Abstract
Objectives
We examined parameters of sexual partnerships, including respondents’ participation in concurrency, belief that their partner had concurrent partnerships (partners’ concurrency), and partnership intervals, among the 2,099 women in HIV Prevention Trials Network 064, a study of women at high risk for HIV infection, in ten US communities.
Methods
We analyzed baseline survey responses about partnership dates to determine prevalence of participants’ and partners’ concurrency, intervals between partnerships, knowledge of whether recent partner(s) had undergone HIV testing, and intercourse frequency during the preceding 6 months.
Results
Prevalence of participants’ and partners’ concurrency was 40% and 36% respectively; 24% of respondents had both concurrent partnerships and non-monogamous partners. Among women with >1 partner and no concurrent partnerships themselves, the median gap between partners was one month. Multiple episodes of unprotected vaginal intercourse with >2 of their most recent partners was reported by 60% of women who had both concurrent partnerships and non-monogamous partners, 50% with only concurrent partners and no partners’ concurrency, and 33% with only partners’ concurrency versus 14% of women with neither type of concurrency (p<.0001). Women who had any involvement with concurrency were also more likely than women with no concurrency involvement to report lack of awareness of whether recent partners had undergone HIV testing (participants’ concurrency 41%, partners’ concurrency 40%, both participants’ and partners’ concurrency 48%, neither 17%; p<.0001).
Conclusions
These network patterns and short gaps between partnerships may create substantial opportunities for HIV transmission in this sample of women at high risk for HIV infection.
INTRODUCTION
Heterosexual contact is the most common mode of HIV transmission among women in the United States.[1] Sexual partnerships are the building blocks of networks through which HIV and other sexually transmitted infections (STIs) disseminate. The sequencing, interval between and duration of partnerships, and frequency of sexual interactions influence individual risk of infection and population transmission. Concurrent sexual partnerships (partnerships that overlap in time) can accelerate the spread of HIV infection.[2], [3], [4] Concurrency confers different levels of risk to the different members of the partnership. Individuals who have concurrent partnerships can more easily transmit infection but have no greater risk of acquiring it than the risk associated with having multiple consecutive partnerships. The partners of individuals who have concurrent partnerships, however, are at increased risk of acquiring infection because of their partner's concurrency. Partners’ concurrency was an independent risk factor for HIV infection among African American men and women with heterosexually transmitted HIV infection who lacked traditional high-risk characteristics.[5] A number of studies have evaluated the prevalence and correlates of individuals’ participation in concurrency in various populations in the US and elsewhere,[6], [7], [8] but partners’ concurrency has received considerably less attention.
In addition to concurrency, other characteristics of partnerships also affect the likelihood of STI transmission to individuals and throughout the population. For example, the interval between partnerships, as well as the frequency and nature of sexual interactions, are critical. For STIs that have a restricted period of maximum infectiousness (such as gonorrhea and chlamydia), longer gaps between consecutive monogamous partnerships decrease the likelihood that a person who acquires infection from one partner will be highly infectious by the time he or she begins a new partnership. Conversely, longer overlaps in partnerships and shorter gaps between consecutive partnerships can dramatically increase the likelihood of transmission. Frequency of intercourse is especially important; more frequent sexual activity provides more opportunities for transmission. The extent of condom use also affects transmission; the protective effect of consistent condom use could conceivably render the sequencing and timing of partnerships inconsequential.
Despite the importance of these parameters of sexual partnerships, data that reflect them can be difficult to collect and are seldom available in one database. This information could improve our understanding of the dynamics of population HIV transmission and inform development of interventions, including behavioral interventions that enhance efficacy of pre-exposure prophylaxis and other biomedical prevention strategies. To address these issues we conducted a descriptive analysis of sexual partnership characteristics at baseline among participants in HIV Prevention Trials Network (HPTN) 064 (The Women's HIV Seroincidence HIV Study (ISIS)), a study of women at high risk for HIV infection. Our analysis focused on participants’ concurrency, their partners’ concurrency, and gaps and overlaps between sexual partnerships.
