Social and sexual network characteristics and concurrent sexual partnerships among urban African American high-risk women with main sex partners

Abstract

Social networks, including sexual networks, have increasingly been considered in research addressing HIV disparities in the United States. The goal of this study is to examine correlates of concurrent involvement in multiple sexual partnerships with social (i.e. non-sexual) and sexual network characteristics among a sample of 337 low-income urban African American women reporting main sexual partnerships longer than six months in duration. In the multivariate analyses, women who had larger non-sexual social networks, more family members in that network, and reported high levels of trust in their partner(s) were less likely to be in concurrent partnerships. Women who had one or more sexual partner who used drugs in the past six months were more likely to be in concurrent partnerships. Our results provide further evidence of the important association of drug use and concurrent sexual partnerships, but suggest that family members, immediate and extended, may be an important area of focus in addition to structural interventions that address the root causes of poverty and drug abuse.

Introduction

HIV/AIDS incidence and prevalence are much higher among African Americans than other ethnic or racial groups within the United States (U.S.) [1]. Evidence suggests that individual behaviors, such as the number of sex partners, condom use, and injection drug use do not adequately account for these disparities [2–5]. Using a systems perspective, Diez Roux [6] argues that disease rates are the products of individual characteristics among people in the population, the interactions and interdependencies among these people, the effects of population-level properties on individual health, and the interplay between individual and population-level factors. Population-level parameters, such as social and sexual networks, have thus been increasingly addressed to confront the HIV/AIDS epidemic [7–17].

One component of sexual networks that is thought to contribute to the high incidence and prevalence of HIV among African Americans in the U.S. is sexual concurrency [9]. Concurrent partnerships are sexual relationships that overlap in time, and operational definitions vary by researcher [18–20], although the UNAIDS Reference Group on Estimates, Modeling, and Projections recently proposed a standard definition of overlapping partnerships where sexual intercourse with one partner occurs between two acts of intercourse with another partner; the proposed standard measure is a point prevalence of concurrency [21]. However, concurrent partnerships, like sexual partnerships in general, can take multiple forms. These variations can affect the structure of the sexual network and the overall risk of HIV transmission within the network [22]. Women involved in concurrent sexual relationships within the context of a long-term relationship may have longer concurrency intervals, and may be logical candidates for interventions to help them make their main partnerships mutually exclusive.

Additionally, researchers have noted that risk behaviors and the probability of becoming infected with HIV depend upon sexual networks as well as larger social networks [5,23]. Decision-making, including sexual partner selection, occurs within socially and environmentally structured parameters. Berkman and Glass [24] argue that social networks affect individual behavior through four pathways: 1) social support, 2) social influence, 3) social engagement and attachment, and 4) access to resources and material goods. People gather information from social ties through social comparison and social control, and thus behaviors are largely socially prescribed [25]. The gathering of this information from the social environment to regulate behavior is often not a conscious process [26], and multiple spheres of influence may be present in a person’s social network, including family, friends, co-workers, and sex or drug partners [25]. Since social network members have been shown to have strong influences on a person’s behavior [25,27], social networks have been used to examine HIV risk behaviors [11–17] in addition to sex networks.

Previous research has demonstrated that African Americans are more likely to have concurrent partnerships than other racial or ethnic groups [8, 28–30]. Research on concurrency has thus far focused on associations with individual and partner characteristics, and has been focused on the sexual network [8,28,30–33]. The current paper adds to our previous research on the association of concurrency and individual and partner characteristics among low-income urban African American women at risk for HIV by considering the relationships between social (i.e. non-sexual) and sexual network characteristics and involvement in concurrency in the context of a long-term main partnership [32].

Methods

This study utilized data from the CHAT Project, a social network based HIV/STI prevention study targeted at women in Baltimore, Maryland at high risk of HIV. The CHAT Project was designed to train women to become peer mentors, who would then discuss HIV and STI risk reduction strategies with their social and sexual network members. The sample of CHAT Project included women at risk for HIV (i.e. index participants) and their social network members (i.e. network participants). Index participants were recruited though targeted street outreach, flyers, and referrals from health clinics and community agencies. To be eligible as an index participant, individuals had to be female, between the ages of 18 and 55 years, report heterosexual sex in the past six months, have not injected drugs in the past six months, and have one of the following risk behaviors: had sex with more than one partner in the past six months, had a sex partner who engages in risky behavior (e.g. injection drug user or male who had sex with other men), or snorted/sniffed or smoked heroin or cocaine. Eligible participants completed a baseline interview and invited social and/or sexual network members to enroll in the study. Network members were eligible to participate in the study if they were 18 years or older and one of the following: injected drugs within the past six months, had sex with the index in the last 90 days, or the index felt comfortable discussing HIV and STIs with the network member and interacts with that network member at least a few times a month. Network participants could be men or women.

