odds of any drug use at last CAI, and twice the odds of receiving drugs, money, or other goods at last CAI. Results also show that over the 1-year period, the rates for each outcome decreased overall for the entire sample, however, remained elevated for BMSMW, as detailed above. BMSMW also continued to report elevated levels of depression (25%) and elevated levels of internalized homophobia (65%) compared with BMSMO.

TABLE 2

TABLE 2

Back to Top | Article Outline

DISCUSSION

Confirming our hypotheses, multivariate GEE models showed that overall differences in experience with substance use, internalized homophobia, sex while under the influence of drugs and alcohol, as well as involvement in sex trade, remained significantly elevated in BMSMW compared with BMSMO, excepting for use of marijuana. BMSMW increased rates of CAI while under the influence of alcohol and other drugs suggest that there may remain a high psychosocial burden associated with engaging in sex with men, which contributes to the use of substances. BMSMW also remained at higher odds of reporting receiving goods for sex, compared with BMSMO. Given the lower socioeconomic status and higher substance-use rates in BMSMW versus BMSMO, survival sex and sex-for-drug-related exchanges are important considerations in this group.

Moreover, the drugs used concomitant with sexual risk taking were frequently crack and cocaine. Although all drug and alcohol use impact cognitive functioning,41 these particular stimulants may also function to allow the men to overcome feelings of depression and thoughts of internalized homophobia sufficiently for the men to engage in desired sexual behaviors with other men. This may explain findings showing that although BMSMW may report greater use of substances, their rates of sexual risk behaviors are lower than BMSMO because they engage in sex with men less often than do BMSMO.5

Findings document that classifying behavioral risk groups into discreet categories using data from a single time point is not sufficient to capture risks faced by a group of BMSMW—specifically, men who reported having only male partners at baseline and then female partners at future time points. An understanding of how varying partner gender shifts over a 1-year time frame may inform recruitment of BMSMW into studies, as well as understanding of their needs over time and how these influence tailoring interventions. At minimum, these findings raise the likelihood of the issue of misclassification bias when categorizing men into behavioral risk groups using cross-sectional data.

It also must be noted that prevalent and incident incarceration was high in the sample,32,33 indicating a syndemic condition, ie, high incarceration rates, along with psychosocial vulnerabilities that may influence choices around partner types and behaviors that may put self at risk, as well as their partners. Incarceration also may have implications when considering survival sex within the BMSMW population.

There are several limitations to the current study. One is that the study was limited to 6 urban US cities, which decreases our ability to generalize findings to the black community in general and BMSM in other geographic regions, more specifically. Because of eligibility criteria for the HPTN 061 study, the cohort was at a higher risk than a more generalized sample that would include BMSM who did not report unprotected sex at enrollment. Although ACASI may minimize social desirability bias, ACASI data are nonetheless based on self-report, and social desirability bias may persist and potentially differ between BMSMO and BMSMW. In addition, the possibility of spurious associations due to misclassification as a result of other forms of bias (eg, recall) cannot be ruled out.

Despite these limitations, the findings have strong implications for research among BMSMW and BMSMO. Of specific interest is understanding the risk contexts of BMSMW and BMSMO that may change over time. Using a repeated-measures study design allows the men to be classified as BMSMW and BMSMO based on self-reported sexual partners over time, reducing the potential for misclassification bias that may arise from assessing self-reported sexual partners within a short time frame (eg, 6 months). The longitudinal nature of the current analysis also allowed for the documentation of sexual behavior and partnership types over a longer period, thus reducing the potential for misclassification. In addition, although the study was limited to 6 urban US cities, there is strength in that this sample represents different geographic areas and hence different epidemic profiles of BMSMW and BMSMO.

Back to Top | Article Outline

CONCLUSIONS

The findings from this study highlight the fact that BMSMW engaged in more substance use were also more psychosocially vulnerable and had elevated risk of engaging in HIV-related sexual risk behaviors when engaging in sex with men. However, it should be noted that findings from the repeated measures indicated that patterns of risk were similar to what was found at baseline for BMSMW compared with BMSMO. This is important because it reflects some persistent risks and vulnerability within this group that may otherwise be characterized as “going through a phase” (ie, misclassified) or that BMSMW were “out” enough to be participants in a study, which was tailored for BMSM.

