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. Author manuscript; available in PMC: 2024 Nov 25.
Published in final edited form as: Prev Sci. 2024 Feb 19;25(4):638–649. doi: 10.1007/s11121-023-01639-6

A Network Science Approach to Sex-Polydrug Use Among Black Sexually Minoritized Men and Transgender Women: The N2 Cohort Study

Cho-Hee Shrader 1,2, Dustin T Duncan 1, Justin Knox 3,4,5, Yen-Tyng Chen 6, Redd Driver 4, Jonathan S Russell 1,2, Raymond L Moody 1, Mariano Kanamori 7, Mainza Durrell 8,9, Hillary Hanson 8,9, Rebecca Eavou 8,9, William C Goedel 10, John A Schneider 8,9
PMCID: PMC11588306  NIHMSID: NIHMS2033669  PMID: 38372856

Abstract

Black sexually minoritized men (SMM) and transgender women (TW) are subgroups with lower rates of substance use and comparable rates of condom use relative to White SMM and TW yet experience heightened vulnerability to HIV. This study sought to explore associations of substance use, including sex-drug use (i.e., drug or alcohol use during sex to enhance sex), and condomless sex among Black SMM and TW. Data were collected from Black SMM and TW living in Chicago, Illinois, enrolled in the Neighborhoods and Networks (N2) cohort study, from November 2018 to April 2019. We used bivariate analyses followed by a multilevel egocentric network analysis to identify factors associated with condomless sex. We conducted Spearman correlation coefficients to examine correlations between pairs of sex-drugs to enhance sex. We used a bipartite network analysis to identify correlates of sex-drug use and condomless sex. A total of 352 Black SMM and TW (egos) provided information about 933 sexual partners (alters). Of respondents, 45% reported condomless sex and 61% reported sex-drug use. In unadjusted analyses, marijuana (34%) and cocaine/crack (5%) sex-drug use were associated with condomless sex (p < 0.05). Condomless sex was positively associated with sex-polydrug use, or the use of 2+ drugs or 1 drug and alcohol (OR = 1.48; 95% CI: 1.02–2.14; p = 0.039), and negatively associated with sharing an HIV-negative serostatus with a sexual partner (OR = 0.57; 95% CI: 0.33–0.98; p = 0.041), having a different HIV serostatus with a sexual partner (OR = 0.37; 95% CI: 0.21–0.64; p < 0.001) or not knowing the HIV serostatus of a sexual partner (OR = 0.47; 95% CI: 0.26–0.84; p = 0.011). The following pairs of sex-polydrug use had Spearman correlation coefficients higher than 0.3: marijuana and alcohol, ecstasy and alcohol, cocaine/crack and ecstasy, and methamphetamine and poppers (p < 0.05). HIV prevention interventions for Black SMM and TW designed to reduce HIV transmission through egocentric sexual networks could address sex-drug use through sex-positive and pleasure-centered harm reduction strategies and provide and promote biomedical prevention and care options at supraoptimal levels.

Keywords: Sexual minority men, HIV prevention, Multilevel modeling, Polysubstance use, Condom use

Introduction

Black sexually minoritized men (SMM) and transgender women (TW) in the USA continue to experience HIV-related health disparities (Centers for Disease Control & Prevention, 2021a, b; Hess et al., 2017). While new HIV infections significantly decreased among White SMM from 2010 to 2019, incidence did not decrease among Black SMM and TW during this same time period (Pitasi et al., 2021). Ample research, including Baral’s modified social ecological model, has suggested that disparities in HIV prevention uptake are not due to lack of uptake but multilevel barriers to care including individual and network factors (Baral et al., 2013). Millet et al. (2007a, b) and Maulsby et al. (2014) found that network-level factors (i.e., sexual assortativity or homo-phily) could begin to explain racial disparities in HIV vulnerability among SMM (Maulsby et al., 2014; Millett et al., 2007a, b). Black SMM were found to have sexual partners who were also Black at a threefold higher level than chance alone (Raymond & McFarland, 2009). In the context of this study, this means that Black SMM and TW may be more likely to have sex with other Black SMM and TW (relative to White SMM and TW for example), groups experiencing the highest HIV prevalence, thereby increasing vulnerability to HIV relative to sex with other racialized groups (Maulsby et al., 2014; Millett et al., 2007a, b).

Substance use and HIV are interrelated epidemics (Baral et al., 2013), or a syndemic (Singer & Clair, 2003; Singer et al., 2017). Black SMM and TW experience enhanced vulnerability to substance use during sex despite having lower rates of substance use and sexual behaviors with heightened HIV vulnerability (Callander et al., 2019). Not only are substance use and sex-drug use higher among White SMM, but also the consequences are greater for Black SMM and TW due to a lack of access to biomedical prevention options (Centers for Disease Control & Prevention, 2018), health disinvestment (Nuriddin et al., 2020), and within-group mixing (Maulsby et al., 2014; Millett et al., 2007a, b; Schneider et al., 2013). Sex-drug use could increase sexual behaviors with heightened vulnerability to HIV, such as condomless sex (Yu et al., 2015) or sex with someone living with HIV (LWH) or unknown serostatus (Sewell et al., 2017).

