El VIH en los negros HSH de EEUU. Paralelo con nuestra clase humilde. Imprimir

El Ministerio de Salud de la Nación dice que en Argentina hay dos subepidemias: una de gays de clase media y otra heterosexual de clase baja. Nuestra hipótesis es que hay tres: una de gays de clase media, otra de homosexuales de clase baja, y una tercera en las mujeres de clase baja casada con esos homosexuales que, por ser de clase baja, ven como una obligación cultural casarse.

Entre la epidemia de clase media, educada y blanca, y la epidemia de clase baja sospechamos que hay poco contacto, o la transmisión HSH tendría muchas más víctimas que las que tiene, porque vivimos en un país machista donde la relación penetrativa entre varones es una práctica de extensión desconocida.

La clase humilde y la clase media argentina se diferencian por niveles socioeconómicos primero, y después por el color de su piel; en los Estados Unidos, la diferencia racial entre negros y blancos equivale a grandes rasgos a la diferencia entre pobres y ricos. Y en el siguiente artículo se muestra la notable incomunicación que hay entre negros y otras razas en las redes sexuales de San Francisco.

En los negros norteamericanos la epidemia de VIH está avanzando mucho más velozmente que en otros subgrupos poblacionales. Creemos que esto es lo que puede suceder con los homosexuales de nuestra clase humilde, una vez que el virus haga su camino desde la Universidad a la clase baja de primera completa o incompleta, donde a nuestro parecer todavía no se ha difundido en gran medida.

RF

ENSAYO ORIGINAL

 

Mezcla Racial y Riesgo de VIH Entre Hombres que Hacen Sexo con Hombres

 

H. Fisher Raymond & Willi McFarland

 

San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102-6033, USA e-mail: hfi Esta dirección electrónica esta protegida contra spam bots. Necesita activar JavaScript para visualizarla

 

Resumen

Condujimos una encuesta transeccional de HSH usando un diseño de muestreo de tiempo y lugar en San Fran­cisco durante 2007–2008. la investigación se concentró en la selección dee parejas sexuales, preferencias de parejas, percepciones de riesgo de VIH y mezcla social en relación con la raza/etnicidad. La muestra de 1.142 HSH fue 56% blanca, 22% latina, 14% asiática y 9% negra e informó sobre 3.532 sociedades [partnerships] sexuales. Los HSH negros tenía un nivel significativo de encontrar pareja sexual de la misma raza tres veces más alto que lo que debería esperarse si fuera solamente casualidad (i.e. en ausencia de fuerzas selectivas relativas a la raza entre parejas). De los HSH negros se informó que eran los menos preferidos como parejas sexuales, aquellos de los que se creía estaban en mayor riesgo de VIH, aquellos a los que se contaba con menos frecuencia entre los amigos, se los consideraba los más difíciles de conocer, y se los percibía como menos bienvenidos por otros HSH en los lugares de reunión comunes donde asisten hombres gays en San Francisco. Nuestros resultados dan apoyo a la hipótesis de que las redes sexuales de los HSH negros, constreñidos por las preferencias y actitudes de los no negros y del ambiente social, son empujadas a estar más altamente intercontectadas que las de otros grupos, con la consecuencia potencial de una difusión más rápida del VIH y una prevalencia de infección sostenida más alta. La disparidad racial en VIH observada por más de una década no desaparecerá hasta que no se enfrenten los desafíos propuestos por un legado de racismo contra los negros en los EEUU.

 

Keywords Race/ethnicity HIV MSM Disparities

Sexual mixing Sexual networks Social networks

Social epidemiology

 

Introducción

 

Una desdichada característica de la actual epidemia de VIH en los Estados Unidos es la carga desproporcionada de infección que recae sobre los afronorteamericanos (CDC 2006). Los negros eran casi la mitad de todos los casos de VIH/SIDA diagnosticados en el 2006, lo que producía una tasa per capita de cuatro veces el promedio nacional. Entre los HSH, numerosos estudios de múltiples ciudades norteamericanas encontraron consistentemente que los HSH negros tenían una incidencia y prevalencia significativamente más alta de VIH (Harawa et al. 2004; Millett et al. 2007; Valleroy et al. 2000). En San Francisco, la prevalencia estimada de VIH entre HSH negros es del 32%, comparada con una cifra general del 24% (Departamento de Salud Pública de San Francisco [SFDPH] 2004).

