Victor J. Schoenbach

Social Context, Sexual Networks, and Racial Disparities in Rates of Sexually Transmitted Infections

BACKGROUND Social context (demographic, socioeconomic, macroeconomic, and sociopolitical features of the environment) influences the epidemiology and consequences of individual behaviors that affect health outcomes. This article examines the role of social context in heterosexual networks that facilitate the spread of human immunodeficiency virus (HIV) infection and other sexually transmitted infections (STIs), particularly in relation to persistent racial disparities in rates of STIs in the United States. METHODS Review of the medical, public health, and social science literature. RESULTS Contextual factors, such as poverty, discrimination, epidemiology of illicit drug use in the community, ratio of men to women, incarceration rates, and racial segregation, influence sexual behavior and sexual networks directly and indirectly through a variety of mechanisms. Disparities in these contextual features likely contribute substantially to the persistence of marked racial disparities in rates of STIs. CONCLUSIONS Given the importance of contextual factors and the sharply contrasting social contexts for blacks and whites, exclusive emphasis on individual risk factors and determinants is unlikely to produce solutions that will significantly decrease HIV rates among blacks. Effective HIV prevention in this population will require multidisciplinary research to address the contextual factors that promote patterns of sexual networks that facilitate transmission of STIs.

Self-Help Quit Smoking Interventions: Effects of Self-Help Materials, Social Support Instructions, and Telephone Counseling.

Smokers requesting self-help materials for smoking cessation (N = 2,021) were randomized to receive (a) an experimental self-quitting guide emphasizing nicotine fading and other nonaversive behavioral strategies, (b) the same self-quitting guide with a support guide for the quitters family and friends, (c) self-quitting and support guides along with four brief counselor calls, or (d) a control guide providing motivational and quit tips and referral to locally available guides and programs. Subjects were predominantly moderate to heavy smokers with a history of multiple previous quit attempts and treatments. Control subjects achieved quit rates similar to those of smokers using the experimental quitting guide, with fewer behavioral prequitting strategies and more outside treatments. Social support guides had no effect on perceived support for quitting or on 8- and 16-month quit rates. Telephone counseling increased adherence to the quitting protocol and quit rates.

Concurrent Sexual Partnerships Among Men in the United States

OBJECTIVES We sought to determine the prevalence, distribution, and correlates of US mens involvement in concurrent sexual partnerships, a sexual network pattern that speeds population dissemination of HIV. METHODS For this analysis, we compared sexual partnership dates of 4928 male respondents in the 2002 National Survey of Family Growth to determine the prevalence of concurrent sexual partnerships and evaluated associations between concurrency and demographic risk characteristics. RESULTS Approximately 11% of men had concurrent sexual partnerships during the preceding year. Concurrency was associated with being unmarried (odds ratio [OR] = 4.59; 95% confidence interval [CI] = 2.54, 8.29), non-Hispanic Black (OR=2.56; 95% CI=1.61, 4.07) or Hispanic (OR=2.25; 95% CI=1.32, 3.85) race/ethnicity, and incarceration during the past year (OR=2.10; 95% CI=1.18, 3.74). Men with concurrent sexual partnerships were also more likely to report drug or alcohol intoxication during sexual intercourse (OR=2.10; 95% CI=1.37, 3.21), nonmonogamous female sexual partners (OR=6.11; 95% CI=4.10, 9.11), and history of sexual intercourse with a man (OR = 1.93; 95% CI = 1.09, 3.42), than those without concurrent partnerships. CONCLUSIONS The higher concurrency prevalence in various groups, dense sexual networks, and mixing between high-risk subpopulations and the general population may be important factors in the US epidemic of heterosexual HIV infection.

Hiv and African Americans in the Southern United States: Sexual Networks and Social Context

Background: Heterosexual HIV transmission among African Americans in the rural southern United States has climbed in recent years. Concurrent partnerships and bridge populations have emerged as key elements in the spread of sexually transmitted infections (STIs). Goal: The goal of this study was to examine published empiric data and other literature concerning the extent of these network patterns and their relationship to the socioeconomic context among African Americans in the rural South. Study Design: The authors conducted a review of public health, medical, and social sciences literature. Results: In areas of the rural South with high STI rates, there is extensive concurrency with evidence of dense sexual networks and bridging among the general population, core group members, and other high-risk subpopulations. Qualitative research reveals socioeconomic factors that support these network patterns: low ratio of men to women, economic oppression, racial discrimination, and high incarceration rates of black men. Conclusion: Concurrency and bridging likely contribute to increased heterosexual HIV transmission among blacks in the South; contextual factors promote these network patterns in this population.

Concurrent sexual partnerships among women in the United States.

