Abstract
Objectives. We examined differences in sexual partner selection between Black and White men who have sex with men (MSM) to better understand how HIV status of participants' sexual partners and related psychosocial measures influence risk taking among these men.
Methods. We collected cross-sectional surveys from self-reported HIV-negative Black MSM and White MSM attending a gay pride festival in Atlanta, Georgia.
Results. HIV-negative White MSM were more likely than were HIV-negative Black MSM to report having unprotected anal intercourse with HIV-negative men, and HIV-negative Black MSM were more likely than were HIV-negative White MSM to report having unprotected anal intercourse with HIV status unknown partners. Furthermore, White MSM were more likely to endorse serosorting (limiting unprotected partners to those who have the same HIV status) beliefs and favorable HIV disclosure beliefs than were Black MSM.
Conclusions. White MSM appear to use sexual partner–related risk reduction strategies to reduce the likelihood of HIV infection more than do Black MSM. Partner selection strategies have serious limitations; however, they may explain in part the disproportionate number of HIV infections among Black MSM.
Men who have sex with men (MSM) continue to make up the majority of people who are HIV infected in the United States. About one third of US HIV infections among MSM occur in Black men1; however, Black men account for only 13% of the US male population.2 Several published reports of HIV risks that stratify risk behavior by race do not demonstrate elevated risk behavior among Black MSM as compared with White MSM.3,4 For example, Black MSM overall report fewer sexual partners and similar rates of unprotected anal intercourse when compared with White MSM. Because rates of risk behaviors fail to explain the racial disparities in HIV infections, contextual factors may offer important information for explaining the disproportionate HIV infections. Alarming rates of HIV among Black MSM have led this group to be among the top priority HIV prevention populations in the United States.5 Thus, a comprehensive understanding of HIV risk factors relevant to this population is warranted.
Multiple contextual factors potentially drive disparities in HIV/AIDS between Black MSM and White MSM. Perceived HIV prevention strategies such as selecting unprotected sexual partners thought to have the same HIV status, or serosorting, may play a role in explaining racial disparities in HIV infections. Many HIV-infected and non–HIV-infected men believe serosorting makes HIV transmission less likely and, thus, condom use unnecessary.6,7 This relationship may stem from the tendency for people to dislike using condoms8–10 and to practice alternative behaviors they believe are protective, such as serosorting. As a result, partner HIV serostatus is often a determining factor in sexual risk decision making.11,12 Several studies have found that MSM commonly use serosorting in general, but less is known about serosorting among MSM of various ethnicities.7,13–15
Data on the effectiveness of serosorting are somewhat mixed, but it is known that serosorting can lead to HIV exposure.16 Although some studies have noted the potential for serosorting to reduce overall HIV rates,17,18 limitations of this practice, including infrequent HIV testing, lack of open communication about HIV status, and acute HIV infection place MSM who serosort at risk for HIV transmission.19,20
There are at least 2 factors that directly influence whether or not an individual is motivated to serosort. First, individuals who serosort likely do so to lower their perceived risk for HIV infection, that is, to make them feel safe while not using condoms. In this sense, serosorting can reduce HIV transmission anxiety. Hence, the perception that serosorting makes unprotected sex safer is most likely driving sexual behavior risk taking. Notably, risk perceptions have been previously demonstrated to play an important role in predicting other health-related behaviors.21–23 Second, serosorting requires explicit verbal discussion about HIV status. As such, those who engage in serosorting need to be capable of discussing their own and their partners' HIV status.7 When serosorting, merely assuming the HIV status of a partner is often substituted for explicit disclosure20; however, serosorting cannot be effective under these conditions.