En una paradoja aparente, la mayoría de lose studios encuentran que los HSH negros no se involucran en conductas sexuales de alto riesgo en tasas más altas que otros grupos raciales/étnicos de HSH (Millett et al. 2007; Harawa et al. 2004; Meyers et al. 2003). De hecho, los HSH negros tendían a informar niveles más abajos de relación sexual anal no protegida, menos parejas sexuales, menos parejas sexuales VIH positivas, uso más bajo de sustancias relacionadas con el sexo de alto riesgo (incluyendo metanfetamina y drogas inyectables), e involucrarse en menos trabajo sexual comercial que los HSH de otras razas/etnicidades. Una reseña reciente de la literatura cualitativa científica generó varias otras hipótesis que pueden explicar las altas tasas de VIH entre HSH negros (Millett et al. 2006). Una hipótesis se concentraba en las redes sexuales de HSH negroOne hypothesis focused on the sexual net­works of Black MSM; es decir, que podría haber menos elección de parejas sexuales para los HSH negros, creando en consecuencia redes sexuales más estrechamente tejidas que las de otros grupos. Las redes sexuales interconectadas estrechamente pueden crear condiciones para la rápida difusión de VIH incluso si las cantidades de parejas y episodios de sexo no protegido informados por los individuos que componen la red no fueran más altos que los de otros grupos. Esto es, si la infección de VIH entra en una parte de la red, puede rápidamente llegar a una gran proción de la población conectada a través de la red. La alta carga viral durante la infección aguda puede amplificar todavía más la transmisión de VIH cuando las redes sexuales se superponen en el tiempo. Esta situación parece haber sido el caso de los jóvenes negros HSH de un estudio de infección VIH aguda de Carolina del Norte (CDC 2004). Otra investigación da como resultado que la mezcla asortativa [apareamiento no azaroso basado en caracteristicas similares o disímiles] (i.e., elección de pareja sexual que tiende hacia lo homogéneamente intraracial) puede aumentar el peso de la enfermedad sexualmente transmitida dentro de los grupos étnicos donde la prevalencia de enfermedad es ya elevada (Aral 2000). De este modo, una estructura de red sexual puede causar una difusión rápida de VIH y mantener un alto nivel de infección VIH a lo largo del tiempo incluso si los otros factores son constantes. En una reseña subsiguiente de los datos cuantitativos sobre el tema, los autores sacaron la conclusion de que la hipótesis de la red sexual seguía siendo viable a la luz de la evidencia a favor y en contra de otras posibilidades, pero que había datos específicos insuficientes sobre el tópico (Millett et al. 2007).

Una encuesta previamente informada de HSH conducida en San Francisco en 2004 que encontró que era más probable que los HSH negros hicieran pareja con otros HSH negros, en contraste con los HSH de otras razas/etnicidades (Berry et al. 2007). Estos resultados corroboraron una investigación previa de Los Angeles (Bingham et al. 2003). Si bien el estudio registraba la raza/etnicidades de los respondientes y sus parejas sexuales, los datos, sin embargo, no exploraban ninguna de las posibles razones para el alto nivel de formación de parejas de la misma raza entre HSH negros. Informamos aquí sobre los resultados de una encuesta más amplia de HSH, conducida 4 años más tarde en San Francisco, que incluía una serie de preguntas relativas a la mezcla social y sexual entre diferentes razas/etnicidades. Las metas del estudio presente son determinar los niveles catuales de mezcla sexual entre los grupos raciales y étnicos de HSH en San Francisco e identificar razones potenciales que subyacen en los patrones de la mezcla sexual.