Index and network participants completed the same baseline survey, administered through trained interviewers and Audio Computer Assisted Software (ACASI), and were offered HIV antibody testing (OraSure HIV testing). Participants were compensated with $35 for completion of the visit. (For more details about recruitment and the intervention see [34]). The Johns Hopkins Bloomberg School of Public Health Institutional Review Board approved the study protocol and materials. The current study focused on baseline data collected from September 2005 through July 2007.

Main Partner Concurrency and Inclusion in the Present Study

For this study, main partner concurrency was defined as having a main sexual partner for more than six months but also reporting multiple sexual partners during the past 90 days. Each participant was asked, “Right now do you have a main sex partner?” Participants were not provided a definition of main partner, however, the researchers leading the CHAT study have a long history of conducting research (including ethnographic research) in the low-income, urban areas of Baltimore. The term “main partner” is widely used to indicate a sex partner that is frequented more than any other, regardless of their official relationship standing. If the respondent indicated that she had a main partner, she was asked how long she had been together with this partner and timeframes were provided (e.g. less than one month, 1–6 months, etc.). Participants were asked how many sex partners they had had in the past 90 days at two different times in the survey. If women reporting main sexual partners for longer than six months duration reported having more than one sex partner in the past 90 days at either time, they were identified as participating in main partner concurrency.

Of the 567 African American women enrolled in the CHAT study, 337 reported that they had a main partner and had been with this main partner for longer than six months, and thus were included in the current analysis; 195 had a main sexual partner more than six months and reported only one sexual partner in the last 90 days, and 142 had a main partner for more than six months and reported more than one sexual partner in the past 90 days. The latter were thus identified as being in concurrent partnerships. The sample included 262 indexes and 75 network members; 47.7% of index participants and 22.7% of network participants were identified as participating in main partner concurrency. (For a detailed comparison of the index and network participants see [32]).

Social Network Variables

A social network inventory was used to collect social and sexual network data for both the index and network member participants. Participants provided the first name and initial of their last name to individuals named in response to questions such as “During the last six months, who could you talk to about things that were personal and private or who could you get advice from?” and “During the last six months, who actually loaned or gave you some money over $25 (or some valuable object that you needed)?” After the network lists were created, characteristics of each network member were collected, including age, gender, nature of the relationship (e.g. friend, relative, neighbor, sex partner), time known, trust (ranging from 1 - “don’t trust at all” - to 10 -“trust with my life”), employment, drug use, and incarceration history. The overall size of the network is a count of the number of people listed in the network inventory. For the purpose of this study, the size of the social network includes only the people identified who are not sex partners, and the size of the sexual network includes only sexual partners.

Eleven aspects of the social and sexual networks that we hypothesize may influence engaging in concurrent relationships were considered for this analysis. Each network variable was measured as the total number: 1) social and sexual network size and subnetwork size for kin, close friends, and female friends; 2) social and sexual network members who provided emotional support (participant actually talked to about things that were personal or private, or who actually gave advice); 3) social and sexual network members who provided financial support (actually provided money or valuable items needed to the participant); 4) social and sexual network members who pitched in to help with tasks such as running errands, giving rides, or watching the children; 5) social and sexual network members who provided any support, including emotional, financial, and/or healthcare; 6) social and sexual network members who the participants are in conflict with (i.e. do not get along with); 7) social and sexual network members who socialize with the participant (including going shopping, to clubs, or just hanging out); 8) social and sexual network members who received financial or material support from the participant; 9) social and sexual network members who use or have used heroin, cocaine, or crack in the past six months; 10) mean length of time the participant has known social and sexual network members (in years); and 11) the mean trust felt for social and sexual network members. Individuals may have been named in multiple categories, and thus these categories are not mutually exclusive [35].

Data Analysis

Univariate, bivariate, and multivariate analyses were conducted with SPSS Software (version18.0). Network variables were highly skewed and thus were dichotomized at the median. Since behaviors and other variables among the index and their recruited network participants could be correlated with each other, all analyses used generalized estimating equations (GEE) to obtain odds ratios (OR) and confidence intervals (CI), using the index and recruited network members as the cluster [36].

