Abstract
Despite evidence of the link between STI and HIV transmission, STI rates remain alarmingly high, particularly among racial/ethnic minorities. This study examined the relationship between earlier STI diagnoses (gonorrhea and chlamydia) and future STI acquisition and its implications for HIV prevention among a sample of urban Black men who have sex with men (Black MSM). Data from a cohort of 600 Black MSM (15–29 years of age) residing in a medium-size Southern city enrolled in a HIV prevention intervention were analyzed. We used multivariate logistic regression to assess the association between STI diagnosis (baseline: Time 1) and subsequent STI diagnosis (90-day post-diagnosis: Time 2). Repeated measures analyzed at Time 1 and Time 2 included condomless sex, insertive and receptive sex, concurrent sexual partnerships, multiple partners, and age of partner. Independent of socio-demographic factors, we found having a prior GC/CT increased the likelihood of a future GC/CT by a factor of 15 (OR = 15.2, p = 0.01). Participants were statistically more likely to have been diagnosed with an extragenital STI (OR = 2.3, p = 0.05). Present findings suggest that time of initial STI diagnosis is a critical period in which to intervene to reduce future STI/HIV acquisition. Screening guidelines should be expanded to include testing for extragenital infection. STI screening and treatment and counseling programs should be culturally appropriate to account for the unique needs and the social and environmental context of the population. Additional research is needed to design STI prevention interventions that address social and environmental factors to reduce sexual risk behaviors that increase HIV vulnerability for Black MSM.
Keywords: Sexually transmitted infections, Sexually transmitted diseases, Extragenital, Acquired immunodeficiency syndrome, AIDS, Human immunodeficiency virus, HIV, HIV/AIDS, Gonorrhea, Chlamydia, Men who have sex with men, MSM, Black MSM
Introduction
Research has shown that having a sexually transmitted disease (STI) increases the likelihood of acquiring human immunodeficiency virus (HIV) [1–3]. As such, STI prevention and interventions are public health priorities in the USA and globally. Black/African-American men who have sex with men are disproportionately impacted by HIV, particularly in the Southern region of the USA [4–6]. According to the Centers for Disease Control and Prevention (CDC), Blacks represent 14% of the US population, yet they account for 50% of syphilis cases, two thirds of reported cases of gonorrhea, one third of chlamydia, and 59% of HIV diagnoses [7]. In 2016, among all men who have sex with men, Black MSM was the most affected group representing 38% of new HIV diagnoses [8]. Research suggests that patterns of stigma and discrimination, residential segregation-derived sexual networks, and lack of access to STI testing and treatment are associated with increased rates of STIs among African-Americans [9–12]. Also, studies have shown disparities in STI rates are more pronounced among Black MSM who are younger, unemployed, and from lower socioeconomic strata [13–15].
The prevention of sexually transmitted infections has been widely promoted as an efficacious strategy in preventing HIV infection, particularly among high-risk populations [16–19]. The CDC recommends all sexually active men who have sex with men (MSM) are screened at least once a year for syphilis, chlamydia, and gonorrhea [1]. Despite these efforts, STIs remain some of the most common infections in the USA. It is estimated that annually 19 million Americans are diagnosed with an STI and the overall medical costs associated to be approximately $14 billion/year [20]. Effective STI control depends on ensuring access to and utilization of sexual health services as well as an understanding of the social and contextual factors that drive sexual risk behavior. While a number of studies have examined the relationship between STIs and HIV vulnerability [21–30], there is limited research examining the influence of receiving a STI diagnosis on subsequent STI acquisition [5]. Typically, these studies examine subsequent STI diagnosis by STI type such as syphilis, gonorrhea, or chlamydia. However, little is known about the influence of the site of the infection on subsequent acquisition. Further research is needed to better understand pathways to STI risk as well as factors promoting safer sex and condom use to inform the development of effective HIV preventive interventions and policies.
Given the high rates of STI and HIV infections, particularly among Black MSM residing in urban areas, there is an urgent need for research that helps to identify new pathways and mechanisms for HIV acquisition. Understanding the potential role of the anatomical site of STI exposure on predicting subsequent STI acquisition may (1) advance our knowledge regarding STI/HIV transmission among understudied populations; (2) determine whether existing screening guidelines are sufficient; and (3) assist in the development of new and innovative HIV prevention interventions to improve the HIV prevention continuum for young Black MSM.
In the present study, we extend STI/HIV research by elaborating and testing hypotheses regarding the association of receiving a gonorrhea/chlamydia (GC/CT) diagnosis and subsequent GC/CT outcomes, specifically diagnoses of new infections by anatomical type. We examine associations between being diagnosed with a GC/CT across time points, Time 1 (baseline) and later infection at Time 2 (90 days) on five site-specific categories: (1) any GC/CT, (2) pharyngeal GC/CT, (3) urethral GC/CT, (4) rectal GC/CT, and (5) extra-genital GC/CT. To our knowledge, this is the first longitudinal study to examine correlates of STI diagnosis stratified by anatomical site among a cohort of Black MSM. Notably, our findings are context-specific for young urban Black MSM residing in the South, which is a subpopulation that has the highest prevalence of HIV in the USA.