We sought to examine partner selection practices that potentially contribute to disparate HIV infection rates among Black MSM and White MSM. First, we examined the sexual behavior of Black MSM versus that of White MSM. On the basis of previous studies, we hypothesized that Black MSM and White MSM would report similar numbers of unprotected anal intercourse partners. However, because the HIV status of partners men choose may drive the differences in HIV infection rates, we hypothesized that Black MSM would report more partners of unknown or positive HIV status than would White MSM and that White MSM would report more partners of negative HIV status than would Black MSM. In keeping with these hypotheses, we also predicted that Black MSM would report less favorable beliefs about serosorting and HIV status disclosure. Finally, we predicted that Black MSM would report higher HIV perceived risk because of their choosing serodiscordant partners.
Participants were 549 self-reported HIV-negative men surveyed in Atlanta, Georgia, at the gay pride festival in June 2006 and the Black gay pride festival in September 2006. We used common venue intercept procedures to collect surveys.24,25 We offered participants $4 for completing the survey and gave them the option of donating their incentive payment to a local AIDS service organization. Approximately 80% of the men approached agreed to complete a survey.
We asked participants to report on demographics, sexual partners, last sexual experience, substance use, HIV status disclosure beliefs, serosorting beliefs, and perception of risk for HIV infection.
We asked participants their age, years of education, income, ethnicity, employment status, relationship status, HIV status, and when they were last tested for HIV.
We asked participants to report number of partners by HIV status (HIV negative, HIV positive, and HIV unknown) and with whom they had unprotected receptive and insertive anal intercourse within the past 6 months. We assessed number of partners because partners are more reliably recalled than number of sexual acts,26 number of partners is closely linked to HIV transmission risk,27,28 and we were interested in HIV status of partners men select. In some cases, participants may have assumed partners' HIV status. We asked participants to report the total number of partners from the past 6 months. Variables were transformed using logarithm (base 10) of variable plus one to improve fit.29
For these items, we asked participants to think about their last sexual experience when answering questions about their sexual risk behaviors. Participants were asked to report the following: if they, their partner, or both were drinking or using drugs during this act, if they had anal intercourse with this person, if they used a condom, and if they knew the HIV status of this most recent partner.
We asked participants if they had used alcohol, marijuana, nitrite inhalants, crack cocaine, ecstasy, methamphetamine, Viagra or similar medication without a prescription, or any other drug in the past 6 months. We coded these items as a dichotomous response of “yes” or “no.” We analyzed alcohol by itself and created a composite score for drug use. Scores for drug use ranged from 0 to 7, with 0 = no drug use and 7 = having taken 7 different drugs in the past 6 months.
Participants were asked to respond to the following 3 items about discussing their HIV status: (1) “I am comfortable telling my sexual partners my HIV status before having sex”; (2) “I am confident that I can ask my sexual partners if they have been tested for HIV before we have sex”; and (3) “I make sure I know what to say to a sexual partner about my HIV status before we have sex.” These 3 items were used to form a scale (Cronbach α = 0.68); responses ranged from 1 = strongly disagree to 6 = strongly agree.
Participants were asked to respond to the following 3 items about their serosorting beliefs: (1) “If my sexual partner tells me that his HIV status is the same as mine, I am more likely to have unprotected sex with him”; (2) “If my sexual partner tells me his HIV status is the same as mine, we don't have to worry about using condoms”; and (3) “If my sexual partner tells me his HIV status is the same as mine, then I worry less about HIV.” These 3 items were used to form a scale (Cronbach α = 0.82); responses ranged from 1 = strongly disagree to 6 = strongly agree.
To assess perceptions of risk, we asked participants to mark, along a 248-millimeter continuum visual analog scale,30 how much risk they were taking for HIV transmission. Specifically, we directed participants as follows: “Think about your sex behaviors for the past 6 months. Based on your sex behaviors from the past 6 months, how much risk do you believe you are at for getting HIV or infecting someone with HIV? Mark a line showing how much risk you are at.” The 2 visual analog scale anchors were no risk, abstinent, not having sex at all, and extremely high risk—having anal sex to ejaculation without a condom when the top partner is HIV positive.