 

Methods

 

Study Subjects, Recruitment and Sampling Design

 

We conducted a cross-sectional survey of MSM attending public venues in San Francisco from December 2007 through October 2008 using time-location sampling (TLS). The TLS methodology is used to approximate a probability sample in hidden or hard-to-reach populations through creation of a sampling frame that comprises the universe of venues, days, and time periods where and when the pop­ulation can be found to congregate. From the roster of all possible venue-day-time (VDT) periods, a random sample of VDT is drawn. At the randomly selected VDT, the attendance of all potentially eligible subjects is recorded and individuals entering or exiting the venue or crossing a predetermined line are intercepted, assessed for eligibility, and invited to participate. Intercepts and interviews are done consecutively without choice on the part of field staff until all staff are occupied. Once a staff is available, intercepts and interviews resume. In the analysis, data are weighted according to the sample fraction obtained at the VDT and adjustments are made to standard errors to account for clustering. TLS is the sampling methodology selected for the US National HIV Behavioral Surveillance (NHBS) system for MSM coordinated by the Centers for Disease Control and Prevention (CDC) in several cities throughout the US and is used for biological and behavioral surveillance in diverse ‘‘most-at-risk populations’’ throughout the world (Valleroy et al. 2000; CDC 2005; Magnani et al. 2005; MacKellar et al. 1996; MacKellar et al. 2007). The methods have been applied to several previous surveys of MSM in San Francisco and have been described in detail previously (CDC 2005; MacKellar et al. 1996, 2007).

The present study recruited a sample of MSM separately from the NHBS but using the same TLS methods. The formative research phase constructed an up-to-date uni­verse or sampling frame of gay-identified recruitment venues, which included bars, dance clubs, cruising areas, bookstores, gyms, social organizations, churches, street locations, and other venue types and the days and time periods of attendance. Venues included in the sampling frame were any venues known to be frequented by MSM and did not only focus on venues that were perceived to be more openly gay identified. Persons eligible for the study were male gender, age 18 years and older, being a resident of any of ten Bay Area counties, and had to be consecu­tively approached by the staff at the randomly selected VDT (i.e., they could not approach staff on their own or at a later time). Of note, identifying as MSM at the time of screening was not an eligibility criterion, thus allowing non-gay identified MSM to participate and reducing the risk that persons who did not wish to initially acknowledge male–male sexual behavior would not be excluded. For analysis, we included any participant reporting a male partner in the past year or who identified as gay or bisexual. After determining eligibility, staff obtained written informed consent.

 

Measures

 

The measures on race/ethnicity and sexual mixing pre­sented in this current report were collected as part of a larger survey on sexual risk, drug use, and other health related behaviors. After informed consent, staff oriented participants to a handheld computer-assisted interview completed in a private area near the venue. Once participants were familiar with the operation of the hand­held computer, they completed a self-administered ques­tionnaire approximately 30 min in length. Participants self-identified their own race/ethnicity using the following questions: ‘‘Are you Latino/Hispanic?’’ (yes/no) and then ‘‘Which of the following racial group or groups do you consider yourself to be? (Check all that apply) Asian, African American/Black, American Indian/Alaska Native, Native Hawaiian/Pacific Islander, Caucasian, Other (spec­ify)’’. All participants responding yes to Latino/Hispanic were classified as Latino/Hispanic and nothing else. Those respondents reporting just one of the groups (but not Latino/Hispanic) were classified as the self-reported race. Those participants who respond to more than one of the racial groups (but not Latino/Hispanic) were classified as multi-racial and are not included in the analysis of mixing. Observations with an ‘‘other’’ response written in were examined and re-coded if appropriate (e.g., ‘‘Irish’’ would be re-coded to ‘‘Caucasian’’). In the present report, we use the words ‘‘Asian’’, ‘‘Black’’, ‘‘White’’, and ‘‘Latino’’ for simplicity. A similar procedure was used to classify the race/ethnicity of sexual partners by the respondent. Respondents were asked the race/ethnicity of each sexual partner, consecutively backwards starting with the most recent, for up to 5 partners in the last 6 months.

