Black men who have sex with men (MSM) bear a disproportionate burden of the U.S. HIV/AIDS epidemic compared with MSM of other racial/ethnic groups,(Centers for Disease Control and Prevention, 2001, 2007, 2009; Hall et al., 2008; HIV incidence among young men who have sex with men--seven U.S. cities, 1994–2000," 2001; G. A. Millett, Flores, Peterson, & Bakeman, 2007; Subpopulation estimates from the HIV incidence surveillance system--United States, 2006," 2008) comprising 35% of new HIV infections among MSM.("Subpopulation estimates from the HIV incidence surveillance system--United States, 2006," 2008) Among MSM, blacks are more likely to have female sex partners than MSM of other races and ethnicities.(Adimora & Fullilove, 2006; Gorbach, Murphy, Weiss, Hucks-Ortiz, & Shoptaw, 2009; Maulsby, Sifakis, German, Flynn, & Holtgrave, 2011; G. Millett, Malebranche, Mason, & Spikes, 2005; Montgomery, Mokotoff, Gentry, & Blair, 2003; Young, Shoptaw, Weiss, Munjas, & Gorbach, 2011), and black men who have sex with men and women (MSMW) are more likely to have unprotected anal or vaginal sex with women compared with white MSMW.(McKirnan, Stokes, Doll, & al., 1995) In a study in Los Angeles of predominantly black and Latino HIV-infected MSM and MSMW, being black compared with being white and being MSMW compared with being MSM was associated with unrecognized HIV infection.(Young et al., 2011) However, the impact of HIV transmission from black MSMW to their female partners remains uncertain.(Adimora & Fullilove, 2006; Gorbach et al., 2009; Malebranche, Arriola, Jenkins, Dauria, & Patel; Mays, Cochran, & Zamudio, 2004; Mutchler et al., 2008; Siegel, Schrimshaw, Lekas, & Parsons, 2008) Several studies have noted that black MSMW have higher risk behaviors, including more sexual partners and lower rates of condom use, and higher HIV infection rates compared with black men who only have sex with men (MSMO) and with heterosexual men.(Brooks, Rotheram-Borus, Bing, Ayala, & Henry, 2003; Dodge, Jeffries, & Sandfort, 2008; Lehner & Chiasson, 1998; Myers, Javanbakht, Martinez, & Obediah, 2003) More data on black MSMW and HIV transmission risk of HIV-infected black MSMW to both their male and female partners are needed to inform development of HIV prevention interventions tailored specifically to black MSMW and their sexual partners,(Brooks et al., 2003; Dodge et al., 2008) consistent with the U.S. National HIV/AIDS Prevention Strategy’s emphasis on prevention interventions focusing on black MSM and black women.(Maulsby et al., 2011)

The primary objectives of this study were to compare sociodemographic and risk behavior characteristics between black MSMW and men who have sex with men only (MSMO), and to evaluate factors associated with any unprotected vaginal and/or anal intercourse (UVAI) with female partners in the last 3 months among black MSMW. This analysis was based on baseline data from DiSH, a behavioral intervention study in New York City (NYC) to reduce behaviors associated with HIV acquisition and transmission among black MSM.

In this analysis of baseline data of 326 HIV-infected and uninfected black MSM in NYC, more than a quarter reported having sex with both men and women in the last 3 months, with the remainder reporting having sex with men only during this time period. Several key differences were noted between black MSMW and MSMO in our sample. MSMW were less likely to be HIV-infected, report recent use of amyl nitrates, and have unprotected receptive anal sex with most recent male partner than MSMO. MSMW were more likely to be >40 years old and report recent heroin use. Previously published studies have documented sociodemographic and risk behavior differences between MSMW and MSM, some of which mirror our study findings.(Brooks et al., 2003; Gorbach et al., 2009; Lehner & Chiasson, 1998; Maulsby et al., 2011; G. Millett et al., 2005; Wheeler, Lauby, Liu, Van Sluytman, & Murrill, 2008; Zule, Bobashev, Wechsberg, Costenbader, & Coomes, 2009) For example, in a Los Angeles study using respondent-driven sampling, in which 52.8% of the sample were black, MSMW were found to be older and less likely to be HIV infected compared with MSMO. However, in contrast to our findings, MSMW in that study were more likely to recently use cocaine and less likely to recently use opiates/heroin and amphetamines/methamphetamines compared with MSMO.(Gorbach et al., 2009) A study of black MSMO and MSMW in NYC and Philadelphia found that, among other differences, MSMW were older and more likely to use illicit drugs or drink alcohol in the last 3 months compared with MSMO.(Wheeler et al., 2008) Our study did not detect any difference in total number of male sex partners in the last 3 months between MSMW and MSMO, which is similar to a finding noted in a study of black HIV-infected men.(G. Millett et al., 2005)