Materials and Methods
Study Population
Data for this investigation were derived from an NIH-funded randomized controlled trial (RCT) of a HIV prevention intervention to reduce STI incidence and risk of HIV acquisition/transmission among young Black MSM [31]. Recruitment occurred at a publicly funded clinic designated for the diagnosis and treatment of HIV and other STIs. Consenting, age-eligible volunteers were asked to participate in an HIV prevention intervention study. All study procedures were approved by the Institutional Review Boards of the University of Mississippi Medical Center, the Mississippi State Department of Health, and the University of Kentucky.
The study comprised 600 young Black MSM residing in Jackson, MS, a medium-sized city located in the Southern region of the USA. Participant inclusion criteria included (1) assigned male at birth; (2) self-identification as Black/African-American; (3) aged 15 to 29 years; (4) attending the clinic to be tested for HIV or other STIs; (5) having engaged in penile-anal sex with a male partner at least once in the past 6 months; and (6) the ability to speak and comprehend English. Specimen collection and specimen processing have been described in detail previously [31].
Measures
Following informed consent procedures, participants were provided a computer equipped with audio computer-assisted self-interview (ACASI) software to complete a survey. Participants responded to questions about their demographic characteristics, sexual role (anal insertive or anal receptive), STI history (e.g., STI diagnoses and HIV status), and sexual risk behaviors (response categories are shown in Table 1).
Table 1.
Differences in sexual risk behavior and GC/CT diagnosis between baseline and Time 2 (HIV-negative)
| HIV-negative status | ||||
|---|---|---|---|---|
| Time 1 (n = 421) | Time 2 (n = 277) | |||
| Mean or n (%) | Mean or n (%) | χ 2/t | p | |
| Sexual risk behavior | ||||
| Concurrent sexual partners | 105 (25.4%) | 57 (20.6%) | 1.57 | 0.05 |
| Has older partner (≥ 5 years) | 68 (16.5%) | 43 (15.5%) | 1.26 | 0.20 |
| Number of sex partners (AI) | 2.6 (8.1) | 2.1 (9.4) | 3.04 | 0.003 |
| Number of sex partners (AR) | 2.1 (4.4) | 2.1 (12.3) | 4.92 | 0.000 |
| Anal receptive | 261 (62.0%) | 173 (58.9%) | 10.10 | 0.001 |
| Anal insertive | 297 (70.6%) | 178 (42.3%) | 16.89 | 0.000 |
| Used condom (AI) | 277 (72.5%) | 183 (69.1%) | 1.95 | 0.05 |
| Used condom (AR) | 250 (88.7%) | 159 (57.6%) | 5.34 | 0.000 |
| STI type | ||||
| Any GC/CT | 120 (34.4%) | 47 (21.0%) | 3.60 | 0.0004 |
| Pharyngeal | 50 (13.3%) | 17 (7.2%) | 2.84 | 0.005 |
| Urethral | 45 (11.3%) | 13 (5.2%) | 3.24 | 0.0013 |
| Rectal | 87 (23.9%) | 31 (13.1%) | 3.22 | 0.0015 |
| Extragenital | 111 (31.4%) | 39 (17.0%) | 3.81 | 0.0002 |
Note. AI = anal insertive; AR = anal receptive
*p < 0.05, **p < 0.01, ***p < 0.001
Sociodemographic Characteristics
Sociodemographic variables associated with sexual risk behavior were added to control for socioeconomic status. For age, we categorized individuals as young adults (15–19 years) or adults (20–29 years of age). Education was divided into a dichotomous variable (0 = high school or less; 1 = some college or higher). Income was a dichotomous variable (0 = < US$1000/month, 1 = > US$1000/month).
STI History
All eligible patients were screened for gonorrhea and chlamydia. Those who were diagnosed with a gonorrhea or chlamydia infection were treated at point of care according to CDC guidelines. For gonorrhea, a dual therapy consists of a single dose of 250 mg of intramuscular ceftriaxone and 1 g of oral azithromycin and 1 g of azithromycin orally in a single dose for treatment of chlamydia. These medications have been shown to be highly efficacious for treating gonorrhea and chlamydia with a cure rate of 97% and 95%, respectively. A meta-analysis of 12 randomized clinical trials of azithromycin for the treatment of urogenital chlamydial found microbial cure rates of 97% [32]. Additionally, studies show that standard treatment regimen for gonorrhea has a cure rate of 95% [33]. All participants were instructed to return to the clinic if symptoms persisted after a few days post-treatment for reevaluation. Any participants who returned for treatment prior to 90-day follow-up were treated and monitored for reinfection. Only participants with new infections were included in the analysis.
STI Risk Factors
Sexual risk behaviors hypothesized to be associated with STI transmission included the following variables:
Participants were characterized as anal insertive (AI) or anal receptive (AR). Anal insertive (AI) intercourse: defined as inserting the penis rectally during anal sex (0 = no, 1 = yes).
