Tuesday, December 30, 2008

The Interaction of Sexual Identity With Sexual Behavior and Its Influence on HIV Risk Among Latino Men: Results of a Community Survey

The Interaction of Sexual Identity With Sexual Behavior and Its Influence on HIV Risk Among Latino Men: Results of a Community Survey in Northern San Diego County, California

Abstract (Summary)

We examined the sexual behavior, sexual identities, and HIV risk factors of a community sample of Latino men to inform efforts to reduce Latinos' HIV risk. In 2005 and 2006, 680 Latino men in San Diego County, California, in randomly selected, targeted community venues, completed an anonymous, self-administered survey. Most (92.3%) respondents self-identified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. Overall, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. Compared with behaviorally heterosexual men, heterosexually identified men who had sex with both men and women were more likely to have had a sexually transmitted infection, to have unprotected sexual intercourse with female partners, and to report having sex while under the influence of alcohol or other drugs. Bisexually identified men who had sex with men and women did not differ from behaviorally heterosexual men in these risk factors. Latino men who have a heterosexual identity and bisexual practices are at greater risk of HIV infection, and efforts to reduce HIV risk among Latinos should target this group.


Copyright American Public Health Association Jan 2009

[Headnote]
Objectives. We examined the sexual behavior, sexual identities, and HIV risk factors of a community sample of Latino men to inform efforts to reduce Latinos' HIV risk.
Methods. In 2005 and 2006, 680 Latino men in San Diego County, California, in randomly selected, targeted community venues, completed an anonymous, self-administered survey.
Results. Most (92.3%) respondents self-identified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. Overall, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. Compared with behaviorally heterosexual men, heterosexually identified men who had sex with both men and women were more likely to have had a sexually transmitted infection, to have unprotected sexual intercourse with female partners, and to report having sex while under the influence of alcohol or other drugs. Bisexually identified men who had sex with men and women did not differ from behaviorally heterosexual men in these risk factors.
Conclusions. Latino men who have a heterosexual identity and bisexual practices are at greater risk of HIV infection, and efforts to reduce HIV risk among Latinos should target this group. (Am J Public Health. 2009;99:125-132. doi:10.2105/AJPH.2007.129809)

Latinos and sexual minorities are disproportionately affected by HIV/AIDS. Latinos represented 14% of the US population in 2005,1 but they accounted for18%ofHIV/AIDS cases diagnosed in 2006.2 Although an estimated6%to9%of the US population has a lifetime history of homosexual sex,3,4 menwho have sexwithmen accounted for 49% of all HIV/AIDS cases diagnosed in the United States in 2006.2 Sexual risk for HIV varies considerably by sexual orientation, with gay-identified and bisexually identified men generally at greater risk.5,6 However, a person's selfidentified sexual orientation frequently does not correspond to his or her sexual behavior.7-9

Within Latino culture, it is possible for a man to have sex with men while maintaining a heterosexual identity and protecting his sense of masculinity.10-13 For Latino men, sexual identity appears to be contingent upon certain behavioral and contextual factors, such as whether they have female sexual partners, are primarily attracted to women, adopt an insertive role in sexual practices, have sex with effeminate men, or have sex with men when under the influence of alcohol or drugs. Homophobia, social stigma attached to same-sex practices, and sexual conservatism are commonly found throughout Latino culture andmay inhibit Latino men who have sex withmen fromself-identifying as gay or bisexual.9,10,14-16 Research suggests that Latino men are more likely than are White men to engage in bisexual behavior (i.e., to have sex with both men and women)8,17,18 but are less likely than are White men to disclose a nonheterosexual orientation.16,19,20

Among men, bisexual behavior appears to be more prevalent than bisexual identity. Although approximately1%to 2% of the US male population identifies as bisexual,3,4 rates of male bisexual behavior in national samples have ranged from 1% to 5%.4,21,22 However, these estimates are questionable because of differences in sampling methods and varying definitions of bisexuality.23 Recent research conducted in the United States suggests that men who have sex with men and women (MSMW) are at greater risk of HIV infection than men who have sex with men (MSM) exclusively and men who have sex with women (MSW) exclusively.24-26 By contrast, investigators in Mexico have found that MSMW who self-identify as bisexual practice less risky sexual behaviors with their male partners than do exclusively gay men.6

It has been difficult to quantify the population of heterosexually identified Latino MSMWbecause of the secretive nature of their sexual practices. In a homophobic cultural context, the fear of social rejection encourages people to hide their same-sex sexual behavior and lead a double life.10Astudy involving a large population ofHIVpositive MSM found that 15% of the Latino sample identified as heterosexual had a history of same-sex intercourse,27 whereas a survey of 455 men recruited from gay-oriented publications and venues in 12 US cities found that17% (n=26) of Hispanic respondents (as per terminology used in the original survey) reported being "on the down low".9 Although these results may not generalize to community-based US samples of Latino men, they suggest that a substantial proportion of heterosexually identified Latino men have a history of sex with men. Similarly, a household probability survey in Mexico City found that 73% of men with a lifetime history of bisexual practices identified as heterosexual, as did 29%of those with a lifetime history of having sex only with men.6

Men's nondisclosure of sexual practices with men has implications for the health of their female sexual partners.8,17 In the United States in 2006, Latinas accounted for 23.7% of HIV infections among Hispanics; of these, an estimated 51.7% were infected through heterosexual contact.2 Although most cases of heterosexual transmission to Latinas are related to sex with injection drug users,28 women who have unprotected sex with heterosexually identified MSMWare also at risk and are likely a subset of this population.

Although there is some evidence of greater HIV risk among MSMW than among MSM or MSW,24-26 previous research has not examined the roles that both sexual behavior and sexual identity play in HIV risk among Latino men in particular. Sexual identitymay influenceHIV risk among Latino MSMW because a man who identifies as heterosexual may perceive that he is at lower risk of sexually transmitted infections (STIs) than are gay or bisexual men and may thus take fewer measures to protect himself or his partner. MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.29

Our goal was to learn more about the sexual practices of Latino men and to better understand the interactions among sexual behaviors and sexual identities in this population so as to inform efforts to reduce HIV risk among Latinos. Using survey data, we examined the sexual behavior of a community sample of Latino men; determined the proportions of MSM, MSW, and MSMW among them; elicited any discrepancies between their sexual behavior and their sexual identity; and searched for differences in HIV risk by sexual orientation.

METHODS

Design and Procedures

We used baseline data collected as part of a larger study that evaluated a social marketing campaign to reduce HIV risk among heterosexually identified Latino MSMW in northern San Diego County, California. From December 2005 through April 2006, a cross-sectional community-based survey was conducted with Latino men recruited from 12 local venues. Using formative research, venues were selected to represent both high-risk and low-risk locations, with risk level determined by the extent to which sexual risk practices were likely to occur at or in proximity to the venue. Twelve sites covering the geographic region of northern San Diego County were identified, including 7 low-risk venues (i.e., a workplace, a migrant camp, a labor pickup site, 2 shopping centers, a center for the teaching of English as a second language, and a men's shelter) and 5 high-risk venues (i.e., an adult bookstore and 4 bars or clubs).

Sampling shifts at each venue were selected based on days and times when sampling venues were operating (e.g., bars and clubs were only open in the evening) and when access to Latino men could be ensured (e.g., men congregated at labor pickup sites only in the morning). During every sampling period, random selection procedures were used to screen and recruit eligible participants. Eligibility included self-reported Latino ethnicity, being 18 years or older, and being alone or in the company of other men. Venue-specific recruitment goals were established based on the results of previous enumeration activities, to ensure that the number of completed surveys for each venue was proportional to the size of the target population visiting each site. The survey design included 3 sampling periods (December 2005, February 2006, and April 2006) and was based on the aims of the larger intervention study for which these data served as baseline. The response rate across all venues was 63% (70% for low-risk venues and 53% for high-risk venues).

Measures

Participants completed a self-administered intercept survey on a handheld computer using Questionnaire Development Software's HAPI data-collection module (NOVA Research Company, Bethesda, MD). The survey was anonymous and was available in either Spanish or English. Survey topics included demographic information; lifetime history of HIV and STI testing; lifetime and recent (previous 60 days) sexual behavior with both female and male partners, including vaginal intercourse, insertive anal intercourse, and receptive anal intercourse; and recent (previous 60 days) substance use.

Statistical Analysis

We defined sexual orientation according to 2 dimensions: gender of lifetime sexual partners and self-identified sexual orientation. We defined men as behaviorally heterosexual if they self-identified as heterosexual and reported no history of sexual activity with men (heterosexually identified MSW). We defined men as gay if they self-identified as gay or homosexual (gay-identified MSM). We defined men as bisexual if they self-identified as bisexual (bisexually identified MSMW). We defined men as heterosexually identified MSMW if they identified as heterosexual but had a history of having sex with men. All other men were classified as having an orientation of "other."

Descriptive statistics and frequencies were computed for demographics, sexual behavior, substance use, and HIV and STI testing history. Bivariate (likelihood ratio) analyses explored differences in sexual behavior, substance use, and HIV and STI testing history by sexual orientation. Logistic regression models were estimated with each of the HIV risk variables as dependent variables, with sexual orientation as the main predictor variable, and with age, marital status, education, acculturation, and survey venue as covariates. Because of the small sample size and heterogeneity of the "other" sexual orientation category, this subgroup was included in descriptive analyses for the whole sample but was excluded from subsequent bivariate and multivariate analyses comparing HIV risk among sexual orientation categories. All analyses were computed using SPSS version 14.0 (SPSS Inc, Chicago, IL).

RESULTS

Sample Characteristics

A total of 781 Latino men completed the survey. After excluding repeat survey participants, we included 680 participants (mean age=28.4 years; SD=9.1; range=18-65 years) in descriptive analyses. More than half (53%) were single or never married. Only 21.8% had completed a high school education or higher. The vast majority (92%) were born in Mexico, with an additional 5% born in the United States and 3% in another country. Among foreignborn participants (n=647), more than two thirds had been in the United States for 5 or fewer years , with 30% reporting US residency of less than1year. The percentage in our sample who reported being of Mexican origin matched US Census data for San Diego County, as did the percentage of foreign-born respondents who reported Mexico as their place of birth.30,31 Almost all respondents were primarily employed in 1 of 4 occupations: agriculture (29%), manufacturing (21%), service industry (24%), and construction (20%).

The majority (92.3%) of participants selfidentified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. However, a smaller percentage (86.2%) reported a lifetime history of sexual practices with female partners exclusively. About 6% of men reported having a history of having sex with both men and women, 5.4% reported a history of sex with men only, and 2.4% reported no previous sexual practices with males or females. In all, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. According to our criteria, 87.6% of respondents were classified as heterosexually identified MSW; 4.4% as heterosexually identified MSMW; 2.4% as bisexually identified MSMW; and 4.7% as gay-identified MSM. The following percentages of respondents were recruited from high-risk recruitment venues: 46% of heterosexually identified MSW, 66.7% of heterosexually identified MSMW, 71.9% of gay-identified MSM, and 75% of bisexually identified MSMW.