Social norms surrounding a behavior within a network have been shown to be associated with alcohol use (Knox et al., 2019), drug use (Schneider et al., 2013), and sexual behaviors with heightened vulnerability to HIV such as group sex and sex-drug use during sex (Shrader et al., 2023). Additionally, sex-drug use is associated with negative HIV outcomes among Black SMM (Morgan et al., 2016). Substance use plays a complex role in HIV acquisition: daily marijuana use (Knox et al., 2022) and stimulant use have been associated with HIV acquisition (Pakianathan et al., 2018) perhaps because SMM may use substances to cope with negative emotions, in part due to intersecting discrimination at societal levels (Duncan et al., 2020; English et al., 2020; Feinstein & Newcomb, 2016). Not only does sex-drug use enhance sexual arousal and pleasure during sex (Feinstein & Newcomb, 2016; Wray et al., 2020), but also alcohol or drug use may decrease internalized homophobia to make sex more pleasurable (Feinstein & Newcomb, 2016). Sex-drug use is also linked to behavioral disinhibition through the moderation of sensation seeking (Newcomb et al., 2011) and the impairment of judgement to reduce condom use (Allen et al., 2015; Steele & Josephs, 1990). Previous studies have found that 58% of Black SMM and TW report using drugs or alcohol before sex in the past 6 months (Dangerfield et al., 2021) and 33% of Black SMM reported stimulant use during sex at least monthly (Mimiaga et al., 2010); however, it is unclear whether these substances are used to enhance sex and what other factors at the individual level (i.e., ego) or sexual partner level (i.e., alter) influence condom use during sex.

There is also a gap in characterization of the specific drug combination during sex-drug use among Black SMM and TW which may enhance HIV vulnerability. Previous studies have focused on the utility of latent class analyses and found that SMM who use substances can be typologized into different patterns of substance use, group assignments which are associated with increased HIV risk behaviors such as condomless sex (McCarty-Caplan et al., 2014; Scholz-Hehn et al., 2022; Wong et al., 2020). For example, people who engage in sex-drug use (also known as “chemsex” in European and Asian contexts) have been grouped into labels such as “intense drug users” (i.e., extensive use of different types of drugs including poppers, methamphetamine, GHB, and erectile dysfunction drugs),“sex drug users” (i.e., use of methamphetamine, poppers, club drugs (MDMA, ecstasy, ketamine, GHB), and erectile dysfunction drugs) (McCarty-Caplan et al., 2014), and “polyvalent users” (i.e., use of a wide range of substances including cannabis, poppers, MDMA, cocaine, amphetamine, methamphetamine, ketamine, GHB) (Scholz-Hehn et al., 2022). However, these studies did not examine which drugs were specifically used together to enhance the sexual experience and instead focused on broader drug use. Exploration of a two-mode affiliation network, whereby modes are the drugs used during sex and the sexual encounters (Borgatti & Everett, 1997), could provide greater insight into which drugs are used together during sex among Black SMM and TW while accounting for other critical factors operating at relevant network levels. This understanding could refine intervention components to be inclusive and tailored to specific potential sex-polydrug use, or the use of 2 or more drugs, or one or more drugs and alcohol use during sex.

Previous studies have focused on general substance use and associations of condom use without examining condom use at the sexual partner level using an egocentric approach. Other studies have also focused on describing typologies of substance use without examining specific sexual partner-level substance use and associations of condomless sex. To provide a clearer understanding of factors associated with condomless sex at the sexual partner level, including sex-drug and sex-polydrug use, this study aims to examine the sexual network-level associations of condom use during anal sex among Black SMM and TW living in Chicago, Illinois, USA. We hypothesize that there are associations of individual respondent-level (i.e., age, gender, sexual orientation, housing stability, education, relationship status, income, employment status, and adherence to PrEP or viral suppression) and sexual partner-level (i.e., gender, Black racial identity, type of partner, HIV serostatus difference, communication frequency, sex-drug use) factors, on the outcome of condomless sex, a sexual behavior with heightened vulnerability to HIV.