METHODS
HPTN 064 study methods have been described elsewhere.[9] Briefly, HPTN 064 was a multi-site, longitudinal cohort study that enrolled eligible women between May 2009 and July 2010 from 10 urban and peri-urban communities with high prevalences of both poverty and reported HIV infection rates in six sites in the Northeastern and Southeastern US (Atlanta, GA; Baltimore, MD; New York City, NY; Newark, NJ; Raleigh-Durham, NC; Washington, DC), using venue- based sampling (i.e., recruitment of persons who attend specific locations within defined geographic areas). Eligible individuals were 18 to 44 years of age, self-identified as a woman (transgender individuals were eligible), reported at least one episode of unprotected vaginal and/or anal sex with a man in the six months before enrollment as well as an additional personal or partner HIV risk characteristic, resided in an area with high rates of poverty and HIV/AIDS prevalence, and were willing to undergo HIV rapid testing and receive HIV test results. Participants underwent HIV testing and audio computer-assisted self-interviews (ACASI) at entry to the study and at 6-month intervals for up to 12 months. The baseline ACASI, which collected demographic and psychosocial data and information concerning sexual behaviors and drug use, was the data source of this analysis. Institutional review boards at each study site and collaborating institution approved the HPTN 064 study, and a Certificate of Confidentiality was obtained.
Data collection and measures
The ACASI asked each respondent to list the three men with whom she most recently had vaginal or anal intercourse during the six months before the interview and to provide the dates (month and year) of first and last (most recent) intercourse with each of these men. The survey asked the respondent about the risk characteristics of each of these male partners (e.g., HIV infection status, substance use, etc) and asked whether each man had undergone HIV testing Response choices were yes, no, or don't know. For every partner listed, the survey asked approximately how many times during the past six months the respondent and he had: vaginal sex, vaginal sex without a condom, and anal sex. Response choices were: more than 10 times, 2-10 times, once, or never. The survey also asked the women whether each of their partners had sex with other people during the last six months while he was in a sexual relationship with the respondent. Response choices were: definitely did, probably did, probably did not, or definitely did not.
Participants’ concurrency
We identified participants’ concurrency by comparing the dates (month and year, not day) of first and last sexual intercourse for the most recent partners described in the ACASI (up to a maximum of three partners). Two partnerships were defined as concurrent when the month of first sexual intercourse with one partner occurred before the month of last intercourse with another partner.
We calculated the prevalence of participants’ concurrency by dividing the number of women with at least one concurrent partnership by the number of women in the study population.
Partners’ concurrency
Partners’ concurrency occurred if a participant reported that any of her last three partners “definitely did” have sex with another person during the course of her sexual relationship with him. We calculated the prevalence of partners’ concurrency by dividing the number of women with this response by the number of women in the study population with a non-missing response.
Gaps and overlaps in sexual partnerships
We evaluated the gap or overlap between the last two partners reported by women with at least two partners during the preceding six months. If the date of first intercourse with the second most recent partner preceded the date of first intercourse with the most recent partner, the gap/overlap was defined as the difference in months between the date of first intercourse with the most recent partner and the date of last intercourse with the next most recent partner (positive differences correspond to gaps, negative differences to overlaps). If the date of first intercourse with the second most recent partner occurred after the date of first intercourse with the most recent partner, the overlap was defined as the difference in months between the dates of first and last intercourse with the second most recent partner. Thus, the overlap duration of concurrent partnerships are less than or equal to -1 (because only partnerships that overlapped by more than 1 month were categorized as concurrent). The gaps of all non-concurrent partnerships are greater than or equal to 0 and can be no greater than six months due to the study design.[10], [11]
Analyses
We examined the associations for participants’ concurrency and partners’ concurrency with age, race/ethnicity, marital status, education, income, use of illicit drugs (other than marijuana) and binge alcohol consumption within the past six months, and STI history, as previous research has demonstrated associations between concurrency and these variables.[6], [12], [13], [8] We fit multiple log binomial regression models with participants’ concurrency and partners’ concurrency as the dependent variables. Independent variables were removed from the model if they were not associated with the dependent variable (p >0.1 and their removal did not change the coefficients of other variables by more than 10%).
To evaluate the distribution of risky sexual practices among women with different partnership patterns, we stratified respondents according to their participation in partnerships during the past six months: only participants’ concurrency, only partners’ concurrency, both participants’ and partners’ concurrency, and neither. We then compared respondents with respect to frequency and type of intercourse and risk characteristics of partners overall and with each of their last two partners. Chi square statistics were used to compare proportions. The Kruskal-Wallis Test compared median gap lengths among the four partnership categories. All statistical analyses were performed with SAS version 9.2 (SAS, Cary, NC).