Sexual Risk Practices

Most (56.5%) of the total sample of men reported sex with a female partner during the previous 60 days; of these, 58.2% reported not using a condom during 1 or more of these encounters, with percentages ranging from 25% among bisexually identified MSMW to 77.5% among heterosexually identified MSMW (Table 1). A minority of respondents (6.8%) reported engaging in anal intercourse with a male partner during the previous 60 days, with 57.8% of these reporting 1 or more unprotected encounters. The percentage of insertive anal intercourse equaled that of receptive anal intercourse (3.97%). By sexual orientation, percentages of insertive anal intercourse during the previous 60 days ranged from 31.2% among gay-identified MSM and bisexually identified MSMW to 36.7% among heterosexually identified MSMW. Percentages of receptive anal intercourse during the previous 60 days ranged from 10% among heterosexually identified MSMW to 50% among gayidentified MSM (P=.002). A majority (53.8%) of those who had insertive anal intercourse did so without using a condom, as did almost half (48.1%) of those who had receptive anal intercourse (Table 1).

Out of 30 heterosexually identified MSMW, 40% (n=12) were estimated to have engaged in sex with both female and male partners during the previous 60 days. Among this subset, 91.7% (n=11) reported engaging in unprotected sex with both female and male partners. By contrast, 25% of 16 bisexually identified MSMW (n=4) reported sexual intercourse with both men and women during the previous 60 days; among them, only 1 reported unprotected sex with both genders.

After adjusting for covariates, we found that heterosexually identified MSMW were 3.5 times more likely than were heterosexually identified MSW to report not using a condom with a female partner during the previous 60 days (95% confidence interval [CI]=1.15, 10.81; Table 2). Given the small size of the subsamples that reported recent anal intercourse with male partners, we performed no multivariate tests for significant differences in unprotected insertive and receptive anal intercourse with males by sexual orientation.

Other HIV-Risk-Related Practices

Condom carrying and risk perception. Overall, 23.1% of participants were carrying condoms at the time of the survey, with percentages ranging from 21% among heterosexually identified MSMW to 53.1% among gay-identified MSM (Table 3). With regard to perceived risk for HIV infection, 26.9% of participants considered themselves at medium or high risk, with percentages of risk perception being lowest among heterosexually identified MSW (23.4%) and highest among bisexually identified MSMW (68.8%; P<.001).

After adjusting for covariates, we observed significant differences in the distribution of condom carrying and risk perception. Gayidentified MSM were 3.3 times more likely than were heterosexually identified MSW to report current condom carrying (95% CI=1.5, 7.2; Table 4). Gay-identified MSM were 4.8 times more likely than were heterosexually identified MSW to perceive themselves as being at risk of HIV infection (95% CI=2.2, 10.4), and bisexually identified MSMW were 7.4 times more likely than were heterosexually identified MSW to perceive themselves as being at risk of HIV infection (95% CI=2.5, 22.1). A trend was observed suggesting that heterosexually identified MSMW were more likely to perceive themselves as being at risk of HIV infection than were heterosexually identified MSW; however, this result did not reach statistical significance (P =.07). No significant differences were found between heterosexually identified MSMW and heterosexually identified MSW for condom carrying.

Substance use. Almost one quarter of participants (23.4%) reported having sex while under the influence of alcohol during the previous 60 days, with percentages varying from18.8% among bisexually identified MSMW to 50% among heterosexually identified MSMW. In addition, 11.5% reported using illegal drugs, 6.1% reported having sex under the influence of illegal drugs, and 14.9% reported injection of a substance (e.g., medication, vitamins, illegal drugs). Heterosexually identified MSMWtended to report the highest percentages of illegal drug use (43.3%), drug use during sex (30%), and substance injection (26.7%). Bivariate statistical tests indicated significant differences in alcohol use before or during sex (P=.004), illegal drug use (P<.001), and drug use during sex (P<.001), by sexual orientation (Table 3).

After adjusting for covariates, we found that heterosexually identified MSMW were 3.3 times more likely to report sex under the influence of alcohol (95% CI=1.5, 7.1), 6 times more likely to report illegal drug use (95% CI=2.7, 13.5), and 6.2 times more likely to report sex under the influence of illicit drugs (95% CI=2.4, 16.1) than were heterosexually identified MSW (Table 4). Bisexually identified MSMW were also significantly more likely than were heterosexually identified MSW to report use of illegal substances (odds ratio [OR]=3.8; 95% CI=1.2, 11.8). Sexual orientation was not predictive of substance injection.

HIV and STI testing. Only 38.2% of the sample reported having been tested for HIV. Of these, 3.5% (n=9) reported that they were HIV positive. Among those who were HIV negative or whose HIV status was unknown, 46.5% did not know where they could get tested, and 43.4% had no intention of being tested in the next 6 months. Only 23% of men reported having been tested for STIs. Of these, 11% reported having had an STI in their lifetime (Table 3). Results from multivariate analysis indicated that, compared with heterosexually identified MSW, heterosexually identified MSMW and gay-identified MSM were significantly more likely to have been tested for HIV (heterosexually identified MSMW: OR=4.5; 95% CI=2.0, 10.2; gay-identified MSM: OR=11.3; 95% CI=3.8, 33.6). Gay-identified MSM were more likely than were heterosexually identifiedMSWto intend to be tested in the next 6 months (OR=2.7; 95% CI=1.2, 6.4). Heterosexually identified MSMW (OR=4.1; 95% CI=1.9, 9.0), bisexually identified MSMW (OR=3.1; 95% CI=1.1, 8.8), and gay-identified MSM (OR=3.7; 95% CI=1.7, 8.1) were more likely than were heterosexually identified MSW to have been tested for other STIs (Table 4). Heterosexually identified MSMW were more than 4.3 times more likely than were heterosexually identified MSW to report having had a STI (OR=4.3; 95% CI: 1.8, 9.9).

DISCUSSION

The estimate of behavioral bisexuality found among the present sample of Latino men (6%) was slightly larger than those previously reported in Mexico6 (2.1% for lifetime bisexual practices) and national US samples (1%-4.9% for various time frames).4,21,22 This may reflect our definition of behavioral bisexuality, which was based on lifetime sexual practices instead of recent sexual practices, and the fact that some of our venues had a significant proportion of gay-identified patrons. It may also be indicative of the higher rates of behavioral bisexuality among men of color reported in previous research. 8,9,17,18,26,29 However, we obtained a smaller percentage of heterosexually identified MSMW in our sample than those obtained in previous studies that included Latinos in the United States.8,9 This difference could be explained by an underreporting of sexual practices, particularly those that are stigmatized; a lack of measures on oral sex in our study; sampling biases in our study and in previous research; or the paucity of research that has simultaneously examined sexual identity and sexual behaviors with both women and men. Regardless, these results indicate that a significant proportion of heterosexually identified Latino men in our sample have engaged in sexual intercourse with men.

HIV testing rates for our sample (38.2%) were lower than those estimated for Latino males in the United States (45%)32 and may be explained by the fact that most of the respondents in our sample were foreign born or recent immigrants. However, our HIV and STI testing rates were higher than were those estimated for migrants returning to Mexico from the United States (HIV testing: 22%-29%; STI testing: 10%-13%).33 A surprisingly high proportion of men reported being HIV positive; in the context of limited HIV testing, this finding may actually reflect underestimated rates of infection. However, these data must be interpreted cautiously, because the inclusion of high-risk venues may have caused us to find higher HIV rates than would be seen in the general population and because our data on HIV status are based solely on self-reports. Still, these findings call attention to the need to promote HIV and STI testing for low-acculturated Latinos.

Compared to heterosexually identified MSW, heterosexually identified MSMW were more likely to report a history of STIs and recent unprotected sexual intercourse with a female partner. Moreover, half of heterosexually identified MSMW reported recent anal intercourse with a male partner; among them, 3 out of 4 reported inconsistent condom use during same-sex encounters. These findings add to previous research on behavioral bisexuality24-26,34 and have significant implications for the health of our respondents' sexual partners. Previous studies have suggested that risky bisexual behavior among men may serve as a bridge for HIV transmission from high-prevalence groups to the general population. 6,25,35 Research suggests that a relatively small proportion of HIV infections in the United States are attributable to bisexual behavior.35 However, these estimates rely on openly reported bisexual behavior. Because of stigma associated with homosexual practices,19,36 many behaviorally bisexual men may underreport or deny same-sex practices. Underreporting of same-sex practices among heterosexually identified MSMW may lead to an underestimation of the contribution that this transmission avenue makes to the HIV epidemic in the United States.

Heterosexually identified MSMW were also more likely to report recent drug use and sexual intercourse while under the influence of alcohol or other drugs. This finding is consistent with previous research suggesting that substance use is frequently a contextual factor in same-sex intercourse among heterosexually identified MSMW14,16,37 and may contribute to increased risk for HIV infection among these men and their sexual partners.37 With less than 50% of men in our sample reporting using a condom during every recent sexual encounter, additional efforts clearly must be taken to encourage heterosexually identified MSMW to consistently use condoms with both male and female partners.

Despite their same-sex sexual practices and substance-influenced encounters, heterosexually identified MSMW did not perceive their risk for HIV to differ significantly from that of heterosexually identified MSW. A considerable proportion of heterosexually identified MSMW in our sample (27%; data not shown) only adopted an insertive role in anal intercourse with men, reducing to some extent their risk of acquiring HIV. However, HIV and STI prevention interventions clearly should be targeted toward this population, including efforts to raise risk awareness.

Implications

These findings have important implications for future HIV prevention research and practice. First, more research is warranted to elucidate the relative contributions of male sexual identity and bisexual behavior to the increasing proportion of Latinas among new HIV cases. Previous studies have suggested that Latino MSM and MSMW are more likely to maintain a heterosexual identity than are Whites.16,19 However, more comparative studies are needed because little research has been conducted with White men on this issue. Additional research is also required to identify factors associated with the adoption of a heterosexual identity among MSMW. Because the only thing that differentiates bisexually identified MSMW from heterosexually identified MSMW is sexual identity, a comparison between these 2 groups would be particularly interesting.

Second, these findings underscore the need for HIV prevention efforts targeting heterosexually identified Latino MSMW and their male and female sexual partners, such as efforts to reduce social stigma attached to same-sex intercourse and campaigns to raise HIV awareness regardless of sexual identity. Other interventions may include (but are not limited to) those promoting routine HIV and STI screening as a standard part of well-adult care38 and those attempting to normalize condom use regardless of sexual identity or the gender of one's sexual partners. Programs need to be consistent with and respectful of these men's sexual identities; they also must reduce the stigma associated with HIV testing and condom use, which are often perceived among Latinos as practices associated with homosexuality and signs of distrust or infidelity within relationships.39,40 Finally, interventions targeting Latinas as the sexual partners of MSMW are needed, especially in light of recent findings that sex within marriage may be the single greatest risk for HIV among Mexican women.34,41These interventions should be gender sensitive, taking into account potential constraints upon women's abilities to respond to their partners' risk, and routine opt-out HIV testing should be promoted.38

Our findings offer additional evidence that both behavior and identity are important dimensions of sexual orientation that need to be contemplated when assessing HIV risk and evaluating prevention interventions. Our results point to the need for future research that will help investigators develop a better understanding of how heterosexual identity might increase HIV risk among behaviorally bisexual Latino men. There is also a need for research examining whether the differences among various sexual orientation groups observed here extend to Latino men in general or to other racial/ethnic male populations. Research on these topics should be carefully framed to avoid adding stigma and generating sensationalist discourses regarding heterosexually identified MSMW of color, or the so-called "down low" phenomenon.

