Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2014 Mar 12.
Published in final edited form as: Int Public Health J. 2012;4(4):435–446.

Beyond Sexual Partnerships: The Lack of Condom Use during Vaginal Sex with Steady Partners

Lara DePadilla 1, Kirk W Elifson 1, Claire E Sterk 1
PMCID: PMC3949990  NIHMSID: NIHMS558008  PMID: 24634708

Abstract

Purpose:

The purpose of this paper is to identify independent correlates of the lack of condom use when engaging in vaginal sex with steady partners among HIV-negative African American adults. The conceptual model includes proximal as well as more distal domains.

Methods:

Cross-sectional data were collected between May 2009 and August 2011. Recruitment involved active and passive recruitment strategies. Computer-assisted, individual interviews were conducted with 1,050 African American adults. Multivariate logistic regression was used to identify independent predictors of a lack of condom use with steady partners in the past 30 days.

Results:

In multivariate analysis, being older than 35, being partnered, perceiving having a steady partner as important, and ever having been homeless were associated positively with the odds of a lack of condom use during vaginal sex with steady partners in the past 30 days. On the other hand, reporting more than one steady partner in the past 30 days, having health insurance during the past 12 months, and perceived neighborhood social cohesion were negatively associated.

Conclusions:

These findings highlight the need for HIV risk-reduction prevention and intervention efforts that consider distal as well as proximal domains. Such a perspective allows for a broader sociological inquiry into health disparities that moves beyond epidemiological factors that commonly guide public health research.

Keywords: Condom, Steady Partner, Socioeconomic Status, African American

Introduction

African Americans, specifically those belonging to the lower socioeconomic strata and who typically live in disadvantaged urban neighborhoods, have been impacted disproportionately by HIV (1). In 2009, African Americans comprised 14% of the U.S. population, but 44% of new HIV infections occurred among them (2). Between 2005 and 2008, African Americans experienced the largest increase in rate of HIV diagnoses as compared to members of other racial groups (2). In addition, African Americans were found to have the highest lifetime risk for a diagnosis of HIV infection of all racial/ethnic groups. Specifically, the rate among African Americans was one in 22 as compared to a rate of one in 170 among whites, and one in 52 among Hispanics/Latinos (3). These data also show that, by region in the U.S., African Americans accounted for the majority of HIV cases in the South (55.7%) (3).

Since the 1990s, social scientists have called for a “syndemic” approach to the HIV epidemic and associated disparities (4-7). In the public health community, the increasing recognition need for such an approach is reflected in the emerging body of literature on multi-level approaches to the HIV/AIDS epidemic, including an emphasis on the social determinants of health and health disparities (8-10). By placing individual behaviors in the larger context of poverty, unequal access to health care, uneven criminal justice involvement, and residence in crumbling neighborhoods with limited social capital, tailored prevention and intervention efforts may be more likely to be effective in curtailing the devastating impact of the HIV/AIDS epidemic on African Americans. As one of its main goals, the National HIV/AIDS Strategy calls for prioritizing the reduction of HIV-related health disparities (11). Given that condom use as a safer sex strategy remains one of the most effective risk-reduction strategies among African Americans, especially in the U.S. South where much of the epidemic is driven by heterosexual transmission (3), in this paper, we focus on condom use during vaginal sex with steady partners. Specifically, we aim to gain a better understanding of distal and proximal factors that influence the use of condoms during vaginal sex with steady partners. Examples of proximal factors include relationships and sexual partnerships and in the more distal domain, socioeconomic status and neighborhood social capital.

Partner Type and Condom Use

The way in which a person categorizes a sex partner seems to impact condom use behaviors. In this inquiry, we limit the focus to male condoms because the use of female condoms is relatively low in the United States (12). Among women, researchers have found condom use with new or casual partners to be more common than condom use with regular partners (13). In addition, study findings show condom use to be least consistent with steady partners and explanations given for this include the notion that a steady partnership, beyond a sexual engagement, also involves emotional connectedness and trust (14, 15). The identification of the nature of a partner type (e.g., steady and casual) typically is left to study participants. Consequently, researchers as well as prevention and intervention experts may be applying definitions that do not capture everyday complexities of steady and casual partnerships, with the latter including transactional sex for which one partner is paid and the other one pays. Having sex with a steady partner has been associated with a decrease in the odds of protected vaginal sex among women (16, 17), while having sex with a casual partner has been associated with an increased likelihood of condom use among women as well as men (18). Among the barriers to condom use identified in the context of sex with steady partners are the perceived distraction from sexual intimacy and a possible reduction of sexual pleasure, its association with distrust in a partner and the assumption of unfaithfulness, and inadequate communication and negotiation skills (14, 19, 20). Foregoing condom use with a steady partner may serve as a means of establishing trust (21). When examining gender, some researchers found that women generally are more communicative about condom use and safer sex than men (22, 23) (although others found no gender differences; see (24, 25).

Much of the research on condom use and sex partner type has focused on at-risk individuals, which include vulnerable African American men and women (26) who live in a social context characterized by distress that is triggered by negative social conditions such as poverty, easy access to alcohol and other drugs, and limited social cohesion. Several researchers found such macro-level factors to lead to partner concurrency (27, 28). Partner concurrency refers to having multiple sex partners during the same time period, possibly including steady and non-steady partners. Partner concurrency has been associated with a higher number of unprotected vaginal sex acts with all types of sex partners, including steady and non-steady partners alike, but not specifically with steady partners (29). The impact of having more than one partner and how the partners are categorized may be important to consider when examining partner types and condom use.