Using SPSS version 15 (SPSS Inc., Chicago, Illinois), we conducted univariate and multivariate logistic regression analyses predicting White MSM and Black MSM (we coded White MSM as 0 and Black MSM as 1) as the criterion variable. We used ethnicity as a criterion variable to identify sexual risk variables that are uniquely associated with being either Black MSM or White MSM.
We surveyed 1051 men attending either a gay pride festival (n = 800) or a Black gay pride festival (n = 251) in Atlanta, Georgia. Of these men, 50 (5%) identified as heterosexual; 88 (8%) were Hispanic, Asian, or another race; 89 (178 [17%]) took the survey at both events (1 set of their responses was removed); 153 (15%) were HIV positive; and 33 (3%) reported unknown HIV status and thus were excluded from analyses, leaving 549 (52%) men included in all further analyses. We recruited 96 Black MSM from a gay pride festival and 84 Black MSM from a Black gay pride festival. Data analyses revealed that which festival we recruited Black MSM from made no substantial difference. The total sample of participants was 369 White MSM (67%) and 180 Black MSM (33%).
We compared demographic characteristics of Black MSM with those of White MSM (Table 1). Black MSM were significantly younger, had less education, reported lower incomes, and were less likely to be in a committed relationship than White MSM. White MSM were significantly more likely to report alcohol use in the past 6 months and were equally as likely compared with Black MSM to report drug use in the past 6 months. The time since last HIV test was similar between groups, with the time of the last test being on average more than 1 year before taking the survey.
TABLE 1 Demographic Characteristics and Substance Use Among White MSM and Black MSM: Atlanta, GA, 2006
| White MSM, Mean (SD) or No. (%) | Black MSM, Mean (SD) or No. (%) | Wald χ2 | OR (95% CI) | P | |
| Age, y | 34.77 (10.72) | 32.34 (9.36) | 6.60 | 0.98 (0.96, 0.99) | <.05 |
| Education | 15.05 (2.02) | 14.53 (2.11) | 7.46 | 0.88 (0.81, 0.98) | <.01 |
| Months since last HIV test | 14.79 (25.22) | 13.98 (27.26) | 0.11 | 0.99 (0.99, 1.01) | .74 |
| Income, $ | 10.22 | 0.75 (0.63, 0.90) | <.01 | ||
| 0–15 999 | 32 (8.7) | 16 (8.9) | |||
| 16 000–30 999 | 72 (19.7) | 54 (30.2) | |||
| 31 000–45 999 | 81 (22.1) | 54 (30.2) | |||
| > 46 000 | 181 (49.5) | 55 (30.7) | |||
| Employment | 0.59 | 1.22 (0.73, 2.04) | .44 | ||
| Working | 321 (87.2) | 151 (84.8) | |||
| Not working | 47 (12.8) | 27 (15.2) | |||
| Relationship status | |||||
| Not having sexual relations (Ref) | 44 (11.9) | 37 (20.6) | 1.00 | ||
| Having sex but do not have an exclusive partner | 110 (29.8) | 71 (39.4) | 7.54 | 3.06 (1.38, 6.79) | <.01 |
| In an exclusive relationship with 1 person (no outside partners) | 175 (47.4) | 59 (32.8) | 5.23 | 2.35 (1.13, 4.88) | <.05 |
| In an exclusive relationship with 1 person (with outside partners) | 40 (10.8) | 11 (6.1) | 0.30 | 1.23 (0.59, 2.54) | .58 |
| Report drug use past 6 mo | 160 (43.6) | 75 (42.1) | 0.64 | 0.94 (0.81, 1.09) | .42 |
| Report alcohol use in past 6 mo | 347 (96.4) | 143 (80.3) | 33.67 | 0.57 (0.48, 0.69) | <.001 |
Note. CI = confidence interval; MSM = men who have sex with men; OR = odds ratio.