Limitations

Our sampling procedures were part of a larger intervention study and included targeted sampling at venues in which heterosexually identified MSMW were likely to be found. Thus, the results may not reflect the risk dynamics of Latinos outside northern San Diego County and may be limited to the population of Latino men who frequent these types of venues. In addition, the inclusion of lifetime versus recent sexual practices in our definition of behavioral bisexuality may have overestimated the proportion of behaviorally bisexual men among our sample. Estimates of bisexuality have been found to vary substantially depending on the time frame of sexual behavior selected.6 Our use of lifetime sexual practices may have captured early same-sex experiences (e.g., single-incident youthful experimentation or instances of childhood sexual abuse) that are not indicative of recent sexual practices. The use of alternate time frames to differentiate past sexual experimentation from current behavioral practices should be explored, and clear distinction should be made between consensual sexual experiences versus those that were forced or coerced. Future research should also examine the number of male partners and sexual encounters, because these factors would affect the probability of viral exposure and thus the risk for HIV infection.

More than 90% of our sample was born in Mexico, limiting our ability to generalize these results to other foreign-born Latino men. Future research should include larger subsamples of Latino males from countries other than Mexico to allow analysis of possible differences by country of origin. Because of survey space and time limitations, we were also unable to directly assess contextual and sociodemographic factors that might be associated with sexual risk, such as housing type and urban versus rural place of residence. Future research should include measures of these factors and assess the extent to which they may confound the observed association between sexual identity and HIV risk.

Participants in our survey were only asked about anal intercourse with other men, because these present the highest risk for HIV infection or transmission. However, oral sex with male partners may be a more common sexual practice for behaviorally defined bisexual Latino men.6 Although oral sex may represent a low-risk behavior from an HIV-transmission perspective, if the experience is perceived favorably, it may serve as a gateway to riskier same-sex practices. Oral sex also has significant implications for STI transmission. Future research should therefore estimate the prevalence of oral sex with male partners among heterosexually identified MSMW and explore the relationship of these practices to subsequent sexual risk behavior.

Finally, because of the small number of men reporting recent anal intercourse with another man, we were unable to explore the relationship between sexual identity and condom use with male partners. Because unprotected anal intercourse represents the greatest risk for HIV and STI transmission between male partners, further research is needed to examine the extent to which heterosexually identified MSMWmay differ from men of other sexual orientations in their same-sex sexual practices.

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32. Anderson JE, Chandra A, Mosher WD. HIV testing in the United States, 2002. Adv Data. 2005; 363:1-32.
33. Rangel M, Martínez-Donate A, Hovell M, Santibanez J, Sipan C, Izazola-Licea J. Prevalence of risk factors for HIV infection among Mexican migrants and immigrants: probability survey in the north border of Mexico. Salud Pública Méx. 2006;48:3-12.
34. Pulerwitz J, Izazola-Licea JA, Gortmaker SL. Extrarelational sex among Mexican men and their partners' risk of HIV and other sexually transmitted diseases. Am J Public Health. 2001;91:1650-1652.
35. Kahn JG, Gurvey J, Pollack LM, Binson D, Catania JA. How many HIV infections cross the bisexual bridge? An estimate from the United States. AIDS. 1997;11:1031-1037.
36. Rosario M, Schrimshaw EW, Hunter J. Ethnic/racial differences in the coming-out process of lesbian, gay, and bisexual youths: a comparison of sexual identity development over time. Cultur Divers Ethnic Minor Psychol. 2004;10:215-228.
37. Dolezal C, Carballo-Dieguez A, Nieves-Rosa L, Diaz F. Substance use and sexual risk behavior: understanding their association among four ethnic groups of Latino men who have sex with men. J Subst Abuse. 2000;11:323-336.
38. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006; 55(RR-14):1-17.
39. Hirsch JS, Higgins J, Bentley ME, Nathanson CA. The social constructions of sexuality: marital infidelity and sexually transmitted disease-HIV risk in a Mexican migrant community. Am J Public Health. 2002;92:1227-1237.
40. McQuiston C, Gordon A. The timing is never right: Mexican views of condom use. Health Care Women Int. 2000;21:277-290.
41. Hirsch JS, Meneses S, Thompson B, Negroni M, Pelcastre B, del Rio C. The inevitability of infidelity: sexual reputation, social geographies, and marital HIV risk in rural Mexico. Am J Public Health. 2007;97(6): 986-996.

[Author Affiliation]
Jennifer A. Zellner, PhD, Ana P. Martínez-Donate, PhD, Fernando Sañudo, MPH, Araceli Fernández-Cerdeño, MA, Carol L. Sipan, MPH, RN, Melbourne F. Hovell, PhD, MPH, and Héctor Carrillo, DrPH
About the Authors
At the time of the study, Jennifer A. Zellner, Ana P. Martínez-Donate, Araceli Fernández-Cerdeño, Carol L. Sipan, and Melbourne F. Hovell were with the Center of Behavioral Epidemiology and Community Health, Graduate School of Public Health, San Diego State University, San Diego, CA. Ana P. Martínez-Donate was also with the Department of Population Health Sciences, University of Wisconsin, Madison. Fernando Sañudo was with Vista Community Clinic, Vista, CA. Héctor Carrillo was with the Department of Human Sexuality Studies, San Francisco State University, San Francisco, CA.
Requests for reprints should be sent to Ana P. Martínez-Donate, Department of Population Health Sciences, University of Wisconsin-Madison, 610 Walnut St, WARF 605, Madison, WI 53726-2397 (e-mail: martinezdona@ wisc.edu).
This article was accepted May 6, 2008.
Contributors
J. A. Zellner supervised the study, assisted with analyses, and led the writing of the article. A. P. Martínez-Donate originated and directed the study, performed the data analyses, and contributed substantially to the writing of the article. F. Sañudo was the co-principal investigator of the study. A. Fernández-Cerdeño, C. L. Sipan, M. F. Hovell, and H. Carrillo assisted with the design and implementation of the study. All authors helped interpret findings and reviewed drafts of the article.
Acknowledgments
This research was supported by the California HIV/AIDS Research Program of the University of California, Office of the President (grants AL04-SDSUF-804 and AL04-VCC-805), and by intramural support from the Center of Behavioral Epidemiology and Community Health at San Diego State University.
Human Participant Protection
All study procedures were reviewed and approved by the San Diego State University institutional review board and by the social and behavioral sciences institutional review board at the University of Wisconsin-Madison.

Influence of Coping, Social Support, and Depression on Subjective Health Status Among HIV-Positive Adults With Different Sexual Identities

Abstract (Summary)

The authors examined associations between psychosocial variables (coping self-efficacy, social support, and cognitive depression) and subjective health status among a large national sample (N = 3,670) of human immunodeficiency virus (HIV)-positive persons with different sexual identities. After controlling for ethnicity, heterosexual men reported fewer symptoms than did either bisexual or gay men and heterosexual women reported fewer symptoms than did bisexual women. Heterosexual and bisexual women reported greater symptom intrusiveness than did heterosexual or gay men. Coping self-efficacy and cognitive depression independently explained symptom reports and symptom intrusiveness for heterosexual, gay, and bisexual men. Coping self-efficacy and cognitive depression explained symptom intrusiveness among heterosexual women. Cognitive depression significantly contributed to the number of symptom reports for heterosexual and bisexual women and to symptom intrusiveness for lesbian and bisexual women. Individuals likely experience HIV differently on the basis of sociocultural realities associated with sexual identity. Further, symptom intrusiveness may be a more sensitive measure of subjective health status for these groups. [PUBLICATION ABSTRACT]

Copyright Heldref Publications Winter 2009

[Headnote]
The authors examined associations between psychosocial variables (coping self-efficacy, social support, and cognitive depression) and subjective health status among a large national sample (N = 3,670) of human immunodeficiency virus (HIV)-positive persons with different sexual identities. After controlling for ethnicity, heterosexual men reported fewer symptoms than did either bisexual or gay men and heterosexual women reported fewer symptoms than did bisexual women. Heterosexual and bisexual women reported greater symptom intrusiveness than did heterosexual or gay men. Coping self-efficacy and cognitive depression independently explained symptom reports and symptom intrusiveness for heterosexual, gay, and bisexual men. Coping self-efficacy and cognitive depression explained symptom intrusiveness among heterosexual women. Cognitive depression significantly contributed to the number of symptom reports for heterosexual and bisexual women and to symptom intrusiveness for lesbian and bisexual women. Individuals likely experience HIV differently on the basis of sociocultural realities associated with sexual identity. Further, symptom intrusiveness may be a more sensitive measure of subjective health status for these groups.
Index Terms: coping, depression, HIV, sexual identity, symptoms, social support


Human immunodeficiency virus (HIV) is increasingly considered a chronic disease. For a person living with HIV, this means having to cope with a range of HIV-related symptoms for extended periods. Symptoms may be related to the infection itself, comorbid illnesses, or iatrogenic effects from HIV-related medications.1,2 Commonly experienced symptoms include fatigue, stiff or painful joints, muscle aches, diarrhea, depression, and neuropathy.3,4 Side effects from certain antiretroviral therapies used to treat HIV include gastrointestinal distress, hyperlipidemia, and nephrolithiasis.2 These illness-related experiences can negatively influence one's quality of life by impairing social functioning and physical health.3,5-9 Although the vast majority of people living with HIV experience HIV-related symptoms,2 the degree to which the symptoms affect them varies.10 This variation raises questions about potential contributors to symptom experience,9 including psychosocial factors. Longitudinal studies involving diverse samples of HIV-positive people indicate that mental health variables, such as depression, hopelessness, and social support, can impact HIV-related biological markers11 and symptom reports.12 We designed this study to further understand the role psychosocial factors may play in the experience of physical symptoms.

