Pamina M. Gorbach

Do people really know their sex partners? Concurrency, knowledge of partner behavior, and sexually transmitted infections within partnerships

Background and Objective: An individual’s risk of sexually transmitted infections (STIs) has been associated empirically with the individual having concurrent sexual partners (individual’s concurrency) and, theoretically, with the individual’s partner having concurrent partners (partner’s concurrency). Goals: The goals of this study were to assess the relationship of STI to individual’s concurrency, the partner’s concurrency, and awareness of the partner’s concurrency. Study Design: We recruited 192 individuals aged 18 to 30 from sexually transmitted disease and family planning clinics in 96 partner dyads that reported first sexual contact during the previous 3 months. All individuals underwent computer interviews and testing for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Individuals’ self-reports of concurrency and perceptions of partners’ concurrency were compared within dyads by kappa statistic; associations of STI with individual’s concurrency, partner’s concurrency, and knowledge of partner’s concurrency were examined using chi-squared analysis, t tests, and multivariate logistic regression. Results: Only 26% of individuals whose partners had other partners were aware of this (kappa = 0.17 for agreement of perceptions vs. partners’ reports of concurrency). In multivariate models, STI in individuals was independently associated with partners’ concurrency (odds ratio [OR], 3.6), lack of awareness of partner’s concurrency (OR, 4.5), perceiving a partner to have concurrent partners when the partner did not (OR, 4.7), living in south San Diego, and sexual contact within 1 week of acquaintance, but not with individuals’ concurrency. Conclusion: This study demonstrates that STI is associated with partner’s concurrency and with not knowing one’s partner’s behavior.

It takes a village: understanding concurrent sexual partnerships in Seattle, Washington.

Background Sexually transmitted infections (STIs) are efficiently spread via concurrent partnerships. Goal This study identifies patterns of concurrency in Seattle STI clinics and community samples to enhance partner notification and counseling. Study Design Semistructured interviews with heterosexuals (108 with gonorrhea, chlamydial infection, or nongonococcal urethritis and 120 from high STI prevalence and randomly selected neighborhoods) were tape-recorded, transcribed, and analyzed for content. Results Six main forms of concurrency were identified: experimental, separational, transitional, reciprocal, reactive, and compensatory. Experimental concurrency, overlapping short-term partnerships, was most common. Men practiced concurrency to avoid becoming partnerless during partnership disintegration; more women, especially STI patients, reported reactive concurrency, recruiting new partners rather than leaving partners with other partners. Concurrency clustered by age and when occurring during separation and transitioning between partners was socially acceptable. Conclusions Prevalence of concurrent partnerships in all groups studied suggests linkages to individuals’ life stage and some social acceptability. STI programs should develop prevention messages to reflect different forms of concurrency.

Unprotected anal intercourse and substance use among men who have sex with men with recent HIV infection.

Objectives:To examine within-subjects and combined between- and within-subjects associations between substance use and unprotected anal intercourse (UAI) among men who have sex with men (MSM) with recent HIV infection. Methods:One hundred ninety-four MSM who were recently infected with HIV completed a computer-assisted questionnaire regarding sexual behaviors and substance use with their last 3 partners. Associations between UAI and substance use were assessed using conditional logistic regression (CLR) to assess associations among the 116 MSM reporting UAI with some but not all partners and generalized linear mixed effects models (GLMMs) to examine a combination of within- and between-subjects associations in the entire sample (N = 194). Results:In multivariate CLR models and GLMMs, UAI was associated with the use of methamphetamine (odds ratio [OR] = 4.9 and OR = 3.5, respectively), marijuana (OR = 4.0 and OR = 2.2, respectively) and erectile dysfunction medications (EDMs) when used with a main partner (OR = 13.8 and OR = 10.1, respectively). Conclusions:Results indicate that a direct association may exist between specific substances and UAI and provide evidence that the use of methamphetamine and EDMs may contribute to HIV transmission.

Discord, Discordance, and Concurrency: Comparing Individual and Partnership-Level Analyses of New Partnerships of Young Adults at Risk of Sexually Transmitted Infections

Background and Objectives: Partnerships that are discordant by demographic and behavioral characteristics or are concurrent may facilitate transmission of sexually transmitted infections (STIs) by bridging sexual networks. Goal: The goal of this study was to examine if STI risk within partnerships is associated with discordance and concurrency using the partnership as the unit of analysis. Study: One hundred ninety-two individuals, in 96 new partnerships, recruited from sexually transmitted disease and family planning clinics, underwent a computer-assisted interview; were tested for chlamydia, gonorrhea, and trichomonas; and their medical records were reviewed. Partnership variables for discordance by ethnicity, education level, number of lifetime partners, and relationship commitment, as well as concurrency and consistent condom use were tested for associations with partnership STI by chi-squared analysis and logistic regression. Associations between individual level STI, individual characteristics, relationship commitment, and concurrency were tested in bivariate and multivariate models. Results: STI was detected in 22% of partnerships; discordance for demographics or relationship commitment was reported in 40% to 50%; and partner concurrency in 26%. Few partnerships (18%) reported consistent condom use in the prior month. In multivariate analyses, partnership-level STI was associated with discordance by ethnicity (odds ratio [OR], 3.4; P = 0.04), commitment (OR, 4.2; P = 0.02), number of lifetime partners (OR, 4.9; P = 0.01), and concurrency (OR, 3.8; P = 0.03). Individual-level STI was associated with the individual’s concurrency and Hispanic ethnicity. Conclusions: Discordance and concurrency are associated with STI at the partnership level and may reflect bridging between high- and low-risk STI networks. Partnership factors allowed additional assessment of STI risk over individual factors, suggesting that data on partnerships may identify individuals linked to risky networks.