At the end of the survey, a series of questions were included that pertained to race/ethnicity and social and sexual mixing. Race/ethnicity preference in sexual partners was measured using a four-point Likert-like scale (from ‘‘strongly disagree’’ to ‘‘strongly agree’’) in response to four separate questions phrased as ‘‘I prefer to have sexual partners who are—(Asian, Black, White, Latino)’’. The same scale as was used for perceived ease of meeting sexual partners of different race/ethnicities (‘‘It seems easier for me to meet sexual partners who are—[Asian, Black, White, Latino]’’ and for describing the environ­ments of places to meet sex partners (‘‘Bars and dance clubs catering to gay men in San Francisco are less wel­coming to—[Asians, Blacks, Whites, Latinos]’’. Perception of risk for HIV infection was measured using four ques­tions with a three point scale to the question ‘‘Having sex with a—(Asian, Black, White, Latino) partner has (more risk, no difference in risk, or less risk) for HIV infection.’’ A measure of friendship networks was constructed using four questions with a five-point scale in response to this statement ‘‘(None, a few, some, most, all) of my friends are (Asian, Black, White, Latino)’’.

 

Statistical Methods

 

Observations were included in this study’s race/ethnicity analyses if respondents reported their race as Asian, Black, White, or Latino. Other racial groups (e.g., Native Americans, Native Alaskans, Native Hawaiians, and those reporting being ‘‘Other’’ or ‘‘Mixed’’) were not included in these analyses due to small cell sizes. To assess a statistical tendency towards partnering with the same versus other race/ethnic groups we compared the expected number of race–race partnerships based on the race/ethnicity distri­bution of the sample and number of partnerships reported by respondents’ race/ethnicity to the observed number of same-race and different-race partnerships using the chi-square test. Differences in preferences, perceptions, and numbers of friends by race/ethnicities were assessed using paired T-tests. All statistical comparisons are within respondents’ race/ethnicity groups.

We also preliminarily explored correlates of interracial mixing among MSM overall to better understand this phenomenon. We explored differences in interracial mix­ing by classifying MSM as having sexual partners of all the same race as their own (‘‘assortative’’) or having at least one partner of a different race/ethnicity (‘‘disassortative’’) and using the chi-square test or Fisher’s exact test to identify factors associated with these distinctions. Due to multiple, exploratory comparisons, we used p \ 0.01 as the cut off for significance. Due to small sample sizes of each individual group we collapsed our sample into White ver­sus Men of color. All statistical analyses were conducted using SAS version 9.13.

 

Results

 

Data were collected between December 2007 and October 2008. Study staff enumerated 24,333 men at 153 randomly selected venue-day-time periods and consecutively approached 2,558 men as interviewers were available. Of the 2,558 men approached, 2,186 (85%) agreed to eligi­bility screening; 1,769 (81%) were eligible; 1,321 (75%) agreed to participate in the survey; and 1,305 (99%) men completed the interview. During the interview, 92 men identified as heterosexual and did not report any male partners in the past 12 months or were duplicate enroll­ments, leaving 1,213 unique MSM. Of these, analyses were conducted on those self-identifying as Asian, Black, White, and Latino (N = 1,142).

A majority of MSM reported being White (56%), with the next largest group Latino (22%), followed by Asian (14%), and Black (9%). Table 1 shows demographic characteristics by race/ethnicity. Overall, subjects ranged in age from 18 to 77 years old (median 35, interquartile range 27–45). A large majority of participants identified as gay (89%) or bisexual (9%) with the remaining men identifying as heterosexual or some other orientation (2%) while also reporting male sexual partners in the last 12 months. In terms of educational attainment, 13% reported a high school or less level of education, 33% had attended some college, and 53% had a college degree.

 

Table 1.

(a) Participant demographic

characteristics

by race/ethnicity,

men who have

sex with men,

San Francisco, 2008

(N = 1,142);

(b)

Race/ ethnicity of

reported sexual partnerships

among men who

have sex with

men past 6 months,

San Francisco,

2008 (N = 3,532)

 

Asiático n(%)

Negro n(%)

Blanco n(%)

Latino n(%)

 

(a) Characteristic

 

 

 

 

 

Total men

160

98

641

243

 

Age group (years)

 

 

 

 

 

18–25

36 (23)

26 (27)

85 (13)

68 (28)

 

26–35

83 (52)

30 (31)

164 (26)

91 (38)

 

36–45

30 (19)

22 (22)

183 (29)

56 (23)

 

46?