Psychosocial functioning among HIV-positive persons likely varies as a function of sexual identity.13-17 For example, among men who have sex with men (MSM), a gay sexual identity has been associated with less loneliness and isolation,18 less depression, and better social support.19 Similarly, higher levels of distress and depression have been associated with not identifying as gay, queer, or homosexual among MSM in the Urban Men's Health Study.20 Heterosexual men and women tend to have different social support experiences, coping mechanisms, and stressors than do gay men or women.21 Familial social support is more readily available and satisfactory for HIV-positive heterosexual women than for HIV-positive heterosexual men22 or gay men.17 Further, HIV is considered to be a more stigmatizing condition for non-gay-identifying men23 and heterosexual women24 than for gay men. Coping strategies and depression also vary by gender and sexual identity.14,17

Less is known about the association between sexual identity and health or whether psychological differences among individuals with diverse sexual identities influence their particular illness experiences. Differences with regard to the role of psychological predictors of physiological functioning could have very real implications for disease morbidity and mortality among individuals of diverse sexual identities. For example, some analyses have indicated that a heterosexual identity is associated with poorer functional health status.13 Others found that a concealed minority sexual identity was associated with faster disease progression, at least in the pre-HAART (highly active antiretroviral therapy) era.25 This association was significant, even after controlling for age, health practices (such as substance use, exercise, and sleep), psychosocial characteristics (including anxiety, depression, coping, and social support), sexual behavior, and the use of azidothymidine (AZT). More recent research has found similar associations between immune system suppression and concealed homosexual identity.19 Our study extends research on the association between psychosocial and physical functioning among HIV-positive persons by examining these relationships in a large sample of individuals of diverse sexual identities. This study also offers insight into the functioning of individuals in the era of HAART, which has been shown to lower disease morbidity and mortality rates.26-28

In addition to physiological markers, such as CD4 count and viral load, it is useful to examine subjective indicators of health status, including symptom reports,29,30 which can provide information about how individuals perceive illness and the effects of illness on other aspects of their functioning.31 Investigating symptom reports affords researchers the unique opportunity to understand the physiological markers of illness and the perceptions of illness impact.9 In fact, physical symptoms, rather than physiological markers, are more closely related to psychological distress.32

First, we examine whether individuals with diverse sexual identities differ with regard to either their physical or psychosocial functioning and, second, the degree to which psychosocial indicators are associated with subjective health status. The results of this study could have important implications for the delivery of more tailored mental health interventions for HIV-positive persons. For example, if we find that a minority sexual identity is associated with poorer physical or psychological functioning, health care providers and researchers would need to make a more concerted effort to address factors that may contribute to lowered resilience among such groups. Likewise, identifying differences in the degree to which psychosocial indicators are associated with illness experiences will help those developing targeted interventions focus their resources on the most relevant factors, contributing to better health outcomes among these groups.

METHODS

Procedure

The data reported in this article are from screening/baseline interviews from a multisite, randomized, controlled trial of a behavioral intervention designed to decrease transmission risk for HIV-infected persons.32-34 The Institutional Review Board from each participating institution approved the study's procedures. Eligibility criteria included being at least 18 years old and providing medical documentation of HIV-positive status. Interviews were conducted between May 2000 and February 2002 using computer-assisted personal interview technology. Participants were paid $50 for their time.

Measures

Demographic Characteristics

Demographic characteristics assessed included participant gender, sexual identity, race/ethnicity, age, relationship status, educational level, and employment status. All items were self-reported. Sexual identity was assessed by asking participants whether they currently identify as heterosexual/ straight, homosexual/gay, or bisexual.

Coping Self-Efficacy

We measured coping self-efficacy using a 15-item version of Chesney, Folkman, and Chambers'35 measure of self-efficacy for coping with challenges and threats. Participants rated items on a Likert scale from 0 (cannot do at all) to 10 (certain can do) according to their level of confidence in their ability to perform particular coping strategies. Examples of items included "Break an upsetting problem down into smaller parts." The mean item score was computed for use in the analysis. For the present study, internal consistency reliability was good (α = .92).

Social Support

We measured social support by the 24-item Social Provisions Scale,36 which includes types of support, such as guidance, reliable alliance, attachment, social integration, reassurance of worth, and the opportunity to provide support to others. Respondents consider their entire support network in assessing the extent to which they believe such provisions are available to them, and they respond on a 4- point Likert scale from 1 (strongly disagree) to 4 (strongly agree), such that higher scores reflected greater provisions of social support. A mean scale score was computed. This scale has demonstrated adequate validity and reliability in other samples.36 In this sample, the Social Provisions Scale was highly internally consistent (α = .92).

Cognitive Depression

The Beck Depression Inventory37 (BDI) is a 21-item measure assessing cognitive, affective, behavioral, and somatic symptoms of depression. Although we administered the full inventory, on the basis of the concerns raised by Kalichman et al38 regarding the confounding of HIV symptoms with BDI items reflecting somatic symptoms of depression, we restricted our data analysis to the 12-item cognitive subscale. The items included in this subscale include sadness, pessimism, failure, dissatisfaction, guilt, punishment, disappointment, weakness, suicide, crying, irritation, and social withdrawal. Summing the item ratings creates a score of cognitive depression. Items are rated on a 4-point scale from 0 (representing the absence of the symptom) to 3 (representing greatest symptom intrusiveness), such that higher scores reflected greater levels of cognitive depression. Following the recommendations of Kalichman et al,37-38 we considered a score of 10 or higher to indicate clinical depression. For the present study, α =. 85.

Health Status and Medication Use

We defined subjective health status as (1) the total number of HIV-related symptoms and (2) symptom intrusiveness. We measured total number of symptoms using the HIV Symptom Index.39 Examples of symptoms included dizziness, nausea, nervousness, and muscle aches. (Because of confounding with the BDI, we did not include the sadness/ depression item in the index.) We first asked participants to indicate which of 25 HIV-related symptoms they had experienced in the past 3 months. The number of symptoms was summed to create a total symptom report score. Participants then indicated the degree to which those symptoms bothered them (ie, symptom intrusiveness) using a 4-point scale (1 [It doesn't bother me at all], 2 [It bothers me a little], 3 [It bothers me quite a bit], 4 [It bothers me a great deal]). For the multiple regression analyses, we calculated the symptom intrusiveness score by summing the number of symptoms for which each participant indicated being bothered quite a bit or a great deal. Thus, if a particular symptom did not bother the person or bothered them only a little, it was not included in the total score. We used this method to diminish the relative influence any particular reported symptom may have on the overall intrusiveness score when it does not, in fact, disrupt one's quality of life. We conducted separate multivariate analyses using the symptom report and symptom intrusiveness scores as outcome variables. Other indicators of health status included date of diagnosis, CD4 count, and antiretroviral use. These items were selfreported. We measured CD4 count by a single, self-reported item of participants' most recent clinical measurement. A single dichotomous item measured current (in the past 3 months) antiretroviral use.

Data Analysis

We used SPSS (Version 12.0) for data analysis. Prior to multivariate analysis, we screened data for accuracy of data entry, missing values, and concordance between their distributions and the assumptions of the multivariate analyses. Descriptive statistics were computed for demographics, psychosocial scale scores, CD4 count, HIV symptom report, and antiretroviral use for each group. Tests of differences were conducted to examine differences by sexual orientation groups for the demographic variables. Bivariate correlation coefficients were computed to examine multicollinearity among the predictors. We conducted 2 separate univariate analysis of variances (ANOVAs) to test whether the number of symptoms reported or symptom intrusiveness differed by sexual identity. Ethnicity has been associated with biological markers and subjective health status among HIV-positive persons.3,40-43 In addition, an earlier analysis using this same sample revealed ethnic differences with regard to perceived effects of antiretroviral therapy.3 Therefore, ethnicity was entered as a covariate. Hierarchical regression analyses predicting the number of symptoms reported and symptom intrusiveness were performed (controlling for ethnicity, age, and CD4 counts) for each sexual identity group to examine the relationships with coping self-efficacy, social support, and cognitive depression.

RESULTS

Sample Description

We interviewed 3,819 participants for this project (see Weinhardt, Kelly, Brondino, et al34 for a more detailed description of the sample). To examine differences on the basis of sexual identity, only men and women who identified as being heterosexual, bisexual, or gay were included in this study. Individuals who did not identify as being heterosexual, bisexual, or gay (n = 89) were excluded from these analyses. Likewise, because individuals who identified as being transgender or other (n = 68) do not represent a monolithic group with regard to either gender or sexual identity, we excluded these data from the analyses. (We excluded 13 individuals for reasons pertaining to gender and sexual identity criteria.) The participants for this study (N = 3,670) included 1,505 (41.0%) gay men, 840 (22.9%) heterosexual men, 365 (9.9%) bisexual men, 808 (22.0%) heterosexual women, 61 (1.7%) lesbian women, and 91 (2.5%) bisexual women.

Sexual Identity, Sociodemographics, and Health Status

Sociodemographic characteristics of participants by sexual identity groups are shown in Table 1. Preliminary analyses indicated differences by groups in terms of data collection site, ethnicity, educational level, employment status, the number of years they had been HIV-positive, and age. The presence of specific symptoms in the past 3 months and symptom intrusiveness are presented in Table 2. The 11 most frequently occurring symptoms were reported by more than half the sample. The most intrusive symptoms were fatigue, sleep disruptions, muscle/joint and nonspecific pain, and diarrhea. Eighty percent of the sample had been diagnosed with HIV prior to 1995. CD4 counts ranged widely from 0-2,675 (M = 440.5; SD = 298.6). Twenty-one percent of participants had CD4 counts lower than 200 copies, the clinical cutoff for an acquired immune deficiency syndrome (AIDS) diagnosis. Less than 9% of the study participants had never received antiretroviral therapies.

Sexual Identity and Psychosocial Indicators

Nearly one-quarter (24.8%) of the participants met the criteria for cognitive depression. Descriptive statistics for social support, coping self-efficacy, and cognitive depression are reported in Table 3 for each of the sexual identity groups. The groups differed on social support (F[5, 3,660] = 5.8, p < .001) and coping (F[5, 3,664] = 2.4, p = .03), but not on cognitive depression (ns, p = .69). Post hoc analyses indicate that heterosexual men reported less social support than either heterosexual women or gay men did and bisexual men reported less social support than heterosexual women did. However, heterosexual men reported greater coping self-efficacy than either gay or bisexual men did and heterosexual women reported greater coping self-efficacy than gay men did.

To test the hypothesis that sexual identity group membership was predictive of subjective health status, we performed two separate univariate ANOVAs. The results indicated that after partialing out the effects of ethnicity, the number of symptoms differed across sexual identity groups (F[5, 3,657] = 4.14, p <.01). Post hoc analyses revealed that heterosexual men reported fewer symptoms (M = 10.9, SD = 5.7) than either bisexual (M = 12.0, SD = 5.5) or gay (M = 12.0, SD = 5.1) men did. In addition, heterosexual women reported fewer symptoms on average (M = 11.7, SD = 5.6) than bisexual women (M = 12.8, SD = 5.0). Symptom intrusiveness also differed across sexual identity groups after controlling for the effects of ethnicity (F[5, 3,643] = 7.31, p < .01). Post hoc analyses revealed that heterosexual women and bisexual women reported greater symptom intrusiveness (M = 8.5, SD = 5.8 and M = 9.7, SD = 5.3, respectively) than either heterosexual men (M = 7.3, SD = 5.6) or gay men (M = 7.7, SD = 5.4) did.

Hierarchical multiple regression analyses were then conducted to examine the relative influence of coping self-efficacy, social support, and cognitive depression on symptom reports and intrusiveness scores in the subsamples of heterosexual, gay, and bisexual men; and heterosexual, lesbian, and bisexual women. The results for the number of symptom reports (provided in Table 4) indicate that after controlling for ethnicity, age, and most-recent CD4 counts, coping self-efficacy and cognitive depression independently explained symptom reports for heterosexual, gay, and bisexual men. Cognitive depression significantly contributed to the number of symptom reports for heterosexual and bisexual women. None of the independent variables significantly predicted symptom reports for lesbians. When taken together, the predictors accounted for 14-23% of the adjusted variance in symptom reports for the other 5 sexual orientation groups.