Socioeconomic Status, Social Capital, and Condom Use

Recognizing the influence of the larger socioeconomic context on condom use, it seems important to consider factors such as employment, income, and economic stability when exploring reasons for using or not using condoms. Economic hardship has been shown to have a negative association with condom use in a national sample of young adults (30). Perhaps as an example of extreme economic difficulties, being homeless has been found to be associated with unprotected sex among women as their homeless status resulted in more immediate challenges for daily survival and might overshadow the long-term HIV risk due to unprotected sex (17).

Finally, being in an economically motivated sexual relationship was associated with reduced condom use among African American women (31). The authors hypothesize that this is because the women’s limited financial and material resources results in a reliance on sex partners and cultural norms in the women’s social and sexual networks may be more accepting of economically motivated sexual relationships. It may also be that women in such relationships that do not use condoms seek to emulate primary relationships where sexual intimacy is driven by mutual trust as opposed to financial support (14).

Social capital has emerged in the literature as a valuable concept to understanding inequality, including health disparities (32-34). It has been used to examine the unequal distribution of social resources available to individuals within their communities and across social networks (35-37). In recent years, social capital has been joined with the concept of “community” in an effort to promote “community as the site where responsibility for ameliorating social problems lies” (38).

In this paper, we define social capital as the resources of individuals in social relationships as well as the resources within their social networks and community (39). Two key dimensions of social capital are perceived social cohesion and perceived social disorder. Social capital, specifically perceived social cohesion, has been associated negatively with gonorrhea rates (40, 41) and increased odds of condom use at last sex among African American youth (42). However, a qualitative investigation that highlighted the presence of positive role models as a form of social capital found that the lack of such role models was perceived to increase HIV risk-taking (43). Similarly, a study on gang membership also found it to reduce HIV protective behaviors (41). Whereas gang membership likely results in social capital, especially perceived social cohesion, it also may encourage behaviors that place a person at risk for HIV (e.g., social norms unsupportive of condom use result in unsafe sex). Yet others found that women who ceased using drugs and no longer engaged in transactional sex to pay for their habit increasingly became alienated from their social and sexual networks (44). Hence, as their HIV risk-taking decreased, their social capital did so as well.

Perceived social disorder, our second dimension of social capital, has also been associated with sexual risk-taking. For example, findings from recent studies show a link between social disorder (e.g., public drinking and visible drug sales and use) and increased rates of sexually transmitted infections (STIs) (41, 45). Additionally, perception of violence and homicide rates have also been associated with increased STI rates (41).

Substance Use and Condom Use

Substance use as a risk factor for unprotected sex arises in the context of relationships and sexual partnerships, as a correlate of socioeconomic status and as a characteristic of the social environment, making it an important situational construct to consider. The use of alcohol and other drugs has been associated with unprotected sex (46, 47). However, interesting gender differences emerge and it seems that the interaction of alcohol use by partner type and unsafe sex holds for women but to a more limited extent for men as men may have more direct control over condom use than women (48). For example, binge drinking has been associated with increased STI incidence among women seeking treatment at a clinic although the association was not found for men (46).

Similar dynamics may come into play when drugs other than alcohol are being used. Female drug users tend to be more stigmatized by their male counterparts as well as by society-at- large (7). Others have challenged the link between the use of alcohol and other drugs and the lack of condom use, especially when exploring this at the event level (18). Among users of illicit drugs, recent findings show unsafe sex to be related to the use of certain types of drugs (e.g., cocaine, methamphetamine and amphetamine) but not other drugs (e.g., marijuana and heroin) among drug-offending males (47).

Finally, researchers found that the setting in which drugs are being used and in which sex occurs influences condom use (49). For example, use in a crack house in which the norms allow for the exchange of sex for crack tends not to involve condom use. This may account for why recent crack use has demonstrated an association with reduced odds of condom use among low-income women (17).

The multi-domain approach of this study, including proximate and more distal factors, guides our inquiry to assess independent correlates of the lack of condom use during vaginal sex with steady partners, while controlling for substance use. We consider relationships and sexual partnerships as a key proximal domain and socio-economic status and social capital as more distal domains. By adding to the current knowledge about the dynamics regarding the lack of condom use with steady partners, we hope to contribute to ongoing efforts to reduce the health disparities, specifically those related to HIV/AIDS, faced by poor African Americans who reside in inner-city neighborhoods with limited social capital.

Methods

Procedures

Data for this study were collected as part of People and Places, a cross-sectional study of people and their perceptions of how their neighborhood impacted their daily lives and actions. Data were collected between May 2009 and August 2011 in Atlanta, Georgia. Participants (n=1,050) were recruited from 77 census block groups, using active community outreach strategies (e.g., recruiting directly in neighborhoods or via key respondents) and passive methods, specifically by posting flyers. The sampling frame was designed to ensure sufficient variability by gender, age, and drug use.

Eligible respondents self-identified as African American, were at least age 18, and had lived in the same neighborhood for the past year. Additional eligibility criteria for this paper were having had vaginal sex with a steady partner in the past 30 days and self-reporting as HIV-negative. The sexual activity criterion was added to ensure that we would be able to explore condom use behaviors in the context of vaginal sex in the past 30 days. A negative HIV status was included as a means of recognizing that condom use among HIV negative individuals serves as a main means to protect against HIV acquisition.

The survey included demographics, psychosocial characteristics, licit and illicit drug use history, sexual activity history, criminal justice involvement, and neighborhood perceptions. The Emory University Institutional Review Board approved the study protocol. Interviews lasted approximately 90 minutes and were conducted in a private office at the study site, which was located in one of the neighborhoods. Participants were compensated $30 for their time.

Measures

Outcome Measure

Lack of Condom Use during Vaginal Sex with Steady Partners was derived from two questions. Participants were asked the number of times they engaged in any type of sex with steady partners in the past 30 days prior to the interview and then the question: “Of the [insert number of times] that you had vaginal sex with a steady partner or partners in the past 30 days, how many times did you or your partner use a male condom?” The responses were dichotomized as no condom use (1) and having used condoms at least once (0).

