The associations of binge alcohol use with HIV/STI risk and diagnosis among heterosexual African American men
Introduction
Recent data from the United States (US) Centers for Disease Control and Prevention document that new HIV infections in the US are 40% greater than originally thought (56,300 new infections per year), and African Americans, though only 13% of the US population, account for 45% of these new infections (Hall et al., 2008, Centers for Disease Control and Prevention, 2008). Although African American MSMs remain the population at greatest risk for HIV/AIDS (Hall et al., 2008), 22% of HIV-infected African American males acquired the virus via heterosexual transmission (Centers for Disease Control and Prevention, 2008). Notably, 66% of US men who acquired HIV heterosexually are African American (Centers for Disease Control and Prevention, 2007). High rates of heterosexual HIV in this population are likely linked to their disproportionate representation in US STI cases (Centers for Disease Control and Prevention, 2006); STI-infected men (and women) are at heightened risk for acquiring HIV (Freeman et al., 2006, Fleming and Wasserheit, 1999, Cohen, 1998). Condom use has been identified as the most effective means of preventing HIV and some STIs among those who are sexually active, and as such, is recommended broadly to reduce HIV/STI risk across populations (Sangani et al., 2004). However, condom use is actually greater among African American compared with White males (Eaton et al., 2006), and racial/ethnic disparities in HIV/STI persist (Centers for Disease Control and Prevention, 2006, Centers for Disease Control and Prevention, 2007, Centers for Disease Control and Prevention, 2008). Other factors must be explored to understand what propels the HIV/STI epidemics in African American communities despite higher rates of condom use.
Both binge alcohol and illicit drug use have been identified as risk factors associated with HIV/STI diagnosis among with heterosexual African American males; notably, unprotected sex appears not to be associated with HIV/STI diagnosis in this population (Adimora et al., 2006a, Adimora et al., 2006b, Raj et al., 2008). Such findings may best be explained by other risky sexual practices linked with substance use. In terms of illicit drug use, a number of studies indicate that such use, particularly crack/cocaine use, increases African American males’ involvement in concurrent and multiple sex partnering as well as sex trade, risky sexual behaviors which are in turn associated with HIV/STI (Adimora et al., 2001, Adimora et al., 2003, Adimora et al., 2004, Adimora et al., 2006a, Adimora et al., 2006b, Adimora and Schoenbach, 2002, Adimora and Schoenbach, 2005, Braithwaite and Stephens, 2005, Essien et al., 2005, Jones, 1997, Lane et al., 2004a, Lane et al., 2004b, Whitehead, 1997). Those engaging in heavier illicit drug use appear additionally to be more likely to engage in unprotected sex (Braithwaite and Stephens, 2005, Raj et al., 2007, Rasch et al., 2000).
These risky sexual behaviors, and the illicit drug use related to them, are more common among African American men contending with social marginalization (i.e., poverty, homelessness) and a history of incarceration (Adimora et al., 2001, Adimora et al., 2003, Adimora et al., 2004, Adimora et al., 2006a, Adimora et al., 2006b, Adimora and Schoenbach, 2002, Adimora and Schoenbach, 2005, Cooke, 2004, Essien et al., 2005, Jones, 1997, Lane et al., 2004a, Lane et al., 2004b, Whitehead, 1997). Overall, these findings indicate that unprotected sex in isolation is not propelling the HIV epidemic among heterosexual African American men. However, among those men engaging in illicit drug use, unprotected sex does occur, and it occurs in the context of multiple partnering and sex trade involvement and within a climate of social risk. Hence, even if fewer unprotected sex episodes occur, exposure opportunities are greater for these more socially vulnerable men contending with illicit drug use.
The above findings provide important insight into the impact of illicit drug use on HIV/STI risk heterosexual African American men. However, such research on the role of binge alcohol use in this population is more limited. Alcohol use may be heightening risk for HIV/STI among heterosexual African American men by impeding their condom use at sexual incidents, however, it could also, like illicit drug use, be a marker or a risk factor for other risky sexual behaviors, such as multiple partnering and sex trade involvement (Collins et al., 2005, Corte and Sommers, 2005, Maisto et al., 2004). Research directly assessing associations between alcohol use and HIV/STI risks among exclusively or predominantly heterosexual samples of African American males has been limited to substance using or prison populations and reveals mixed findings. Alcohol was associated with multiple partnering and unprotected sex among African American crack users (Rasch et al., 2000), but not among detoxification patients (Raj et al., 2007) or incarcerated males (Braithwaite and Stephens, 2005). Research is needed to needed to explore these issues with a more generalizable samples of heterosexually at risk African American males, e.g., those not exclusively substance using or currently incarcerated. The purpose of this study is to assess associations between binge alcohol use and risky sex practices, as well as HIV/STI diagnosis, among heterosexually at risk African American men (i.e., men reporting multiple female sex partners), recruited from primary and urgent clinical care.
Section snippets
Study population
Study participants were from the Black and African American Men's Health Study (BAAMH), a cross-sectional study of black/African American adult men at sexual risk for HIV acquisition and/or transmission (n = 703). Participants were recruited from primary care and urgent care clinics within community health centers and a large teaching hospital; all recruitment sites were located in the Roxbury, Dorchester, and South End neighborhoods in Boston, Massachusetts; these neighborhoods have higher
Sample characteristics
The majority of participants were unemployed (61%), and 23% were homeless (see Table 1). The majority (73%) reported current involvement in a steady relationship with a main partner, 88% of these had been in this relationship for 6 months or more, 40% had been in the relationship for 3 or more years.
Risky sexual behaviors and HIV/STI diagnosis history
In this sample of men reporting two or more female sex partners in the past year, 45% (n = 279) reported six or more female sex partners in the past year. (Note: Subsample sizes will be provided in
Discussion
Findings from the current study with heterosexually at risk African American men recruited from urban primary and urgent clinic care demonstrate that one-third of these men have engaged in binge alcohol use within the past 30 days; this is a higher level of binge alcohol use than that seen in population-based national data with African American men (34% vs. 19%) (Substance Abuse and Mental Health Services Administration, 2007). Study results additionally document that such behaviors are
Role of funding source
This project was funded under a grant from the Centers for Disease Control and Prevention (CDC) (grant number: CCU123364). Dr. Stephen A. Flores, CDC project officer on this study was involved with the development of this paper and is included as an author on the paper. However, the findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
Contributors
Drs. Raj, Welles, Horsburgh and Flores were involved in the study design and protocol development for this project. Drs. Raj, Reed, Silverman and Walley conducted the literature review for the development of this paper. Drs. Raj, Reed, Silverman and Welles were involved in development of the analysis plan for the paper, and Drs. Raj and Reed conducted all data analyses. Ms. Santana assisted in the writing of this paper and oversaw all aspects of project implementation in the field. All authors
Conflict of interest
There are no actual or potential conflicts of interest for any authors of this study.
Acknowledgements
We would like to thank the following organizations and agencies for housing and consulting on our study: Multicultural AIDS Coalition, Whittier Street Health Center, DOTWELL: Codman Square and Dorchester House Community Health Services, and Boston Medical Center's Urgent Care Clinic. We would also like to thank Dumas Lafontant and C. Robert Horsburgh, as well as our CDC Project Officers Stephen Flores and Lisa Fitzpatrick, for their support and guidance on this project.
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