In terms of sexual partners, Black MSM were significantly more likely than were White MSM to report unprotected insertive and receptive anal intercourse with a partner of unknown HIV status (Table 2). White MSM were significantly more likely than were Black MSM to report unprotected insertive and receptive sex with an HIV-negative partner. No differences emerged between groups in terms of numbers of unprotected receptive or insertive sex with HIV-positive partners, and overall numbers of HIV-positive partners reported were few. The total number of partners, both condom protected and unprotected, from the past 6 months was fewer for White MSM (mean = 3.58; SD = 5.182) than it was for Black MSM (mean = 5.06; SD = 7.72; t[260] = −2.325; P < .05).
TABLE 2 Male Anal Intercourse Partners in the Past 6 Months Among White MSM and Black MSM: Atlanta, GA, 2006
| Type of Intercourse and HIV Status of Partner | White MSM, Mean (SD) | Black MSM, Mean (SD) | Wald χ2 | OR (95% CI) | P |
| Unprotected, receptive, negative | 0.97 (2.22) | 0.54 (1.13) | 10.50 | 0.24 (0.10, 0.57) | <.01 |
| Unprotected, insertive, negative | 0.78 (1.31) | 0.55 (1.24) | 7.28 | 0.34 (0.13, 0.72) | <.01 |
| Unprotected, receptive, positive | 0.05 (0.33) | 0.08 (0.46) | 0.54 | 2.25 (0.26, 19.50) | .46 |
| Unprotected, insertive, positive | 0.08 (0.37) | 0.15 (0.66) | 1.67 | 3.00 (0.57, 15.84) | .20 |
| Unprotected, receptive, unknown | 0.11 (0.68) | 0.23 (1.00) | 4.60 | 4.60 (1.14, 18.47) | <.05 |
| Unprotected, insertive, unknown | 0.14 (0.71) | 0.33 (1.19) | 5.16 | 3.90 (1.21, 12.64) | <.05 |
Note. CI = confidence interval; MSM = men who have sex with men; OR = odds ratio. For mean and standard deviation, raw data are used to facilitate interpretation.
No differences emerged between Black MSM and White MSM in terms of drinking at last sexual encounter. About 43% of the total sample reported that they, their partner, or both had been drinking before sex. Black MSM were significantly more likely to report that their partner had been using drugs before sex. A majority of the total sample reported no drug use before sex. Black MSM and White MSM were equally likely to report having anal intercourse during their last sexual act, but White MSM were less likely to report condom use. Consistent with overall partner findings, Black MSM were significantly more likely to report that the HIV status of their last partner was unknown (Table 3).
TABLE 3 Characteristics of Last Sexual Experience Among White MSM and Black MSM: Atlanta, GA, 2006
| White MSM, No. (%) | Black MSM, No. (%) | Wald χ2 | OR (95% CI) | P | |
| Had either of you been drinking before sex? | |||||
| I had been drinking (Ref) | 27 (7.4) | 19 (10.6) | 1.00 | ||
| My partner had been drinking | 18 (4.9) | 16 (8.9) | 1.39 | 1.46 (0.77, 2.75) | .24 |
| Both of us had been drinking | 109 (29.8) | 42 (23.5) | 2.84 | 1.85 (0.91, 3.77) | .09 |
| Neither of us had been drinking | 212 (57.9) | 102 (57.0) | 1.04 | 0.80 (0.52, 1.23) | .31 |
| Had either of you been using other drugs before sex? | |||||
| I had been using (Ref) | 7 (1.9) | 12 (6.7) | 1.00 | ||
| My partner had been using | 14 (3.8) | 9 (5.1) | 8.39 | 4.10 (1.57, 10.62) | <.01 |
| Both of us had been using | 18 (4.9) | 20 (11.2) | 0.95 | 1.53 (0.65, 3.63) | .33 |
| Neither of us had been using | 327 (89.3) | 137 (77.0) | 8.21 | 2.65 (1.36, 5.17) | <.01 |
| Did you have anal intercourse with this person? | |||||
| Yes | 248 (67.4) | 121 (67.6) | 0.01 | 0.99 (0.67, 1.45) | .95 |
| No | 120 (32.6) | 58 (32.4) | |||
| If yes, did you use a condom? | |||||
| Yes | 111 (44.8) | 88 (73.3) | 25.34 | 0.30 (0.18, 0.47) | <.001 |
| No | 137 (55.2) | 32 (18.9) | |||
| What was the HIV status of this person? | |||||
| Positive (Ref) | 18 (4.9) | 14 (7.9) | 1.00 | ||
| Negative | 303 (82.8) | 124 (69.7) | 0.10 | 0.88 (0.39, 1.98) | .75 |
| Don't know | 45 (12.3) | 40 (22.5) | 10.27 | 0.46 (0.29, 0.74) | <.001 |
Note. CI = confidence interval; MSM = men who have sex with men; OR = odds ratio.