Anal receptive (AR) intercourse: defined as being penetrated during anal sex (0 = no, 1 = yes). The association between unprotected receptive anal intercourse and HIV acquisition in MSM is well documented [34]. For this study, we examined the potential effect of role segregation on STI acquisition defined by two broad categories AI and AR. These independent measures were designed to help us better understand transmission dynamics among our target population. Participants responded to two separate questions regarding their sexual role (AI vs AR) during intercourse in the last 90 days. Those respondents who indicate dual roles are included in both categories.
Condom use: defined as using a condom during sex in the past 90 days. Two separate variables were created: (1) condom usage if anal receptive (0 = no, 1 = yes) and (2) condom usage if anal insertive (0 = no, 1 = yes).
Concurrent sexual partners: defined as overlapping sexual partnerships in which sexual intercourse with one partner occurs between two acts of intercourse with another sexual partner [8] was coded (0 = no, 1 = yes).
Older sexual partner: defined as a having a sexual partner 5 years or older than the respondent (0 = no; 1 = yes). The difference in age of sexual partner has been associated with increased risk of HIV infection [9].
Multiple sexual partners: measured by two separate continuous variables defined by the respondent’s sexual role: (a) number of sexual partners (anal receptive) and (b) number of sexual partners (anal insertive).
Data Analysis
We used logistic regression to assess the association between STI risk factors (i.e., sexual role, concurrent partnerships, and condomless sex) and STI diagnosis among a sample of Black MSM participants. Participants’ HIV status was dichotomized (positive vs negative) to assess how perceived risk might influence sexual risk behavior.
First, we performed bivariate comparisons of individual characteristics by HIV status using t-test (Tables 1 and 2). Bivariate analysis of association of background characteristics (socio-demographics and sexual risk behaviors) of participants at Time 1 (baseline) and Time 2 (90-day post-diagnosis) was performed to determine variables of interest for inclusion in a multivariable model (Table 3-4). Variables significant at the bivariate level and conceptually relevant covariates were included in a multivariable logistic regression model predicting STI diagnosis. Next, we performed logistic regression to assess associations between baseline, time-dependent STI risk factors, and STI outcomes in a 90-day interval using robust variance estimation to account for repeated measures on participants (Table 5). The final model was simplified using stepwise variable selection.
Table 2.
Differences in sexual risk behavior and GC/CT diagnosis between baseline and Time 2 (HIV-positive)
| HIV-positive status | ||||
|---|---|---|---|---|
| T1 (n = 179) | T2 (n = 107) | |||
| Mean (SD) or n (%) | Mean (SD) or n (%) | χ 2 or t | p | |
| Sexual risk behavior | ||||
| Concurrent sexual partners | 48 (27.3%) | 22 (20.6%) | 1.34 | 0.18 |
| Older partner (≥ 5 years) | 58 (32.9%) | 29 (27.1%) | 1.58 | 0.12 |
| Number of sex partners (AI) | 2.2 (4.8) | 1.2 (1.5) | 3.04 | 0.003 |
| Number of sex partners (AR) | 2.5 (3.7) | 1.0 (1.2) | 4.92 | 0.000 |
| Anal receptive | 143 (79.9%) | 82 (45.8%) | 8.31 | 0.000 |
| Anal insertive | 118 (65.9%) | 56 (31.3%) | 8.37 | 0.000 |
| Used condom (AI) | 125 (82.8%) | 67 (65.7%) | 2.91 | 0.005 |
| Used condom (AR) | 136 (93.8%) | 65 (61.9%) | 4.55 | 0.000 |
| STI type | ||||
| Any GC/CT | 64 (44.4%) | 21 (26.3%) | 2.35 | 0.01 |
| Pharyngeal^ | 26 (17.0%) | 9 (10.7%) | 0.89 | 0.37 |
| Urethral^ | 15 (9.8%) | 5 (5.6%) | 1.30 | 0.20 |
| Rectal | 53 (34.6%) | 16 (19.1%) | 3.22 | 0.0015 |
| Extragenital | 63 (42.3%) | 21 (25.6%) | 3.81 | 0.0002 |
Note. AI = anal insertive; AR = anal receptive
*p < 0.05, **p < 0.01, ***p < 0.001
Table 3.
