Correlates of Risk Patterns and Race/Ethnicity Among HIV-Positive Men Who Have Sex With Men

Ann O'Leary; Holly H. Fisher; David W. Purcell; Pilgrim S. Spikes; Cynthia A. Gomez

Disclosures

AIDS and Behavior. 2007;11(5):706-715. 

In This Article

Method

Participants and Procedures

Between 1996 and 1998, a total of 456 HIV-positive MSM from New York and San Francisco were recruited into a cross-sectional study of qualitative and quantitative predictors of HIV transmission risk behavior. Participants were recruited through active staff outreach, via posted advertisements, and through friend referral. Quotas based on race/ethnicity were designed to result in roughly equivalent numbers of European American, African American, and Latino participants. Additional quotas were set for recruitment venue, with the goal of recruiting roughly equivalently from AIDS Service Organizations (ASOs); Mainstream Gay Environments (MGEs) such as pride events and gay bars; and Public Sex Environments (PSEs) such as commercial sex venues and outdoor cruising areas. The race/ethnicity quotas resulted in roughly equal numbers of men from the three major ethnic groups from each recruitment venue. Entry criteria included: (1) self-reported HIV-seropositive status; (2) sex with other men within the previous year; and (3) age 18 or older. Table 1 gives basic socio-demographic information for men within each group.

Potential participants called a toll-free telephone number to be screened for eligibility. Those who met study criteria were scheduled to meet with an interviewer for a qualitative interview (first 255 participants only) that elicited, among other factors, detailed narratives describing recent sexual episodes including, if appropriate, protected/safe sex, unprotected/unsafe sex, and sex with women. When this one-hour interview was completed, all participants were asked to complete a paper-and-pencil questionnaire eliciting information regarding sexual behavior, social-cognitive and other quantitative predictors of risk behavior, health care utilization, and mental health factors. Respondents were permitted to complete the instrument at the interview site, or to take it home and mail it. They were paid $30.00 for both the interview and/or the questionnaire completion. All of the data included in the present analyses were obtained from the questionnaire. All study procedures were approved by the Institutional Review Boards at the Centers for Disease Control and Prevention and the participating institutions.

Measures

Demographics and Sexual Orientation

Demographic measures included age, years since diagnosis, education (less than high school, high school degree/GED, some college/Associate's degree, Bachelor's degree or higher), income (less than $10,000, $10,000-19,999, $20,000 or more), religious denomination (Catholic, Protestant, Other religion, No religion), importance of religion or spirituality in life (very important, not very important), and race/ethnicity (African American, European American, Latino, Other). The "Other" race/ethnicity category comprised men who endorsed the following categories: American Indian, Asian/Pacific Islander, Alaskan Native, Mixed heritage/race, Other, or Unknown. Regarding sexual orientation, participants indicated whether they considered themselves to be "gay/queer/homosexual," "straight/heterosexual," "bisexual," or "questioning/unsure."

Sexual Attitudes

Internalized Homophobia. A five-item scale ranging from 1 = "strongly disagree" to 5 = "strongly agree" assessed internalized homophobia. This scale was adapted from Ross and Rosser's (1996) measure. Responses were averaged across the five items, with higher values signifying stronger internalized homophobia. Example items are "I wish I was not attracted to men" and "I am extremely comfortable with being very open about my sexual relationships with men" (reverse coded). Cronbach's α for this subscale in our sample was .78.

Sexual Sensation-seeking. Participants completed five items of the Sexual Sensation Seeking Scale (Kalichman et al, 1994; Kalichman & Rompa, 1995). These items were rated on a four-point scale ranging from "not at all like me" to "very much like me." Responses were averaged across the five items with higher values signifying stronger sexual sensation-seeking. Example items are "I like to have new and exciting sexual experiences and sensations" and "I feel like exploring my sexuality." Cronbach's α for this subscale in our sample was .83.