White MSM were significantly more likely to report being able to discuss HIV status with sexual partners than were Black MSM. White MSM were significantly more likely to have favorable beliefs about the HIV-related protective benefits of serosorting (Table 4).
TABLE 4 Social Cognitive Factors Related to Sexual Risk Among White MSM and Black MSM: Atlanta, GA, 2006
| White MSM, Mean (SD) | Black MSM, Mean (SD) | Wald χ2 | OR (95% CI) | P | |
| HIV disclosure scalea | 5.07 (1.08) | 4.79 (1.29) | 8.01 | 0.82 (0.72, 0.94) | <.01 |
| Serosorting beliefs scaleb | 2.61 (1.41) | 2.25 (1.34) | 6.68 | 0.82 (0.71, 0.95) | <.05 |
| HIV risk perception scalec | 52.74 (55.01) | 70.65 (65.87) | 10.54 | 1.01 (1.01, 1.02) | <.01 |
Note. CI = confidence interval; MSM = men who have sex with men; OR = odds ratio.
a Measured by 3 items discussing HIV status. Responses ranged from 1 (strongly disagree) to 6 (strongly agree).
b Measured by 3 items about serosorting beliefs. Responses ranged from 1 (strongly disagree) to 6 (strongly agree).
c Participants were asked to mark along a 248-milimeter continuum visual analog scale29 how much risk they were taking for HIV transmission. The 2 visual analog scale anchors were no risk to extremely high risk.
Black MSM were significantly more likely than were White MSM to report that they perceived themselves as having taken risk for HIV transmission in the past 6 months (Table 4). Overall, both Black MSM and White MSM perceived themselves to be at little to moderate risk for HIV, with scores on average falling below the center point of the scale.
For the multivariate model, we sought to identify unique independent variables in our model predicting White MSM versus Black MSM (Table 5). Inclusion in the model resulted from significant prediction of ethnicity during univariate analyses (with the exception of last sexual encounter items that were not included because of overlap with both the general substance use items and sexual partners items). The following variables were included in the model: age, education, income, relationship status, alcohol use, serosorting beliefs, HIV disclosure beliefs, HIV risk perception, number of instances of unprotected insertive and receptive anal intercourse with HIV-negative partners, and number of instances of unprotected insertive and receptive anal intercourse with partners whose HIV status was unknown. Results of this model demonstrated that age (White MSM were older), relationship status (White MSM reported more committed relationships), alcohol use (White MSM reported more alcohol use), serosorting beliefs (White MSM reported more favorable serosorting beliefs), HIV risk perception (Black MSM reported higher perceived HIV risk), unprotected insertive sex with HIV-negative partners (White MSM reported more of these partners), and unprotected insertive sex with partners whose HIV status was unknown (Black MSM reported more of these partners) all remained significant and thus were unique independent variables predicting White MSM versus Black MSM.