Odds ratios for STI infection types and sociodemographic and sexual risks (Time 1) (n = 600)
| Sexually transmitted disease (GC/CT) anatomical type | |||||
|---|---|---|---|---|---|
| GC/CT | Pharyngeal | Urethral | Rectal | Extra-genital | |
| OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | |
| Sociodemographic characteristics | |||||
| Age | 0.79 (0.52–1.19) | 0.82 (0.47–1.45) | 0.77 (0.41–1.44) | 0.67 (0.42–1.06) | 0.71 (0.46–1.09) |
| HIV status | 1.53 (1.03–2.27)* | 1.33 (0.80–2.24) | 0.86 (0.46–1.58) | 1.68 (1.11–2.54)** | 1.60 (1.08–2.37)** |
| Educational status | 1.12 (0.78–1.61) | 1.29 (0.79–2.10) | 0.89 (0.52–1.51) | 1.14 (0.77–1.69) | 1.16 (0.80–1.67) |
| Income | 1.14 (0.79–1.65) | 1.13 (0.69–1.85) | 1.14 (0.67–1.97) | 1.33 (0.89–1.97) | 1.25 (0.86–1.81) |
| Employment status | 0.66 (0.46–0.97)* | 0.89 (0.53–1.44) | 0.62 (0.35–1.10) | 0.74 (0.50–1.10) | 0.70 (0.48–1.02)* |
| Sexual risk behavior | |||||
| Concurrent sexual partners | 1.74 (1.15–2.64)** | 1.81 (1.09–3.03)** | 1.09 (0.59–2.00) | 1.33 (0.86–2.06) | 1.78 (1.18–2.70)** |
|
Has older partner (≥ 5 years) |
0.92 (0.58–1.44) | 1.21 (0.68–2.15) | 0.65 (0.31–1.38) | 0.89 (0.55–1.44) | 0.96 (0.6–1.51) |
|
Number of sex partners (AI) |
1.01 (0.98–1.03) | 1.00 (0.96–1.04) | 1.02 (1.00–1.05) | 1.00 (0.97–1.03) | 1.01 (0.97–1.03) |
|
Number of sex partners (AR) |
1.02 (0.98–1.06) | 1.00 (0.95–1.06) | 0.92 (0.81–1.04) | 1.02 (0.98–1.06) | 1.02 (0.98–1.06) |
| Anal receptive | 1.34 (0.90–2.00) | 1.50 (0.86–2.61) | 0.61 (0.36–1.06) | 1.73 (1.11–2.70)** | 1.53 (0.88–2.30) |
| Anal insertive | 1.46 (0.97–2.19) | 1.91 (1.05–3.48)** | 3.10 (1.44–6.69)** | 0.94 (0.62–1.43) | 1.24 (0.82–1.86) |
| Used condom (AI) | 1.13 (0.72–1.77) | 0.77 (0.44–1.34) | 1.27 (0.63–2.55) | 1.19 (0.73–1.94) | 1.10 (0.70–1.74) |
| Used condom (AR) | 0.86 (0.43–1.71) | 0.98 (0.39–2.46) | 1.23 (0.36–4.23) | 0.78 (0.38–1.60) | 0.78 (0.39–1.56) |
Note. AI = anal insertive; AR = anal receptive
*p < 0.05, **p < 0.01, ***p < 0.001
Table 4.
Odds ratios for GC/CT infection types by sociodemographic and sexual risks (Time 2) (n-600)
| Sexually transmitted disease (GC/CT) anatomical type (n = 600) | |||||
|---|---|---|---|---|---|
| GC/CT | Pharyngeal | Urethral | Rectal | Extra-genital | |
| OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | OR (95% CI) | |
| Sociodemographic characteristics | |||||
| Age | 0.97 (0.89–1.06) | 1.04 (0.91–1.18) | 1.03 (0.89–1.20) | 0.95 (0.86–1.05) | 0.98 (0.90–1.07) |
| HIV status | 1.34 (0.74–2.43) | 1.55 (0.66–3.63) | 1.09 (0.38–3.14) | 1.56 (0.80–3.02) | 1.68 (0.92–3.07) |
| Educational status^ | |||||
| Income | 1.06 (0.61–1.82) | 1.34 (0.60–3.03) | 0.81 (0.31–2.09) | 1.05 (0.56–1.97) | 1.26 (0.71–2.23) |
| Employment status | 0.76 (0.43–1.32) | 0.61 (0.27–1.36) | 0.67 (0.26–1.76) | 0.89 (0.47–1.71) | 0.73 (0.41–1.31) |
| Sexual risk behavior | |||||
| Has multiple partners | 1.15 (0.59–2.27) | 0.99 (0.36–2.74) | 0.52 (0.12–2.31) | 1.31 (0.62–2.74) | 1.35 (0.69–2.67) |
|
Has older partner (≥ 5 years) |
1.22 (0.50–2.06) | 0.59 (0.17–2.05) | 1.41 (0.45–4.44) | 0.82 (0.35–1.95) | 0.94 (0.44–1.99) |
|
Number of sex partners (AI) |
0.89 (0.34–0.97)* | 1.00 (0.95–1.04) | 1.00 (0.95–1.05) | 0.58 (0.33–0.71)* | 0.99 (0.93–1.05) |
|
Number of sex partners (AR) |
0.75 (0.91–0.78)* | 0.99 (0.94–1.05) | 0.80 (0.51–1.24) | 1.00 (0.96–1.03) | 0.99 (0.93–1.05) |
| Anal receptive | 0.99 (0.51–1.58) | 1.46 (0.59–3.58) | 0.88 (0.33–2.33) | 0.79 (0.42–1.50) | 0.88 (0.49–1.59) |
| Anal insertive | 1.00 (0.58–1.72) | 1.16 (0.51–2.64) | 1.82 (0.63–5.22) | 0.87 (0.47–1.63) | 0.99 (0.56–1.75) |
| Used condom (AI) | 1.35 (1.23–7.64)* | 0.93 (0.40–2.16) | 1.12 (0.38–3.26) | 1.09 (0.55–2.17) | 1.01 (0.55–1.86) |
| Used condom (AR) | 1.75 (1.59–4.91)* | 2.52 (1.98–6.46)* | 0.91 (0.35–2.37) | 0.98 (0.52–1.85) | 1.20 (0.67–2.15) |
Note. AI = anal insertive; AR = anal receptive
*p < 0.05, **p < 0.01, ***p < 0.001
^Data not collected at Time 2
Table 5.