Our study found that over half of black MSMW (55.6%) reported having at least some UVAI with female partners in the last 3 months, with 75% of these men reporting UAI with a male partner during last sex and 40% being HIV-infected. These rates of unprotected sex are slightly higher than previous reports.("HlV/STD risks in young men who have sex with men who do not disclose their sexual orientation--six U.S. cities, 1994–2000," 2003; McKirnan et al., 1995; Siegel et al., 2008) In a study among black and white MSMW in Chicago, 42% of the men reported having any UVAI with women in the last 6 months compared with 31% of the men reporting any unprotected insertive or receptive anal sex with men.(McKirnan et al., 1995) Although black MSMW in that study were not more likely to have any UAI with male partners compared with white men, they were more likely to have any UVAI with women than white MSMW. Black MSMW were also more likely to have unprotected penetrative sex with both men and women in the last 6 months compared with white MSMW in that study.(McKirnan et al., 1995)

It is encouraging that MSMW who reported having any UVAI with their female partners in our study were less likely to be HIV-positive; however, their risky sexual risk behavior (as evidenced by the higher number of male sex partners) places them at risk for new HIV infection if they engage in unprotected anal sex and possible HIV transmission to their female and male partners. Several studies have found that increased rates of HIV and other STIs among female partners of black MSMW were associated with the men’s lack of disclosure of their bisexuality.(Dodge et al., 2008; Montgomery et al., 2003) In contrast, among black MSM aged 15–29 years in the Young Men’s Survey, HIV prevalence was higher among men who disclosed compared with men who did not disclose their sexual orientation (24% vs. 14%, respectively). Although nondisclosers were less likely to have ≥5 lifetime male partners and less likely to have UAI with men in the preceding 6 months compared with disclosers, they were more likely to report having UVAI with their female partners in the last 6 months compared with disclosers (23% vs. 7%). ("HlV/STD risks in young men who have sex with men who do not disclose their sexual orientation--six U.S. cities, 1994–2000," 2003) In our study, over 70% of MSMW reported that they had disclosed to female partners (main or non-main) that they have sex with men. This disclosure rate is higher than previously published disclosure rates of 10–30% among black MSMW.(Dodge et al., 2008) In this study, we found that black MSMW who disclosed to their female partners (either main or non-main partner) that they have sex with men were independently less likely to have any UVAI with women in the last 3 months compared with men who did not disclose. This association is consistent with several previously published reports.(Dodge et al., 2008; HlV/STD risks in young men who have sex with men who do not disclose their sexual orientation--six U.S. cities, 1994–2000," 2003) In addition, a high rate of disclosure of HIV serostatus to their female main partners (nearly 85%) was noted among MSMW in our sample who have female main partners. Our analysis was limited in that disclosure of HIV serostatus to female non-main partners among MSMW was not directly asked, but this rate is likely to be lower than the disclosure rate to female main partners. The high rates of disclosure of bisexuality to female partners (both main and non-main) and disclosure of HIV serostatus to female main partners in our study are encouraging. Additional attention should be directed towards HIV prevention efforts that target barriers to disclosure of MSM behaviors. Interventions fostering open communication about sexual history with both male and female partners are important.

The study had several limitations. There was potential selection bias related to the non-random sample, which might affect the generalizability of our findings to all black MSMO and MSMW in NYC. This study recruited sexually active MSM having unprotected sex with male partners in the past 3 months. Our findings might not be applicable to less sexually active and risky black MSMO and MSMW populations in NYC and other urban areas. The study had a relatively small sample of MSMW and even a smaller sample of MSMW who reported having any UVAI with female partners in the last 3 months, which reduced statistical power, yet we found several significant associations. Because sociodemographic and risk behavior data were obtained by self-report, there was a potential for recall bias and socially desirable responding, though these problems were likely mitigated by the 3-month recall period and ACASI use.

Our study findings highlight key differences in sociodemographic and risk behavior characteristics between black MSMW and MSMO and support some tailoring of HIV prevention interventions to MSMW to reduce risk of HIV transmission to both their female and male partners.(G. Millett et al., 2005) Although the rate of disclosure of bisexuality among black MSMW to their female partners was relatively high in our sample, it is important that black MSMW be encouraged to disclose their bisexuality so that their female partners are fully knowledgeable about their HIV acquisition risk and take appropriate precautions to reduce their risk.