11 (7)

20 (20)

209 (33)

27 (11)

 

Sexual identity

 

 

 

 

 

Gay

148 (93)

74 (76)

589 (92)

207 (85)

 

Bisexual

10 (6)

19 (19)

44 (7)

29 (12)

 

Straight (and had male partners)

0

2(2)

6(1)

5(2)

 

Other (and had male partners)

2(1)

 

3(3)

2(\1)

2(1)

 

Highest education level achieved

 

 

 

High school or less

6 (4)

18 (18)

72 (11)

51 (21)

 

Some college

43 (27)

43 (44)

200 (31)

96 (40)

 

College degree

111 (69)

36 (37)

361 (56)

95 (39)

 

Other

0

1(1)

8(1)

1(\1)

 

Residence

 

 

 

 

 

San Francisco county

112 (70)

69 (70)

548 (85)

195 (80)

 

Other San Francisco Bay Area county

48 (30)

29 (30)

93 (15)

48 (20)

 

b) Respondent race/ethnicity

 

 

 

 

Total men

160

98

641

243

 

Total partnerships

457

288

2,021

766

 

Partner race/ethnicity (n,%)

 

 

 

Asian

79 (17)

28 (10)

303 (15)

103 (13)

 

Black

10 (46)

76 (26)

115 (6)

57 (7)

 

White

333 (76)

151 (52)

1,332 (66)

472 (62)

 

Latino

35 (8)

33 (11)

271 (13)

134 (17)

 

The 1,142 men in our analysis reported on 3,532 sexual partnerships with other men during the past 6 months. Overall, 17, 9, 14 and 13% of partnerships of Asian, Black, White and Latino respondents were with partners of the same race/ethnicity, respectively (Table 1). Among part­nerships for all men in our analyses, we compared the observed number of same race/ethnicity partnerships to the expected number that would occur under a null hypothesis of no racial/ethnic tendency in partnering. Black men were 3 times more likely to have partners that were also Black compared to what would be expected by chance; that is, for all partnerships, 2.1% were observed to be Black–Black partnerships compared to 0.7% expected by chance, v 2 78.5, p \ 0.001. Put another way, within the partner­ships of Black MSM, 8.5% would be expected to be with other Black MSM, yet 29% were observed to be. In addi­tion, White MSM were about one and a third times more likely to partner with another White MSM than would be expected by chance (37% observed vs. 32% expected, v 2 45.4, p \ 0.001). This finding is significant but most likely due to the greater numbers of White MSM in the sample. We detected no significant race/ethnicity tendencies in partners of Asian and Latino men; that is, the number of partnerships of same race/ethnicity neither exceeded nor fell short of what would be expected by chance.

 

 

 

Fig. 1 Agreement with a series of questions posed as: ‘‘I prefer to have sexual partners who are—(Asian, Black, White, Latino)’’ by respondents’ race/ethnicity, men who have sex with men, San Francisco, 2008

 

Fig. 2 Percent agreeing with statement: ‘‘Having sex with a(n)— (Asian, Black, White, Latino) partner has more risk of HIV infection’’ by respondents’ race/ethnicity, men who have sex with men, San Francisco, 2008

 

 

 

Fig. 3 Responses to a series of questions posed as:’’How many of your friends are—(Asian, Black, White, Latino)’’ by respondents’ race/ethnicity, men who have sex with men, San Francisco, 2008

 

Fig. 4 Agreement with a series of questions posed as: ‘‘It seems easier for me to meet sexual partners who are—(Asian, Black, White, Latino) by respondents’ race/ethnicity, men who have sex with men, San Francisco, 2008

 

After reporting the race/ethnicities of their sexual part­ners in the preceding 6 months, men were subsequently asked about their general preferences when choosing sex­ual partners (Fig. 1). With the exception of Blacks them­selves, all other racial/ethnic groups scored Blacks lowest in terms of their preference for sexual partners (all p-val­ues \ 0.01 when comparing Black preference scores to scores for all other race/ethnicities). Black MSM signifi­cantly preferred Latinos over other Black MSM (p \ 0.01), while their preferences for men from other racial/ethnic groups did not differ significantly. No other racial prefer­ences scores were significantly different; that is, the only evidence of racial/ethnic preferences in sex partners was against Black MSM by all other groups and towards Latinos by Black MSM. When asked to report whether having sex with men of specific race/ethnicities presented more or less risk for HIV infection, all race/ethnicity groups, including Blacks themselves, perceived Black men to be riskier (Fig. 2). The pattern of perceiving Latinos as second most risky, fol­lowed by Whites, and Asians as least risky was consistent for all groups although not all comparisons achieved sta­tistical significance. Of note, these perceptions approxi­mate the relative prevalence of HIV for these groups in the US and San Francisco.