Demographics

Gender was self-identified as “male” (0) and “female” (1). Age (in years) was calculated using the participant’s date of birth and the date of the interview.

Use of Alcohol and Other Drugs

Alcohol use, crack/cocaine use and marijuana use in the past 30 days were dichotomized with 0=No and 1=Yes. Crack/cocaine and marijuana were selected in addition to alcohol due their prevalence in the Atlanta area (50).

Relationship and Sexual Partnership

Partnered was coded as not having a partner (0) or being with a partner, regardless of the living situation (1). The importance of a relationship with a steady partner was dichotomized into it being important (1) versus it not being important (0). Participants were asked about number of sexual partners by type of partner (steady, casual, and paid or paying) during the last 30 days. For this study, multiple partners was conceptualized as a three-level variable: having one steady partner, having more than one steady partner and possibly other types of partners, or only one steady partner with other types of partners. Given the focus on condom use with steady partners, which is least likely to be the case as compared with other partner types, each response option includes steady partners.

Socioeconomic Status

Income was measured through a series of questions about the amount of income received in the past 30 days from a variety of sources including legal employment, “under the table” income, public assistance, retirement benefits, unemployment benefits, family sources, illegal income, and other sources. A total was calculated and the participant was asked to confirm the amount. For the purposes of this study, the square root of income was computed to make the variable conform to a normal distribution. The square root was applied as it resulted in a less skewed and less kurtotic transformed variable then taking the natural log. Employed reflected the respondent’s current employment status and was dichotomized as not being employed (0) and being employed, either full or part-time (1). Homelessness was dichotomized as never having been homeless (0) to ever having been homeless (1). Educational attainment was captured by dichotomizing the responses between less than a high school education (0) and a high school education (including GED) or greater (1). Having health insurance was measured as no or inconsistent health insurance coverage in the past 12 months (0) versus having had health insurance coverage for all of the last 12 months (1). Current living situation was assessed as residing in your own house, condominium, townhome, or apartment (1) versus not having your own residence (0).

Social Capital

Perceived social cohesion was measured using a 5-item scale (51) with questions such as “How often do you and people in your neighborhood do favors for each other?” and “How often do you and other people in the neighborhood ask each other for advice about personal things, such as child-rearing or job-openings?” (Cronbach’s alpha = .78). Item responses ranged from 0=Never to 3=Often and scores were summed such that higher scores corresponded to greater perception of social cohesion. Perceived neighborhood disorder was assessed with a 7-item scale (52) that included statements such as “In my neighborhood, people watch out for each other” and “Police protection in my neighborhood is adequate” (alpha=.81). One item from the original scale was removed due to its similarity to perceived social cohesion. Response options ranged from 0=Strongly Disagree to 4=Strongly Agree. Higher scores corresponded to greater perceived disorder. Knowledge of crime in the neighborhood was measured by asking if the respondent knew if any of a series of violent events (e.g., shooting, sexual assault, robbery, or mugging) occurred in their neighborhood during the past 6 months, with responses ranged from never (0) to often (3) (alpha=. 71). Observed violence in the neighborhood was measured with seven questions from the Community Experiences Questionnaire (53). The items addressed having observed in the neighborhood during the past year events such as “somebody got hit, punched, or slapped” and “somebody got arrested or taken away by the police”. Response options ranged from never (0) to often (3). Higher scores corresponded to greater levels of having observed violence (alpha=. 87).

Analysis

Generalized estimating equations (GEE) applying a logit link were used to conduct logistic regression with the software package SPSS Statistics 19. The respondents were sampled by census block group and GEE was used because it provides a means of accounting for the correlation between people within these groups. GEE calculates the standard errors of parameter estimates based upon the within-cluster similarity of the residuals (54) thereby providing more accurate confidence intervals. Crude odds ratios were calculated and variables found to be significant at the level of p < .10 were including in the multivariate analysis. Missing data were minimal (2.6%) and any cases lacking a variable included in the multivariate model were dropped for that analysis. A sensitivity analysis was also conducted with respect to the outcome variable of a lack of condom use. It has been asserted that grouping the “sometimes users” of condoms with the “always” users of condoms or “never” users of condoms can lead to inaccurate assessment of statistical associations (55). To avoid such errors, the alternate proportion of always using condoms versus sometimes or never using condoms was tested as the outcome in multivariate analysis and the analysis revealed that the results did not alter the basic conclusions of the study.

Results

Descriptive statistics are displayed in Table 1. The study sample included nearly equal proportions of men and women (49% and 51%) and 51% were over the age of 35. The age of 35 is used as a cut-off because we are interested in exploring the impact of drug use. Drug researchers tend to refer to those over 35 as older (56).

Table 1.

Descriptive Statistics and Crude Odds Ratios (n=1050)