TABLE 5 Multivariate Model Predicting White MSM Versus Black MSM: Atlanta, GA, 2006
| Predictor | Wald χ2 | OR (95% CI) | P |
| Age | 7.20 | 0.97 (0.95, 0.99) | <.01 |
| Education | 0.52 | 0.96 (0.86, 1.08) | .47 |
| Income | 1.60 | 0.86 (0.67, 1.09) | .21 |
| Relationship status | 4.89 | 0.76 (0.59, 0.97) | <.05 |
| Alcohol | 29.88 | 0.55 (0.44, 0.68) | <.001 |
| Serosorting beliefs | 7.30 | 0.80 (0.68, 0.94) | <.001 |
| HIV disclosure beliefs | 2.35 | 0.87 (0.73, 1.04) | .13 |
| HIV risk perception | 4.62 | 1.01 (1.00, 1.01) | <.05 |
| Unprotected, insertive, negative partners | 7.76 | 0.21 (0.07, 0.63) | <.001 |
| Unprotected, insertive, unknown partners | 6.42 | 6.26 (1.51, 25.86) | <.05 |
| Unprotected, receptive, negative partners | 2.51 | 0.46 (0.17, 1.20) | .11 |
| Unprotected, receptive, unknown partners | 0.18 | 1.47 (0.24, 9.04) | .68 |
Note. CI = confidence interval; MSM = men who have sex with men; OR = odds ratio.
We found that a substantial number of both White MSM and Black MSM reported unprotected anal intercourse partners. However, a difference lies in the partners whom these men chose: Black MSM were more likely to report having unprotected anal intercourse with a partner of unknown HIV status. Similarly, Black MSM were more likely to report not knowing the HIV status of their last sexual partner; however, Black MSM were also more likely to have used condoms during this act. The HIV status of unprotected anal intercourse partners reported was consistent with our measures of prevention beliefs, risk perceptions, and partner selection strategies. White MSM reported a greater number of unprotected HIV-negative partners, were more likely to believe that serosorting offers protection from HIV, and were more likely to endorse positive HIV status disclosure beliefs. Perception of risk reported by Black MSM and White MSM was also consistent with the HIV status of partners they reported. Furthermore, in the multivariate model that controlled for key variables, number of unprotected insertive HIV-status–unknown partners and unprotected insertive HIV-negative partners remained significant independent variables predicting ethnicity.
Understanding the HIV status of the sexual partners Black MSM chose may help explain, in part, the higher rates of HIV infection among this group. Data from our study suggest that a further understanding of serostatus of sexual partners among Black MSM is warranted. The elevated rates of sexual partners whose HIV status is unknown may explain differences in HIV infection rates between Black MSM and White MSM. However, it is important to stress that serosorting should not be promoted as an HIV prevention strategy as it can lead to HIV infection.16 HIV infection occurs during serosorting because of such factors as acute HIV infection, the difficulty of being certain of one's HIV status during periods of engagement in risk behavior, and lack of overt HIV status disclosure. Finally, in looking at protected sexual acts among Black MSM and White MSM, we found that Black MSM were more likely to report condom use at last sexual act. This finding, taken on the whole, suggests that Black MSM do take critical steps to protect themselves; yet when they do not use condoms, they appear to engage in considerable risk (i.e., have a greater number of partners of unknown HIV status).
Although both White MSM and Black MSM reported risks for HIV or other sexually transmitted infections, additional research is warranted on how Black MSM choose sexual partners whom they consider to be risky or less risky for HIV and other sexually transmitted infections and what steps they may take to reduce risks. Research should focus on the role of homophobia, discrimination, and stigma as possible impediments to having open discussions with sexual partners about HIV testing and HIV status.31 Internalized homophobia, particularly among Black MSM, is an important factor to consider when examining sexual decision making among these men.32 It is possible that these pervasive contextual factors lead to negative expectations about discussions of sexual decision making and thus discourage its likelihood.
Race of sexual partners and sexual networks also are important considerations for future research in this area. Specifically, cultural norms that dictate sexual decision-making discussions may vary among sexual networks. As such, further research on what discussions are acceptable during sexual decision making may explain differences between White MSM and Black MSM and their partner selection.