Multiple logistic regression of STI-related factors predicting STI diagnosis (n-600)
| Any STI | Pharyngeal | Urethral | Rectal | Extragenital | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| OR | P | CI | OR | P | CI | OR | P | CI | OR | P | CI | OR | P | CI | |
| Sociodemographic characteristics | |||||||||||||||
| Age | 0.46 | 0.30 | 0.11–2.00 | 0.32 | 0.33 | 0.03–3.21 | 0.67 | 0.76 | 0.05–8.76 | 1.19 | 0.81 | 0.29–4.85 | 0.51 | 0.34 | 0.12–2.06 |
| Income | 1.13 | 0.81 | 0.39–3.29 | 1.35 | 0.70 | 0.28–6.52 | 1.96 | 0.67 | 0.20–18.88 | 0.51 | 0.26 | 0.15–1.66 | 0.88 | 0.38 | 0.20–1.83 |
| Education | 1.27 | 0.66 | 0.43–3.71 | 0.66 | 0.59 | 0.15–2.95 | 0.92 | 0.94 | 0.10–8.25 | 1.55 | 0.47 | 0.47–5.17 | 1.71 | 0.32 | 0.58–5.01 |
| Employment | 0.70 | 0.51 | 0.24–2.04 | 1.11 | 0.89 | 0.25–5.02 | 1.68 | 0.63 | 0.22–14.00 | 0.59 | 0.39 | 0.17–1.99 | 0.61 | 0.39 | 0.20–1.83 |
| STI types | |||||||||||||||
| Any GC/CT | 15.19 | 0.01** | 3.27–45.54 | 5.31 | 0.51 | 0.18–35.28 | 9.74 | 0.29 | 0.14–64.05 | 11.03 | 0.11 | 0.55–52.98 | 2.31 | 0.03* | 1.33–43.21 |
| Pharyngeal1 | 3.45 | 0.05* | 1.35–8.68 | 1.35 | 0.79 | 0.14–4.23 | 0.46 | 0.60 | 0.02–8.61 | 3.15 | 0.15 | 0.60–24.89 | 3.89 | 0.05* | 1.74–19.34 |
| Urethral1 | 1.36 | 0.74 | 0.21–7.58 | 2.69 | 0.35 | 0.33–21.88 | 3.89 | 0.39 | 0.18–81.06 | 1.43 | 0.94 | 0.60–24.89 | 0.99 | 0.99 | 0.16–5.32 |
| Rectal1 | 1.42 | 0.75 | 0.16–11.67 | 1.17 | 0.91 | 0.07–18.62 | 0.58 | 0.76 | 0.18–18.28 | 1.35 | 0.05* | 1.22–19.92 | 5.33 | 0.20 | 0.38–67.16 |
| Extragenital1 | 1.24 | 0.05* | 1.04–5.95 | 0.55 | 0.80 | 0.05–5.19 | 1.29 | 0.92 | 0.01–22.71 | 1.27 | 0.34 | 0.10–24.89 | 2.19 | 0.001*** | 0.06–2.65 |
| HIV status1 | 0.55 | 0.43 | 0.16–2.22 | 1.19 | 0.84 | 0.21–6.58 | 0.97 | 0.98 | 0.08–11.77 | 1.24 | 0.05** | 1.04–2.47 | 0.71 | 0.60 | 0.25–2.43 |
| Sexual risk behaviors | |||||||||||||||
| Condom (AI) | 1.43 | 0.57 | 0.42–4.63 | 0.81 | 0.81 | 0.14–4.47 | 0.17 | 0.17 | 0.01–2.19 | 2.12 | 0.22 | 0.57–10.48 | 2.30 | 0.21 | 0.62–8.56 |
| Condom (AR) | 0.24 | 0.04 | 0.05–0.87 | 0.80 | 0.86 | 0.07–8.58 | 0.21 | 0.16 | 0.22–1.89 | 0.41 | 0.05* | 1.05–11.38 | 0.41 | 0.30 | 0.08–2.21 |
| Anal insertive | 0.18 | 0.004* | 0.05–0.65** | 0.89 | 0.88 | 0.181 | 0.64 | 0.71 | 0.06–6.43 | 0.13 | 0.007** | 0.03–0.57 | 0.27 | 0.03* | 0.08–0.91 |
| Anal receptive | 3.45 | 0.38 | 0.30–25.44 | – | – | – | 0.88 | 0.93 | 0.04–18.84 | 1.37 | 0.77 | 0.16–11.40 | 2.09 | 0.48 | 0.29–16.22 |
| Concurrent partner | 1.99 | 0.22 | 0.67–5.77 | 2.35 | 0.27 | 0.51–10.86 | 3.15 | 0.34 | 0.29–33.13 | 1.13 | 0.31 | 0.57–6.14 | 1.89 | 0.24 | 0.65–5.51 |
| Age partner (> = 5) | 3.42 | 0.02 | 1.21–5.53* | 0.60 | 0.54 | 0.10–3.50 | 6.22 | 0.10 | 0.69–8.98 | 4.24 | 0.01** | 1.31–13.67 | 2.31 | 0.12 | 0.81–6.63 |
| Multiple partners (AR) | 1.86 | 0.05 | 1.71–7.03* | 1.04 | 0.67 | 0.87–1.23 | 1.07 | 0.36 | 0.92–1.24 | 1.12 | 0.05* | 1.07–1.23 | 1.10 | 0.10 | 0.98–1.24 |
| Multiple partners (AI) | 0.86 | 0.13 | 1.03–4.13 | 0.91 | 0.57 | 0.64–1.28 | 0.56 | 0.27 | 0.20–1.54 | 0.88 | 0.14 | 0.75–1.04 | 0.91 | 0.21 | 0.18–1.31 |
| Intervention | 0.48 | 0.14 | 0.18–1.26 | 0.72 | 0.65 | 0.19–2.82 | 1.6 | 0.21 | 0.21–12.13 | 0.42 | 0.25 | 0.16–1.58 | 0.49 | 0.16 | 0.18–5.81 |