RESULTS
Study Sample
A total of 2,099 were enrolled in the study. Estimates of participants’ concurrency could not be determined for 471 women; these participants reported having more than one sexual partner but did not provide first and last dates of sexual intercourse and were therefore excluded from the concurrency analyses. Table 1 outlines characteristics of the overall study population as well as the 1,628 participants who were eligible for the concurrency analysis. Most respondents were Black (85%); smaller proportions were White or Hispanic (7% and 12%, respectively). Only 7% of the study population was currently married; more than half (52%) had never married; 24% were unmarried but living with a sexual partner; and 7% were divorced, widowed, or separated. More than one-third (35%) had less than high school education. Nearly half of the participants (46%) reported an annual household income of less than $10,000, 63% were unemployed, and almost half (46%) reported concern about having enough food during the preceding 30 days. Almost one-quarter (22%) reported use of illicit drugs other than marijuana during the last six months, and 23% reported binge alcohol consumption at least weekly. Participants reported a median of two male sex partners in the last 6 months.
Table 1.
Demographic and Risk Characteristics of HPTN 064 Participants at Baseline
| Full Cohort N (%) N = 2,099 | Subsample Eligible for Concurrency Analyses N (%) N = 1,628 | |
|---|---|---|
| 1Age (years) | ||
| Median [interquartile range] | 29 [23 – 38] | 29 [23 – 38] |
| 18-26 | 837 (40%) | 681/1628 (42%) |
| 27-33 | 502 (24%) | 390/1628 (24%) |
| ≥34 | 760 (36%) | 557/1628 (34%) |
| Race/ethnicity | ||
| Black | 1802 (86%) | 1387/1628 (85%) |
| White | 143 (7%) | 112/1628 (7%) |
| Mixed | 54 (3%) | 43/1628 (3%) |
| Hispanic | 245 (12%) | 201/1628 (12%) |
| Other | 100 (5%) | 86/1628 (5%) |
| Marital status and relationship characteristics | ||
| Did not answer | 51 (2%) | 33/1628 (2%) |
| Married | 159 (8%) | 121/1628 (7%) |
| Cohabitating | 479 (23%) | 852/1628 (24%) |
| Never married | 1129 (54%) | 388/1628 (52%) |
| Divorced/Separated/Widowed | 129 (6%) | 107/1628 (7%) |
| Other | 152 (7%) | 127/1628 (8%) |
| Education Level | ||
| < High School | 777 (37%) | 570/1628 (35%) |
| Income, Food Security & Employment | ||
| Total household income before taxes in last 12 months <=$10k | 933 (44%) | 744/1628 (46%) |
| Concerned about having enough food for yourself or your family in the last six months? | 97 (46%) | 743/1628 (46%) |
| Unemployed in the past 12 months | 1357 (65%) | 1020/1628 (63%) |
| Self-Reported General Health | ||
| Excellent/Very good | 969 (46%) | 746/1628 (46%) |
| Good | 782 (37%) | 616/1628 (38%) |
| Fair/Poor | 344 (16%) | 263/1628 (16%) |
| Alcohol & Drug Use | ||
| Use of illicit drugs (other than marijuana) during past 6 months | 459 (22%) | 352/1628 (22%) |
| Binge alcohol consumption (≥ 4+ drinks on one occasion at least weekly during past 6 months) | 498 (24%) | 375/1628 (23%) |
| Sexual Behavior | ||
| Self-reported diagnosis of STI (gonorrhea, chlamydia, or syphilis) in the past 6 months | 232 (11%) | 180/1628 (11%) |
| Median number of sex partners in past 6 months (25%ile, 75%ile) | 2 (1, 3) | 2 (1, 3) |
| Participants' concurrency only | 267 | |
| Partners' concurrency only | 208 | |
| Both participants' and partners' concurrency | 389 | |
| Neither participants' nor partners' concurrency | 764 |
Concurrency
Of the 1,628 women who were eligible for analysis, 267 (16%) had concurrent partners themselves but believed their partners were monogamous (i.e., participants’ concurrency only), 208 (13%) had non-monogamous partners but did not have concurrent partners themselves (partners’ concurrency only), 389 (24%) had concurrent partners and also had non-monogamous partners), (both participants’ and partner's concurrency), and 764 (47%) had neither concurrent partnerships nor non-monogamous partners (neither participants’ nor partners’ concurrency). Thus, a total of 656 (40%) women had concurrent partnerships themselves and 597 (36%) believed their partners definitely had other partners during the course of their relationship.