Variable Mean (SD)/
Number (%)		 Lack of Condoms Past 30 Days
with Steady Partners
OR 95% CI
Never Use of Condoms Steady Partners .57
Demographics
 Gender .51 1.09 (0.88, 1.35)
 Age (>35) .51 2.12 (1.70, 2.65)***
Use of Alcohol and Other Drugs
 Alcohol Past 30 Days .71 1.27 (0.96, 1.68)†
 Crack/Cocaine Past 30 Days .27 1.17 (0.91, 1.52)
 Marijuana Past 30 Days .52 0.96 (0.75, 1.23)
Relationship and Sexual Partnerships
 Partnered .74 2.82 (2.12, 3.74)***
 Steady Partner Important .78 1.86 (1.39, 2.48)***
 Multiple Partnersa
 At least two steady partners .10 0.20 (0.12, 0.34)***
 Only one steady partner with other
 partners		 .10 0.99 (0.62, 1.56)
Socioeconomic Status
 Incomeb 25.75 (13.72) 1.00 (0.99, 1.01)
 Employed .23 0.89 (0.67, 1.18)
 Homeless .37 1.63 (1.27, 2.08)***
 High school .60 1.09 (0.83, 1.44)
 Health Insurancec .36 0.73 (0.56, 0.95)*
 Own Home .10 0.93 (0.61, 1.41)
Social Capital
 Perceived Social Cohesion 9.08 (3.91) 0.96 (0.93, 0.99)*
 Perceived Neighborhood Disorder 16.11 (5.57) 1.03 (1.00, 1.05)*
 Knowledge of Crime 3.79 (2.53) 1.00 (0.95, 1.06)
 Observed Crime 11.37 (5.88) 1.00 (0.98, 1.02)
Open in a new tab
†

p < .10,

*

p < .05,

** p < .01,

***

p < .001

a

Reference category is having only one steady partner

b

Square root transformed

c

Reference category is not having health insurance consistently over the past 12 months

Being over 35 was associated with increases in the odds of the lack of condom use when engaging in vaginal sex in the past 30 days with steady partners (hereafter referred to as “lack of condom use”). Alcohol use demonstrated a trend toward a positive association with a lack of condom use, whereas crack cocaine or marijuana use was not associated with lack of condom use. The relationship and sexual partnership characteristics demonstrated significant associations with the lack of condom use: having a partner and considering a steady relationship to be important were associated positively with a lack of condom use, while having more than one steady partner (but not having other types of partners in addition to a single steady partner) was associated negatively with a lack of condom use compared to having only one steady partner. In the domain of socioeconomic status, having ever been homeless was associated with an increase in the odds of a lack of condom use, while having health insurance was associated with a decrease in the odds of a lack of condom use. Among the social capital indicators, perceived social cohesion was associated with a decrease in the odds of a lack of condom use, but perceived neighborhood disorder was associated with an increase the odds of a lack of condom use.

Table 2 includes the variables that were associated significantly with a lack of condom use at the level of p < .10 in bivariate analysis. In multivariate analysis, being older than 35 was associated with an increase in the odds of a lack of condom use. The relationship variables were associated significantly with the outcome variable also. Both being partnered (OR=2.64; CI: 1.96, 3.54) and considering having a steady partner to be important (OR=1.35; CI: 1.02, 1.81) were associated positively with a lack of condom use. Having more than one steady partner and possibly other types of partners compared to having only one steady partner in the past 30 days was protective against a lack of condom use (OR=0.22; CI: 0.13, 0.36). However, having only one steady partner and other types of partners compared to having only one steady partner was not associated with a lack of condom use.

Table 2.

Adjusted Odds Ratios

Lack of Condoms Past 30 Days
with Steady Partners
(n=1023)
Variable OR 95% CIa
Demographics
Age (>35) 2.12 (1.61, 2.79)***
Use of Alcohol and Other Drugs
 Alcohol Past 30 Days 1.12 (0.80, 1.55)
Relationship and Sexual Partnerships
 Partnered 2.64 (1.96, 3.54)***
 Steady Partner Important 1.35 (1.02, 1.81)*
 Multiple Partnersa
 At least two steady partners 0.22 (0.13, 0.36)***
 Only one steady partner with other partners 1.08 (0.66, 1.78)
Socioeconomic Status
 Homeless 1.38 (1.06, 1.81)*
 Health Insuranceb 0.71 (0.52, 0.96)*
Social Capital
 Perceived Social Cohesion 0.96 (0.92, 0.99)*
 Perceived Neighborhood Disorder 1.02 (1.00, 1.05)†
Open in a new tab
†

p < .10,

*

p < .05,

** p < .01,

***

p < .001

a

Reference category is having only one steady partner

b

Reference category is not having health insurance consistently over the past 12 months

The domains of socioeconomic status and social capital also revealed significant associations with a lack of condom use. Ever having been homeless was associated positively (OR: 1.38, CI: 1.06, 1.81) with the outcome variable, while having health insurance consistently over the past 12 months was associated negatively (OR: 0.71, CI: 0.52, 0.96) with the outcome variable. An increase in perceived social cohesion was associated with reduced odds of lack of condom use with a steady partner (OR: 0.96; CI: 0.92, 0.99).

DISCUSSION

In this study, we examine the impact of relationship and sexual partnership factors as well as more distal social factors on a lack of condom use when engaging in vaginal sex with steady partners among African American men and women. A majority of the sample (57%) reported not having used a condom when having vaginal sex with a steady partner in the past 30 days prior to the interview. A lack of condom use with steady partners commonly is reported in the literature (29, 57), due to a partner’s negative attitude toward condoms (57) and the association of condom use with a lack of trust and love (21). Our findings show that being partnered and perceiving having a steady partner as important were associated positively with a lack of condom use, the latter independent of relationship status. Considering having a steady partner as important may result in unsafe behaviors, without considering the potential HIV status of the partner or recognizing that many individuals are unaware of their HIV status (58). A second concern is that the decision not to use condoms may be based on the assumption that a steady partner is not having sex with other people (59). In the literature, concurrent sexual partnerships have been highlighted as contributing to the HIV epidemic, especially among African American men and women (60).