Note. AI = anal insertive; AR = anal receptive
*p < 0.05, **p < 0.01, ***p < 0.001,1Time 1
Results
Profile of Respondents
In this section, we present sociodemographic, behavioral, and clinical characteristics for the entire sample. Of the 600 respondents surveyed, they ranged in ages from 15 to 29, with a median age of 22.6 years. Two fifths (40%) had a high school education or less, 44% earned less than US$1000/month, and 42% indicated they were currently not working. In regard to their sexual role, 67% indicated they were anal receptive compared to 69% who were anal insertive. Among anal receptive participants, 90.4% used a condom compared to only 75% of anal insertive participants. The mean (2.3) number of sexual partners was the same for both anal receptive and anal receptive respondents. Over a quarter (26%) had a concurrent partnership, and 20% had an older sexual partner (≥ 5 years). Results indicate nearly a third (30%) of participants were HIV-positive at baseline. Many (37.3%) tested positive for either gonorrhea or chlamydia. Of those respondents who tested, 35% tested positive for gonorrhea and 26% for chlamydia.
Bivariate Analyses
In Tables 1 and 2, we present bivariate associations stratified by HIV status of selected covariates associated with STI acquisition. A t-test was calculated to assess whether sexual risk behavior and STI diagnoses decreased from Time 1 to Time 2. Participants sexual risk behavior and STI diagnosis varied between baseline evaluation and Time 2 (90-day post-initial diagnosis). In Table 1, we present findings for HIV-negative participants. Overall, we found significant declines in sexual risk behavior between T1 and T2 on a number of sexual behavior characteristics including concurrent partners (25.4% vs 20.6%), having an older partner (16.5% vs 15.5%), anal receptive (AR) 62% vs 59%, anal insertive (AI) 71% vs 42%, used condom (AI) (73% vs 69%), and used condom (AR) (89 vs 57%). In terms of STI diagnosis, extragenital STI was the most common diagnosis at baseline (31%) and at T2 (17%). There were statistically significant declines for each anatomical type: any GC/CT (13%); pharyngeal (5.1%), urethral 5.9%, rectal (10.8), and extragenital (14.4%) among HIV-negative participants.
Among HIV-positive participants, we found similar patterns in sexual risk behavior and STI diagnosis 90-day post-initial evaluation (Table 2). Comparing T1 and T2, we found statistically significant differences in sexual risk behavior on all variables except sexual concurrency and having a sexual partner (≥ 5 years). The mean number of sexual partners declined for both AI (2.2 vs 1.2) and AR (2.5 vs 1.0) participants. Also, our findings show significant declines between T1 and T2 among HIV-positive participants who are AR and AI identified. At baseline 80% indicated, they were AR, however, 90 days later only 45.8% identified as AR. At 90-day post initial diagnosis, 35 % fewer participants surveyed indicated they were AI. Additionally, there was an 18% decline in overall GC/CT diagnoses; and for rectal GC/CT, we saw a decline from 35% to 19% and 42% vs 27% for extragenital GC/CT between T1 and T2. However, extragenital (42%) was the most common STI diagnosis type among HIV-positive participants.