Back to Top | Article Outline

ACKNOWLEDGMENTS

Steven Shoptaw with the UCLA Vine Street Clinical Research Site and HPTN Scholar mentor; HPTN 061 Study Participants; HPTN 061 Protocol Co-Chairs: Beryl Koblin, PhD, Kenneth Mayer, MD, and Darrell Wheeler, PhD, MPH; HPTN 061 Protocol Team Members; HPTN Black Caucus; HPTN Network Laboratory, Johns Hopkins University School of Medicine; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center; HPTN CORE Operating Center, FHI 360; The Black Gay Research Group; Clinical Research Sites, Staff and CABs at Emory University, Fenway Institute, GWU School of Public Health and Health Services, Harlem Prevention Center, New York Blood Center, San Francisco Department of Public Health, and UCLA.

Back to Top | Article Outline

REFERENCES

1. Centers for Disease Control and Prevention. Social Determinants of Health and Selected HIV Care Outcomes Among Adults With Diagnosed HIV Infection in 32 States and the District of Columbia, 2014, HIV Surveillance Supplemental Report; 2016.
2. El-Sadr WM, Mayer KH, Hodder SL. AIDS in America—forgotten but not gone. N Engl J Med. 2010;362:967–970.
3. Mayer K. Bacterial Sexually Transmitted Diseases Among American Black Men Who Have Sex With Men: Results From a Six-City Study, 2012 National STD Prevention Conference: CDC; 2012.
4. Koblin BA, Mayer KH, Eshleman SH, et al. Correlates of HIV acquisition in a cohort of black men who have sex with men in the United States: HIV prevention trials network (HPTN) 061. PLoS One. 2013;8:e70413.
5. Dyer TP, Regan R, Pacek LR, et al. Psychosocial vulnerability and HIV-related sexual risk among men who have sex with men and women in the United States. Arch Sex Behav. 2015;44:429–441.
6. Dyer TP, Regan R, Wilton L, et al. Differences in substance use, psychosocial characteristics and HIV-related sexual risk behavior between Black men who have sex with men only (BMSMO) and Black men who have sex with men and women (BMSMW) in six US cities. J Urban Health. 2013;90:1181–1193.
7. Harawa N, Wilton L, Wang L, et al. Types of female partners reported by Black men who have sex with men and women (MSMW) and associations with intercourse frequency, unprotected sex and HIV and STI prevalence. AIDS Behav. 2014;18:1548–1559.
8. Latkin C, Yang C, Tobin K, et al. Differences in the social networks of African American men who have sex with men only and those who have sex with men and women. Am J Public Health. 2011;101:e18.
9. Jeffries WL. Beyond the bisexual bridge: sexual health among US men who have sex with men and women. Am J Prev Med. 2014;47:320–329.
10. Lauby JL, Millett GA, LaPollo AB, et al. Sexual risk behaviors of HIV-positive, HIV-negative, and serostatus-unknown Black men who have sex with men and women. Arch Sex Behav. 2008;37:708–719.
11. Singh S, Hu X, Wheeler W, et al. HIV diagnoses among men who have sex with men and women—United States and 6 dependent areas, 2008–2011. Am J Public Health. 2014;104:1700–1706.
12. Spikes PS, Purcell DW, Williams KM, 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. Am J Public Health. 2009;99:1072–1078.
13. Bruce D, Kahana S, Harper GW, et al. Alcohol use predicts sexual risk behavior with HIV-negative or partners of unknown status among young HIV-positive men who have sex with men AIDS Care. 2013;25:559–565.
14. Gorbach PM, Murphy R, Weiss RE, et al. Bridging sexual boundaries: men who have sex with men and women in a street-based sample in Los Angeles. J Urban Health. 2009;86:63–76.
15. Mayer KH, Colfax G, Guzman R. Club drugs and HIV infection: a review. Clin Infect Dis. 2006;42:1463–1469.
16. Plankey MW, Ostrow DG, Stall R, et al. The relationship between methamphetamine and popper use and risk of HIV seroconversion in the multicenter AIDS cohort study. J Acquir Immune Defic Syndr. 2007;45:85.
17. Vosburgh HW, Mansergh G, Sullivan PS, et al. A review of the literature on event-level substance use and sexual risk behavior among men who have sex with men. AIDS Behav. 2012;16:1394–1410.
18. Boone MR, Cook SH, Wilson P. Substance use and sexual risk behavior in HIV-positive men who have sex with men: an episode-level analysis. AIDS Behav. 2013;17:1883–1887.
19. Buttram ME, Kurtz SP, Surratt HL. Substance use and sexual risk mediated by social support among black men. J Community Health. 2013;38:62–69.