Two models were used to obtain ORs and 95% CIs for each social and sexual network characteristic. Model 1 considers each network variable independently, adjusting only for the size of the overall network. In Model 2 each social and sexual network characteristic is controlled for overall network size and individual characteristics. Individual characteristics were included in the models based on previous research that has shown an association with the outcome. The individual variables included were age, education (dichotomized as high school diploma/GED equivalent versus lower), age of sexual debut, relationship status (dichotomized as committed versus not committed as designated by participant), incarceration within the last six months, smoked crack or cocaine in past 3 months, and indication of greater history of drug use. Variables that indicate greater history of drug use included sex for drugs in the past six months, sex while high half or more of the time in the last 90 days, and ever enrolled in a detoxification program and the constructed variable was dichotomized as none or one or more indicator of problem drug use. Additionally, each multivariate model controlled for participant type (index or network).

Results

Demographic and Social Network Characteristics

The mean age of the women included in analysis was 41 years (sd = 7.96). This group of women had low educational attainment (51% did not receive a high school diploma or GED), was largely unemployed but seeking work (46.3%), and had little income in the previous 30 days (49.1% receiving less than $500 a month). One-fourth (25.2%) had been homeless in the past 6 months, and 12.5% had been incarcerated in the past 6 months. Reported crack cocaine use in the last 3 months was high (56.5%), and thus, indicators of problem drug use were also considered; 61.3% of the women had previously been enrolled in a detoxification program, 27.6% reported having sex while high half or more of the time in the past 90 days, and 66.1% had engaged in sexual activity to obtain drugs in the past six months [32].

To be included in the current analysis, women had to have a main sexual partner for longer than six months; however, only 48.4% reported that they were in a committed relationship (married or not) despite many having their main sexual partner for greater than six months. Most of the women reported having their main sexual partner for 1–5 years (42.7%) or more than 5 years (47.8%). Main partner concurrency was reported by 42.1% of the women.

Women reported a median of 7 (sd = 3.65) social network members, which included a median of 4 (sd = 2.65) family members and a median of 3 nonkin (sd = 2.77) members. Most kin members listed were adults, as the median number of children (<18 years) listed was 1 (sd = 1.66). Trust for these social network members was high, with a median trust score of 8.67 (sd = 1.59). The median time social network members were known was 19 years (sd = 8.4). Women also reported high levels of trust in their sex partners (median = 9.0, sd = 2.01) and knew them for a median of 8 years (sd = 9.84).

Social and Sexual Network Correlates of Concurrent Sexual Partnerships

The results of Models 1 and 2 are presented in Table 1 for social (non-sexual) networks and sexual networks. When controlling only for network size (Model 1), having a large social network, a large number of family members, and a large number of women in the social network were protective against main partner concurrency (OR = 0.38, 95% CI: 0.18, 0.83, p = 0.015; OR = 0.50, 95% CI: 0.29, 0.86, p = 0.012; OR = 0.52, 95% CI: 0.27, 1.00, p = 0.05, respectively). Having a large number of social network members who were not family increased the risk of main partner concurrency (OR = 1.94, 95% CI: 1.14, 3.30, p = 0.015). When controlling for network size and individual characteristics (Model 2), having a large social network with a large number of family members included remained protective against main partner concurrency (OR = 0.37, 95% CI: 0.14, 0.94, p = 0.038 and OR = 0.39, 95% CI: 0.18, 0.82, p = 0.014, respectively).

Table 1.

Adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) for concurrent partnerships among urban African American women participating in the CHAT Project

