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Try out PMC Labs and tell us what you think. Learn More. Concurrent sexual partnerships, or sexual partnerships that overlap in time, have been associated with HIV and sexually transmitted infections STI infection. How best to measure concurrency and the personal characteristics and predictors of concurrency are not yet well understood.
We compared two frequently used concurrency definitions, including a self-reported measure based on participant response regarding overlapping sex with partners, and the UNAIDS measure based on overlapping dates of last sex and intention to have sex again. We performed multivariable logistic regression analyses to identify socio-demographic, behavioral, and structural predictors of concurrency among 1, patients at an urban STI clinic in Jackson, Mississippi.
Using the self-reported concurrency measure, the strongest predictors of concurrency were perceived partner concurrency, drug use at last sex, having more than 10 lifetime partners, and being recently incarcerated. Strongest predictors of concurrency using the UNAIDS measure were lifetime of partners and perceived partner concurrency.
Concurrency is highly prevalent in this population in the Deep South and social, structural and behavioral factors were important predictors of concurrency for both measures. Future research should use time anchored data collection methods and biomarkers to assess whether both definitions of concurrency are associated with HIV outcomes. Behavioral risk factors, including condom use, of lifetime sexual partners, and substance use, do not fully for these racial disparities 2 — 4.
Mississippi ranks ninth in the nation in new HIV case rates, with an estimated rate of Concurrent sexual partnerships, or partnerships that overlap in time, are a type of sexual network characteristic that has been posited to raise HIV transmission risks more than having the same of consecutive, monogamous partnerships 2 , 11 — However, the role of concurrency in potentiating the spread of HIV is controversial and not yet fully understood Debates about how best to measure concurrency are ongoing 16 — One commonly used measure of concurrency is self-reported overlapping sexual relationships with more than one partner within the past year, which evaluates period prevalence.
This measure allows for easier reporting and may include more complete information, but the data may subject to recall bias. A second frequently employed measure developed by UNAIDS requires overlapping dates of sex within the past year and intention to have sex with these partners again. This calculated measure evaluates period prevalence and aims to provide a more precise measure of concurrency, but can also be subject to even greater recall bias and has been shown to underestimate concurrency 16 , Regardless of the definition used, concurrency has been associated with specific socio-demographic, behavioral and structural factors.
Few studies have examined prevalence and correlates of concurrent sexual partnerships in African Americans at high-risk for contracting HIV, particularly in the South. The purpose of this investigation was to employ and compare two commonly used measures of concurrency to assess prevalence and correlates of concurrent sexual partnerships among male and female patients at an urban sexually transmitted infection STI clinic in Jackson, Mississippi.
Eligibility criteria included: 1 being at least 18 years of age, 2 presenting for STI or HIV screening, 3 willingness to complete a minute computerized survey, and 4 speaking English. Participants did not receive compensation for their participation. The survey included questions about socio-demographic, behavioral, and structural factors. All participants provided informed consent and this study was approved by the University of Mississippi Medical Center, the Mississippi State Department of Health, and the Miriam Hospital institutional review boards.
Of the 1, participants, 9. Socio-demographic characteristics included gender, ethnicity, age, self-identified sexual orientation heterosexual; homosexual; and bisexual never having been married, level of education, monthly income, and monthly religious service attendance.
Behavioral characteristics included variables related to sexual behaviors and substance use. Additionally, individuals were asked about having ever had sex in exchange for things like money, drugs or alcohol. Participants were asked about alcohol and drug use at last sex, defined by reported use of alcohol or drugs at last sex with at least one partner.
Participants were also asked event level questions about whether their three most recent partners had used alcohol or drugs during their last sexual encounter. Sex in this context is defined as vaginal, anal or oral intercourse. There will be a set of questions for each partner. So you can keep track, please enter each person's initials below. The second measure utilized the UNAIDS consensus measure, which uses overlapping partnership dates within the last year and intentions to have sex again with each partner For the UNAIDS measure, participants were coded as concurrent if they had overlapping dates of sex between any two partners, and reported that they intended to have sex with their prior partner again.
Only data from the past year were included; therefore participants were only considered concurrent if there were overlapping dates of sex during that time period. The two measures of concurrency were compared by calculating the sensitivity and specificity of the self-reported measure of concurrency for estimating the UNAIDS measure. Calculating sensitivity and specificity requires that one measure be considered a gold standard for measuring concurrency.
However, we do not have a gold standard for concurrency. We calculated sensitivity the proportion of those concurrent by the UNAIDS definition who were also concurrent according to the self-reported measure and specificity the proportion of those not concurrent by the UNAIDS definition who were also not concurrent according to the self-reported definition.