Results from the examination of the relative influence of coping self-efficacy, social support, and cognitive depression on symptom intrusiveness (provided in Table 5) indicate that after controlling for ethnicity, age, and most-recent CD4 count, coping self-efficacy and cognitive depression independently explain symptom intrusiveness for heterosexual, gay, and bisexual men and heterosexual women. Cognitive depression significantly contributed to symptom intrusiveness for lesbian and bisexual women. When taken together, the predictors accounted for 10-29% of the variance in symptom intrusiveness for the 6 sexual identity groups.

COMMENT

We examined the relative contribution that social support, coping self-efficacy, and cognitive depression made on illness symptom reports among a US national sample of HIV-positive persons. In a much smaller sample, other researchers found that depression was more comprehensively related to HIV-related quality of life than either coping or social support was.44 However, this is the first time these relationships have been examined for their association with subjective health status using a large, diverse national sample. We conducted the analyses across different sexual identity groups, controlling for the effects of ethnicity, age, and CD4 counts on subjective health status.

Our analyses indicated that heterosexual and bisexual women, in particular, experience more symptom intrusiveness than either heterosexual men or gay men do. This gender difference is consistent with research that has found that HIV-positive women have lower health-related quality of life, particularly with regard to pain and physical functioning.45 Cultural factors may be related to the perception of pain or discomfort as well.42 Further, socioeconomic status, life stressors associated with poverty, racial discrimination, and single parenthood likely affect certain groups more than others, particularly HIV-positive ethnic minority women.46-47 Future research needs to be conducted to better understand the interaction between illness experiences and related cultural norms or life stressors for women in particular.

Cognitive depression was evident in a quarter of the sample, and there were no significant differences between groups on depressive symptoms. Depression independently explained symptom reports and intrusiveness for nearly all groups (although it did not explain symptom reports for lesbians). Further, cognitive depression independently accounted for the largest percentage of the variance for the number of symptoms reported and symptom intrusiveness in all groups. Consistent with other research,48-51 our results demonstrate the presence of a relationship between psychological symptoms and physiological disease. When taken together, the results suggest that the most salient point of intervention with regard to illness adjustment or health-related quality of life is the alleviation of cognitive depression, regardless of sexual identity status. Therefore, identifying and treating psychological distress is likely to decrease physiological morbidity among a substantial proportion of HIV-positive persons. This has important implications for structural change with regard to standard-of-care medical practice in the treatment of HIV disease such that HIV-positive patients may experience significant improvement in overall health outcomes if infectious disease practitioners regularly assess depression and provide appropriate referrals to mental health services.

Lower coping self-efficacy also independently predicted more symptom reports and greater symptom intrusiveness for all 3 groups of men. These results suggest that a strength-based approach may assist HIV-positive men, in particular, to achieve a sense of competence in adjusting to their illness. Cognitive-behavioral interventions can promote the identification of personal strengths and facilitate the development of skills to cope with particularly difficult or stressful life events. Individuals can then learn how to reframe life stressors as manageable challenges and develop strategies to effectively deal with them, which reduces psychological stress by improving not only their overall mental health, but also their symptom experiences.

Last, although statistically significant differences were found among the groups on a measure of social support, the degree of difference may not be clinically significant. Furthermore, social support did not independently explain symptom reports or intrusiveness as cognitive depression or coping self-efficacy did. Although social support likely plays an important role in disease management and quality of life, subjective health status may be better reflected in measures of cognitive depression and coping self-efficacy.

A paucity of quantitative research exists related to the experience of HIV-positive sexual minority women. Although we were able to recruit a small sample of lesbian (n = 61) and bisexual (n = 91) women for our study, the small sample sizes limited statistical power. For example, we failed to find differences with regard to psychosocial variables for lesbian and bisexual women, although our data suggest that lesbians may actually experience more social support and less cognitive depression than the other groups. The hierarchical regression results indicate that cognitive depression accounts for a significant amount of the variance in symptom intrusiveness for this group. Yet, limited power may have resulted in nonsignificant relationships between the psychosocial variables and symptoms reports. For example, the standardized beta indicating the relationship between cognitive depression and symptom reports was identical to that for heterosexual men (.27), although these results were not significant in the former sample. Researchers must use targeted sampling plans to further quantitative research agendas related to the experience of living with HIV among lesbians in particular. We know little about the psychosocial stressors that may influence physical symptoms in this population, and such nescience likely results in inadequate approaches to addressing sexual minority women's specific illness adjustment needs.

We used 2 measures of subjective health status for this study. The results indicate that measures of symptom intrusiveness, particularly questions about how much the symptoms bother people, may be a better indicator of subjective health status than the total number of symptoms experienced. The symptom intrusiveness model accounted for a larger portion of the variance for each subsample, and the individual predictors appear to be more strongly associated with symptom intrusiveness than the number of symptoms experienced. For these reasons, symptom intrusiveness may be a more salient measure of subjective health status, a contradiction of others' findings.30 The results also suggest that it may be beneficial for health care providers to evaluate the degree to which particular symptoms influence an individual's quality of life or daily functioning. Moreover, self-report symptom checklists should be used to facilitate a discussion about symptom intrusiveness and not as the sole indicator of functional status.

There are 2 significant limitations to this study. First, this is a cross-sectional analysis. Therefore, we cannot determine causality. In this article, we chose to examine the influence of psychosocial factors on symptom reporting to test the hypothesis that poorer psychosocial functioning manifests in relation to greater experience of negative symptoms. This perspective is consistent with results from longitudinal studies that have demonstrated the influence of psychosocial factors on salient health outcomes.11,12,52 For example, depression and coping style could influence not only the perception of symptoms, but also important physiological processes, such as immunological functioning.11,49,50,53 However, illness experiences, such as a greater number of or more intrusive symptoms, could lead to clinical depression,54,55 although this relationship has received less research attention. Ultimately, we are able to examine 1 piece of the puzzle with these data; longitudinal studies, ideally with more frequent assessments, are needed to provide a thorough analysis of the nature of the association between psychological and physiological symptoms and their recursive influence.

The second limitation of this study is related to the demographics and health status of the samples. There were substantial differences among the groups in terms of key demographic variables. On the basis of these differences and those that appear to be most salient in the literature in terms of illness experiences, we controlled for ethnicity, CD4 counts, and age in the hierarchical regression analyses. Beyond variability among the groups, the mean age was approximately early 40s in each group, and 80% of the participants learned of their HIV status prior to 1995. Therefore, this sample is overrepresented by those who are somewhat older and have been living with HIV for many years. In addition, more than one-fifth of the sample had an AIDS diagnosis at the time of the interview, and nearly the entire sample had taken antiretroviral therapies. Thus, these results may be more generalizable to those who have lived with HIV for a number of years compared with those who have been recently diagnosed or those who are significantly younger. Although this study contributes to a better understanding of the mental and physical health correlates of long-term survivors in the contemporary HAART era, understanding the needs of younger and newly diagnosed individuals is also necessary to address mental health, HIV-related risk behavior, and treatment adherence factors that may have serious and long-term effects on illness adjustment and disease progression.

ACKNOWLEDGMENTS

The Healthy Living Project was funded by cooperative agreements between the National Institute of Mental Health (NIMH) and Columbia University (U10MH057636); the Medical College of Wisconsin (U10MH057631); University of California, Los Angeles (U10MH057615); and the University of California, San Francisco (U10MH057616). The NIMH Healthy Living Trial Group includes members of the research steering committee (site principal investigators and NIMH staff collaborator): Margaret A. Chesney, PhD; Anke A. Ehrhardt, PhD; Jeffrey A. Kelly, PhD; Willo Pequegnat, PhD; and Mary Jane Rotheram-Borus, PhD. Collaborating scientists, coprincipal investigators, and investigators were Eric G. Benotsch, PhD; Michael J. Brondino, PhD; Sheryl L. Catz, PhD; Edwin D. Charlebois, PhD, MPH; Don C. Des- Jarlais, PhD; Naihua Duan, PhD; Theresa M. Exner, PhD; Rise B. Goldstein, PhD, MPH; Cheryl Gore-Felton, PhD; A. Elizabeth Hirky, PhD; Mallory O. Johnson, PhD; Robert M. Kertzner, MD; Sheri B. Kirshenbaum, PhD; Lauren E. Kittel, PsyD; Robert Klitzman, MD; Martha Lee, PhD; Bruce Levin, PhD; Marguerita Lightfoot, PhD; Stephen F. Morin, PhD; Steven D. Pinkerton, PhD; Robert H. Remien, PhD; Fen Rhodes, PhD; Wayne T. Steward, PhD, MPH; Susan Tross, PhD; Lance S. Weinhardt, PhD; Robert Weiss, PhD; Hannah Wolfe, PhD; Rachel Wolfe, PhD; and F. Lennie Wong, PhD. Data management and analytic support were provided by Philip Batterham, MA; W. Scott Comulada, MS; Tyson Rogers, MA; and Yu Zhao, MS. Site project coordinators were Kristin Hackl, MSW; Daniel Hong, MA; Karen Huchting, BA; Joanne D. Mickalian, MA; and Margaret Peterson, MSW. NIMH staff include Christopher M. Gordon, PhD; Dianne Rausch, PhD; and Ellen Stover, PhD.

NOTE

For comments and further information, address correspondence to Dr Katie E. Mosack, Assistant Professor, Department of Psychology, University of Wisconsin Milwaukee, PO Box 413, Milwaukee, WI 53201, USA (e-mail: kemosack@uwm.edu).