Network characteristic	Network Sizea	%	Model 1b: AOR (95% CI)	Model 2c: AOR (95% CI)
Social (non-sexual) network
Size of network	Large (> 7)	41.5	0.38f (0.18, 0.83)	0.37f (0.14, 0.94)
Number of kin in network	Large (> 4)	38.6	0.50f (0.29, 0.86)	0.39g (0.18, 0.82)
Number of network members, non-sex partner, non-kin	Large (> 3)	43.6	1.94f (1.14, 3.30)	1.79 (0.91, 3.53)
Number of close friends in network	Large (> 2)	38.6	1.06 (0.67, 1.67)	1.20 (0.68, 2.09)
Number of women in network	Large (> 5)	39.2	0.52f (0.27, 1.00)	0.55 (0.25, 1.17)
Social network members whod
Provided emotional support	Large (> 1)	28.8	0.84 (0.50, 1.41)	0.75 (0.39, 1.44)
Provided financial support	Large (> 1)	23.4	1.02 (0.59, 1.76)	1.21 (0.60, 2.42)
Pitched in to help	Large (> 1)	25.5	1.22 (0.71, 2.09)	1.17 (0.59, 2.35)
Provided any support	Large (> 3)	35.0	0.60 (0.35, 1.04)	0.72 (0.35, 1.46)
Are in conflict	Large (> 0)	45.7	0.61f (0.38, 0.97)	0.56 (0.31, 1.01)
Client socialized with	Large (> 1)	38.9	0.78 (0.49, 1.24)	0.92 (0.52, 1.64)
Received financial support from respondent	Large (> 0)	47.2	1.36 (0.86, 2.16)	1.66 (0.94, 2.95)
Used heroin, cocaine, or crack	Large (> 1)	43.9	0.81 (0.51, 1.30)	0.69 (0.37, 1.30)
Mean trust client has for network memberse	Large (> 8.67)	48.1	0.84 (0.53, 1.32)	0.86 (0.49, 1.52)
Length of time client has known network members (in years)	Large (> 19)	49.7	0.81 (0.52, 1.27)	0.77 (0.44, 1.36)
Sexual network
Sexual network members whod
Provided emotional support	Large (> 0)	39.7	1.15 (0.72, 1.83)	1.33 (0.75, 2.37)
Provided financial support	Large (> 0)	48.4	1.53 (0.97, 2.41)	1.65 (0.93, 2.93)
Pitched in to help	Large (> 0)	55.9	0.92 (0.59, 1.45)	0.75 (0.42, 1.32)
Provided any support	Large (> 1)	73.1	0.91 (0.55, 1.49)	1.17 (0.59, 2.33)
Are in conflict	Large (> 0)	32.5	1.71f (1.06, 2.78)	1.51 (0.82, 2.78)
Client socialized with	Large (> 0)	47.2	1.05 (0.66, 1.67)	1.22 (0.68, 2.18)
Received financial support from respondent	Large (> 0)	15.9	0.90 (0.49, 1.65)	0.86 (0.40, 1.84)
Used heroin, cocaine, or crack	Large (> 0)	44.7	1.93g (1.22, 3.04)	1.83f (1.04, 3.25)
Mean trust client has for network memberse	Large (> 9)	48.8	0.22h (0.14, 0.36)	0.30h (0.17, 0.53)
Length of time client has known network members (in years)	Large (> 8)	48.3	1.02 (0.65, 1.61)	1.53 (0.86, 2.74)

^aNetwork size was determined by the median. The odds ratios are based on comparison to network size less than shown in column.

^bControlled for overall network size

^cControlled for participant type (index or network), network size, and individual factors (age, education, sexual debut, relationship status, incarceration in past 6 months, smoked crack or cocaine in past 3 months, indicators of a greater history of drug use)

^dPast 6 months

^eTrust was for network members ranged from 1 –“don’t trust at all” – to 10 – “trust with my life”

^fp ≤ 0.05,

^gp ≤ 0.01,

^hp ≤ 0.001

When controlling for network size (Model 1), reporting conflict with one or more sexual network members and having one or more sexual network members who have used heroin, cocaine, or crack in the past 6 months increased the risk of main partner concurrency (OR = 1.71, 95% CI: 1.06, 2.78, p = 0.029 and OR = 1.93, 95% CI: 1.22, 3.04, p = 0.005, respectively). Having a high level of trust for the sexual partner(s) was protective against main partner concurrency (OR = 0.22, 95% CI: 0.14, 0.36, p < 0.001). When controlling for network size and individual characteristics (Model 2), women who had one or more sex partner who have used heroin, cocaine, or crack in the past 6 months were significantly more likely to be in concurrent partnerships (OR = 1.83, 95% CI: 1.04, 3.25, p = 0.038), while women reporting high levels of trust in their sex partner(s) were less likely to report main partner concurrency (OR = 0.30, 95% CI: 0.17, 0.53, p < 0.001).