Don’t ask, don’t tell: patterns of HIV disclosure among HIV positive men who have sex with men with recent STI practising high risk behaviour in Los Angeles and Seattle

Objectives: A high incidence of HIV continues among men who have sex with men (MSM) in industrialised nations and research indicates many MSM do not disclose their HIV status to sex partners. Themes as to why MSM attending sexually transmitted infection (STI) clinics in Los Angeles and Seattle do and do not disclose their HIV status are identified. Methods: 55 HIV positive MSM (24 in Seattle, 31 in Los Angeles) reporting recent STI or unprotected anal intercourse with a serostatus negative or unknown partner from STI clinics underwent in-depth interviews about their disclosure practices that were tape recorded, transcribed verbatim, coded, and content analysed. Results: HIV disclosure themes fell into a continuum from unlikely to likely. Themes for “unlikely to disclose” were HIV is “nobody’s business,” being in denial, having a low viral load, fear of rejection, “it’s just sex,” using drugs, and sex in public places. Themes for “possible disclosure” were type of sex practised and partners asking/disclosing first. Themes for “likely to disclose” were feelings for partner, feeling responsible for partner’s health, and fearing arrest. Many reported non-verbal disclosure methods. Some thought partners should ask for HIV status; many assumed if not asked then their partner must be positive. Conclusions: HIV positive MSM’s decision to disclose their HIV status to sex partners is complex, and is influenced by a sense of responsibility to partners, acceptance of being HIV positive, the perceived transmission risk, and the context and meaning of sex. Efforts to promote disclosure will need to address these complex issues.

Behaviors of recently HIV-infected men who have sex with men in the year postdiagnosis: effects of drug use and partner types.

Objectives:Assess behavior change of recently HIV-infected men who have sex with men (MSM). Methods:From 2002 to 2006, 193 recently HIV-infected MSM in the Southern California Acute Infection and Early Disease Research Program were interviewed every 3 months. Changes in HIV status of partners, recent unprotected anal intercourse (UAI), drug use, use of antiretroviral therapy (ART), detectable viral load, and partnership dynamics over 1 year were used to predict recent UAI in a random effect logistic regression. Results:Over a year significantly fewer partners in the past 3 months were reported (mean 8.81 to 5.84; P < 0.0001). Percentage of recent UAI with HIV-status unknown last partners decreased from enrollment to 9 months (49%-27%) and rebounded at 12 months to 71%. In multivariable models controlling for ART use, recent UAI was significantly associated with: baseline methamphetamine use [adjusted odds ratio (AOR): 7.65, 95% confidence interval (CI): 1.87 to 31.30], methamphetamine use at follow-up (AOR: 14.4, 95% CI: 2.02 to 103.0), HIV-uninfected partner at follow-up (AOR: 0.14, 95% CI: 0.06 to 0.33), and partners with unknown HIV status at follow-up (AOR: 0.33, 95% CI: 0.11 to 0.94). HIV viral load did not influence rate of UAI. Conclusions:Transmission behaviors of these recently HIV-infected MSM decreased and serosorting increased after diagnosis; recent UAI with serostatus unknown or negative partners rebounded after 9 months, identifying critical timepoints for interventions targeting recently HIV-infected individuals. There was no evidence in this cohort that the viral load of these recently infected men guided their decisions about protected or unprotected anal intercourse.

Anal intercourse among young heterosexuals in three sexually transmitted disease clinics in the United States.

Objective: To examine factors associated with heterosexual anal intercourse (AI). Methods: Between 2001 and 2004, 1084 heterosexual adults aged 18 to 26 attending public sexually transmitted disease clinics in Seattle, New Orleans, and St Louis were interviewed using computer-assisted self interview and tested for STIs; Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, Trichomonas vaginalis, and genital herpes (HSV-2). Characteristics associated with AI were identified using logistic regression. Results: Overall 400 (37%) reported ever having had AI, 266 (28.9%) reported AI with at least 1 of their last 3 partners, and 19% reported AI with their last partner. Fewer women than men reported condom use at last AI (26% vs. 45%, P <0.001). Ever having AI was associated with sex on the same day as meeting a partner [AOR 3.9 (95% CI, 2.46–6.21)], receiving money for sex [AOR 2.8 (1.40–5.45)], and >3 lifetime sex partners [AOR 2.8 (1.56–5.07)] among women, and sex on the same day as meeting a partner [AOR 2.0 (1.33–3.06]) among men. AI with the last partner was associated with sex toy use [AOR 5.6 (2.63–12.0)] and having concurrent partners [AOR 2.2 (1.21–4.11)] among men, and with sex within a week of meeting [AOR 2.4 (1.28–4.37)], believing the partner was concurrent (AOR 1.9 [1.12–3.22]), and sex toy use [AOR 5.7 (2.31–14.0)] among women. Prevalent vaginal and urethral sexually transmitted infections were not associated with AI. Conclusions: Many young heterosexuals attending sexually transmitted disease clinics reported AI, which was associated with other sexual risk behaviors, suggesting a confluence of risks for HIV infection.