Correlates of participants’ and partners’ concurrency
Participants’ concurrency was strongly associated with relationship status (Table 2). Compared to married women, those who had never married; or were divorced, separated, widowed, or in “other” types of relationships were significantly more likely to engage in concurrent partnerships. Women who were cohabiting were not statistically different from married women in terms of likelihood of concurrency. Substance use, binge alcohol consumption, and history of STI were also associated with concurrency. Age, race/ethnicity, education, and income were not significantly associated with participants’ concurrency. Multivariable analysis revealed an attenuated relationship between participants’ concurrency and STI history, but the relationship between concurrency and other variables persisted (Table 3).
Table 2.
Unadjusted Relative Risk (RR) for Participants' and Partners' Concurrency
| RR – Participants' Concurrency | P Value | RR – Partners' Concurrency | P Value | |
|---|---|---|---|---|
| Age (ref 18-26 yrs) | ||||
| ≥34 years | 0.984 [0.861, 1.126] | 0.8157 | 0.774 [0.68, 0.882] | 0.0001 |
| 27-33 | 0.910 [0.779, 1.064] | 0.2366 | 0.796 [0.687, 0.922] | 0.0024 |
| Race (Non-Black=ref) | ||||
| Black | 1.093 [0.917, 1.302] | 0.3217 | 1.010 [0.858, 1.19] | 0.9006 |
| Ethnicity (Non-Hispanic=ref) | ||||
| Hispanic | 0.958 [0.797, 1.152] | 0.6493 | 0.936 [0.779, 1.125] | 0.4809 |
| Marital status (married = ref) | ||||
| Never married | 1.903 [1.384, 2.616] | <.0001 | 1.867 [1.382, 2.522] | <.0001 |
| Cohabiting | 1.279 [0.907, 1.802] | 0.1602 | 1.328 [0.96, 1.836] | 0.0864 |
| Divorced, Separated, Widowed | 1.659 [1.129, 2.436] | 0.0099 | 1.690 [1.169, 2.444] | 0.0052 |
| Other | 1.493 [1.016, 2.192] | 0.0411 | 1.763 [1.237, 2.513] | 0.0017 |
| Education Level (>= High school=ref) | ||||
| Less than high school | 1.078 [0.954, 1.217] | 0.2272 | 0.953 [0.847, 1.073] | 0.4292 |
| Annual Income (>$20,000=ref) | ||||
| <$10,000 | 1.192 [0.951, 1.494] | 0.1285 | 1.021 [0.838, 1.245] | 0.8329 |
| $10,001-$20,000 | 1.122 [0.852, 1.478] | 0.4113 | 0.982 [0.766, 1.259] | 0.8862 |
| Alcohol & Drug Use | ||||
| Use of illicit drugs (other than marijuana) during past 6 months | 1.486 [1.317, 1.676] | <.0001 | 1.236 [1.091, 1.401] | 0.0009 |
| Binge alcohol consumption (≥ 4 drinks on one occasion at least weekly during past 6 months) | 1.266 [1.115, 1.436] | 0.0003 | 1.090 [0.958, 1.24] | 0.1915 |
| Sexual Behavior | ||||
| Self-reported diagnosis of STI (gonorrhea, chlamydia, or syphilis) in the past 6 months | 1.273 [1.085, 1.494] | 0.0030 | 1.556 [1.357, 1.784] | <.0001 |
Table 3.