Material and Methods

This study utilized baseline data from Black SMM and TW from the Neighborhoods and Networks (N2) Cohort Study. Black SMM and TW were recruited using convenience sampling at a community health center and clinic in Chicago, Illinois, USA, and peer referral sampling, which has been successfully used in recruiting this population previously (Coombs et al., 2014; Schneider et al., 2017). Respondent inclusion criteria included (a) identifying as Black or African American, (b) being age 16 years or older, (c) being assigned male at birth, (d) residing in the Chicago Metropolitan Statistical Area (MSA), (e) reporting at least one sexual encounter with a cisgender man or transgender woman in the past year, (f) being willing to wear a GPS device, and (g) having no plans to move from the Chicago MSA during the course of the study. Respondents provided informed written consent, and then, data were collected by trained interviewers from January 2018 until December 2019 using interviewer-administered computer-assisted assessments in a private room at the study site. Assessments lasted 1–2 h in length and consisted of respondents (i.e., egos) completing a sociodemographic and behavioral assessment and an egocentric network inventory of sexual partners (i.e. alters) and providing blood for an HIV test and viral load count. Respondents were provided $150 for their time. Additional information about the study can be found elsewhere (Duncan et al., 2019). We used the STROBE guidelines to prepare our manuscript (Vandenbroucke et al., 2007).

Respondent-Level Sociodemographic and Behavioral Characteristics

Respondents provided their age (in years), gender (cisgender man; transgender woman or a non-binary identity), housing instability in the past year (experienced housing instability; did not experience housing instability), educational obtainment (high school degree; no high school degree), relationship status (single; in a relationship), income (below $20,000 or $20,000 or above), HIV serostatus (LWH; HIV negative), and adherence to PrEP or ART. Respondents’ HIV serostatus was assessed at baseline through an HIV test, PrEP use was self-reported, and viral suppression was assessed at baseline through a lab-confirmed blood test if respondents had an HIV viral load of 200 copies/mL.

Sexual Partner-Level Sociodemographic, Behavioral, and Relationship Characteristics

Respondents named up to 5 people that they had sex with in the past 6 months. Respondents provided each sexual partner’s gender (cisgender man, cisgender woman; or transgender) and race (Black; not Black). Respondents also provided the HIV serostatus of their sexual partners, from which we calculated measures of HIV homophily, otherwise known as status concordance (the respondent and sexual partner are both HIV negative (concordant); the respondent and sexual partner are both PLWH (concordant); the respondent’s and sexual partner are serostatus different (discordant); the respondent does not know the HIV status of their sexual partner), communication frequency (continuous; 0 = never or less than once a year, 1 = once a year, 2 = couple times a year, 3 = once a month, 4 = once every 2 weeks, 5 = once a week, 6 = several times a week, 7 = every day, 8 = several times a day), and type of partner (main; casual; exchange partner). Additionally, respondents provided information about the respondent’s or the sexual partners’ use of drugs or alcohol to enhance sex (i.e., sex-drug or sexpolydrug use) through the questions “When you had sex, did you or [sexual partner’s name] use alcohol or drugs to enhance the sexual experience?” (yes; no) and “Which of the following did you or [sexual partner’s name] use when you had sex?” (select all that apply options included alcohol; marijuana (weed, hash, blunt, etc.); ecstasy, E, or molly, cocaine/crack, poppers (volatile nitrates); methamphetamine (crystal, “tina,” meth, speed); psychedelics or party drugs (acid, LSD, mushrooms, G or GHB, K or Special K, PCP, etc.); prescription painkillers (oxycodone, Vicodin, T3, etc.); and heroin). Finally, respondents provided information about consistent condom use during anal or vaginal sex: if respondents indicated that they did not consistently use a condom during anal or vaginal sex with a sexual partner, they were considered to have engaged in condomless sex.

Descriptive Analysis

We compiled descriptive statistics for respondents and sexual partners stratified by the outcome variable of interest, condomless sex. We used a series of bivariate analyses to compare differences between sexual partners using the chi-squared test, Fisher’s exact test, or independent sample t-tests at alpha < 0.05.

Multilevel Logistic Regression Models Examining Condomless Sex

We specified a series of multilevel logistic regression models to assess the relationship between respondents (level 2) and sexual partner-level variables (level 1) (Wong & Mason, 1985). Our logistic regression models estimated odds ratios (ORs) and 95% confidence intervals. First, we specified the null model examining condomless sex as the outcome variable and identified the intra-class correlation. Then, we specified the final hierarchical logistic regression model examining condomless sex as the outcome variable, including our variables of interest at the respondent and sexual partner level.