Background. The marked racial disparity in sexually transmitted infection (STI) rates in the United States remains inadequately explained. One important factor may be concurrent sexual partnerships (relationships that overlap in time), which can transmit STIs more rapidly through a population than does sequential monogamy. Methods. To determine prevalence, distribution, and correlates of U.S. women’s involvement in concurrent partnerships, we analyzed sexual partnership data reported by the 10,847 women, age 15–44 years, in the 1995 National Survey of Family Growth. Overlapping sexual partnership dates were determined by computer program and visual review of the data. Results. Prevalence of concurrent partnerships since January 1991 was 12% overall. Prevalence was lowest among currently married respondents (4%) and highest among those who were formerly married (22%), never married (19%), in the lowest income stratum (17%), age 18–24 years when interviewed (23%), or who first had sexual intercourse at age 12 or 13 (35%). Prevalence was 21% among blacks, 11% among whites, 8% among Hispanics, and 6% among Asian American and Pacific Islanders. Multiple logistic analysis substantially weakened the relationship between concurrency and black race (OR = 1.2; 95% CI = 1.1–1.4). Conclusions. Marital status in particular is strongly related to concurrency; thus, lower marriage rates among blacks and the associated higher concurrency of sexual partners may contribute to racial disparities in STI rates.

Heterosexually Transmitted Hiv Infection Among African Americans in North Carolina

Context: Rates of heterosexually transmitted HIV infection among African Americans in the southeastern United States greatly exceed those for whites. Objective: Determine risk factors for heterosexually transmitted HIV infection among African Americans. Methods: Population-based case-control study of black men and women, aged 18-61 years, reported to the North Carolina state health department with a recent diagnosis of heterosexually transmitted HIV infection and age- and gender-matched controls randomly selected from the state driver s license file. A lower-risk stratum of respondents was created to identify transmission risks among people who denied high-risk behaviors. Results: Most case subjects reported annual household income <

Contextual factors and the black-white disparity in heterosexual HIV transmission.

16,000, history of sexually transmitted diseases, and high-risk behaviors, including crack cocaine use and sex partners who injected drugs or used crack cocaine. However, 27% of case subjects (and 69% of control subjects) denied high-risk sexual partners or behavior. Risk factors for HIV infection in this subset of participants were less than high school education (adjusted odds ratio [OR] 5.0; 95% CI: 2.2, 11.1), recent concern about having enough food for themselves or their family (OR 3.7; 1.5, 8.9), and having a sexual partner who was not monogamous during the relationship with the respondent (OR 2.9; 1.3, 6.4). Conclusion: Although most heterosexually transmitted HIV infection among African Americans in the South is associated with established high-risk characteristics, poverty may be an underlying determinant of these behaviors and a contributor to infection risk even in people who do not have high-risk behaviors.

Epidemiology of Depressive Symptoms in Young Adolescents

ABSTRACT African-Americans have the highest rates of human immunodeficiency virus (HIV) transmission, including heterosexual transmission, in the United States. Although numerous factors probably contribute to the extreme racial disparity, reasons for its persistence remain poorly explained. Mathematical modeling demonstrates that concurrent sexual partnerships speed transmission of HIV through sexual networks more effectively than does serial monogamy, for the same total number of sexual partners. This paper examines the evidence that the social and economic environment for many African-Americans discourages long-term monogamy and promotes concurrent sexual partnerships, which may, in turn, fuel the HIV epidemic in this population.

Social context of sexual relationships among rural African Americans.

Center for Epidemiologic Studies Depression Scales, completed by 677 junior high school students, were used to investigate the significance and measurement of depressive symptoms in young adolescents. Responses differentiated transient and more persistent symptoms. Few students noted the most persistent symptoms (less than 15% for any one item). Minority race, lower social economic status, lower school grade, family constellation, and poorer school progress were associated with higher depressive symptom scores. Findings from this study suggest that high persistent depressive symptomatology is not a universal adolescent experience and that persistent depressive symptoms may be associated with other adverse events.

Concurrent Partnerships among Rural African Americans with Recently Reported Heterosexually Transmitted HIV Infection

Background Reasons for the strikingly increased rates of HIV and other sexually transmitted infections (STIs) among African Americans in the rural Southeastern United States remain unclear. Investigators have devoted little attention to the potential influence of the social and economic context on sexual behaviors. Goal To examine the potential influence of these contextual factors on behaviors that promote the transmission of STIs. Study Design Focus group interviews in which African Americans from rural North Carolina discussed life in their communities and contextual factors affecting sexual behavior. Results Respondents reported pervasive economic and racial oppression, lack of community recreation, boredom, and resultant substance abuse. Many perceived a shortage of black men because of their higher mortality and incarceration rates compared with whites, and believed this male shortage to be partly responsible for the concurrent sexual partnerships that they perceived as widespread among unmarried persons. Conclusion Contextual features including racism, discrimination, limited employment opportunity, and resultant economic and social inequity may promote sexual patterns that transmit STIs.