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18. Williams JK, Wyatt GE, Resell J, Peterson J, Asuan-O'Brien A. Psychosocial issues among gay- and non-gay-identifying HIV-seropositive African American and Latino MSM. Cultur Divers Ethnic Minor Psychol. 2004;10:268-286.
19. Ullrich PM, Lutgendorf SK, Stapelton JT. Concealment of homosexual identity, social support, and CD4 cell count among HIV-seropositive gay men. J Psychosom Res. 2003;54:205- 212.
20. Mills TC, Paul J, Stall R, et al. Distress and depression in men who have sex with men: the Urban Men's Health Study. Am J Psychiatry. 2004;161:278-285.
21. Leslie MB, Stein JA, Rotheram-Borus MJ. The impact of coping self-efficacy strategies, personal relationships, and emotional distress on health-related outcomes of parents living with HIV or AIDS. J Soc Pers Relat. 2002;19:45-66.
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23. Coleman CL. The contribution of religious and existential well-being to depression among African American heterosexuals with HIV infection. Issues Ment Health Nurs. 2004;25:103-110.
24. Crandall CS. AIDS-related stigma and the lay sense of justice. Contemp Soc Psychol. 1991;15:66-67.
25. Cole SW, Kemeny ME, Taylor SE, Visscher BR, Fahey JL. Accelerated course of human immunodeficiency virus infection in gay men who conceal their homosexual identity. Psychosom Med. 1996;58:219-231.
26. Bartlett JA. Addressing the challenges of adherence. J AIDS. 2002;29(suppl):2-10.
27. Cain LE, Cole SR, Chmiel JS, Margolick JB, Rinaldo CR, Jr Detels R. Effects of highly active antiretroviral therapy on multiple AIDS-defining illnesses among male HIV seroconverters. Am J Epidemiol. 2005;163:310-315.
28. Cook JA, Grey D, Burke J, et al. Depressive symptoms and AIDS-related mortality among a multisite cohort of HIV-positive women. Am J Public Health. 2004;94:1133-1140.
29. Pakenham KI, Rinaldis M. The role of illness, resources, appraisal, and coping self-efficacy strategies in adjustment to HIV/AIDS: the direct and buffering effects. Behav Med. 2001;24:259-279.
30. Wu AW, Dave NB, Diener-West M, Sorenson S, Huang IC, Revicki DA. Measuring validity of self-report symptoms among people with HIV. AIDS Care. 2004;16:876-881.
31. Teva I, Bermúdez MP, Hernández-Quero J, Buela-Casal G. Evaluación de la calidad de vida relacionada con la salud en pacientes infectados por el VIH. Terapia Psicológica. 2004;22:111-121.
32. Remien RH, Exner TE, Kertzner RM, et al. Depressive symptomatology among HIV-positive women in the era of HAART: a stress and coping model. Am J Community Psychol. 2006;38:275-285.
33. Morin SF, Steward WT, Charlebois ED, et al. Predicting HIV transmission risk among HIV-infected men who have sex with men: Findings from the Healthy Living Project. JAIDS 2005;40:226-235.
34. Weinhardt LS, Kelly JA, Brondino MJ, et al. HIV transmission risk behavior among men and women living with HIV in 4 cities in the United States. J AIDS. 2004;36:1057-1066.
35. Chesney MA, Folkman S, Chambers D. Coping effectiveness training for men living with HIV: preliminary findings. Int J STD AIDS. 1996;7:75-82.
36. Cutrona CE, Russell D. The provisions of social relationships and adaptation to stress. In: Jones WH, Perlman D, eds. Advances in Personal Relationships, Volume 1. Greenwich, CT: JAI Press; 1987:37-68.
37. Beck AT, Steer RA. BDI: Beck Depression Inventory Manual. New York, NY: Psychological Corporation; 1993.
38. Kalichman SC, Sikkema KJ, Somlai A. Assessing persons with human immunodeficiency virus (HIV) infection using the Beck Depression Inventory: disease processes and other potential confounds. J Pers Assess. 1995;64:86-100.
39. Justice AC, Holmes W, Gifford AL, et al; for the Adult AIDS Clinical Trials Unit Outcomes Committee. Development and validation of a self-completed HIV symptom index. J Clin Epidemiol. 2001;54(suppl):77-90.
40. Dobalian A, Tsao JC, Duncan RP. Pain and the use of outpatient services among persons with HIV: results from a nationally representative survey. Med Care. 2004;42:129-138.
41. Heckman BD. Psychosocial differences between whites and African Americans living with HIV/AIDS in rural areas of 13 US States. J Rural Health. 2006;22:131-139.
42. Rotheram-Borus MJ. Variations in perceived pain associated with emotional distress and social identity in AIDS. AIDS Patient Care STDS. 2000;14:659-665.
43. Vidrine DJ, Amick BC III, Gritz ER, Arduino RC. Functional status and overall quality of life in a multiethnic HIV-positive population. AIDS Patient Care STDS. 2003;17:187-197.
44. Jia H, Uphold CR, Wu S, Reid K, Findley K, Duncan PW. Health-related quality of life among men with HIV infection: effects of social support, coping, and depression. AIDS Patient Care STDS. 2004;18:594-603.
45. Mrus JM, Williams PL, Tsevat J, Cohn SE, Wu AW. Gender differences in health-related quality of life in patients with HIV/AIDS. Qual Life Res. 2005;14:479-491.
46. Arend ED. The politics of invisibility: homophobia and lowincome HIV-positive women who have sex with women. J Homosex. 2005;49:97-122.
47. Springer E. Reflections on women and HIV/AIDS in New York City and the United States. In: Bury J, Morrison V, McLachlan S, eds. Working with Women with AIDS: Medical, Social, and Counseling Issues. New York, NY: Tavistock/ Routledge; 1992:32-40
48. Antoni MH, Baggett L, Ironson G, et al. Cognitivebehavioral stress management intervention buffers distress responses and immunologic changes following notification of HIV-1 seropositivity. J Consult Clin Psychol. 1991;59:906-915.
49. Leserman J, Petitto JM, Perkins DO, Folds JD, Golden RN, Evans DL. Severe stress, depressive symptoms, and changes in lymphocyte subsets in human immunodeficiency virusinfected men: a 2-year follow-up study. Arch Gen Psychiatry. 1997;54:279-285.
50. Leserman J, Petitto JM, Golden RN, et al. Impact of stressful life events, depression, social support, coping self-efficacy, and cortisol on progression to AIDS. Am J Psychiatry. 2000;157:1221-1228.
51. Simoni JM, Ng MT. Abuse, health locus of control, and perceived health among HIV-positive women. Health Psychol. 2002;21:89-93.
52. Cruess DG, Douglas SD, Petitto JM, et al. Association of resolution of major depression with increased natural killer cell activity among HIV-seropositive women. Am J Psychiatry. 2005;162:2125-2130.
53. Villes V, Spire B, Lewden C, et al and ANRS CO-8 APROCOCOPILOTE Study Group. The effect of depressive symptoms at ART initiation on HIV clinical progression and mortality: implications in clinical practice. Antiviral Ther. 2007;12:1067-1074.
54. Davis S. Clinical sequelae affecting quality of life in the HIVinfected patient. J Assoc Nurses AIDS Care. 2004;15(suppl):28- 33.
55. Moneyham L, Sowell R, Seals B, Demi A. Depressive symptoms among African American women with HIV disease. Sch Inq Nurs Pract. 2000;14:9-39.

[Author Affiliation]
Katie E. Mosack, PhD; Lance S. Weinhardt, PhD; Jeffrey A. Kelly, PhD; Cheryl Gore-Felton, PhD; Timothy L. McAuliffe, PhD; Mallory O. Johnson, PhD; Robert H. Remien, PhD; Mary Jane Rotheram- Borus, PhD; Anke A. Ehrhardt, PhD; Margaret A. Chesney, PhD; Stephen F. Morin, PhD
Dr Mosack is with the Department of Psychology at the University of Wisconsin in Milwaukee. Drs Weinhardt, Kelly, and McAuliffe are with the Department of Psychiatry and Behavioral Medicine at the Medical College of Wisconsin in Milwaukee. Dr Gore-Felton is with the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine. Drs Johnson and Morin are with the Center for AIDS Prevention Studies at the University of California in San Francisco. Dr Remien is with the HIV Center for Clinical and Behavioral Studies in New York, NY. Dr Rotheram- Borus is with the Center for HIV Identification, Prevention, and Treatment Services at the University of California in Los Angeles. Dr Ehrhardt is with the HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University in New York, NY. Dr Chesney is with the National Center for Complementary and Alternative Medicine in Bethesda, MD.
Copyright © 2008 Heldref Publications

The Interaction of Sexual Identity With Sexual Behavior and Its Influence on HIV Risk Among Latino Men

The Interaction of Sexual Identity With Sexual Behavior and Its Influence on HIV Risk Among Latino Men: Results of a Community Survey in Northern San Diego County, California

Abstract (Summary)

We examined the sexual behavior, sexual identities, and HIV risk factors of a community sample of Latino men to inform efforts to reduce Latinos' HIV risk. In 2005 and 2006, 680 Latino men in San Diego County, California, in randomly selected, targeted community venues, completed an anonymous, self-administered survey. Most (92.3%) respondents self-identified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. Overall, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. Compared with behaviorally heterosexual men, heterosexually identified men who had sex with both men and women were more likely to have had a sexually transmitted infection, to have unprotected sexual intercourse with female partners, and to report having sex while under the influence of alcohol or other drugs. Bisexually identified men who had sex with men and women did not differ from behaviorally heterosexual men in these risk factors. Latino men who have a heterosexual identity and bisexual practices are at greater risk of HIV infection, and efforts to reduce HIV risk among Latinos should target this group.


Copyright American Public Health Association Jan 2009

[Headnote]
Objectives. We examined the sexual behavior, sexual identities, and HIV risk factors of a community sample of Latino men to inform efforts to reduce Latinos' HIV risk.
Methods. In 2005 and 2006, 680 Latino men in San Diego County, California, in randomly selected, targeted community venues, completed an anonymous, self-administered survey.
Results. Most (92.3%) respondents self-identified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. Overall, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. Compared with behaviorally heterosexual men, heterosexually identified men who had sex with both men and women were more likely to have had a sexually transmitted infection, to have unprotected sexual intercourse with female partners, and to report having sex while under the influence of alcohol or other drugs. Bisexually identified men who had sex with men and women did not differ from behaviorally heterosexual men in these risk factors.
Conclusions. Latino men who have a heterosexual identity and bisexual practices are at greater risk of HIV infection, and efforts to reduce HIV risk among Latinos should target this group. (Am J Public Health. 2009;99:125-132. doi:10.2105/AJPH.2007.129809)


Latinos and sexual minorities are disproportionately affected by HIV/AIDS. Latinos represented 14% of the US population in 2005,1 but they accounted for18%ofHIV/AIDS cases diagnosed in 2006.2 Although an estimated6%to9%of the US population has a lifetime history of homosexual sex,3,4 menwho have sexwithmen accounted for 49% of all HIV/AIDS cases diagnosed in the United States in 2006.2 Sexual risk for HIV varies considerably by sexual orientation, with gay-identified and bisexually identified men generally at greater risk.5,6 However, a person's selfidentified sexual orientation frequently does not correspond to his or her sexual behavior.7-9

Within Latino culture, it is possible for a man to have sex with men while maintaining a heterosexual identity and protecting his sense of masculinity.10-13 For Latino men, sexual identity appears to be contingent upon certain behavioral and contextual factors, such as whether they have female sexual partners, are primarily attracted to women, adopt an insertive role in sexual practices, have sex with effeminate men, or have sex with men when under the influence of alcohol or drugs. Homophobia, social stigma attached to same-sex practices, and sexual conservatism are commonly found throughout Latino culture andmay inhibit Latino men who have sex withmen fromself-identifying as gay or bisexual.9,10,14-16 Research suggests that Latino men are more likely than are White men to engage in bisexual behavior (i.e., to have sex with both men and women)8,17,18 but are less likely than are White men to disclose a nonheterosexual orientation.16,19,20

Among men, bisexual behavior appears to be more prevalent than bisexual identity. Although approximately1%to 2% of the US male population identifies as bisexual,3,4 rates of male bisexual behavior in national samples have ranged from 1% to 5%.4,21,22 However, these estimates are questionable because of differences in sampling methods and varying definitions of bisexuality.23 Recent research conducted in the United States suggests that men who have sex with men and women (MSMW) are at greater risk of HIV infection than men who have sex with men (MSM) exclusively and men who have sex with women (MSW) exclusively.24-26 By contrast, investigators in Mexico have found that MSMW who self-identify as bisexual practice less risky sexual behaviors with their male partners than do exclusively gay men.6

It has been difficult to quantify the population of heterosexually identified Latino MSMWbecause of the secretive nature of their sexual practices. In a homophobic cultural context, the fear of social rejection encourages people to hide their same-sex sexual behavior and lead a double life.10Astudy involving a large population ofHIVpositive MSM found that 15% of the Latino sample identified as heterosexual had a history of same-sex intercourse,27 whereas a survey of 455 men recruited from gay-oriented publications and venues in 12 US cities found that17% (n=26) of Hispanic respondents (as per terminology used in the original survey) reported being "on the down low".9 Although these results may not generalize to community-based US samples of Latino men, they suggest that a substantial proportion of heterosexually identified Latino men have a history of sex with men. Similarly, a household probability survey in Mexico City found that 73% of men with a lifetime history of bisexual practices identified as heterosexual, as did 29%of those with a lifetime history of having sex only with men.6

Men's nondisclosure of sexual practices with men has implications for the health of their female sexual partners.8,17 In the United States in 2006, Latinas accounted for 23.7% of HIV infections among Hispanics; of these, an estimated 51.7% were infected through heterosexual contact.2 Although most cases of heterosexual transmission to Latinas are related to sex with injection drug users,28 women who have unprotected sex with heterosexually identified MSMWare also at risk and are likely a subset of this population.