Two-Mode Analyses

We explored the relationship between specific substance use and condomless sex using a series of chi-squared analyses of Fisher’s test (cell count < 5) and a bipartite network approach (i.e., two-mode). In a bipartite network, we can examine the relationship between substances to identify which substances were used during sex in tandem. As bipartite networks are difficult to analyze in their natural state, we first converted this network into a one-mode network (Borgatti & Everett, 1997; Snijders et al., 2013). Once we projected the relationships between substances used during sex into a one-mode network, we conducted a Spearman correlation plot to identify significant relationships between substances at alpha < 0.05 and for which correlation is equal to or higher than 0.30. We chose to identify correlations above 0.30 in our exploratory analysis because this indicates a fair correlation (Akoglu, 2018; Chan, 2003). Correlations above 0.5 are considered to be strong and we indicate these correlations as well (Akoglu, 2018; Chan, 2003). We also determined the percentage of the relationships in which two substances were used in tandem during sex, when either substance was used during sex (i.e., sex-polydrug use). All descriptive and statistical analyses were conducted using the R environment (R Core Team, 2013). After projecting our one-mode networks of substance use, we visualized the one-mode network of polysubstance use using Cytoscape (Shannon et al., 2003).

Results

A total of 412 respondents were enrolled into the N2 study, of which 379 Black SMM and TW provided information about 998 sexual partners. There were complete data available for 352 respondents and 933 sexual partners. Respondents reported being a median age of 25 years. The majority of respondents identified as cisgender men (89%), did not experience housing instability (70%), were high school educated (87%), and reported single relationship status (62%) and an income below $20,000 (66%). Of respondents, 21% reported currently using PrEP and 26% were virally suppressed. We found that of respondents, 61% reported sex-drug use, 40% reported sex-polydrug use, and 79% reported condomless sex. Additional information about respondents can be found in Table 1.

Table 1.

Background information about respondents, n = 352

Overall
Median age [min, max] 25.0 [16.0, 36.0]
Gender
 Cisgender man 312 (88.6%)
 Transgender woman 40 (11.4%)
Housing instability 105 (29.8%)
High school education 305 (86.6%)
Single relationship status 218 (61.9%)
Income is below $20,000 231 (65.6%)
HIV care cascade continuum
 HIV negative, not engaged in care (not using PrEP) 127 (36.1%)
 Living with HIV, not engaged in care (not virally suppressed) 61 (17.3%)
 HIV negative, engaged in care (PrEP use) 72 (20.5%)
 Living with HIV, engaged in care (virally suppressed) 92 (26.1%)
Used any drugs or alcohol to enhance sex (sex-drug use) 214 (60.8%)
Used 2+ drugs or 1 drug and alcohol to enhance sex (poly sex-drug use) 140 (39.8%)
Reported condomless sex 280 (79.5%)
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Respondents reported a mean of 2.6 sexual partners and described sexual partners as majority cisgender men (84%), Black (86%), casual sex partners (68%), and serostatus concordant (59%). Respondents reported sex-drug use to enhance sex with 45% of sexual partners; sex-polydrug use to enhance sex with 26% of respondents; exchanging sex for money, food, drugs, or shelter with 6% of sexual partners; and condomless sex with 56% of sexual partners. There were statistically significant differences between sexual partners with whom respondents had condomless sex with relative to whom they did not have condomless sex regarding gender (of sexual partners that respondents had condomless sex with, 80% were cisgender men, 13% were cisgender women, and 7% of transgender women, but among those sexual partners that respondents consistently used condoms with during sex, 89% were cisgender men, 7% were cisgender women and 3.5% were transgender women; p < 0.001), partner type (of sexual partners that respondents had condomless sex with, 35% were main partners, 61% were casual partners, and 4% were exchange partners, but among those sexual partners that respondents consistently used condoms with during sex, 17% were main partners, 77% were casual partners, and 6% were exchange partners; p < 0.001), and communication frequency (of sexual partners that respondents had condomless sex with, 39% communicated daily, 38% communicated weekly, 20% communicated monthly, and 20% communicated yearly, but among those sexual partners that respondents consistently used condoms with during sex, 25% communicated daily, 30% communicated weekly, 21% communicated monthly, and 24% communicated yearly; p < 0.001). In addition, there were statistically significant differences in condom use based on HIV homophily: of sexual partners that respondents had condomless sex with, 48% were homophilous on HIV-negative serostatus, 16% were homophilous on LWH, 20% had different HIV serostatus, and 17% of sexual partners’ HIV serostatus was unknown, but among those sexual partners that respondents consistently used condoms with during sex, 45% were homophilous on HIV-negative serostatus, 7% were homophilous on HIV-positive serostatus, 26% had different HIV serostatus, and 21% of sexual partners’ HIV serostatus was unknown (p < 0.001). Further, there were statistically significant differences in the use of drugs or alcohol to enhance sex (i.e., sex-drug use), with a higher percentage of sex-drug use being reported during condomless sex relative to consistent condom use during sex (49% vs 38%; p = 0.001). More specifically, sex-polydrug use (30% vs 20%; p = 0.002), mari-juana as a sex-drug (41% vs 26%; p < 0.001), and cocaine/crack as a sex-drug (6% vs 3%; p = 0.007) were higher during condomless sex relative to consistent condom use during sex. Table 2 provides additional information about sexual partners and sex-drug use, stratified by whether respondents ever had condomless sex with the sexual partner in the past 6 months.