It has been asserted that examining not only the individual but also the nature of the partnership is necessary to improve the understanding of HIV acquisition, particularly as it relates to concurrent partnerships (57). In this study, one-fifth of the participants reported having more than one partner in the past 30 days. Among those who reported more than one steady partner (compared to having only one steady partner) in the past 30 days a negative association was found in the odds of a lack of condom use with steady partners. However, for study participants who indicated having had at least one steady and additional non-steady partner (e.g., casual or transactional partners) compared to having only one steady partner, no association was found with the lack of condom use with steady partners. Past qualitative research findings also showed the importance of differentiating between the patterns of concurrent relationships (61). That study showed that people in multiple partnerships used condoms only with partners other than their “primary” or steady partners in most situations. The failure to show an association between having only one steady partner in addition other types of partners and a lack of condom use with steady partners is consistent with those findings. Condom use within the steady partnership would not be impacted by additional partners. However, the results of the current study also imply that if more than one person is considered steady that demarcation may not preclude condom use with steady partners.

Beyond the relationship and sexual partnerships, we found condom use to be impacted by dimensions from more distal domains. The socioeconomic factor of ever having been homeless was associated positively with a lack of condom use. Experiencing homelessness may represent acute economic deprivation and reduce concerns about future HIV acquisition due to a lack of condom use (17). Having health insurance during the past 12 months also was associated negatively with a lack of condom use. It may be that those who have health insurance are more likely to seek regular health checks and exhibit healthy behaviors more generally. For example, a study of a national sample of women found that women who had health insurance were more likely to have received health checks such as a pap smear (62).

The domain of social capital revealed an association between perceived social cohesion and a reduction in the odds of a lack of condom use. This finding is consistent with previous research that has found that social cohesion exhibited a protective effect against HIV risk behaviors (40, 42). Other dimensions of social capital were not associated with a lack of condom use, possibly because these are too distal for our inquiry.

Substance use was not associated with a lack of condom use. This is not unexpected given that drinking in particular is more often associated with condom use with non-steady partners (18, 63). It may also be that situational factors do not impact condom use with steady partners because condom use is not prevalent with steady or regular partners in general (29, 57).

Limitations

This study has a number of limitations. The sampling approach is not a random sampling strategy and there may be an inherent bias in was enrolled in People and Places (64). All interviews were conducted in the Atlanta, Georgia metropolitan area. There may very well be local or regional influences or subcultural differences between these participants and those residing elsewhere that could affect the generalizability of the data.

Sexual behavior represents a sensitive topic that may be subject to respondent social desirability bias. Given the fact that sexual behavior was assessed based on self-reports, the extent to which respondents under or over-reported their behaviors is unknown. Nevertheless, others have shown information on (e.g., sexual behaviors, alcohol consumption, and drug use) to be accurate (65-68). Another potential limitation of the self-reported information is recall bias. We focused mainly on the time frame of the “past 30 days” as a means to minimize recall bias. Although we are unable to determine the extent to which recall bias affected the data, others who conducted research on similar topics reported that bias is sufficiently nominal that its impact upon study findings is likely to be minimal (69).

The cross-sectional design precludes any causal inferences. Among the measures, the non-steady partners included both casual and paid or paying partners; and these two alternatives to steady partners may be qualitatively different. Overall, there is a need for more refined research on partner types. The analysis also did not account for same sex partnerships, as the focus was heterosexual vaginal sex given the salience of this behavior for the HIV/AIDS rates among African Americans. Finally, we only examined the concurrency status of the participants. It would be useful to include a measure of their perception of whether their partners also have additional partners to understand better the nature of the relationship and how it relates to a lack of condom use with steady partners.

Social Science Implications

Given that a lack of condom use when engaging in vaginal sex with steady partners during the past 30 days is prevalent, factors beyond the individual and outside the interpersonal domain become more important. Much attention has been paid to the economic disparities among African Americans in the United States; this study accounts for the importance of socioeconomic status when assessing the lack of condom use in this specific type of partnership. Patterns of deprivation have been linked to concurrency among African Americans (60) and increase the importance of identifying specific aspects of disparities that are associated with a lack of condom use with steady partners. The results of this study suggest that is not only extreme indicators such as the experience of homelessness, but also access to health resources such as health insurance, that influence whether one will consider using condoms with a steady partner. These findings also indicate that not only personal but also collective resources, such as perceived social cohesion, impact a lack of condom use with steady partners. Trust and reciprocity within social networks have been associated with health and psychological well-being more generally (70), and may contribute to health-related decision making involving condom use. Factors outside the partnership (e.g., social and sexual network norms) provide potential pathways to increasing the use of condoms even in steady partnerships where a lack of condom use is the norm (13, 29).

The multi-domain approach to understanding why people do or do not use condoms with certain partners is typical of sociological inquiry. In addressing our research question, we aimed to provide an epistemology of the HIV-related health disparities experienced by African Americans. We show how factors beyond the individual impact actions, in this case, the influence of socioeconomic characteristics and social capital. These tap into the position of the individual in society (e.g., homelessness and having health insurance) as well as the conditions of the neighborhood in which one resides. Recently, public health has gained an appreciation for the importance of social capital, specifically social cohesion and our findings support this path of inquiry. It is through this type of epistemology that social science may make contributions; it shows the importance of considering epidemiological information in the larger socio-political and ecological context.

Acknowledgments

This research was supported by funding from the National Institute on Drug Abuse RO1DA025607) and the Center for AIDS Research at Emory University (P30AI050409). The views presented are those of the authors.