1Adjusted Relative Risks (RR) of Participants' and Partners' Concurrency
| RR – Participants' Concurrency | P Value | RR – Partners' Concurrency | P Value | |
|---|---|---|---|---|
| Age (18-26 years=ref) | ||||
| ≥34 years | 0.870 [0.748, 1.012] | 0.0708 | 0.706 [0.608, 0.819] | <.0001 |
| 27-33 years | 0.911 [0.781, 1.062] | 0.2340 | 0.796 [0.685, 0.926] | 0.0031 |
| Marital status (married =ref) | ||||
| Never married | 1.891 [1.387, 2.578] | <.0001 | 1.727 [1.283, 2.324] | 0.0003 |
| Cohabiting | 1.270 [0.91, 1.772] | 0.1599 | 1.277 [0.929, 1.755] | 0.1317 |
| Divorced, separated, or widowed | 1.557 [1.07, 2.267] | 0.0208 | 1.631 [1.131, 2.351] | 0.0088 |
| Other | 1.461 [1, 2.134] | 0.0497 | 1.557 [1.094, 2.215] | 0.0138 |
| Alcohol & Drug Use | ||||
| Use of illicit drugs (other than marijuana) during past 6 months | 1.545 [1.346, 1.774] | <.0001 | 1.412 [1.225, 1.626] | <.0001 |
| Binge alcohol consumption (≥ 4+ drinks on one occasion at least weekly during past 6 months) | 1.174 [1.032, 1.335] | 0.0146 | 1.035 [0.908, 1.18] | 0.6053 |
| Sexual Behavior | ||||
| Self-reported diagnosis of STI (gonorrhea, chlamydia, or syphilis) in the past 6 months | 1.156 [0.984, 1.359] | 0.0780 | 1.405 [1.222, 1.617] | <.0001 |
Relative risks adjusted for other variables in the table
Partners’ concurrency
Partners’ concurrency was significantly associated with younger age of the participant (ages 18 through 26 years, compared to age 27 and older). Partners’ concurrency, like participants’ concurrency, was significantly associated with relationship status: compared to married women, those who had never married; or were divorced, separated widowed, or in “other” types of relationships were more likely to believe their partner had outside sexual partnerships. Cohabiting women were not significantly different from married women in reporting partners’ concurrency. Partners’ concurrency was also associated with history of substance abuse and STI during the past six months. There was no relationship between partners’ concurrency and race/ethnicity, education, or income. In multivariable analysis the relationships between partners’ concurrency and all other covariates remained unchanged (Table 3).
Gaps and overlaps in sexual partnerships
The mean and median overlaps in partnership dates among women who had concurrent partnerships were, respectively, -17 and -5 months (Table 4). The mean and median gap in partnerships was about 1 month among women who reported only partners’ concurrency or no involvement with concurrent partnerships.
Table 4.
Characteristics of most recent sexual partnership. Numbers may not add up to 100% due to missing values
| Participants' Concurrency Only N=267 (%) | Partners' Concurrency Only N=208 (%) | Both N=389 (%) | Neither N=764 (%) | 1P | |
|---|---|---|---|---|---|
| Interval for 2 most recent partnerships (gap in months) | <.0001 | ||||
| Mean | −17 | 0.958 | −16.8 | 0.851 | |
| Median | −5 | 1 | −5 | 1 | |
| 25th, 75th %tile | −16, −1 | 0, 1 | −18, −1 | 0, 1 | |
| Frequency of vaginal sex (during last 6 months) with most recent partner? | .0018 | ||||
| ≤ 10 times | 121/267 (45%) | 111/208 (53%) | 155/389 (40%) | 301/764 (39%) | |
| More than 10 times | 146/267 (55%) | 97/208 (47%) | 234/389 (60%) | 463/764 (61%) | |
| 2Frequency of vaginal sex without a condom (during last 6 months) with most recent partner? | 0.0036 | ||||
| ≤ 10 times | 145/262 (55%) | 119/204 (58%) | 181/386 (47%) | 349/749 (47%) | |
| More than 10 times | 117/262 (45%) | 85/204 (42%) | 205/386 (53%) | 400/749 (53%) | |
| Frequency of anal sex (during last 6 months) with most recent partner? | 0.2394 | ||||
| More than 10 times | 12/267 (4%) | 6/208 (3%) | 12/389 (3%) | 21/764 (3%) | |
| 2-10 times | 26/267 (10%) | 21/208 (10%) | 53/389 (14%) | 84/764 (11%) | |
| Once | 17/267 (6%) | 11/208 (5%) | 26/389 (7%) | 73/764 (10%) | |
| Has most recent partner been tested for HIV? | <.0001 | ||||
| No or don't know | 101/267 (38%) | 98/208 (47%) | 176/389 (45%) | 221/764 (29%) | |
| Yes | 166/267 (62%) | 110/208 (53%) | 213/389 (55%) | 543/764 (71%) | |
| Has most recent partner ever used a needle to inject drugs? | 0.8686 | ||||
| No or don't know | 258/267 (94%) | 199/208 (96%) | 366/389 (94%) | 724/764 (95%) | |
| Yes | 15/267 (6%) | 9/208 (4%) | 23/389 (6%) | 40/764 (5%) | |
P values reflect tests for differences between the 4 concurrency groups
Among those who had vaginal sex in the last 6 months
Sexual behaviors: Frequency of unprotected intercourse and partner risk characteristics
A substantial proportion of women in all concurrency categories reported frequent (more than 10 times) unprotected vaginal intercourse with their most recent partner during the six months before the interview (Table 4). Frequent unprotected vaginal intercourse was more likely to be reported by women who were involved with neither type of concurrency (53%) and those who had both concurrent partners and non-monogamous partners (53%) than women who only had concurrent partners (participants’ concurrency only) (45%) and those who only had non-monogamous partners (partners’ concurrency only) (42%) (p=.0036). Twenty-two percent of participants reported having had anal intercourse at least once with their most recent partner; 14% (235/1,1628) had anal sex with their most recent partner multiple times, but the distribution of this behavior did not vary by concurrency status.