Table 2.

Sexual partner characteristics of Black sexually minoritized men and transgender women by condom use behaviors, 2019, n = 933

No condomless sex (N = 405) Had condomless sex (N = 528) Overall (N = 933) Test statistic p-value
Gender χ2 = 15.28 < 0.001
 Cisgender man 362 (89.4%) 422 (79.9%) 784 (84.0%)
 Cisgender woman 29 (7.2%) 71 (13.4%) 100 (10.7%)
 Transgender woman 14 (3.5%) 35 (6.6%) 49 (5.3%)
Black identity 340 (84.0%) 461 (87.3%) 801 (85.9%) χ2 = 1.86 0.172
Partner type χ2 = 38.19 < 0.001
 Main partner 68 (16.8%) 184 (34.8%) 252 (27.0%)
 Casual partner 311 (76.8%) 321 (60.8%) 632 (67.7%)
 Exchange partner 26 (6.4%) 23 (4.4%) 49 (5.3%)
Communication frequency χ2 = 21.53 < 0.001
 Daily 101 (24.9%) 205 (38.8%) 306 (32.8%)
 Weekly 123 (30.4%) 137 (25.9%) 260 (27.9%)
 Monthly 85 (21.0%) 98 (18.6%) 183 (19.6%)
 Yearly 96 (23.7%) 88 (16.7%) 184 (19.7%)
HIV homophily χ2 = 21.75 < 0.001
 Respondent and sexual partner have HIV-negative serostatus 183 (45.2%) 251 (47.5%) 434 (46.5%)
 Respondent and sexual partner are LWH 29 (7.2%) 84 (15.9%) 113 (12.1%)
 Respondent and sexual partner have different HIV serostatus 107 (26.4%) 103 (19.5%) 210 (22.5%)
 Respondent does not know sexual partner’s HIV serostatus 86 (21.2%) 90 (17.0%) 176 (18.9%)
Used drugs or alcohol to enhance sex (sex-drug use) 155 (38.3%) 261 (49.4%) 416 (44.6%) χ2 = 11.11 0.001
 Poly sex-drug use (used 2+ drugs or 1 + drugs and alcohol to enhance sex) 82 (20.2%) 156 (29.5%) 238 (25.5%) χ2 = 9.95 0.002
 Marijuana (weed, hash, blunt, etc.) 104 (25.7%) 214 (40.5%) 318 (34.1%) χ2 = 21.85 < 0.001
 Alcohol 115 (28.4%) 178 (33.7%) 293 (31.4%) χ2 = 2.77 0.096
 Ecstasy, E, or molly 17 (4.2%) 34 (6.4%) 51 (5.5%) χ2 = 1.82 0.178
 Cocaine/crack 10 (2.5%) 34 (6.4%) 44 (4.7%) χ2 = 7.18 0.007
 Poppers (volatile nitrates) 8 (2.0%) 21 (4.0%) 29 (3.1%) χ2 = 2.42 0.120
 Methamphetamine (crystal, “tina,” meth, speed) 10 (2.5%) 17 (3.2%) 27 (2.9%) χ2 = 0.23 0.631
 Psychedelics or party drugs (acid, LSD, mushrooms, G or GHB, K or Special K, PCP, etc.) 1 (0.2%) 5 (0.9%) 6 (0.6%) χ2 = 0.833 0.242
 Prescription painkillers (oxycodone, Vicodin, T3, etc.) 1 (0.2%) 2 (0.4%) 3 (0.3%) χ2 = 0.00 1.000
 Heroin 0 (0%) 1 (0.2%) 1 (0.1%) χ2 = 0.00 1.000
Exchanged sex for money, food, drugs, or shelter 25 (6.2%) 28 (5.3%) 53 (5.7%) χ2 = 0.18 0.670
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“Did not have condomless sex” and “Condomless sex” display row variable percentages and “Overall” column displays column percentages