Next, using bivariate logistic regression, we examined statistical associations between sociodemographic characteristics, STI risk factors, and five STI diagnosis categories including GC/CT (combined gonorrhea and chlamydia and four site-specific STIs). As shown in Table 3, HIV-positive individuals with GC/CT were almost 53% more likely (OR.1.53; p = 0.05) to be diagnosed with gonorrhea or chlamydia, 68% more likely to be diagnosed with rectal (OR 1.68, p = 0.05) and 60% more likely for extra-genital (OR 1.60, p = 0.05). Also, being in a concurrent relationship increased the likelihood of being diagnosed with gonorrhea or chlamydia by 74% (OR 1.74, p = 0.05), 81% for pharyngeal (OR 1.81, p = 0.05), and 78% for extra-genital (OR 1.78, p = .0.05). Respondents who were anal receptive were at greater risk (73%) for rectal (OR 1.73, p = 0.0.1) and 53% for extra-genital (OR 1.53, p = 0.10). Anal insertive respondents were nearly twice as likely to be diagnosed with pharyngeal (OR 1.91, p = 0.01) and three times more like for urethral (3.10, p = 0.01) GC/CT. These analyses were repeated at Time 2 (Table 4). Those individuals who were diagnosed with any GC/CT were more likely to use a condom, both anal receptive (AR) (1.75, p = 0.05) and anal insertive (AI) (1.35, p = 0.05) at Time 2. Also, we found that they were less likely to have multiple partners AI (0.89, p = 0.05) and AR (0.75, p = 0.05). For those who were diagnosed with pharyngeal GC/CT, they were 2.5 times more likely to use a condom (2.5; p = .0.05).
Multivariate Regression Analysis of STI-Related Risk Factors and STI Diagnosis
Table 5 shows adjusted odds ratios (OR) for five STI diagnosis categories by anatomical site: (1) any GC or CT (gonorrhea or chlamydia), (2) pharyngeal, (3) urethra, (4) rectal, or (5) extragenital gonorrhea or chlamydia. Respondents who had an STI diagnosis at Time 1 were 15 times more likely to be diagnosed with gonorrhea or chlamydia at Time 2 (OR 15.2, CI 3.27–45.54). These individuals were 24% more likely to have an extragenital GC/CT (OR = 1.24, CI 1.04–5.95), 82% less likely to be anal insertive (OR = 0.18, CI0.05–0.65), and almost 3.5 times more likely to have an older sexual partner (≥ 5 years) (OR = 3.42, CI 1.35–8.68). Also, individuals diagnosed with rectal GC/CT at Time 1 were 35% more likely to have a rectal GC/CT at Time 2 (OR 1.35, CI 1.22–19.92). There was a statistically significant likelihood to be HIV-positive (OR 1.24, CI 1.04–2.47) and less likely to be anal insertive (OR = 0.13, CI 0.03–0.57).. Also, having an older sexual partner ≥ 5 years increased the likelihood of being diagnosed with a rectal GC/CT by a factor of four (OR = 4.24, CI 1.31–13.67).
Next, our findings show individuals diagnosed with extragenital GC/CT at Time 2 were 2.3 times more likely to have been diagnosed with “any GC/CT” (OR = 2.3 1, CI 1.33–43.21) at Time 1. In addition, they were almost four times more likely to have been diagnosed with pharyngeal (OR = 3.89, CI 1.74–19.34) and twice as likely to be diagnosed with extragenital (OR = 2.19, CI 0.06–2.65) STI GC/CT. Individuals diagnosed with an extragenital GC/CT at Time 2 were 73% (OR = 0.27, CI 0.08–0.91) less likely to be anal insertive.
Discussion
This study examined the effect of receiving a GC/CT diagnosis on five site-specific GC/CT outcomes, 90-day post-diagnosis. We found a high prevalence of gonorrhea and chlamydia among the young Black MSM population in this study, with both HIV-positive and HIV-negative respondents reporting high levels of sexual risk behaviors including anal receptive sexual practices, inconsistent condom use, high frequency of sexual partners, and concurrent sexual partners and having an older sexual partner 5 or more years older. Individuals diagnosed with gonorrhea or chlamydia (GC/CT) at baseline were 15 more likely of being diagnosed with a gonorrhea or chlamydia at T2, and it was statistically more likely to be an extragenital STI. At both baseline and 90-day post-evaluation, extragenital was the most common STI diagnosis among our sample population, 42% and 27%, respectively.