Although there is some evidence of greater HIV risk among MSMW than among MSM or MSW,24-26 previous research has not examined the roles that both sexual behavior and sexual identity play in HIV risk among Latino men in particular. Sexual identitymay influenceHIV risk among Latino MSMW because a man who identifies as heterosexual may perceive that he is at lower risk of sexually transmitted infections (STIs) than are gay or bisexual men and may thus take fewer measures to protect himself or his partner. MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.29

Our goal was to learn more about the sexual practices of Latino men and to better understand the interactions among sexual behaviors and sexual identities in this population so as to inform efforts to reduce HIV risk among Latinos. Using survey data, we examined the sexual behavior of a community sample of Latino men; determined the proportions of MSM, MSW, and MSMW among them; elicited any discrepancies between their sexual behavior and their sexual identity; and searched for differences in HIV risk by sexual orientation.

METHODS

Design and Procedures

We used baseline data collected as part of a larger study that evaluated a social marketing campaign to reduce HIV risk among heterosexually identified Latino MSMW in northern San Diego County, California. From December 2005 through April 2006, a cross-sectional community-based survey was conducted with Latino men recruited from 12 local venues. Using formative research, venues were selected to represent both high-risk and low-risk locations, with risk level determined by the extent to which sexual risk practices were likely to occur at or in proximity to the venue. Twelve sites covering the geographic region of northern San Diego County were identified, including 7 low-risk venues (i.e., a workplace, a migrant camp, a labor pickup site, 2 shopping centers, a center for the teaching of English as a second language, and a men's shelter) and 5 high-risk venues (i.e., an adult bookstore and 4 bars or clubs).

Sampling shifts at each venue were selected based on days and times when sampling venues were operating (e.g., bars and clubs were only open in the evening) and when access to Latino men could be ensured (e.g., men congregated at labor pickup sites only in the morning). During every sampling period, random selection procedures were used to screen and recruit eligible participants. Eligibility included self-reported Latino ethnicity, being 18 years or older, and being alone or in the company of other men. Venue-specific recruitment goals were established based on the results of previous enumeration activities, to ensure that the number of completed surveys for each venue was proportional to the size of the target population visiting each site. The survey design included 3 sampling periods (December 2005, February 2006, and April 2006) and was based on the aims of the larger intervention study for which these data served as baseline. The response rate across all venues was 63% (70% for low-risk venues and 53% for high-risk venues).

Measures

Participants completed a self-administered intercept survey on a handheld computer using Questionnaire Development Software's HAPI data-collection module (NOVA Research Company, Bethesda, MD). The survey was anonymous and was available in either Spanish or English. Survey topics included demographic information; lifetime history of HIV and STI testing; lifetime and recent (previous 60 days) sexual behavior with both female and male partners, including vaginal intercourse, insertive anal intercourse, and receptive anal intercourse; and recent (previous 60 days) substance use.

Statistical Analysis

We defined sexual orientation according to 2 dimensions: gender of lifetime sexual partners and self-identified sexual orientation. We defined men as behaviorally heterosexual if they self-identified as heterosexual and reported no history of sexual activity with men (heterosexually identified MSW). We defined men as gay if they self-identified as gay or homosexual (gay-identified MSM). We defined men as bisexual if they self-identified as bisexual (bisexually identified MSMW). We defined men as heterosexually identified MSMW if they identified as heterosexual but had a history of having sex with men. All other men were classified as having an orientation of "other."

Descriptive statistics and frequencies were computed for demographics, sexual behavior, substance use, and HIV and STI testing history. Bivariate (likelihood ratio) analyses explored differences in sexual behavior, substance use, and HIV and STI testing history by sexual orientation. Logistic regression models were estimated with each of the HIV risk variables as dependent variables, with sexual orientation as the main predictor variable, and with age, marital status, education, acculturation, and survey venue as covariates. Because of the small sample size and heterogeneity of the "other" sexual orientation category, this subgroup was included in descriptive analyses for the whole sample but was excluded from subsequent bivariate and multivariate analyses comparing HIV risk among sexual orientation categories. All analyses were computed using SPSS version 14.0 (SPSS Inc, Chicago, IL).

RESULTS

Sample Characteristics

A total of 781 Latino men completed the survey. After excluding repeat survey participants, we included 680 participants (mean age=28.4 years; SD=9.1; range=18-65 years) in descriptive analyses. More than half (53%) were single or never married. Only 21.8% had completed a high school education or higher. The vast majority (92%) were born in Mexico, with an additional 5% born in the United States and 3% in another country. Among foreignborn participants (n=647), more than two thirds had been in the United States for 5 or fewer years , with 30% reporting US residency of less than1year. The percentage in our sample who reported being of Mexican origin matched US Census data for San Diego County, as did the percentage of foreign-born respondents who reported Mexico as their place of birth.30,31 Almost all respondents were primarily employed in 1 of 4 occupations: agriculture (29%), manufacturing (21%), service industry (24%), and construction (20%).

The majority (92.3%) of participants selfidentified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. However, a smaller percentage (86.2%) reported a lifetime history of sexual practices with female partners exclusively. About 6% of men reported having a history of having sex with both men and women, 5.4% reported a history of sex with men only, and 2.4% reported no previous sexual practices with males or females. In all, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. According to our criteria, 87.6% of respondents were classified as heterosexually identified MSW; 4.4% as heterosexually identified MSMW; 2.4% as bisexually identified MSMW; and 4.7% as gay-identified MSM. The following percentages of respondents were recruited from high-risk recruitment venues: 46% of heterosexually identified MSW, 66.7% of heterosexually identified MSMW, 71.9% of gay-identified MSM, and 75% of bisexually identified MSMW.

Sexual Risk Practices

Most (56.5%) of the total sample of men reported sex with a female partner during the previous 60 days; of these, 58.2% reported not using a condom during 1 or more of these encounters, with percentages ranging from 25% among bisexually identified MSMW to 77.5% among heterosexually identified MSMW (Table 1). A minority of respondents (6.8%) reported engaging in anal intercourse with a male partner during the previous 60 days, with 57.8% of these reporting 1 or more unprotected encounters. The percentage of insertive anal intercourse equaled that of receptive anal intercourse (3.97%). By sexual orientation, percentages of insertive anal intercourse during the previous 60 days ranged from 31.2% among gay-identified MSM and bisexually identified MSMW to 36.7% among heterosexually identified MSMW. Percentages of receptive anal intercourse during the previous 60 days ranged from 10% among heterosexually identified MSMW to 50% among gayidentified MSM (P=.002). A majority (53.8%) of those who had insertive anal intercourse did so without using a condom, as did almost half (48.1%) of those who had receptive anal intercourse (Table 1).

Out of 30 heterosexually identified MSMW, 40% (n=12) were estimated to have engaged in sex with both female and male partners during the previous 60 days. Among this subset, 91.7% (n=11) reported engaging in unprotected sex with both female and male partners. By contrast, 25% of 16 bisexually identified MSMW (n=4) reported sexual intercourse with both men and women during the previous 60 days; among them, only 1 reported unprotected sex with both genders.

After adjusting for covariates, we found that heterosexually identified MSMW were 3.5 times more likely than were heterosexually identified MSW to report not using a condom with a female partner during the previous 60 days (95% confidence interval [CI]=1.15, 10.81; Table 2). Given the small size of the subsamples that reported recent anal intercourse with male partners, we performed no multivariate tests for significant differences in unprotected insertive and receptive anal intercourse with males by sexual orientation.

Other HIV-Risk-Related Practices

Condom carrying and risk perception. Overall, 23.1% of participants were carrying condoms at the time of the survey, with percentages ranging from 21% among heterosexually identified MSMW to 53.1% among gay-identified MSM (Table 3). With regard to perceived risk for HIV infection, 26.9% of participants considered themselves at medium or high risk, with percentages of risk perception being lowest among heterosexually identified MSW (23.4%) and highest among bisexually identified MSMW (68.8%; P<.001).

After adjusting for covariates, we observed significant differences in the distribution of condom carrying and risk perception. Gayidentified MSM were 3.3 times more likely than were heterosexually identified MSW to report current condom carrying (95% CI=1.5, 7.2; Table 4). Gay-identified MSM were 4.8 times more likely than were heterosexually identified MSW to perceive themselves as being at risk of HIV infection (95% CI=2.2, 10.4), and bisexually identified MSMW were 7.4 times more likely than were heterosexually identified MSW to perceive themselves as being at risk of HIV infection (95% CI=2.5, 22.1). A trend was observed suggesting that heterosexually identified MSMW were more likely to perceive themselves as being at risk of HIV infection than were heterosexually identified MSW; however, this result did not reach statistical significance (P =.07). No significant differences were found between heterosexually identified MSMW and heterosexually identified MSW for condom carrying.

Substance use. Almost one quarter of participants (23.4%) reported having sex while under the influence of alcohol during the previous 60 days, with percentages varying from18.8% among bisexually identified MSMW to 50% among heterosexually identified MSMW. In addition, 11.5% reported using illegal drugs, 6.1% reported having sex under the influence of illegal drugs, and 14.9% reported injection of a substance (e.g., medication, vitamins, illegal drugs). Heterosexually identified MSMWtended to report the highest percentages of illegal drug use (43.3%), drug use during sex (30%), and substance injection (26.7%). Bivariate statistical tests indicated significant differences in alcohol use before or during sex (P=.004), illegal drug use (P<.001), and drug use during sex (P<.001), by sexual orientation (Table 3).

After adjusting for covariates, we found that heterosexually identified MSMW were 3.3 times more likely to report sex under the influence of alcohol (95% CI=1.5, 7.1), 6 times more likely to report illegal drug use (95% CI=2.7, 13.5), and 6.2 times more likely to report sex under the influence of illicit drugs (95% CI=2.4, 16.1) than were heterosexually identified MSW (Table 4). Bisexually identified MSMW were also significantly more likely than were heterosexually identified MSW to report use of illegal substances (odds ratio [OR]=3.8; 95% CI=1.2, 11.8). Sexual orientation was not predictive of substance injection.