Sexual bridging by Cambodian men: potential importance for general population spread of STD and HIV epidemics.

Background: Linkages between sexual networks influence STD and HIV epidemics. Goal: This study quantifies male sexual “bridging” and associated factors in Cambodias 1997 behavioral surveillance survey. Study Design: Among persons randomly selected from clusters of military, police, and motorcycle taxidrivers in five cities, associations between individual characteristics, behaviors, social context, and “active bridging” were tested using logistic regression analyses. Results: The authors defined 20.5%, 15.7%, and 14.7% of military, police, and motorcycle taxidrivers as active bridgers (men who have unprotected sex with high and low risk partners). Among the military and police, logistic regression revealed that age (odds ratio [OR], 1.05), age of first sexual intercourse (OR, 0.89), having friends who frequent sex workers (OR, 3.31), and residence in the port city (OR, 3.34) were associated with active bridging. Among motorcycle taxidrivers, residence in the border city (OR, 2.23) or the port city (OR, 2.84) was associated with active bridging. Sexually transmitted disease symptoms during the past year were significantly associated with active bridging. Conclusions: Social characteristics influence sexual bridging more than individual ones. The pervasiveness of bridging and the association with sexually transmitted disease symptoms underscore the potential of men who are active bridgers to spread sexually transmitted disease and HIV in Cambodia beyond high‐risk groups.

Transmission behaviors of recently HIV-infected men who have sex with men

Objectives: Analyze postdiagnosis behaviors of recently HIV-infected men who have sex with men (MSM). Methods: Recently HIV-infected MSM were interviewed at 6 weeks (n = 153) and 3 months (n = 113) after diagnosis. Behaviors from baseline to follow-up were compared; multivariate logistic regression identified associations between baseline characteristics and behavior at follow-up. Results: At follow-up, MSM reported a significantly lower mean of partners (7.9 vs. 5.2) and lower means of 1-time (1.9 vs. 0.8), unknown (3.7 vs. 2.6), and acquaintance (1.1 vs. 0.5) partners than at baseline. In multivariate analyses, unprotected anal intercourse (UAI) with the last partner at follow-up was more likely if the last partner at baseline was a main partner (odds ratio [OR] = 2.94, 95% confidence interval [CI]: 1.04 to 8.33) or HIV-positive partner (OR = 3.36, 95% CI: 1.27 to 8.88) but less likely if, at follow-up, the last partner was HIV-negative (OR = 0.28, 95% CI: 0.08 to 1.00) or of unknown HIV status (OR = 0.23, 95% CI: 0.08 to 0.71), the participant had a history of nonconsensual sex (OR = 0.25, 95% CI: 0.09 to 0.72), or the participant had more than 1 partner (OR = 0.28, 95% CI: 0.09 to 0.86). More than 1 partner at follow-up was associated with no main partner at baseline or follow-up (OR = 2.76, 95% CI: 1.12 to 6.78), more partners in the last 12 months (OR = 1.02, 95% CI: 1.01 to 1.04), and UAI with the last partner (OR = 0.36, 95% CI: 0.14 to 0.90). Conclusions: After diagnosis, some but not all recently HIV-infected MSM reduced risky sexual behavior permitting potential HIV transmission.

Measuring Sex Partner Concurrency: It's What's Missing That Counts

Background: Sex partner concurrency is an important determinant of STI transmission dynamics, yet its measurement is not standardized. Goal: We assessed the agreement, compared correlates, and investigated data quality and completeness between 2 common concurrency measures. Study Design: Young adults (ages 18–26) attending public STD clinics between 2001 and 2004 in Seattle, St. Louis, and New Orleans, provided data on 2 or more sex partners in a computer-administered survey interview (N = 680). Concurrency with last partner was measured in 2 ways: (a) a direct question about other sexual contacts during the most recent sexual relationship and (b) overlapping start and end dates of the 2 most recent relationships. Results: Although 56% reported concurrency by direct questioning and 54% by overlapping dates, the &kgr; statistic for agreement between measures was only fair (0.395). Indeed, 29% of those reporting concurrent partners by the direct question did not do so by overlapping dates and 26% of participants concurrent by overlapping dates were not concurrent by the direct question. Each of the measures had dissimilar correlates, and concurrency data were missing or uninterpretable more often for the overlapping dates measure (21.3%) than the direct question (1.8%). Conclusions: Concurrency was common by both measures but the measures were not interchangeable. Although the overlapping dates measure provided information about partnership duration, it is subject to missing or uninterpretable data. The direct question substantially minimized the amount of missing data and may be more appropriate for use with computer-administered survey interview.