A respondent was more likely to report that her last partner had either never undergone HIV testing or that she was unaware of whether or not he had been tested if she had both types of concurrent partnerships (45%), only non-monogamous partners (47%) or only had concurrent partners herself (38%) compared to women who were involved with neither type of concurrency (29%) (p <.0001).
Only 2% of women believed their most recent partner had sex with men; the prevalence of this belief did not vary by concurrency status (data not shown). There were no significant differences by concurrency status in the prevalence of women who believed that their last partner had injected drugs.
We evaluated frequency of vaginal intercourse with both partners among the 1,193 women who reported two or more partners during the six months preceding the interview (Table 5). Substantial proportions of women reported unprotected intercourse with at least two of their most recent partners on more than one occasion. A woman with multiple partners was more likely to report multiple episodes of unprotected vaginal intercourse with two or more of these partners if she reported both types of concurrency (60%), participants’ concurrency only (50%), or partners’ concurrency only (33%) compared to a woman who was involved with neither type of concurrency (14%) (p<.0001). Of women with both types of concurrency, 16% reported unprotected vaginal intercourse with at least two partners on more than 10 occasions in the last six months. Likewise, 10% of women with only participants’ concurrency, 7% of those with only partners’ concurrency, and 3% of those of those who had neither type of concurrency reported more than 10 episodes of unprotected vaginal intercourse with at least two partners. Women with both types of concurrency were most likely to report that both of their last two partners had not undergone HIV testing or were unaware that they had been tested (48%), followed by women with only participants’ concurrency (41%) or only partners’ concurrency (40%), while women who did not participate in any type of concurrency were least likely (17%) (p<.0001).
Table 5.
Characteristics of participants who reported at least 2 recent sexual partnerships
| Participant's Concurrency Only | Partners' Concurrency Only | Both | Neither | P | |
|---|---|---|---|---|---|
| Total number of women | 267 | 163 | 389 | 374 | |
| Frequency of vaginal sex in last 6 months? | |||||
| Vaginal sex with ≥ 2 of most recent partners more than 10 times | 44/267 (16%) | 16/163 (10%) | 91/389 (23%) | 12/374 (3%) | <.0001 |
| More than one episode of vaginal sex with ≥ 2 of most recent partners | 197/267 (74%) | 89/163 (55%) | 321/389 (83%) | 95/374 (25%) | <.0001 |
| Frequency of vaginal sex without a condom in the last 6 months? | |||||
| Vaginal sex without a condom with ≥ 2 of most recent partners more than 10 times | 28/267 (10%) | 12/163 (7%) | 63/389 (16%) | 12/374 (3%) | <.0001 |
| More than one episode of vaginal sex without a condom with ≥ 2 of most recent partners | 133/267 (50%) | 53/163 (33%) | 234/389 (60%) | 52/374 (14%) | <.0001 |
| Frequency of anal sex in last 6 months? | |||||
| Anal sex with ≥ 2 of most recent partners more than 10 times | 3/267 (1%) | 1/163 (1%) | 2/389 (1%) | 1/374 (<1%) | 0.5703 |
| More than one episode of anal sex with ≥2 partners | 11/267 (4%) | 2/163 (1%) | 19/389 (5%) | 7/374 (2%) | 0.0406 |
| Did partner have sex with women/men/both? | |||||
| ≥ 2 partners had sex with men or men and women | 1/267 (<1%) | 1/163 (1%) | 2/389 (1%) | 0/374 (0%) | 0.5682 |
| Neither of last 2 partners was tested for HIV (respondent indicated either they had not been tested or she didn't know whether they had been tested) | 109/267 (41%) | 65/163 (40%) | 187/389 (48%) | 65/374 (17%) | <.0001 |
DISCUSSION