Moreover, research suggests that Black MSM may become part of tightly interconnected sexual networks where HIV can more rapidly spread.33 The use of focus groups to collect qualitative data on how men assess risk for HIV and other sexually transmitted infections and what steps they take to protect themselves may provide valuable information on this topic. Finally, it is important to point out that research generally relies on condom use to determine the risk a person is taking. However, data from our study suggest that risk taking is more complicated than condom use and that strategies other than condom use, such as serosorting, may offer considerable insight into risk taking and thus HIV incidence.
Demographic data from Black MSM suggest that they may have less access to important health care–related services. Mainly, less education and lower incomes reported among Black MSM may result in larger societal level racial disparities, although these factors were nonsignificant in the multivariate model. Given the larger racial health disparity context—compared with Whites, from birth Blacks have a 2.4 times higher infant mortality rate; to adolescence Blacks are somewhat less likely to be immunized; through adulthood Blacks are 50% more likely to die from a stroke and have lower 5-year cancer survival rates34—higher rates of HIV infection among Black MSM are consistent with patterns found in other illnesses. There are multiple factors contributing to these disparities, including poor or no health insurance, perceiving health care as inadequate, and differential treatment from providers.35
Owing to the nature of convenience samples, our findings may not be generalizable to other communities of gay or bisexual men. It is likely that our sample underrepresents gay or bisexual men who are not open about their sexual orientation. Moreover, our study used a cross-sectional survey method, precluding any inferences of causation regarding HIV serostatus, sexual risk beliefs, and sexual partners. Study measures relied on self-report of sensitive and often stigmatized experiences and behaviors. This information is prone to cognitive and motivational processes that can bias responses. In particular, emotional and personal events, such as risky sexual behavior, are susceptible to social biases.36 The significant numbers of sexual partners reported by this sample may therefore actually be underestimates of risk behaviors. Nevertheless, surveys such as those reported here can yield biased information that must be considered when interpreting study findings.
Our sexual risk measures posed limitations. We assessed the number of unprotected sexual partners rather than frequencies of sexual acts because our study focused on serosorting. This approach allowed us to estimate unprotected sexual partners but did not allow us to estimate frequencies of potential exposure to HIV. Alternatively, we could have assessed frequencies of sexual acts. Sexual acts would have required a partner-by-partner assessment methodology that is difficult to achieve in a self-administered anonymous survey. From a measurement perspective, number of sexual acts is necessary to estimate potential exposure,26 whereas number of sexual partners allows us to estimate risks for HIV transmission at the partner level, in keeping with partner selection strategies.28
Major limitations for number of sexual acts include not specifying if all acts are with 1 partner and poorer recall, and limitations for number of partners include not having a measure of the number of potential exposures with each partner. Likewise, specifying partner type as steady or casual is an important factor in making sexual decisions, thus should be distinguished in future research. Given that the aim of the study was a focus on serosorting sexual partners, measuring number of partners with whom participants engaged in sexual acts was most consistent with our goals. Moreover, some measures used in the survey lack psychometric testing and would benefit from reliability and validity testing. With these limitations in mind, we believe that the current study findings offer new information about HIV risks among Black MSM and White MSM.
The issue of increased risk for HIV infection among Black MSM requires a closer look at partner selection strategies among these men. Gathering more information on how Black MSM strategically protect themselves (or do not protect themselves) from HIV can help inform interventions. Understanding why Black MSM report less favorable beliefs toward discussions of HIV status with sexual partners is also an area that warrants greater understanding. Future research in this area should identify specific ways to improve sexual health options for Black MSM.
Acknowledgments
The National Institute of Mental Health supported this research (grants RO1-MH71164 and T32- MH074387).
Human Participation Protection
The University of Connecticut institutional review board approved this study. Participants provided written consent.