20. Mimiaga MJ, Reisner SL, Bland S, et al. Health system and personal barriers resulting in decreased utilization of HIV and STD testing services among at-risk black men who have sex with men in Massachusetts. AIDS Patient Care and STDs. 2009;23:825–835.
21. Wilton L. Correlates of substance use in relation to sexual behavior in black gay and bisexual men: implications for HIV prevention. J Black Psychol. 2008;34:70–93.
22. Harawa NT, Williams JK, Ramamurthi HC, et al. Sexual behavior, sexual identity, and substance abuse among low-income bisexual and non-gay-identifying African American men who have sex with men. Arch Sex Behav. 2008;37:748–762.
23. Mansergh G, Spikes P, Flores SA, et al. Internalised homophobia is differentially associated with sexual risk behaviour by race/ethnicity and HIV serostatus among substance-using men who have sex with men in the United States. Sex Transm Infect. 2015;91:324–328.
24. Mimiaga MJ, Reisner SL, Fontaine YM, et al. Walking the line: stimulant use during sex and HIV risk behavior among Black urban MSM. Drug Alcohol Depend. 2010;110:30–37.
25. Shoptaw S, Weiss RE, Munjas B, et al. Homonegativity, substance use, sexual risk behaviors, and HIV status in poor and ethnic men who have sex with men in Los Angeles. J Urban Health. 2009;86:77–92.
26. Baldwin A, Dodge B, Schick V, et al. Sexual self-identification among behaviorally bisexual men in the Midwestern United States. Arch Sex Behav. 2015;44:2015–2016.
27. Garcia J, Parker RG, Parker C, et al. The limitations of “Black MSM” as a category: why gender, sexuality, and desire still matter for social and biomedical HIV prevention methods. Glob Public Health. 2016;11:1026–1048.
28. Rutledge SE, Jemmott JB, O'Leary A, et al. What's in an identity label? Correlates of sociodemographics, psychosocial characteristics, and sexual behavior among African American men who have sex with men. Arch Sex Behav. 2016:1–11.
29. Truong N, Perez-Brumer A, Burton M, et al. What is in a label? Multiple meanings of “MSM”among same-gender-loving Black men in Mississippi. Glob Public Health. 2016;11:937–952.
30. Tobin KE, Yang C, King K, et al. Associations between drug and alcohol use patterns and sexual risk in a sample of African American men who have sex with men. AIDS Behav. 2016;20:590–599.
31. Allen VC Jr, Myers HF, Williams JK. Depression among Black bisexual men with early and later life adversities. Cult Divers Ethnic Minor Psychol. 2014;20:128.
32. Brewer RA, Magnus M, Kuo I, et al. Exploring the relationship between incarceration and HIV among Black men who have sex with men in the United States. J Acquir Immune Defic Syndr. 2014;65:218.
33. Brewer RA, Magnus M, Kuo I, et al. The high prevalence of incarceration history among Black men who have sex with men in the United States: associations and implications. Am J Public Health. 2014;104:448–454.
34. Nelson LE, Wilton L, Moineddin R, et al. Economic, legal and social hardships associated with HIV risk among Black men who have sex with men in six US Cities. J Urban Health. 2016;93:170–188.
35. Wheeler DP, Lauby JL, Liu K, et al. A comparative analysis of sexual risk characteristics of black men who have sex with men or with men and women. Arch Sex Behav. 2008;37:697–707.
36. Cooke IJ, Jeremiah RD, Moore NJ, et al. Barriers and facilitators toward HIV testing and health perceptions among African-American men who have sex with women at a south side Chicago community health center: a Pilot study. Front Public Health. 2017;4:286.
37. Naimi TS, Brewer RD, Mokdad A, et al. Binge drinking among US adults. JAMA. 2003;289:70–75.
38. Radloff LS. The CES-D scale. Appl Psychol Meas. 1977;1:385–401.
39. Herek GM, Cogan JC, Gillis JR, et al. Correlates of internalized homophobia in a community sample of lesbians and gay men. J Gay Lesbian Ment Health. 1998;2:17–26.
40. SAS Institute and SAS Publishing. SAS 9.3 Output Delivery System: User's Guide: SAS Institute; 2011.
41. Gautam P, Warner TD, Kan EC, et al. Executive function and cortical thickness in youths prenatally exposed to cocaine, alcohol and tobacco. Dev Cogn Neurosci. 2015;16:155–165.
Keywords:

substance use; black MSM; black MSMW; HIV sexual risk; repeated measures; cohort studies

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.