Moreover, our sample reported high rates of socioeconomic insecurity with 40% of participants with a high school diploma or less, 44% living below the poverty line, and 42% were unemployed. Research has demonstrated social determinants such as race/ethnicity, education, and income are risk factors that increase HIV vulnerability among racial/ethnic and sexual minority groups [35]. HIV vulnerability includes a diverse range of social and structural factors that militate against the ability of some individuals and populations to avoid HIV infection. These vulnerability factors can be divided into three groups: (1) individual-level factors, e.g., the lack of knowledge, skills, and beliefs required to protect oneself and others from acquisition or transmission of HIV/STIs; (2) socioeconomic factors, e.g., educational attainment, income, and racial/ethnic background that may impact the quality and type of services, including accessibility (e.g., distance to healthcare facilities lack of transportation, cost of care, and utilization); and (3) structural level factors (e.g., social and cultural norms, practices, beliefs, and laws that stigmatize and disempower poor and vulnerable populations) may act as barriers to accessing essential HIV/STI prevention, care, and treatment [36]. All of these risk factors may act independently or in combination with other biological mechanisms to contribute to conditions of individual vulnerability or, in the case of Black MSM, a collective vulnerability, which may serve to further exacerbate individual vulnerability. It is within this toxic mix of debilitating vulnerabilities, whereby the distress of receiving a STI diagnosis might explain why some individuals may not adhere to prosocial sexual behavior or HIV prevention messages putting them at increased risk of STI/HIV infection. Since we did not include nor is there a global measure of HIV vulnerability, we cannot categorically state that HIV vulnerability influenced an individual’s sexual risk behavior and subsequent STI diagnoses. However, several studies have documented that HIV vulnerability related to racial/ethnic background, income, and education increases odds for sexual risk behavior and hence the possible influence of an earlier STI diagnosis on subsequent sexual risk behavior and HIV [37–39].
Given the highest prevalence of cases of new infections that are occurring among African-Americans in the Southern USA, it is imperative that we increase research to develop HIV prevention interventions that take into account the unique vulnerabilities that emerge out of a history of persistent and chronic racialized social, economic, and political marginalization. Moreover, additional research is needed to examine the relationship between discrimination, stigma, and shame and racialized HIV vulnerability in regard to sexual risk behaviors that foster STI acquisition and transmission. Moreover, it is critical we have an understanding of the progression and cumulative effect of these social and structural factors in the context of HIV vulnerability and how they interact to promote the onset, persistence, increase, or change in the expression of negative sexual risk behavior and practices, which will be useful for designing and implementing HIV/STI prevention interventions.
Challenges and Limitations
Our findings were limited by the utilization of a convenience sample, and as a result, the findings may not be generalizable to the broader population of Black MSM. Also, the study may be susceptible to recall bias as it relies on the validity of respondents’ self-report of sexual risk behaviors, thus limiting reliability and complete accuracy. Limited sample sizes for HIV-positive participants precluded our ability to conduct additional multivariate analyses stratified by HIV status. Additionally, we acknowledge sexual roles among MSM may be fluid depending on context, therefore using a binary measure (anal receptive vs anal insertive) may not fully capture the complexity of Black MSM as it relates to sex role segregation. Finally, we were constrained by the data, since the socioeconomic measures may not fully capture the impact of minority stress in the context of chronic and persistent structural/racial discrimination and its impact on HIV-related sexual behaviors and outcomes. These limitations, notwithstanding, are among the first longitudinal studies examining the influence of STI diagnosis on future STI acquisition among a sample of young, urban Black MSM.
Conclusion
The relationship between GC/CT diagnosis and subsequent STI acquisition is complex, multifactorial, and site-specific. Evidence has shown biological mechanisms explain only a small part of the STI transmission phenomenon. Our findings suggest that an association between prior GC/CT diagnosis, infection site, and subsequent diagnosis is likely an interaction between biological mechanisms and social and contextual factors (e.g., racial discrimination-related norms and policies in the form of racial segregation-derived sexual networks, poverty, stigma, low educational, limited access, and service utilization rates on/STI resources and services) relevant to our population that increase susceptibility for STIs among urban African-American youth. This study is timely as it highlights the importance of a prior STI diagnosis in predicting future STI acquisition and identifying likely repeaters early, as well as an urgent need to improve current screening guidelines, particularly enhanced extragenital testing and the development of HIV prevention interventions and programs targeting Black MSM.
Given the strength of evidence of the links between STI and HIV and the enormous burden of disease represented by HIV among Black MSM, there is an urgent need for additional research on subsequent STI diagnosis and the development and implementation of more culturally appropriate prevention interventions that take into account the socio-ecological context and realities of the affected populations and communities. Future research should investigate the mechanisms through which structural stigma and discrimination influences sexual risk behavior in the context of the STI screening, diagnosis, and treatment continuum and prioritize the development and the implementation of evidenced-based structural level HIV prevention interventions and policies that reduce racial/ethnic disparities in STI- and HIV-related outcomes. From a population health and service provision point of view, it is imperative for national and local governments, healthcare providers, researchers, and AIDS service organizations (ASOs) take a more integrated approach to meet the HIV prevention, care, and treatment needs of sexual and racial minorities, particularly Black MSM.
Acknowledgements
We wish to thank the participants of the Better Sex with Latex Initiative. The study was supported by the National Institute of Mental Health [5RO1MH092226].
Footnotes
Short Summary
A longitudinal study of Black MSM diagnosed with gonorrhea and chlamydia at baseline found clients were 15 times more likely to have a subsequent diagnosis 90-day post-initial diagnosis compared to those who were not diagnosed with STI. There is an urgent need to expand HIV prevention efforts to include routine STI screening, particularly screening for extragenital STI and to develop new HIV prevention programs that promote condom use and safer sex practices alongside PrEP for at-risk Black MSM.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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