Discussion

Several of the social and sexual network variables were significantly associated with main partner concurrency in this sample of low-income urban women. Women who had a larger social (non-sexual) network were less likely to have concurrent sexual partnerships compared to women with smaller social networks. Additionally, having a large number of kin in a woman’s social network was protective against main partner concurrency when controlling for individual factors. Historically, among African Americans of all ages, the family has been the primary source of support for survival and social mobility [37–39], and African Americans have more often lived with, or participated in, extended family networks [38–40]. Numerous studies have documented the protective roles of family in relation to health issues within African American communities [11,14,41–47]. Latkin and colleagues [11], for example, found that among drug users, having a larger number of kin in a person’s social network was associated with reduced activity in exchange sex. Sex partners fulfill a range of roles [48], and thus, among the current cohort of women, it is possible that family members are providing women with emotional and physical support and thus women do not need to seek out additional sex partners for help. Kin may also exert social control and promote norms of partner stability.

Sexual partner drug use increased the risk that a woman participated in main partner concurrency. Our previous findings on individual characteristics and concurrency among this cohort identified problem drug use as increasing the risk of main partner concurrency as well [32]. It is well established that people who abuse drugs, particularly crack, are also at high risk of HIV infection, primarily due to increased involvement in high-risk sex behaviors, including exchanging sex for money and drugs, unprotected sex, increased number of sex partners, and having sex with high-risk partners [49–52]. However, the role of social networks is important in reducing drug abuse, and changing the physical and social environment may play a key role in stopping crack use [53] and supporting relapse prevention [54–55]. Specifically, separating people from the places, things, and people who encourage drug abuse and establishing a social network that supports recovery has been suggested as one step to recovery [55]. Thus, it is possible that the protection offered against main partner concurrency by large social networks and large presence of kin in those networks may also be related to the reduced risk of drug use, abuse, or relapse for members in those networks.

Finally, having high levels of trust in sex partner(s) reduced the risk of main partner concurrency. Findings from our previous research, as well as others considering concurrency, have highlighted the importance of perceived partner nonmonogamy in concurrency among survey respondents [8,28,30,32,56]. Partner instability, including low rates of marriage, and sexual concurrency are related to numerous interacting factors within lower-income African American communities, including norms about relationships, marriage, and premarital sex, unemployment and economic instability, high drug use and abuse, and disproportionately high rates of incarceration [57–62]. Thus, to successfully address HIV/STI disparities within the U.S., considerable attention must be given to the barriers to stable, monogamous relationships [63].

A major strength of this research is that it expands the literature on sexual concurrency by examining correlates of concurrency and social and sexual networks among African American women within a community with high risk of HIV and includes drug users as well as non-drug users. However, there are several limitations. The results may not be generalizable to other racial and ethnic groups, or to African Americans in low-risk environments or rural areas, since this research included only low-income urban African American women residing in a community with high HIV prevalence and levels of drug use. It would be prudent to examine concurrency in other cities with different enrollment criteria to adequately assess the degree of generalizability. Selection bias may have been introduced through the sample’s nonrandom selection. Women were compensated $35 for participation, which was the community norm for compensation. The behaviors considered were self-reported, and may be subject to recall and social desirability bias, with specific selection criteria for a randomized controlled trial for HIV prevention among high-risk women who were not injection drug users and their network members. This paper includes only women who have had main sex partners for more than 6 months and thus we consider concurrency in the context of a partnership of long duration. Thus, these findings are only generalizable to concurrency within the context of a main sexual partnership of long duration. Additionally, this paper considers only women identified as concurrent in the past 90 days, cannot distinguish between short-term and long-term concurrency or types of concurrency, and does not address norms in this cohort regarding monogamy and nonmonogamy. In this analysis, the outcome, main partner concurrency, was common and thus the odds ratios do not approximate the risk ratios [64]. Finally, the study was cross-sectional and therefore limits the ability to make causal inferences.

Conclusion

This study aimed to look beyond individual and partner characteristics to consider the associations of main partner concurrency with the larger social network, including non-sexual and sexual networks. The findings provide further evidence of the importance of drug use in promoting main partner concurrency, but family members, immediate and extended, may be an important area of focus in addition to structural interventions that address the root causes of poverty. Programs for strengthening families through interventions and initiatives [65–67] and engaging sexual partners in HIV prevention efforts [68–70] in addition to addressing the structural contributions to financial, family, and partner instability, such as unemployment, drug abuse, and incarceration, are desperately needed to address factors that lead to concurrency and HIV/STI transmission.