In this cohort of women at risk for HIV infection who were recruited from 10 communities in the United States, both participants’ and partners’ concurrency were frequently reported. During the six months before the baseline interview 40% of participants had concurrent partnerships, and 36% believed their partners had concurrent partnerships; 24% of all respondents had concurrent partnerships themselves and strongly believed their partners did as well. Marital status, substance use, and history of STI were associated with participants’ and partners’ concurrency. Among the 47% of women who had neither concurrent nor non-monogamous partners, the median gap between partnerships was one month, which is short enough to allow transmission of several STI pathogens, including acute HIV infection. Compared to women who had neither concurrent nor non-monogamous partners, those with any type of concurrency were more likely to report multiple episodes of unprotected vaginal intercourse with at least two of their last three partners, and this was especially evident for women who had both concurrent and non-monogamous partners. These findings suggest substantial opportunities for sexual transmission of HIV and other STIs among the women in this study.
Other studies have also revealed short gaps, but differences in study design make it difficult to directly compare results. Our study examined partnerships that occurred during the last six months. Therefore the maximum possible gap is six months, which may not be comparable to other studies that measured partnerships over shorter or longer intervals. In a representative sample of the US population, among women aged 15-44 years with multiple consecutive partners, the mean gap varied with age from as short as eight months among the youngest women to 18 months among women aged 30-44 and was longer among non-Hispanic Black women (15 months) than non-Hispanic White women (12 months). Of note, roughly 11 to 14% of women had gaps of less than 1.8 months.[10] The 18 to 39 year old male and female Seattle respondents in a random digit dial survey reported a mean gap length of 60.8 days.[11] Gap lengths among male and female patients with consecutive partners in a Malawi STI clinic averaged 21 days.[14] These short gaps would especially facilitate HIV transmission during acute infection when HIV viral load is extremely high.[15]
The duration of overlap in concurrent partnerships varied considerably among respondents in our study, as evidenced by the marked differences between the median of five months and the mean of 17 months, indicating that a small proportion of women had partnerships that overlapped by at least 17 months. Variation in duration of overlap has been observed in other study populations.[11], [14], [16] Long-term concurrency can provide increased opportunities for HIV transmission.[17]
Estimates of per contact risk of HIV acquisition through vaginal intercourse vary from 0.001 to as high as 0.1; risk is especially high if the HIV-uninfected individual has an STI (as did 11% of our participants) or if the index contact has early or late stage HIV infection with high viral load.[18] Anal intercourse further heightens HIV transmission risk.[18] A substantial minority (14%) of all participants in this study had anal intercourse multiple times with their most recent partner. Moreover, women who had both concurrent and non-monogamous partners were especially likely to have had unprotected vaginal intercourse with multiple partners and to report unknown HIV status of those partners. Unprotected intercourse during the course of concurrent partnerships has been previously reported. More than one-third (35%) of men with concurrent partners in a representative sample of the US population did not use condoms during last intercourse with either of their partners.[19] These findings suggest a need for increased availability, promotion, and acceptability of condom use; increased diagnosis and treatment of STIs, other HIV prevention strategies such as pre-exposure HIV prophylaxis; and expansion of HIV testing, as recommended by the US National HIV/AIDS Strategy.[20]
A key strength of this study is its collection of extensive details concerning sexual partnerships among women at high risk for HIV infection. We believe these findings may be generalizable to women with similar characteristics in the US. However, it is important to note that our study population is not representative of any racial/ethnic or demographic group. Rather, participants were recruited because of their high-risk characteristics. Although they may be representative of women at high risk for HIV infection, they are not representative of poor women in general.