Results of the Hierarchical Logistic Regression Model Examining Condomless Sex

According to the null model, approximately 11.5% of the variance of the outcome (condomless sex) is due to within respondent effects. This suggests that there is not much similarity between sexual partners of the same respondent; instead, the variance is due mostly to within sexual partner effects. At the sexual partner level (level 1), we found that respondents had higher odds of condomless sex with sexual partners who were cisgender women (OR = 2.33, 95% CI: 1.30–4.18, p = 0.004) relative to cisgender men and with sex-polydrug use (OR = 1.48, 95% CI: 1.02–2.14, p = 0.039). At the sexual partner level, respondents had lower odds of condomless sex if the sexual partner was either a casual partner (OR = 0.43, 95% CI: 0.29–0.65, p < 0.001) or an exchange partner (OR = 0.36, 95% CI: 0.17–0.78, p = 0.009), relative to a main partner, and if the respondent were concordant or homophilous on HIV-negative serostatus (OR = 0.57, 95% CI: 0.33–0.98, p = 0.041) and had a different HIV serostatus with the sexual partner (OR = 0.37, 95% CI: 0.21–0.64, p < 0.001) or the respondent did not know their sexual partner’s HIV status (OR = 0.47, 95% CI: 0.26–0.84, p = 0.011), relative to the respondent and sexual partner being homophilous on LWH. At the respondent level, respondents who reported an income below $20,000 had lower odds of condomless sex relative to those reported an income of $20,000 or more (OR = 0.67, 95% CI: 0.46–0.98, p = 0.038). The full results of the multilevel logistic regression model examining condomless sex can be found in Table 3.

Table 3.

Multilevel factors associated with condomless sex among Black sexually minoritized men and transgender women in Chicago, n = 352 respondents and 933 sexual partners

Predictors Odds ratios 95% CI P
(Intercept) 2.46 0.54–11.33 0.247
Level 1: sexual partner-level attributes
 Gender (ref = cisgender man)
  Cisgender woman 2.33 1.30–4.18 0.004
  Transgender woman or nonbinary 2.09 0.99–4.40 0.053
 Black (ref = not Black) 1.40 0.90–2.16 0.137
 Type of partner (ref = main)
  Casual partner 0.43 0.29–0.65 < 0.001
  Exchange partner 0.36 0.17–0.78 0.009
 Used drugs or alcohol to enhance sex (ref = no sex-drug use)
  Sex-drug use (only 1 drug or alcohol) 1.36 0.91–2.02 0.130
  Sex-polydrug use (2+ drugs or 1 drug and alcohol) 1.48 1.02–2.14 0.039
HIV status homophily (ref = respondent and sexual partner are LWH)
  Respondent and sexual partner are HIV negative 0.57 0.33–0.98 0.041
  Respondent and sexual partner have different HIV status 0.37 0.21–0.64 < 0.001
  Respondent doesn’t know sexual partner’s HIV status 0.47 0.26–0.84 0.011
 Communication frequency 1.02 0.96–1.10 0.501
Level 2: respondent-level attributes
 Age 1.00 0.96–1.05 0.763
 Transgender woman (ref = cisgender male) 1.76 0.98–3.18 0.059
 Hispanic/Latine identified 0.73 0.40–1.32 0.294
 Sexual orientation (ref = gay/homosexual)
  Bisexual 0.85 0.57–1.26 0.413
  Another LGBTQ sexual identity 0.96 0.25–3.67 0.950
  Straight or heterosexual 0.67 0.28–1.60 0.369
 Housing instability 1.02 0.71–1.48 0.903
 No high school degree 1.19 0.71–2.01 0.506
 Single relationship status 0.93 0.66–1.32 0.703
 Income below $20,000 0.67 0.46–0.98 0.038
 No full-time employment 1.31 0.92–1.87 0.139
 Adherent to PrEP or virally suppressed 0.95 0.68–1.33 0.782
Random effects
 σ2 3.29
 τ00 Respondent 0.28
 ICC 0.08
 N Respondent 352
 Observations 933
 Marginal R2/conditional R2 0.132/0.199
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Results of Bipartite Network Analyses Examining Substance Use During Sex

Figure 1 displays the two-mode bipartite network, projected as a one-mode network using a force-embedded layout, weighted by the edge weight (i.e., number of times a sex-drug was connected to another sex-drug). This figure displays how different substances used during sex are associated with other substances which were used during sex by the respondent and sexual partner dyad. The edges between the substances are weighted; thus, thicker edges indicate a higher number of both substances being used using sex. Edge color indicates the significance of the correlation: black edges indicate that the Spearman correlation value was above 0.3 and significant at p < 0.05 and gray ties indicate that the Spearman correlation value was below 0.3 or not significant at p < 0.05. The weighted edge value is the Spearman correlation value of those two sex-drugs. The size of the node, or the substance, shows how often it was used by a respondent or their sexual partner to enhance sex.

Fig. 1.