References

  • 1.CDC Acquired immunodeficiency syndrome (AIDS) among blacks and Hispanics--United States. MMWR. 1986;35(42):655–8. 63-66. [PubMed] [Google Scholar]
  • 2.CDC HIV among African Americans. 2010 Retrieved from http://www.cdc.gov/hiv/topics/aa/pdf/aa.pdf.
  • 3.CDC Estimated lifetime risk for diagnosis of HIV infection among Hispanics/Latinos--37 states and Puerto Rico, 2007. MMWR. 2010;59(40):1297–301. [PubMed] [Google Scholar]
  • 4.Marshall P, Singer M, Clatts M. NIDA Monograph. Government Printing Office; Washington, D.C.: 1999. Integrating cultural, observational, and epidemiological approaches in the prevention of drug abuse and HIV/AIDS; pp. 97–115. [Google Scholar]
  • 5.Singer M. AIDS and the health crisis of the US urban poor: The perspective of critical medical anthropology. Soc Sci Med. 1994;39:931–48. doi: 10.1016/0277-9536(94)90205-4. [DOI] [PubMed] [Google Scholar]
  • 6.Singer M. ntroduction to syndemics: A systems approach to public and community health. Jossey-Bass; San Francisco, CA: 2009. [Google Scholar]
  • 7.Sterk C. Fast lives: Women who use crack cocaine. Temple University Press; Philadelphia, PA: 1999. [Google Scholar]
  • 8.Aral SO, Adimora AA, Fenton KA. Understanding and responding to disparities in HIV and other sexually transmitted infections in African Americans. Lancet. 2008;372(9635):337–40. doi: 10.1016/S0140-6736(08)61118-6. [DOI] [PubMed] [Google Scholar]
  • 9.CDC Estimates of new HIV infections in the United States, 2006-2009. 2011 Retrieved from http://www.cdc.gov/hiv/topics/surveillance/factsheets.htm.
  • 10.Harrison KM, Dean HD. Use of data systems to address social determinants of health: A need to do more. Public Health Rep. 2011;126(Suppl 3):1–5. doi: 10.1177/00333549111260S301. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.White House Office of National AIDS Policy National HIV/AIDS strategy. 2010 Retrieved from http://aids.gov/federal-resources/policies/national-hiv-aids-strategy/nhas.pdf.
  • 12.Dancy BL, Berbaum ML. Condom use predictors for low-income African American women. West J Nurs Res. 2005;27(1):28–44. doi: 10.1177/0193945904268342. [DOI] [PubMed] [Google Scholar]
  • 13.Macaluso M, Demand MJ, Artz LM, Hook EWI. Partner type and condom use. AIDS. 2000;14(5):537–46. doi: 10.1097/00002030-200003310-00009. [DOI] [PubMed] [Google Scholar]
  • 14.Catania J, Coates TJ, Kegeles S. A test of the AIDS Risk Reduction Model: Psychosocial correlates of condom use in the AMEN cohort survey. Health Psychol. 1994;13(6):548–55. doi: 10.1037//0278-6133.13.6.548. [DOI] [PubMed] [Google Scholar]
  • 15.Wingood G, DiClemente R. Partner influences and gender-related factors associated with noncondom use among young adult African American women. Am J Community Psychol. 1998;26:29–51. doi: 10.1023/a:1021830023545. [DOI] [PubMed] [Google Scholar]
  • 16.Lichtenstein B, Desmond RA, Schwebke JR. Partnership concurrency status and condom use among women diagnosed with trichomonas vaginalis. Womens Health Issues. 2008;18(5):369–74. doi: 10.1016/j.whi.2008.04.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Ober A, Iguchi M, Weiss R, Gorbach P, Heimer R, Ouellet L, et al. The relative role of perceived partner risks in promoting condom use in a three-city sample of high-risk, low-income women. AIDS Behav. 2011;15(7):1347–58. doi: 10.1007/s10461-010-9840-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Scott-Sheldon L, Carey M, Vanable P, Senn T, Coury-Doniger P, Urban M. Alcohol consumption, drug use, and condom use among STD clinic patients. J Stud Alcohol. 2009 Sep;:762–70. doi: 10.15288/jsad.2009.70.762. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Schilling R, El-Bassel N, Schinke S, Gordon K, Nichols S. Building skills of recovering women drug users to reduce heterosexual AIDS transmission. Public Health Rep. 1991;106:297–304. [PMC free article] [PubMed] [Google Scholar]
  • 20.Theall KP, Sterk CE, Elifson KW. Male condom use by type of relationships following an HIV intervention among women who use illegal drugs. J Drug Issues. 2003;33:1–28. [Google Scholar]
  • 21.Corbett AM, Dickson-Gómez J, Hilario H, Weeks MR. A little thing called love: Condom use in high-risk primary heterosexual relationships. Perspect Sex Reprod Health. 2009;41(4):218–24. doi: 10.1363/4121809. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Allen M, Emmers-Sommer TM, Crowell TL. Couples negotiating safer sex behaviors: A meta-analysis of the impact of conversation and gender. In: Allen M, Preiss RW, Gayle BM, Burrell NA, editors. Interpersonal communication research: Advances through meta-analysis. Lawrence Erlbaum Associates; Mahwah, NJ: 2002. pp. 263–79. [Google Scholar]
  • 23.Noar SM, Morokoff PJ, Harlow LL. Condom negotiation in heterosexually active men and women: Development and validation of a condom influence strategy questionnaire. Psychol Health. 2002;17:711–35. [Google Scholar]
  • 24.Aida Y, Falbo T. Relationships between marital satisfaction, resources, and power strategies. Sex Roles. 1991;24(1/2):43–56. [Google Scholar]
  • 25.Noar SM, Zimmerman RS, Atwood KA. Safer sex and sexually transmitted infections from a relationship perspective. In: Harvey JH, Wenzel A, Sprecher S, editors. Handbook of sexuality in close relationships. Lawrence Erlbaum; Mahwah, N. J.: 2004. pp. 519–44. [Google Scholar]