Sensitivity estimates the probability that participants are concurrent under both definitions, and specificity estimates the probability that participants are not concurrent under both definitions. Bivariate associations with concurrency were examined using chi-square tests.
Since concordance between behavior and self-reported sexual orientation was very high, we present data by sexual orientation. Because lifetime of partners can be strongly associated with concurrency and may confound the association of other factors with concurrency, lifetime of partners was also included as a categorical variable with three 1—5, 6—10, 11 or more in the multiple logistic regression models. Gender interactions for all of the correlates were tested in single multiple logistic regression models for each of the definitions; however the final multiple logistic regression models excluded interactions with p-values greater than 0.
Table 1 demonstrates that nearly half of the data analytic sample Table 1 also shows a cross tabulation of the two measures. Agreement between the two measures was relatively low, with only When the two definitions were discordant, Overall, Note: Self-reported concurrency was defined by self-report of having sex with one partner during the time the participant was having sex with another partner during the last year.
UNAIDS-defined concurrency required overlapping partnership dates during the last year and intentions to have sex again with that partner. Participants ranged in age from 18—61 years, with Further, 8. Nearly one fifth Over half of the participants Bivariate for both measures of concurrency are reported in Table 3. We found that men were ificantly more likely to be concurrent on the self-reported measure men: Compared to heterosexual participants, bisexual participants were more likely to be concurrent on the self-reported measure bisexual participants: A sub analysis exploring gender differences by self-reported sexual orientation indicated that women who self-identified as bisexual had the highest rates of concurrency for the self-reported measure The odds ratio for concurrency for bisexual women compared to heterosexual women was 3.
There was no ificant difference in the likelihood of concurrency for homosexual women compared to heterosexual women on either measure. In contrast, heterosexual men had the highest rate of concurrency for the self-reported measure Socio-demographic correlates of concurrency differed across measures. For the UNAIDS measure, completion of some college decreased the odds of concurrency, while it increased the odds of concurrency with the self-reported measure. Participants who attended church services at least once a month had high rates of concurrency self-report: Several behavioral correlates were associated with concurrency.
With respect to sexual network characteristics, both measures found that compared to those with 1—5 lifetime partners, having six or more lifetime sex partners and having had sex in exchange for things like money, drugs or alcohol increased the odds of concurrency.
In addition, the self-reported measure found individuals who did not know if they had sex with a high-risk partner experienced increased odds of concurrency compared to those who had not had sex with a high risk partner. With respect to substance use, frequent heavy episodic drinking compared to no episodic heavy drinking , lifetime use of drugs, and use of alcohol and drugs at last sex by either the participant or partner were associated with an increased odds of concurrency for both measures.
Regarding structural correlates, partner incarceration in the past six months was associated with increased odds of concurrency for both measures, and history of incarceration was associated with an increased odds of concurrency with the self-reported measure only. The sub analysis examining gender differences in beliefs that there are enough suitable partners indicated that, for the self-reported measure, concurrency rates were For men, self-reported concurrency rates were for the multiple logistic regression model are shown in Table 4.
Several socio-demographic, behavioral and structural variables demonstrated statistically ificant effects with concurrency. Having some college education was the only variable associated with a lower likelihood of being concurrent based on the UNAIDS measure. Several behavioral characteristics were associated with concurrency. Having a greater of lifetime partners and perceived or unknown partner concurrency remained ificantly associated with an increased likelihood of concurrency for both measures.
Having sex with a high-risk partner was associated with a decreased likelihood of self-reported concurrency. Using alcohol or drugs at last sex was ificantly associated with an increased likelihod of concurrency with the self-reported measure. Drug use at last sex was associated with an almost three-fold increase in the probability of self-reported concurrency for women compared to men.
Partner use of alcohol at last sex was not ificant for either gender, but the association was positive for women and negative for men. When there was discordance, the participants were more likely to be concurrent based on self-report, but not concurrent based on the UNAIDS measure, suggesting that compared to self-report, the UNAIDS measure is more conservative. The adjusted odds of engaging in concurrent partnerships were 1. High prevalence of concurrency in our sample suggests that concurrency is socially normalized in this population.
While it is not surprising that patients presenting for care at an STI clinic might report higher rates of concurrency than the general population, these are among the highest rates of concurrency presented in scientific literature 8 , 15 , 16 , 29 , These sexual network phenomena may have important impacts on HIV risks in this population and suggest that both reducing concurrent partnerships and encouraging condom use for those engaged in concurrent partnerships are important for reducing HIV transmission. Gender, sexual orientation, of lifetime sexual partners, perceived partner concurrency, and using drugs or alcohol at last sex were among the strongest correlates of self-reported concurrency in this population.