Fig. 1

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One-mode projected network of sexpolydrug use among Black sexually minoritized men and transgender women in Chicago, Illinois

There were statistically significant correlations between marijuana and alcohol (53% of respondents and sexual partners used in tandem during sex when either drug was used), ecstasy and alcohol (15% of respondents and sexual partners used in tandem during sex when either drug was used), cocaine/crack and ecstasy/MDMA (30% of respondents and sexual partners used in tandem during sex when either drug was used), methamphetamine and poppers (20% of respondents and sexual partners used in tandem during sex when either drug was used), and heroin and psychedelics or party drugs (17% of respondents and sexual partners used in tandem during sex when either drug was used). It is important to note that only one respondent reported using heroin as a sex-drug. Because of this, associations with heroin must be interpreted with caution. Additional information about percentage of sexual relationships in which both substances were used when either substance was used can be found in Table 4.

Table 4.

Correlation of poly sex-drug use among Black sexually minoritized men and transgender women in Chicago

Marijuana Alcohol Ecstasy Cocaine/crack Poppers Methamphetamine Psychedelics or party drugs Prescribed painkillers Heroin
Marijuana 1
Alcohol 52.75%*** 1
Ecstasy 12.16% 15.44%*** 1
Cocaine/crack 10.37% 13.09% 30.14*** 1
Poppers 7.10% 6.98% 12.77% 12.31% 1
Methamphetamine 5.35% 2.56% 6.57% 4.41% 21.74%*** 1
Psychedelics or party drugs 1.89% 2.05% 5.56% 8.70% 6.06% 3.13% 1
Prescribed Painkillers 0.94% 1.04% 1.89% 2.17% 0% 0% 0% 1
Heroin 0.31% 0.34% 1.89% 2.27% 3.45% 3.70% 16.67** 0% 1
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*

Spearman correlation values greater than 0.30 and p < 0.05;

**

Spearman correlation values greater than 0.40 and p < 0.05;

***

Spearman correlation values greater than 0.50 and p < 0.05

Discussion

We sought to identify sexual partner-level associations of condomless sex among Black SMM and TW and explore sex-polydrug use using two-mode network analyses. We found that the sexual partner’s gender and sex-polydrug use were positively associated with condomless sex, whereas type of partnership (i.e., casual or exchange partner relative to main partner), having an HIV-negative serostatus and having a partner with an HIV-negative serostatus, having a different HIV serostatus with sexual partners, not knowing a sexual partner’s HIV status, and having an income below $20,000 were negatively associated with condomless sex. Respondents who reported using marijuana or cocaine/crack were more likely to engage in condomless sex. Our findings provide greater insight into which drugs are used together during sex, and the association of sex-drug use and condomless sex. Our findings could contribute towards the refinement of substance use and HIV prevention intervention components to be inclusive and tailored to communities who engage in sex-polydrug use.

Importantly, we found that sex-polydrug use to enhance sex was found to be associated with condomless sex, but sex-drug use (i.e., sex-drug use with only one drug or alcohol) was not associated with condomless sex. To the best of our knowledge, this may be a novel contribution to the literature. The most used sex-drugs by Black SMM and TW included marijuana (34%), alcohol (31%), ecstasy (6%), and cocaine/crack (5%); however, only marijuana and cocaine/crack use were associated with condomless sex. Our findings support previous studies which establish that Black SMM and TW who reported marijuana use (Bustamante et al., 2022; Kelly et al., 2013; Morgan et al., 2016) or cocaine/crack use (Kelly et al., 2013; Tobin et al., 2011) during sex also report condomless sex. Contrary to previous studies, we did not find an association between alcohol use (Hess et al., 2015; Purcell et al., 2001) or methamphetamine use (Ober et al., 2009) with condomless sex in our unadjusted models. Methamphetamine use was low (2.7%) in our sample and lower than cocaine/crack use: a finding in alignment with the existing literature on Black SMM (Millett et al., 2007a, b; Ober et al., 2009). This could be due to the wider availability of marijuana and cocaine/crack in the Chicago area in 2019 (Drug Enforcement Administration, 2019) and the low cost of cocaine/crack relative to other illicit drugs (Palamar et al., 2015). However, as the availability and use of methamphetamine continues to increase among Black communities in Chicago, future interventions may need to redirect focus to also include methamphetamine use if usage increases (Drug Enforcement Administration, 2019). This supports the need for HIV prevention interventions to be tailored for the geographic region, including the unique substance use environment and availability. Future qualitative research is needed to understand the context and characteristics of substance use during sex and how substance use may be introduced into sex (or vice-versa).

