Experiences of Racial Discrimination and Relation to Sexual Risk for HIV among a Sample of Urban Black and African American Men

Abstract

This study aimed to examine racial discrimination and relation to sexual risk for HIV among a sample of urban Black and African American men. Participants of this cross-sectional study were Black and African American men (N = 703) between the ages of 18 and 65 years, recruited from four urban clinical sites in the northeast. Multivariate logistic regression models were used to analyze the relation of reported racial discrimination to the following: (1) sex trade involvement, (2) recent unprotected sex, and (3) reporting a number of sex partners in the past 12 months greater than the sample average. The majority of the sample (96 %) reported racial discrimination. In adjusted analyses, men reporting high levels of discrimination were significantly more likely to report recent sex trade involvement (buying and/or selling) (adjusted odds ratio (AOR) range = 1.7–2.3), having recent unprotected vaginal sex with a female partner (AOR = 1.4, 95 % confidence interval (CI), 1.1–2.0), and reporting more than four sex partners in the past year (AOR = 1.4, 95 % CI, 1.1–1.9). Findings highlight the link between experiences of racial discrimination and men's sexual risk for HIV.

Introduction

The high prevalence of racial discrimination reported by African American men in the USA has been well-documented,^1–6 and growing research showcases significant relations between experiences of racial discrimination and negative physical and mental health outcomes.^7–10 To date, however, less is known about how experiences of racial discrimination may influence health behaviors within this population.

HIV is one health issue of particular concern among African American communities.¹¹ Although African Americans comprise 13 % of the US population, they constitute 49 % of those living with HIV/AIDS.¹² African American men are largely affected; the rate of new HIV infection for African American men is six times as high as that of White men, nearly three times that of Hispanic/Latino men, and more than twice that of African American women.¹¹ Community disenfranchisement and marginalization (resulting in high rates of unemployment, poverty, incarceration, and substance use) related to a history of institutionalized racism experienced by African American communities in the USA have largely been attributed to the disproportionately high prevalence of HIV in African American communities.^13–17 However, less work has examined whether individual experiences of racial discrimination might also contribute to HIV risk behaviors among African American men in the USA. Based on findings in the literature documenting the association between increased HIV risk behaviors (including sex trade involvement) and other forms of social violence and discrimination (e.g., victimization/abuse from intimate partners and other forms of gender-based violence),^18–24 it is reasonable to suggest that individual experiences of victimization from racial discrimination may also be linked to increased HIV risk behaviors, likely through similar mechanisms (e.g., by reducing perceptions of social power and self-worth).

The purpose of the current study was to assess whether experiences of racial discrimination are associated with HIV risk factors among a sample of Black and African American men recruited from urban neighborhoods in a northeast metropolitan area. More specifically, the current study investigated the relevance of racial discrimination to the following: (1) sex trade involvement, (2) recent unprotected anal and/or vaginal sex, and (3) reporting a number of sex partners in the past 12 months higher than the sample average.

Methods

Study Procedures

The current study used data from the Black and African American Men's Health Study, which involved a cross-sectional survey conducted with sexually active Black and African American (B/AA) men (N = 703) between the ages of 18 and 65 recruited from four urban community health centers and primary and urgent care clinics within a large teaching hospital. Eligible B/AA men were those aged 18–65 years, who reported sex with two or more partners in the past year, and demonstrated no cognitive impairment (assessed using the Folstein Mini-mental Exam).¹⁸ Research staff recruited all B/AA men attending collaborating health centers and clinics from May 2005 to May 2006 during designated recruitment days and times. Days and times for recruitment to take place were rotated in order to reduce self-selection that could limit generalizability. Among the 2,331 men approached, 85 % (n = 1,988) agreed to be screened for study eligibility. Of those screened (n = 1,988), 47 % (n = 930) were eligible and 81 % (n = 754) of eligible men agreed to participate in the study. The majority of men who were screened and ineligible did not report two or more sex partners in the past year. Among the 754 surveys collected, 51 (7 %) were removed from further data analysis as a result of survey responses that did not meet study criteria based on age and number of sex partners.

Those who were eligible were invited to complete a 20–25-min audio computer-assisted survey interview (ACASI) assessing demographic variables (income, education, race, immigration, and employment), racial discrimination, and other related variables assessing health risks (e.g., sexual risk and substance use). The participants were reimbursed US $35 upon completion of the survey and provided social and health service referrals. All procedures of this study were approved by the Institutional Review Boards of Boston University Medical Campus and the Centers for Disease Control and Prevention. Additionally, a Federal Certificate of Confidentiality was obtained to provide further protections for study participants.