HIV and STI testing. Only 38.2% of the sample reported having been tested for HIV. Of these, 3.5% (n=9) reported that they were HIV positive. Among those who were HIV negative or whose HIV status was unknown, 46.5% did not know where they could get tested, and 43.4% had no intention of being tested in the next 6 months. Only 23% of men reported having been tested for STIs. Of these, 11% reported having had an STI in their lifetime (Table 3). Results from multivariate analysis indicated that, compared with heterosexually identified MSW, heterosexually identified MSMW and gay-identified MSM were significantly more likely to have been tested for HIV (heterosexually identified MSMW: OR=4.5; 95% CI=2.0, 10.2; gay-identified MSM: OR=11.3; 95% CI=3.8, 33.6). Gay-identified MSM were more likely than were heterosexually identifiedMSWto intend to be tested in the next 6 months (OR=2.7; 95% CI=1.2, 6.4). Heterosexually identified MSMW (OR=4.1; 95% CI=1.9, 9.0), bisexually identified MSMW (OR=3.1; 95% CI=1.1, 8.8), and gay-identified MSM (OR=3.7; 95% CI=1.7, 8.1) were more likely than were heterosexually identified MSW to have been tested for other STIs (Table 4). Heterosexually identified MSMW were more than 4.3 times more likely than were heterosexually identified MSW to report having had a STI (OR=4.3; 95% CI: 1.8, 9.9).

DISCUSSION

The estimate of behavioral bisexuality found among the present sample of Latino men (6%) was slightly larger than those previously reported in Mexico6 (2.1% for lifetime bisexual practices) and national US samples (1%-4.9% for various time frames).4,21,22 This may reflect our definition of behavioral bisexuality, which was based on lifetime sexual practices instead of recent sexual practices, and the fact that some of our venues had a significant proportion of gay-identified patrons. It may also be indicative of the higher rates of behavioral bisexuality among men of color reported in previous research. 8,9,17,18,26,29 However, we obtained a smaller percentage of heterosexually identified MSMW in our sample than those obtained in previous studies that included Latinos in the United States.8,9 This difference could be explained by an underreporting of sexual practices, particularly those that are stigmatized; a lack of measures on oral sex in our study; sampling biases in our study and in previous research; or the paucity of research that has simultaneously examined sexual identity and sexual behaviors with both women and men. Regardless, these results indicate that a significant proportion of heterosexually identified Latino men in our sample have engaged in sexual intercourse with men.

HIV testing rates for our sample (38.2%) were lower than those estimated for Latino males in the United States (45%)32 and may be explained by the fact that most of the respondents in our sample were foreign born or recent immigrants. However, our HIV and STI testing rates were higher than were those estimated for migrants returning to Mexico from the United States (HIV testing: 22%-29%; STI testing: 10%-13%).33 A surprisingly high proportion of men reported being HIV positive; in the context of limited HIV testing, this finding may actually reflect underestimated rates of infection. However, these data must be interpreted cautiously, because the inclusion of high-risk venues may have caused us to find higher HIV rates than would be seen in the general population and because our data on HIV status are based solely on self-reports. Still, these findings call attention to the need to promote HIV and STI testing for low-acculturated Latinos.

Compared to heterosexually identified MSW, heterosexually identified MSMW were more likely to report a history of STIs and recent unprotected sexual intercourse with a female partner. Moreover, half of heterosexually identified MSMW reported recent anal intercourse with a male partner; among them, 3 out of 4 reported inconsistent condom use during same-sex encounters. These findings add to previous research on behavioral bisexuality24-26,34 and have significant implications for the health of our respondents' sexual partners. Previous studies have suggested that risky bisexual behavior among men may serve as a bridge for HIV transmission from high-prevalence groups to the general population. 6,25,35 Research suggests that a relatively small proportion of HIV infections in the United States are attributable to bisexual behavior.35 However, these estimates rely on openly reported bisexual behavior. Because of stigma associated with homosexual practices,19,36 many behaviorally bisexual men may underreport or deny same-sex practices. Underreporting of same-sex practices among heterosexually identified MSMW may lead to an underestimation of the contribution that this transmission avenue makes to the HIV epidemic in the United States.

Heterosexually identified MSMW were also more likely to report recent drug use and sexual intercourse while under the influence of alcohol or other drugs. This finding is consistent with previous research suggesting that substance use is frequently a contextual factor in same-sex intercourse among heterosexually identified MSMW14,16,37 and may contribute to increased risk for HIV infection among these men and their sexual partners.37 With less than 50% of men in our sample reporting using a condom during every recent sexual encounter, additional efforts clearly must be taken to encourage heterosexually identified MSMW to consistently use condoms with both male and female partners.

Despite their same-sex sexual practices and substance-influenced encounters, heterosexually identified MSMW did not perceive their risk for HIV to differ significantly from that of heterosexually identified MSW. A considerable proportion of heterosexually identified MSMW in our sample (27%; data not shown) only adopted an insertive role in anal intercourse with men, reducing to some extent their risk of acquiring HIV. However, HIV and STI prevention interventions clearly should be targeted toward this population, including efforts to raise risk awareness.

Implications

These findings have important implications for future HIV prevention research and practice. First, more research is warranted to elucidate the relative contributions of male sexual identity and bisexual behavior to the increasing proportion of Latinas among new HIV cases. Previous studies have suggested that Latino MSM and MSMW are more likely to maintain a heterosexual identity than are Whites.16,19 However, more comparative studies are needed because little research has been conducted with White men on this issue. Additional research is also required to identify factors associated with the adoption of a heterosexual identity among MSMW. Because the only thing that differentiates bisexually identified MSMW from heterosexually identified MSMW is sexual identity, a comparison between these 2 groups would be particularly interesting.

Second, these findings underscore the need for HIV prevention efforts targeting heterosexually identified Latino MSMW and their male and female sexual partners, such as efforts to reduce social stigma attached to same-sex intercourse and campaigns to raise HIV awareness regardless of sexual identity. Other interventions may include (but are not limited to) those promoting routine HIV and STI screening as a standard part of well-adult care38 and those attempting to normalize condom use regardless of sexual identity or the gender of one's sexual partners. Programs need to be consistent with and respectful of these men's sexual identities; they also must reduce the stigma associated with HIV testing and condom use, which are often perceived among Latinos as practices associated with homosexuality and signs of distrust or infidelity within relationships.39,40 Finally, interventions targeting Latinas as the sexual partners of MSMW are needed, especially in light of recent findings that sex within marriage may be the single greatest risk for HIV among Mexican women.34,41These interventions should be gender sensitive, taking into account potential constraints upon women's abilities to respond to their partners' risk, and routine opt-out HIV testing should be promoted.38

Our findings offer additional evidence that both behavior and identity are important dimensions of sexual orientation that need to be contemplated when assessing HIV risk and evaluating prevention interventions. Our results point to the need for future research that will help investigators develop a better understanding of how heterosexual identity might increase HIV risk among behaviorally bisexual Latino men. There is also a need for research examining whether the differences among various sexual orientation groups observed here extend to Latino men in general or to other racial/ethnic male populations. Research on these topics should be carefully framed to avoid adding stigma and generating sensationalist discourses regarding heterosexually identified MSMW of color, or the so-called "down low" phenomenon.

Limitations

Our sampling procedures were part of a larger intervention study and included targeted sampling at venues in which heterosexually identified MSMW were likely to be found. Thus, the results may not reflect the risk dynamics of Latinos outside northern San Diego County and may be limited to the population of Latino men who frequent these types of venues. In addition, the inclusion of lifetime versus recent sexual practices in our definition of behavioral bisexuality may have overestimated the proportion of behaviorally bisexual men among our sample. Estimates of bisexuality have been found to vary substantially depending on the time frame of sexual behavior selected.6 Our use of lifetime sexual practices may have captured early same-sex experiences (e.g., single-incident youthful experimentation or instances of childhood sexual abuse) that are not indicative of recent sexual practices. The use of alternate time frames to differentiate past sexual experimentation from current behavioral practices should be explored, and clear distinction should be made between consensual sexual experiences versus those that were forced or coerced. Future research should also examine the number of male partners and sexual encounters, because these factors would affect the probability of viral exposure and thus the risk for HIV infection.

More than 90% of our sample was born in Mexico, limiting our ability to generalize these results to other foreign-born Latino men. Future research should include larger subsamples of Latino males from countries other than Mexico to allow analysis of possible differences by country of origin. Because of survey space and time limitations, we were also unable to directly assess contextual and sociodemographic factors that might be associated with sexual risk, such as housing type and urban versus rural place of residence. Future research should include measures of these factors and assess the extent to which they may confound the observed association between sexual identity and HIV risk.

Participants in our survey were only asked about anal intercourse with other men, because these present the highest risk for HIV infection or transmission. However, oral sex with male partners may be a more common sexual practice for behaviorally defined bisexual Latino men.6 Although oral sex may represent a low-risk behavior from an HIV-transmission perspective, if the experience is perceived favorably, it may serve as a gateway to riskier same-sex practices. Oral sex also has significant implications for STI transmission. Future research should therefore estimate the prevalence of oral sex with male partners among heterosexually identified MSMW and explore the relationship of these practices to subsequent sexual risk behavior.

Finally, because of the small number of men reporting recent anal intercourse with another man, we were unable to explore the relationship between sexual identity and condom use with male partners. Because unprotected anal intercourse represents the greatest risk for HIV and STI transmission between male partners, further research is needed to examine the extent to which heterosexually identified MSMWmay differ from men of other sexual orientations in their same-sex sexual practices.

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[Author Affiliation]
Jennifer A. Zellner, PhD, Ana P. Martínez-Donate, PhD, Fernando Sañudo, MPH, Araceli Fernández-Cerdeño, MA, Carol L. Sipan, MPH, RN, Melbourne F. Hovell, PhD, MPH, and Héctor Carrillo, DrPH
About the Authors
At the time of the study, Jennifer A. Zellner, Ana P. Martínez-Donate, Araceli Fernández-Cerdeño, Carol L. Sipan, and Melbourne F. Hovell were with the Center of Behavioral Epidemiology and Community Health, Graduate School of Public Health, San Diego State University, San Diego, CA. Ana P. Martínez-Donate was also with the Department of Population Health Sciences, University of Wisconsin, Madison. Fernando Sañudo was with Vista Community Clinic, Vista, CA. Héctor Carrillo was with the Department of Human Sexuality Studies, San Francisco State University, San Francisco, CA.
Requests for reprints should be sent to Ana P. Martínez-Donate, Department of Population Health Sciences, University of Wisconsin-Madison, 610 Walnut St, WARF 605, Madison, WI 53726-2397 (e-mail: martinezdona@ wisc.edu).
This article was accepted May 6, 2008.
Contributors
J. A. Zellner supervised the study, assisted with analyses, and led the writing of the article. A. P. Martínez-Donate originated and directed the study, performed the data analyses, and contributed substantially to the writing of the article. F. Sañudo was the co-principal investigator of the study. A. Fernández-Cerdeño, C. L. Sipan, M. F. Hovell, and H. Carrillo assisted with the design and implementation of the study. All authors helped interpret findings and reviewed drafts of the article.
Acknowledgments
This research was supported by the California HIV/AIDS Research Program of the University of California, Office of the President (grants AL04-SDSUF-804 and AL04-VCC-805), and by intramural support from the Center of Behavioral Epidemiology and Community Health at San Diego State University.
Human Participant Protection
All study procedures were reviewed and approved by the San Diego State University institutional review board and by the social and behavioral sciences institutional review board at the University of Wisconsin-Madison.