Sexual Compulsivity. Participants completed a version of the Sexual Compulsivity Scale (Kalichman et al., 1994; Kalichman, Greenberg, & Abel, 1997; Kalichman & Rompa, 1995). Four items that loaded most heavily on this scale (see Hart, Wolitski, Purcell, Gomez, & Halkitis, 2003) were rated on a four-point scale ranging from "not at all like me" to "very much like me." Example items are "My desires to have sex have disrupted my daily life" and "I think about sex more than I would like." Responses to the four items were averaged to create an overall sexual compulsivity measure. Cronbach's α for the subscale in our sample was .87.

Self-efficacy to Disclose HIV Status to Sex Partners. A six-item scale to assess self-efficacy to disclose HIV-positive status to potential sex partners in various situations was developed for the study. Participants indicated how sure they were that they could disclose their HIV status before having sex on a five-point scale from "Absolutely sure I CAN NOT" to "Absolutely sure I CAN." Scale scores were the average of these ratings. Sample items are "I can disclose my HIV status before having sex even to: -- a really hot new sex partner; -- a sex partner who wouldn't have sex with me if he knew." Coefficient α for this scale was .89.

Alcohol Use Before or During Sex

Men were also asked how often they had any wine, beer, or liquor to drink before or during sex during the last three months (never, almost never, sometimes, most of the time, every time). This measure was recoded into a dichotomous variable (never/almost never or at least sometimes).

Sexual Behavior

Men were asked about their sexual activities with both men and women. With regard to sexual activities with women, men indicated whether their primary partner was male or female (if they reported having a main partner), whether they had sex with a woman in the past year, number of women they had sex with in past year, and any unprotected vaginal/anal or unprotected insertive oral sex with a woman in the past year. Regarding sexual activities with men, men indicated the number of men they had sex with in past 90 days, and any unprotected sex with HIV negative/HIV unknown status man in past 90 days (receptive oral sex, insertive oral sex, receptive anal sex, and insertive oral sex).

Openness About Sexual Orientation

Openness about sexual orientation was measured with two sets of items: community participation and comfort level discussing sexual relationships with men. Men indicated whether they had participated in different gay community activities and experiences (18 items; yes/no). We developed two scales from a subset of these items. The first scale was participation in gay community activities, scored from 0 to 6 (attended gay pride parade or festival, read a gay newspaper, belonged to a gay club/professional group/community organization, took part in the house/ball/court systems, went to a gay bar or nightclub, worked out at a gay gym). The second scale was experience with HIV/AIDS-related activities, scored from 0 to 4 (read an HIV-related publication or newsletter, attended a safer-sex workshop, went to an HIV/AIDS support group, attended a workshop or community forum about HIV-related issues). The total number of items endorsed in each category was the score.

Comfort level for talking to different people about their sexual relationships with men was measured with seven items, each on a five-point scale ranging from 1 = "very uncomfortable" to 5 = "very comfortable." Items were: comfort level talking to mother, father, brothers and sisters, other relatives, close friends, acquaintances/co-workers/fellow students, and health care providers. Cronbach's α for this subscale in our sample was .77.

Data Analyses

Data were analyzed using the Statistical Package for the Social Sciences (SPSS) 12 for Windows. Three general types of data analyses were performed. One-way analyses of variance were conducted to compare the means of quantitative dependent variables across racial/ethnic groups. Where significant differences were observed, Tukey's honestly significant difference test was performed to make post-hoc pairwise comparisons and determine the source of the significant findings. Second, chi-square tests were used to test associations across groups for different categorical variables. Where significant associations were observed, we conducted pairwise tests of association to determine which specific groups differed significantly from one another. Finally, logistic regression analyses were conducted to identify factors that might be independently associated with having sex with a woman in the previous year. Univariate logistic regression was conducted to examine associations between the socio-demographic and psychosocial measures significantly associated with race/ethnicity and the outcome variable. All variables significant at P ≤ .10 in the univariate regression analysis were entered into a multivariate logistic regression analysis. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for both regression models. The following variables were recoded as dichotomous variables: education (bachelor's degree or higher, no bachelor's degree), religion (affiliated with a religious denomination, no denomination), and race (one variable was created to represent African American versus non-African American; a second variable was created to represent Latino versus non-Latino). Sexual orientation is not included in the regression analyses because of its high collinearity with the outcome measure.

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