Measures

Demographic variables assessed included age (categorized as 18–34, 35–44, and 45–65 years of age), national origin (USA and US territories versus outside of the USA), education level (high school education without graduation, having received a high school diploma or GED, or at least some college), employment (full/part-time employment or unemployed), and current homelessness (living on the streets or in a housing shelter). Experiences of racial discrimination were measured by using seven items measuring major life events and everyday experiences of racial discrimination.^25,26 The items were based on the Everyday Discrimination Scale²⁶ and focused on whether the participants perceived experiencing the following events because of their race: “looked over for a higher position” (mean = 2.8; standard deviation (std dev) = 1.2); “followed by a security guard or watched by store clerks” (mean = 2.6; std dev = 1.2); “followed, stopped, or arrested by police more than others” (mean = 2.3; std dev = 1.1); “house was vandalized” (mean = 1.5; std dev = 1.0) “someone disrespected me or ignored me because of my race” (mean = 2.7; std dev = 1.2); “called insulting names related to my skin color or race” (mean = 2.7; std dev = 1.3); or “was physically attacked or assaulted because of my skin color or race” (mean = 2.0; std dev = 1.1). Items used a five-item Likert response scale either ranging from “strongly disagree” to “strongly agree” or from “never” to “always/daily.” Each Likert response was recorded as a score of 1 (indicating low reported discrimination) to 5 (indicating a high level of discrimination). Average discrimination scores were calculated for each participant. The scores were dichotomized based on the median discrimination score of the sample (sample median = 2.3) and categorized as high discrimination (greater than 2.3) or low discrimination (2.3 or less). The seven items had a Cronbach's alpha (α = 0.81) indicating reliability of these items. The Everyday Discrimination Scale has shown high levels of internal consistency and validity in the samples of African American men.^27–29 While most B/AA men likely experience some form of racial discrimination throughout their lives, these items measure men's perceived experiences of discrimination.

The following self-reported risky sexual behaviors were measured: selling sex for drugs or money (past 6 months), giving drugs or money for sex (past 6 months), any unprotected vaginal or anal sex with a female partner in the past 90 days, any unprotected anal sex with a male partner in the past 90 days, and the number of sex partners (dichotomized as four or more in the past year versus less than four partners, based on a median split).

Data Analysis

Bivariate associations between discrimination (dichotomized as high or low discrimination) and demographics were evaluated using contingency table analysis; chi-square tests were conducted to assess statistically significant differences. Crude and adjusted logistic regression analyses were used to assess the associations of discrimination (dichotomized) with HIV risk variables (sex trade, unprotected sex, and reporting four or more sex partners). Demographic variables associated with an outcome variable (any sexual risk variable) in bivariate analyses at p < 0.1 were included in the adjusted regression model for that outcome. Odds ratios and 95 % confidence intervals were used to assess effect sizes, and significance of associations was measured using Wald chi-square tests.

Results

Demographic Characteristics and Experiences of Racial Discrimination

Three quarters of the sample were 44 years of age or younger. The majority (83 %) were US-born. Slightly more than one fourth of men (28 %) reported having less than a high school education, 62 % were unemployed, and 24 % were homeless in a shelter or on the street (Table 1).

Table 1.

Demographics and distribution by average discrimination score (n = 703)

Variable	Total sample (n = 703)	Average discrimination score ≤ 2.3 (n = 300)a	Average discrimination score > 2.3 (n = 403)a	χ2, degrees of freedom (df), p value
	% (n)	% (n)	% (n)
Age*
18–34 years	45.7 (321)	55.1 (195)	36.1 (126)	χ2 = 25.6
35–44 years	30.4 (214)	24.9 (88)	36.1 (126)	df = 2
45–65 years	23.9 (168)	20.1 (71)	27.8 (97)	p < 0.0001
Education*
Less than high school	27.6 (194)	31.9 (113)	23.2 (81)	χ2 = 13.3
High school diploma/GED	45.7 (321)	46.9 (166)	44.4 (155)	df = 2
Higher education	26.7 (188)	21.2 (75)	32.4 (113)	p < 0.0013
Place of birth*
US-born	83.1 (584)	78.8 (279)	87.4 (305)	χ2 = 9.2
Born outside of USA	16.9 (119)	21.2 (75)	12.6 (44)	df = 1
				p < 0.0024
Current employment
Employed full/half-time	38.0 (267)	39.0 (138)	37.0 (129)	χ  2 = 0.30
No employment	62.0 (436)	61.0 (216)	63.0 (220)	df = 1
				p < 0.58
Living situation*
Homeless	24.3 (171)	19.2 (68)	29.5 (103)	χ2 = 10.1
Not homeless	75.7 (532)	80.8 (286)	70.5 (246)	df = 1
				p < 0.0015