  • 26.Ickovics J, Yoshikawa H. Preventive interventions to reduce heterosexual HIV risk for women: Current perspectives, future directions. AIDS. 1998;12:S197–208. [PubMed] [Google Scholar]
  • 27.Adimora AA, Schoenbach VJ. Social context, sexual networks, and racial disparities in rates of sexually transmitted infections. J Infect Dis. 2005 Feb 1;191(Supplement 1):S115–S22. doi: 10.1086/425280. 2005. [DOI] [PubMed] [Google Scholar]
  • 28.Magnus M, Kuo I, Shelley K, Rawls A, Peterson J, Montanez L, et al. Risk factors driving the emergence of a generalized heterosexual HIV epidemic in Washington, District of Columbia networks at risk. AIDS. 2009;23(10):1277–84. doi: 10.1097/QAD.0b013e32832b51da. [DOI] [PubMed] [Google Scholar]
  • 29.Senn TE, Carey MP, Vanable PA, Coury-Doniger P, Urban M. Sexual partner concurrency among STI clinic patients with a steady partner: correlates and associations with condom use. Sex Transm Dis. 2009 Sep 1;85(5):343–7. doi: 10.1136/sti.2009.035758. 2009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Ford JL, Browning CR. Neighborhood social disorganization and the acquisition of trichomoniasis among young adults in the United States. Am J Public Health. 2011 Sep 1;101(9):1696–703. doi: 10.2105/AJPH.2011.300213. 2011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Dunkle K, Wingood G, Camp C, DiClemente R. Economically motivated relationships and transactional sex among unmarried African American and white women: Results from a U.S. national telephone survey. Public Health Rep. 2010;125(S4):90–125. doi: 10.1177/00333549101250S413. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Schuller T. Reflections of the use of social capital. Rev Soc Econ. 2007;65(1):11–28. [Google Scholar]
  • 33.Lockhart WH. Building bridges and bonds: Generating social capital in secular and faith based poverty-to-work programs. Sociol of Relig. 2005;66(1):45–60. [Google Scholar]
  • 34.Putnam RD. Bowling alone: The collapse and revival of american community. Simon & Schuster; New York, NY: 2000. [Google Scholar]
  • 35.Bourdieu P. Distinction: A social critique of the judgement of taste. Harvard University Press; Cambridge, MA: 1984. [Google Scholar]
  • 36.Coleman JS. Social capital in the creation of human capital. Am J Sociol. 1988;94:95–121. [Google Scholar]
  • 37.Lin N. Social capital: A theory of social structure and action. University Press; Cambridge, MA: 2001. [Google Scholar]
  • 38.Bryson L, , Mowbray M. More spray on solution: Community, social capital and evidence based policy. Aust J Soc Issues. 2005;40(1):91–106. [Google Scholar]
  • 39.Thomas-Slayter BP, Fisher WF. Social capital and AIDS-resilient communities: Strengthening the AIDS response. Glob Public Health. 2011:1–21. doi: 10.1080/17441692.2011.617380. [DOI] [PubMed] [Google Scholar]
  • 40.Ellen JM, Jennings JM, Meyers T, Chung S-E, Taylor R. Perceived social cohesion and prevalence of sexually transmitted diseases. Sex Transm Dis. 2004;31(2):117–22. doi: 10.1097/01.OLQ.0000110467.64222.61. [DOI] [PubMed] [Google Scholar]
  • 41.Thomas J, Torrone E, Browning C. Neighborhood factors affecting rates of sexually transmitted diseases in Chicago. J Urban Health. 2010;87(1):102–12. doi: 10.1007/s11524-009-9410-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Kerrigan D, Witt S, Glass B, Chung S-e, Ellen J. Perceived neighborhood social cohesion and condom use among adolescents vulnerable to HIV/STI. AIDS Behav. 2006;10(6):723–9. doi: 10.1007/s10461-006-9075-9. [DOI] [PubMed] [Google Scholar]
  • 43.Cené C, Akers A, Lloyd S, Albritton T, Powell Hammond W, Corbie-Smith G. Understanding social capital and HIV risk in rural African American communities. J Gen Intern Med. 2011;26(7):737–44. doi: 10.1007/s11606-011-1646-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Sterk C, Elifson K, Theall K. Individual action and community context: The health intervention project. Am J Prev Med. 2007;32(6, Supplement):S177–S81. doi: 10.1016/j.amepre.2007.02.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Lang D, Salazar L, Crosby R, DiClemente R, Brown L, Donenberg G. Neighborhood environment, sexual risk behaviors and acquisition of sexually transmitted infections among adolescents diagnosed with psychological disorders. Am J Community Psychol. 2010;46(3):303–11. doi: 10.1007/s10464-010-9352-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Hutton HE, McCaul ME, Santora PB, Erbelding EJ. The relationship between recent alcohol use and sexual behaviors: Gender differences among sexually transmitted disease clinic patients. Alcohol Clin Exp Res. 2008;32(11):2008–15. doi: 10.1111/j.1530-0277.2008.00788.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Leigh B, Stall R. Substance use and risky sexual behavior for exposure to HIV: Issues in methodology, interpretation, and prevention. Am Psychol. 1993;48:1035–45. doi: 10.1037//0003-066x.48.10.1035. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Pulerwitz J, Amaro H, Jong WD, Gortmaker SL, Rudd R. Relationship power, condom use and HIV risk among women in the USA. AIDS Care. 2002;14(6):789–800. doi: 10.1080/0954012021000031868. 2002/12/01. [DOI] [PubMed] [Google Scholar]