Although only 45% of sexual relationships were contextualized by drug or alcohol use during sex, the majority (61%) of respondents reported drug or alcohol use to enhance sex in the past 6 months and 26% of Black SMM and TW reported engaging in sex-polydrug use. Previous research on sex-drug use has suggested that drug use can enhance sexual arousal and more pleasureful sex (Wray et al., 2020). Marijuana has been established previously as increasing sensitivity, pleasure, and emotional intensity of sex and orgasm (Palamar et al., 2018). Thus, Black SMM and TW may engage in condomless sex after or concurrent with the use of marijuana or cocaine/crack with the goal of engaging in pleasurable sex or “sensation seeking” (Kalichman & Rompa, 1995). It has been established that condom use during sex can diminish pleasure (Randolph et al., 2007; Siegler et al., 2014) or performance (Shrader et al., 2021; Siegler et al., 2014), be a “turn-off” (Crosby et al., 2008), and interfere with the expression of love, intimacy, and trust (Flowers et al., 1997; Mitchell, 2014; Mitchell et al., 2012; Worth et al., 2002). Our study found that Black SMM and TW reported condomless sex with 45% of their sexual partners, suggesting that additional HIV prevention efforts are needed, which should be love-, intimacy-, pleasure-, and trust-centered and account for HIV prevention strategy preferences.

In addition to condoms, biomedical prevention including ART and PrEP can be offered at supraoptimal levels (Fauci, 2016). As our sample had both PLWH- and HIV-negative people and less than half of respondents reported current PrEP use or were found to be virally suppressed (47%), this finding necessitates the importance of increasing the use of biomedical prevention strategies such as ART (Eisinger et al., 2019), oral PrEP (Liu et al., 2013), injectable PrEP (Network, 2017), and PrEP-on-demand (2-1-1 PrEP) (Molina et al., 2015) in addition to condoms among Black SMM and TW. Although PrEP or viral suppression (i.e., U = U) is not a replacement for condom use, it is sometimes perceived that PrEP could replace condoms (Mitchell et al., 2016) or that PrEP/ART could confer protection in instances when condom use was intended but did not occur (Bourne et al., 2017). Thus, HIV prevention interventions designed to reduce HIV transmission through sex could focus on initiation and adherence to long-acting biomedical prevention strategies (i.e., injectable PrEP, ART).

Limitations

This study is not without limitations. First, there may be social desirability bias within our study as survey items were interviewer-administered. Because our data were selfreported and collected by an interview-administered egocentric inventory, our data may be subject to recall bias. Additionally, we used peer referral recruitment to recruit respondents and did not adjust for potential dependencies using an estimator. However, we conducted sensitivity analyses which controlled for possible dependencies related to peer referral recruitment. Further, substance use and condomless sex were assessed at the sexual partner level, and we did not account for specific acts of sex between respondents and their sexual partners because the data were unavailable, which may have provided additional clarity. In addition, because this is a cross-sectional study, we cannot make inferences of causality. Finally, it is important to note that only one respondent reported using heroin with a sexual partner: statistical associations with heroin must be interpreted with caution.

Conclusions

Although sex-drug use was not associated with condomless sex, sex-polydrug use was associated with condomless sex. Sex-polydrug use may have additive and interactive effects related to the substances being used which may further impair HIV risk reduction decision-making. HIV prevention interventions for Black SMM and TW designed to reduce HIV transmission should address sex-polydrug use through sex-positive and love-, intimacy-, trust-, and pleasure-centered harm reduction strategies. Additionally, there is not only a need to continue the provision but also the promotion of biomedical prevention and care options at supraoptimal levels.

Funding

All authors report support from the National Institute on Mental Health (R01MH112406, PI: Duncan and Schneider), the CDC under the Minority HIV/AIDS Research Initiative (U01PS005122, PI: Duncan). Dr. Shrader’s efforts were supported by the National Institute on Drug Abuse (R25DA026401; P30DA011041) and along with Mr. Russell the National Institute of Allergy and Infectious Diseases (T32AI114398). Dr. Chen and Schneider’s efforts were supported by the National Institute on Drug Abuse (R03DA053161). Dr. Driver’s efforts were supported by the National Institute of Mental Health (T32MH019139, PI: Sandfort). Dr. Knox’s effort on this project was funded by NIH grants K01AA028199, R01DA054553, and R21DA053156. Drs. Shrader and Moody were supported by the National Institute on Drug Abuse (T32DA031099) and Dr. Moody by a grant from the National Center for Injury Prevention and Control, CDC to the Center for Injury Epidemiology and Prevention at Columbia University (R49CE003096, PI: Branas). The University of Chicago authors were supported in part by the National Institute on Drug Abuse (U2CDA050098, PI: Schneider).

Footnotes

Ethics Approval All procedures performed in studies involving human respondents were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Columbia University IRB (IRB-AAAS7654) and The University of Chicago Medical Center IRB (IRB16–1419) provided ethical approval and oversight of this study.

Consent to Participate All respondents provided written consent before participating in this study.

Conflict of Interest The authors declare no competing interests.

Data Availability

Data may be requested from the corresponding author and may be provided upon reasonable request. The code may be requested from the first author and may be provided upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data may be requested from the corresponding author and may be provided upon reasonable request. The code may be requested from the first author and may be provided upon reasonable request.

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