These are all column percentages

GED general educational development

*p < 0.05, chi-square

^aCategorized by median discrimination score for sample (median score = 2.3)

Almost the entire sample (96 %) reported experiencing some type of racial discrimination (not shown in table). Men reporting high discrimination scores (i.e., a discrimination score above the sample median) were more likely to be among the older groups of participants (χ² = 25.6, df = 2, p < 0.0001), homeless (χ² = 10.1, df = 1, p = 0.0015), have a higher level of education (χ² = 13.3, df = 2, p = 0.0013), and to be US-born (χ² = 9.2, df = 1, p = 0.0024) compared to men reporting low discrimination scores. Discrimination was not significantly associated with employment in this sample (Table 1).

Crude and Adjusted Findings: the Relevance of Racial Discrimination to HIV Risk Variables

In crude analyses, men reporting high levels of discrimination were significantly more likely to report selling sex for drugs in the past 6 months (OR = 2.5, 95 % CI = 1.4–4.5), giving drugs or money for sex in the past 6 months (OR = 1.9, 95 % CI, 1.3–3.0), having unprotected sex with a female partner (OR = 1.4, 95 % CI, 1.1–2.0), and reporting more than four sex partners in the past year (OR = 1.4, 95 % CI, 1.1–1.9). These findings remained significant in adjusted analyses (Table 2). Notably, while nativity (i.e., whether or not men reported being born in the USA) was adjusted for in all analyses, the analyses were also conducted that were restricted to those born in the USA; no difference in findings was found.

Table 2.

Discrimination and relation to sex trade involvement and other sexual risk factors for HIV (N = 703)

Exposure variables	Total sample, % (n)	Average discrimination score ≤ 2.3 (n = 300) % (n)	Average discrimination score > 2.3 (n = 403) % (n)	Crude odds ratio (OR) (95% CI)	Adjusted OR (95% CI)a
Sell sex for drugs or money, past 6 months
Yes	9.4 (66)	5.3 (16)	12.4 (50)	2.5 (1.4–4.5)*	2.3 (1.3–4.2)*
No	90.6 (637)	94.7 (284)	87.6 (353)	1.0 (referent)	1.0 (referent)
Give drugs or money for sex, past 6 months
Yes	16.6 (117)	11.7 (35)	20.4 (82)	1.9 (1.3–3.0)*	1.7 (1.1–2.6)*
No	83.4 (586)	88.3 (265)	79.7 (321)	1.0 (referent)	1.0 (referent)
Unprotected sex, with male, 90 daysb
Yes	5.4 (38)	4.3 (13)	6.2 (25)	1.2 (0.5–3.4)	1.3 (0.4–3.6)
No	94.6 (665)	95.7 (287)	93.8 (378)	1.0 (referent)	1.0 (referent)
Unprotected sex, with female, 90 days
Yes	58.5 (411)	53.3 (160)	62.3 (251)	1.4 (1.1–2.0)*	1.4 (1.1–2.0)*
No	41.5 (292)	46.7 (140)	37.7 (152)	1.0 (referent)	1.0 (referent)
Reporting more than 4 sex partners, past 12 months
Yes	45.8 (322)	49.1 (198)	41.3 (124)	1.4 (1.1–1.9)*	1.4 (1.1–1.9)*
No	54.2 (381)	50.9 (205)	58.7 (176)	1.0 (referent)	1.0 (referent)

This table presents the findings from logistic regression models with the racial discrimination variable as the independent variable and each sexual risk variable as the dependent variable. Separate crude and adjusted models were created for assessing the relation between racial discrimination and each of the five sexual risk variables (a total of five crude and five adjusted models)

*p < 0.05, Wald

^aAdjusted for age, education, place of birth, and living situation

^bAnalyses restricted to men who report male partners (n = 63)

Discussion

This study is among the first in the public health literature, to our knowledge, to document the association between racial discrimination and HIV risk behaviors specifically among African American men. However, the findings of the current study are in congruence with previous work documenting this link among other populations.^30–32 The results demonstrate that men who experienced high levels of racial discrimination were significantly more likely than men experiencing less discrimination to report selling sex for drugs in the past 6 months, giving drugs or money for sex in the past 6 months, not using a condom for vaginal sex, and reporting a higher number of sex partners in the past year compared to the sample median.

