Consent, power and age difference between young black gay couples may have more effect on HIV transmission than individual characteristics, US study finds

A quite large survey of young black gay and bisexual men in two Texan cities, Houston and Dallas, has found that power dynamics between gay couples may be the most important influence on the onward spread of HIV through the black gay community, rather than factors that disadvantage individuals such as youth, poverty or low education.

The study used a technique called 'Latent Profile Analysis' which looks at characteristics that tend to cluster together among a surveyed population. It related these clusters of characteristics to HIV risk. In this way it was able to generate 'profiles' of the kind of people who had particular degrees of risk of either acquiring or transmitting HIV (it surveyed both HIV-positive and HIV-negative men).

It asked two different types of questions of its participants. One set were the standard demographic questions, about age, income, education and histories of imprisonment and homelessness.

The other set looked at the men’s beliefs and relationships. It asked them to what degree they agreed that they were capable of maintaining safer sex in their relationships, that condoms were easy or difficult to use, whether HIV treatment reduced people’s infectiousness, whether they agreed that stigma against people with HIV was still severe, and so on.

Typical questions in this section included, for instance:

• “How much does pausing to put on a condom ruin the sexual mood?”
• “If a man you are having sex with starts to do something unsafe, how difficult is it for you to stop him?”
• "It is safe to have anal sex without a condom with an HIV-positive man who has an undetectable viral load?”
• "Most people are uncomfortable around someone with HIV”.

They also asked questions, which turned out to be important, about what they called “difficult sexual situations and relationships”. These tended to be situations where there was a conflict between what people wanted to do, and what they felt pressure to do. There were nine questions about difficult sexual situations, and four about difficult relationships. Among the 13 questions asked were (all concerning the last year):

• “How often have you been lonely and depressed and had sex to feel good?”
• “How often have you had sex where you or your partner was high on drugs?”
• “How often have you had sex with someone because you were afraid of losing them?”
• “How often have you been in a sexual situation with someone who asked you to trust them?”

Results

The 1808 men had an average age of 25, and were recruited at a variety of gay-frequented venues ranging from bars to parks, with respondents paid $30 for their time. One in seven (14.4%) said they had HIV. There was a wide range of both income and education in the group: while 24% earned less than $10,000 a year, the same proportion earned over $40,000 and 12% over $60,000. Fifteen per cent had failed to finish high school, but 21% were college graduates.

Twenty-one per cent were unemployed and 13% said they had run out of money at least once last year, but relatively small numbers had ever been in prison (2.6%) or homeless (0.23%).

Over the group as a whole, these young men had relatively high levels of belief they could maintain safer sex and moderate levels of perceived HIV stigma. They thought on the whole that condoms were easy to use.

However, they had remarkably low levels of awareness of 'U=U' (Undetectable equals Untransmittable) and the fact that viral suppression reduces infection risk. The authors are concerned about this. They comment, “Although HIV treatment optimism has been found to be associated with sexual risk behavior in the past, the general lack of high HIV treatment optimism…suggests that it may be an important factor to target if the goal is to engage men living with HIV…to achieve viral suppression.”

Most of the study, however, is concerned with the clustering of demographic factors, experiences and beliefs. The researchers found that the study population tended to group into four characteristic “profiles” of clusters of risk factors.

One important thing to note is that these profiles were quite independent of people’s actual HIV status. HIV-positive people could belong to any profile. Latent profile analysis simply looks at whether particular factors tend to congregate, rather than whether they are related to a particular outcome.

• Half the population clustered into a low-risk profile. These men tended to be HIV negative and relatively well educated. They had high levels of belief they could maintain safer sex and correspondingly low negative attitudes to condoms. They were less worried about HIV stigma than other groups. Interestingly, they were the group least likely to agree with U=U messages.
• A quarter of the respondents clustered into a medium-risk profile. HIV-positive men were more likely to be in this group than any other. They had rather lower levels of belief that they could maintain safer sex, and were twice as likely to have negative attitudes towards condoms than men in the low-risk profile. They were somewhat more likely to believe in U=U messages and were nearly twice as likely to have been in difficult sexual situations than men in the low-risk profile. They were slightly younger, on average, than men in other profiles – the only one where age, in itself, made a difference.
• Just 5% of the men clustered into what the researchers considered to be the high-risk profile. These men were also more likely than average to have HIV and were the only group really significantly more likely to experience poverty. They had the lowest levels of confidence about safer sex and the highest levels of condom scepticism. They were somewhat more likely to be concerned with HIV stigma – but were a lot more aware than others about U=U. What really stood out was that they were three times more likely than the low risk group, and nearly twice as likely as any other group, to have found themselves in difficult sexual situations. Given that this group were three times more likely to have negative attitudes towards condoms than the low-risk group, the researchers comment that “PrEP may be an ideal approach for those who do not use condoms or another form of safer sex, or who have insufficient sense of agency to negotiate safer sex.”
• The cluster that really interested the researchers, though, were the remaining 20% of men, who formed what they called a “mixed profile”. Their belief in their ability to maintain safer sex and condom use was as high as men in the low-risk profile, as was their agreement with U=U statements. They were, however, somewhat more concerned about HIV stigma – and despite their self-beliefs, they were nearly twice as likely as the low-risk group to report difficult sexual situations, over the last year, and more than twice as likely to have been in difficult sexual relationships. In the latter case, they were only 18% less likely than the high-risk group to have experienced difficult sexual relationships. Although age did not predict which profile individual men belonged to, men who were younger and HIV positive were more likely to belong to the mixed profile.

“Having been in difficult sexual relationships” was the factor that varied most between profiles, and so was the feature that most strongly defined the degree to which a profile reflected higher or lower risk.

"For some young black MSM, disempowering sexual situations and relationships in which they feel they lack agency may be appropriate targets of intervention.”

What do these findings signify? They imply that individual socioeconomic factors, as least in the young gay black men surveyed, may be less important predictors of HIV risk than individual beliefs, attitudes and experiences.

They additionally imply that a particularly important group, with HIV risk higher than would have been predicted from socioeconomic factors, may be young men who experience conflict between what they want to do, and even believe they can do, and the pressures to act otherwise from other men.

The researchers comment that, given that this profile made up 20% of the population surveyed and was therefore four times bigger than the high-risk profile, they might contribute disproportionately to ongoing HIV incidence in the US gay black community.

“This pattern of results,” comment the writers, “indicates that for some young black men who have sex with men, disempowering sexual situations and relationships in which they feel they lack agency – especially if decisions are affected by substances – may be more appropriate targets of intervention than individual condom use or attitudes.”

It is interesting that HIV-positive, younger gay men are more likely to have higher-risk profiles, as they may both feel more keenly that they are at risk of rejection, and that they have less agency when it comes to maintaining sexual safety with older men. “Limited sexual networks may contribute to difficult sexual situations,” comment the researchers. In other words, the fewer potential partners you feel are available, the more likely you are to compromise: beggars can’t be choosers.

One interesting finding in this study is that the two groups with the highest apparent risk of HIV nonetheless appeared to be those with the highest levels of knowledge about treatment as prevention (U=U) and whose attitudes to condoms may suggest that they would be interested in PrEP. There are thus opportunities to turn risk around – as long as work is done to reassure young men that situations in which they are pressured into acting against their own self-beliefs and better judgements are not always their fault.