  • 49.Kopetz CE, Reynolds EK, Hart CL, Kruglanski AW, Lejuez CW. Social context and perceived effects of drugs on sexual behavior among individuals who use both heroin and cocaine. Exp Clin Psychopharmacol. 2010;18(3):214–20. doi: 10.1037/a0019635. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.DePadilla L, Wolfe M. Epidemiologic Trends in Drug Abuse: Proceedings of the Community Epidemiology Work Group. U.S. Department of Health and Human Services; Bethesda, MD: 2010. Drug abuse patterns and trends in Atlanta--Update: June 2010. [Google Scholar]
  • 51.Sampson RJ, Morenoff JD, Felton E. Beyond social capital: Spatial dynamics of collective efficacy for children. Am Sociol Rev. 1999;64(5):633–60. [Google Scholar]
  • 52.Ross CE, Mirowsky J. Disorder and decay. Urban Aff Rev. 1999 Jan 1;34(3):412–32. 1999. [Google Scholar]
  • 53.Schwartz D, Proctor LJ. Community violence exposure and children's social adjustment in the school peer group: The mediating roles of emotion regulation and social cognition. J Consult Clin Psychol. 2000;68(4):670–83. [PubMed] [Google Scholar]
  • 54.Hanley JA, Negassa A, Edwardes MDd, Forrester JE. Statistical Analysis of Correlated Data Using Generalized Estimating Equations: An Orientation. Am J Epidemiol. 2003 Feb 15;157(4):364–75. doi: 10.1093/aje/kwf215. 2003. [DOI] [PubMed] [Google Scholar]
  • 55.Crosby R, DiClemente RJ, Holtgrave DR, Wingood GM. Design, measurement, and analytical considerations for testing hypotheses relative to condom effectiveness against non-viral STIs. Sex Transm Infect. 2002 Aug 1;78(4):228–31. doi: 10.1136/sti.78.4.228. 2002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 56.Gfroerer J, Penne M, Pembertin M, Folsom R. Substance Abuse Treatment Need among Older Adults in 2020: The Impact of the Aging Baby-boom Cohort. Drug Alcohol Depend. 2003;69:127–35. doi: 10.1016/s0376-8716(02)00307-1. [DOI] [PubMed] [Google Scholar]
  • 57.Gorbach P, Holmes KK. Transmission of STIs/HIV at the partnership level: Beyond individual-level analyses. J Urban Health. 2003;80(0):iii15–iii25. doi: 10.1093/jurban/jtg079. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 58.Campsmith ML, Rhodes PH, Hall I, Green TA. Undiagnosed HIV prevalence among adults and adolescents in the United States at the end of 2006. J Acquir Immune Defic Syndr. 2010;53(5):619–24. doi: 10.1097/QAI.0b013e3181bf1c45. [DOI] [PubMed] [Google Scholar]
  • 59.Drumright LN, Gorbach PM, Holmes KK. Do people really know their sex partners?: Concurrency, knowledge of partner behavior, and sexually transmitted infections within partnerships. Sex Transm Dis. 2004;31(7):437–42. doi: 10.1097/01.olq.0000129949.30114.37. [DOI] [PubMed] [Google Scholar]
  • 60.Adimora AA, Schoenbach VJ, Doherty IA. HIV and African Americans in the southern United States: Sexual networks and social context. Sex Transm Dis. 2006;33(7):S39–S45. doi: 10.1097/01.olq.0000228298.07826.68. [DOI] [PubMed] [Google Scholar]
  • 61.Gorbach P, Stoner BP, Aral SO, H. Whittington WL, Holmes K. "It takes a village": Understanding concurrent sexual partnerships in Seattle, Washington. Sex Transm Dis. 2002;29(8):453–62. doi: 10.1097/00007435-200208000-00004. [DOI] [PubMed] [Google Scholar]
  • 62.Coughlin SS, Leadbetter S, Richards T, Sabatino SA. Contextual analysis of breast and cervical cancer screening and factors associated with health care access among United States women, 2002. Soc Sci Med. 2008;66(2):260–75. doi: 10.1016/j.socscimed.2007.09.009. [DOI] [PubMed] [Google Scholar]
  • 63.Raj A, Reed E, Santana MC, Walley AY, Welles SL, Horsburgh CR, et al. The associations of binge alcohol use with HIV/STI risk and diagnosis among heterosexual African American men. Drug Alcohol Depend. 2009;101(1-2):101–6. doi: 10.1016/j.drugalcdep.2008.11.008. [DOI] [PubMed] [Google Scholar]
  • 64.Heckathorn DD. Respondent-Driven Sampling: A New Approach to the Study of Hidden Populations. Social Problems. 1997;44(2):174–99. [Google Scholar]
  • 65.Anglin M, Hser Y, Chou C. Reliability and validity of retrospective behavioral self-report by narcotics addicts. Evaluation Rev. 1993;17:91–103. [Google Scholar]
  • 66.Higgins ST, Budney AJ, Bickel WK, Badger GJ, Foerg FE, Ogden D. Outpatient behavioral treatment for cocaine dependence: One-year outcome. Experimental and Clinical Psychopharmacology;Experimental and Clinical Psychopharmacology. 1995;3(2):205–12. [Google Scholar]
  • 67.Miller M, Paone D. Social network characteristics as mediators in the relationship between sexual abuse and HIV risk. Social Science & Medicine. 1998;47(6):765–77. doi: 10.1016/s0277-9536(98)00156-7. [DOI] [PubMed] [Google Scholar]
  • 68.Nurco DN. A discussion of validity: Self-report methods of estimating drug use. 1985 [Google Scholar]
  • 69.Jaccard J, Wan CK. A paradigm for studying the accuracy of self-reports of risk behavior relevant to AIDS: Empirical perspectives on stability, recall bias, and transitory influences. Journal of Applied Social Psychology. 1995;25:1831–58. [Google Scholar]
  • 70.Nieminen T, Martelin T, Koskinen S, Aro H, Alanen E, Hyyppä M. Social capital as a determinant of self-rated health and psychological well-being. Int J Public Health. 2010;55(6):531–42. doi: 10.1007/s00038-010-0138-3. [DOI] [PubMed] [Google Scholar]

RESOURCES