Our study joins an abundant number of research studies documenting the high prevalence of racial discrimination among African American populations^1–6,33,34 and builds on an increasing number of studies demonstrating the relation between racial discrimination and health behaviors for African Americans.^35–38 Our findings are consistent with the existing, but limited, research on this topic area among other populations; ^30–32 for example, our findings are parallel with a previous research among Latino gay and bisexual men indicating that men who reported more experiences with racial discrimination also reported more unprotected sex.³² In such previous work, psychological distress has been identified as a possible mechanism driving the relationship between racial discrimination and HIV risk behaviors. More research is needed to further investigate the mechanisms explaining the relation between racial discrimination and HIV risk, particularly among African American men.

While we did not find significant correlations between high levels of experienced racial discrimination and sex with male partners, it is likely that such analyses were limited in statistical power due to small numbers of men reporting these outcomes; future studies are needed among larger samples for future research on this topic. Likely this group of African American men may not only report racial discrimination, but may also be experiencing discrimination or feeling stigmatized based on having relationships with male partners. Given the heightened risk for HIV among African American men who have sex with men, more work is needed to better investigate how various forms of experienced discrimination as well as marginalization are contributing to men's sexual risk behaviors and risk for HIV.

Additionally, current study findings show that men reporting high levels of racial discrimination were more likely to be US-born. Furthermore, research indicates that Black immigrants generally have better health outcomes compared to their US-born counterparts.³⁹ Thus, more work may be needed to examine whether the relation between discrimination and sexual risk behaviors varies by nativity among Black and African American men.

Altogether, our findings underscore the importance of the structural and social context of HIV risk. Contextual factors such as unemployment, housing instability, and incarceration have been documented as risk factors for HIV (via increasing HIV risk behaviors but also directly increasing HIV risk)^12,40–42 and also rooted in the history of institutionalized racism, particularly among African American communities. However, the current study further highlights that individual exposures to racial discrimination are also driving HIV risk behaviors among this sample of African American men. Thus, racism (as a structural form of violence) and racial discrimination (as an individually experienced form of violence), together, appear to be significantly driving increased HIV risk among Black and African American communities.

Current study findings must be considered with recognition of several study limitations. In terms of measures, reports of HIV risk behaviors may be underestimated; men may feel stigma attached to reporting these behaviors. However, the use of ACASI has been found to reduce reporting biases of stigmatized behaviors such as illicit drug use and sexual practices.^43,44 Future studies may also want to include clinical outcomes for STI/HIV diagnoses as well. Racial discrimination is also subject to potential measurement issues (e.g., variation in recognition of incidents as discrimination), as described in a previous work examining the relevance of discrimination to health.⁴⁵ Like other forms of violence, reported discrimination is likely highly underestimated, both because it is stigmatizing to report victimization and also individuals sometimes do not recognize or identify certain scenarios or events as discrimination or forms of violence against them. Findings also have limited generalizability due to the Northeastern US clinic-based sample of African American men reporting a current female main partner and two or more sex partners in the past year; however, these findings are applicable to men who are at particular risk for HIV within urban, community-based health center settings. Additionally, as this study included men who were seeking varied types of nonmedical programs at recruitment sites, findings cannot be generalized to those seeking traditional or primary care. Given the geographic population of clientele served, the current study sample was also restricted to communities with similar racial/ethnic and sociodemographic profiles. However, such restriction reduced the risk for confounding by further “controlling” for the influence of sociodemographics in determining the relation between racial discrimination and STI/HIV risk and risk behaviors. While we also adjusted for potential confounders (e.g., age, nativity, and education), there may be unrecognized factors that were not measured and considered in the analyses. Overall, future studies on this topic are needed that employ larger and more diverse samples with greater variation in perceived experiences of discrimination in order to better detect various linkages between experiences of discrimination and HIV risk outcomes.

These limitations notwithstanding, our study has important implications for understanding HIV risk in African American communities and for future HIV prevention efforts as well. The findings of this work document that racial discrimination is associated with high-risk sex behaviors among Black and African American men, including sex trade involvement, unprotected sex, and multiple sex partners. More research is needed, however, to understand better the mechanisms driving this association, as this may improve efforts for intervention and prevention. Nonetheless, the current study demonstrates the need for intervention approaches (particularly those that alter social contexts, e.g., policy-related efforts) that consider racially motivated discrimination as a significant factor contributing to HIV risk among African American communities; such an approach corresponds well to the growing efforts toward structural HIV interventions for minority populations.⁴⁶