In bivariate analyses, bisexual women were two times more likely to be concurrent than heterosexual women for both measures of concurrency, whereas bisexual men were less likely than heterosexual men to be concurrent based on the self-report measure. These findings suggest the sexual networks of sexual minorities may be unique and that the social norms related to concurrency for sexual minorities may differ among men and women, particularly given that bisexual women and heterosexual men were most likely to engage in concurrent partnerships. These groups are often not the focus populations for many HIV prevention interventions, but the high rates of concurrency in this sample highlight the need for greater sexual health and HIV risk reduction efforts among these groups in Mississippi.
Although poverty has also been strongly correlated with concurrency in other US populations 11 , 15 , higher household income was correlated with greater likelihood of self-reported concurrency in this population. The relationship between income, sexual networks, and HIV risks in this population is complex and warrants further exploration in subsequent studies. Several different behavioral characteristics were strongly associated with concurrency.
For example, the strongest correlate of self-reported concurrency was perceived partner concurrency. Studies among similar populations in several settings found that perceived partner concurrency was an important factor predicting or influencing concurrency 10 , 21 , 22 , 28 , 31 — Our findings further underscore the role of social factors and relationship dynamics on individual HIV risks; social and structural factors may be paramount for understanding HIV transmission dynamics among African Americans in the Deep South.
Interestingly, high rates of participation in religious services among this high risk community suggests that churches may be important intervention partners in the Deep South. Other research has found that behavioral factors such as heavy episodic drinking 5 , 10 and cocaine use 15 , 21 , 22 , 28 are associated with concurrency. In this investigation, alcohol and drug use at last sex ificantly increased the odds of self-reported concurrency by 1.
Indeed, the association between substance use during sex and self-reported concurrency was stronger than the association between self-reported concurrency and global lifetime indicators of substance use, with the exception of heavy episodic drinking, which decreased the likelihood of concurrency based on the UNAIDS measure. Although cocaine use has been associated with concurrency in men and women 15 , 21 , 22 , 28 , we are unable to conclude whether it played an important role in this population, given the change in direction of the effect from bivariate to multivariate analyses.
Importantly, the effects of drug and alcohol use at last sex on self-reported concurrency varied widely by gender; participant use of drugs at last sex increased the odds of concurrency much more for women than men; whereas partner use of drugs at last sex increased the odds of concurrency much more for men than women.
Other qualitative studies suggest that incarceration and substance abuse may impact concurrency differentially for men and women 36 , 37 ; gender differences in this study suggest that interventions to address concurrency need to address complex gender dynamics related to sexual behaviors. research has found that structural factors such as incarceration 16 , 26 , 28 , 32 and poverty 10 , 23 are associated with concurrent partnerships.
In our analysis, after taking into other factors, self-reported history of incarceration was not associated with concurrency. However, having an incarcerated partner within the last six months was associated with nearly twice the odds of self-reported concurrency for women only. This supports other research showing that high rates of incarceration among African American men have systematically removed men from the community, culminating in detrimental impacts on the sexual networks and health risks of African American women 10 , 35 , Further, the sex ratio, defined as the ratio of eligible African American male to female partners, has been posited as a contributor to racial disparities in HIV and STI infection 2 , Although women in this sample were more likely to perceive a lack of available partners than men This structural phenomenon warrants further exploration with more detailed questions.
After adjusting for key variables of interest, socio-demographic, behavioral, and structural factors were all associated with concurrency in this population using the self-reported concurrency measure, whereas fewer variables were associated with the UNAIDS concurrency measure. These differences may be related to the fact that the two measures differed both in terms of their definition of concurrency and in the methodology used to assess concurrency. Methodological differences may be attributed to participants having greater difficulty recalling exact dates of sex in on a computer-based, self-administered survey that did not include verbal prompts and anchor dates to assist recall in an interview.
Missing data patterns for participants who did provide at least some date information indicated that participants were less likely to be able to provide exact days for dates of first or last sex. Of those providing any date information, 8. In addition, 5. This suggests there may be challenges with recalling precise dates of sex, particularly on a self-administered survey, which could lead to misclassification of true concurrency for a large of participants using the UNAIDS measure. Similar challenges have been reported in other studies employing measures of concurrency using data based on self-report versus overlapping dates 16 , Interestingly, a comparison of participants with insufficient data to determine concurrency on the UNAIDS measure to those who provided enough data to determine concurrency based on both measures, indicated that those who did not provide enough data differed very little on the socio-demographic, behavioral and structural factors examined in this study.
Therefore, despite the greater potential for missing data when using the UNAIDS measure, both produced samples that did not differ substantially on most factors believed to be related to concurrency. As a result, observed differences in this study cannot be attributed solely to differences in the samples produced by each of the measures. The study has several strengths.Women in Jackson Mississippi for sex
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