These results share the limitations of studies that rely on self-reported data, including those involving social desirability, recall, understanding, and communication,[21], [22] and we used a relatively insensitive measure of coital frequency. In addition, concurrency – particularly partners’ concurrency – is difficult to measure. Since our survey only queried women about their last three partners, we may have missed concurrency among women who had four or more partners. In addition, our concurrency definition (which we adopted to avoid misclassifying respondents with short gaps between consecutive partnerships) may have missed concurrent partnerships whose overlap only occurred within one calendar month.
Our comparison of first and last dates of sexual intercourse is considered one of the more robust strategies for measuring concurrency.[23] The UNAIDS Reference Group on Estimates, Modeling, and Projections recommends determination of the 6 month point prevalence of concurrency (i.e., the prevalence of concurrency exactly 6 months prior to the interview).[24, 25] This definition is useful as a standard for comparison of concurrency rates across populations. However, our goal was not to evaluate population prevalence of concurrency; we evaluated the cumulative proportion of concurrency in order to fully capture the characteristics of concurrent partnerships.
Determination of partners’ concurrency is problematic, as people are reporting the usually unobserved behavior of others. Although some studies have noted poor agreement between individuals’ reports of their partners’ concurrency and the partners’ reports of their own concurrent partnerships,[26], [27], [28] the poor agreement stems largely from respondents’ failure to identify their partners’ lack of monogamy and not from over-reports of the partners’ concurrency.[29]
In contrast to previous nationally representative studies, in which the crude and adjusted prevalence of concurrency among Black women exceeded that among Whites and Hispanics,[6], [8] there were no racial differences in concurrency among our respondents. Our study is notable for the exceptional poverty of the participants. Almost half survived on an annual income of less than $10,000, and all resided in an area with high rates of poverty. Given the importance of contextual factors in sexual network patterns,[30], [31] it is likely that the adverse economic context shared by participants of all race/ethnicities may have contributed to the distribution of the observed network patterns.
This study identified several sexual partnership characteristics that contribute to HIV and STI acquisition and transmission, including short time gaps between consecutive partnerships, partners’ concurrency, long-term participants’ concurrency, unprotected intercourse with concurrent partners, and lack of awareness of partner HIV serostatus among individuals whose network position placed them at high risk of acquiring or transmitting STIs, including HIV. These findings can improve our understanding of partnership dynamics and help target behavioral and biomedical interventions to prevent HIV infection.
ACKNOWLEDGEMENTS
The authors thank the study participants, community stakeholders, and staff from each study site. In particular, they acknowledge Lynda Emel, Jonathan Lucas, Nirupama Sista, Kathy Hinson, Elizabeth DiNenno, Ann O’Leary, Lisa Diane White, Waheedah Shabaaz-El, Quarraisha Abdool-Karim, Sten Vermund, Edward E. Telzak, Rita Sondengam, Cheryl Guity, Tracy Hunt, Khadijah Abass, Eileen Rios, Irene Kuo, Christopher Chauncey Watson, Christopher Walker, Oluwakemi Amola, and LeTanya Johnson-Lewis.
Sources of Support: By the National Institute of Allergy and Infectious Diseases, National Institute on Drug Abuse, and National Institute of Mental Health (cooperative agreement no. UM1 AI068619, U01-AI068613, and UM1-AI068613); National Institute of Child Health and Human Development (5 K24HD059358-02); Centers for Innovative Research to Control AIDS, Mailman School of Public Health, Columbia University (5U1Al069466); University of North Carolina Clinical Trials Unit (AI069423); University of North Carolina Clinical Trials Research Center of the Clinical and Translational Science Award (RR 025747); University of North Carolina Center for AIDS Research (AI050410); Emory University HIV/AIDS Clinical Trials Unit (5UO1AI069418), Center for AIDS Research (P30 AI050409), and Clinical and Translational Science Award (UL1 RR025008); The Terry Beirn Community Programs for Clinical Research on AIDS Clinical Trials Unit(5 UM1 AI069503-07) and; The Johns Hopkins Adult AIDS Clinical Trial Unit (AI069465) and The Johns Hopkins Clinical and Translational Science Award (UL1 RR 25005).
Footnotes
Disclaimer: The views expressed herein are solely the responsibility of the authors and do not necessarily represent the official views of the National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, the National Institutes of Health, the HPTN, or its funders.
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