 

Variable

Men of color (N = 343)

White (N = 462)

 

Assortative n (%)

Disassortative n (%)

v 2

Assortative n (%)

Disassortative n (%)

v 2

Total

25

318

231

231

Age group (years)

 

 

 

 

 

18–25

3 (12)

72 (23)

3.57

36 (16)

5 (11)

10.26*

26–35

10 (40)

142 (45)

 

71 (31)

59 (26)

 

36–45

7 (23)

71 (22)

 

73 (32)

66 (29)

 

46?

5 (20)

33 (10)

 

51 (22)

81 (35)

 

Sexual identity

 

 

 

 

 

 

Gay

22 (88)

277 (87)

0.689

218 (94)

210 (91)

3.34

Bisexual

3 (12)

33 (10)

 

12 (5)

18 (8)

 

Straight (and had male partners)

0

4 (1)

 

1 (\1)

1(\1)

 

Other (and had male partners)

0

4 (1)

 

0

2 (1)

 

Somewhat agree/strongly agree with: ‘‘I only feel comfortable going to gay bars and dance clubs in San Francisco that cater to people of the same race as I am’’

8 (32) *

68 (21)

1.5

68 (29)

41 (18)

8.75

All/Most friends are the same race/ethnicity as the respondent

16 (64)

90 (28)

13.83*

173 (75)

125 (54)

21.78*

Somewhat agree/strongly agree with: ‘‘I prefer to have sexual partner who are of the same race/ethnicity as I am’’

19 (76) 1

48 (47)

8.05*

136 (59)

78 (34)

29.28*

Somewhat agree/strongly agree with: ‘‘It seems easier for me to meet sexual partners who are of the same race/ethnicity as I am’’

17 (68)

141 (44)

5.22

160 (69)

109 (47)

23.14*

* p \ 0.01

 

 

 

 

 

 

 

With the exception of Black MSM themselves, all other groups reported fewer Blacks in the make up of their friendships (Fig. 3, p \ 0.001 for all differences between having Black friends versus all other race/ethnicity friends). Also with the exception of Black MSM, all other groups counted their own race/ethnicity most common among their friendships, but only for Whites was this sig­nificantly so (p \ 0.001). Black MSM reported having Black, White, and Latino friends in similar numbers; however, they had fewer Asian friends compared to each of the other groups (all p-values \ 0.001). Latino MSM reported higher but equal numbers of Latino and White friends but significantly lower numbers of Black and Asian friends groups (p-values \ 0.001).

All racial/ethnic groups of MSM found Blacks less easy to meet compared to Whites (Fig. 4, all p-values \ 0.001), including Black MSM themselves. Asian, White, and Latino MSM also ranked Whites easiest to meet, followed by Latino, then Asian least easy, although not all differ­ences were significant. Moreover, there was equal agree­ment among all racial/ethnic groups that Whites felt more welcome than others at gay bars and dance clubs. For example, 90% of White MSM and 81% of Asian, Black, and Latino men agreed with the statement ‘‘It is easy for White men to feel welcome in most bars and dance clubs that cater to gay men in San Francisco’’. Conversely, only 50% of White and 52% of Asian, Black, and Latino men agreed with ‘‘It is easy for men of color to feel welcome in most bars and dance clubs that cater to gay men in San Francisco’’.

In order to identify correlates of inter-racial partnering, we classified MSM as ‘‘assortative’’ (i.e., where all their sex partners are of the same race/ethnicity) and ‘‘disas­sortive’’ (i.e., where at least one of their partners was of a different race/ethnicity). Men must have reported having more than one partner to be included in this analysis. Table 2 compares assortative and disassortative MSM separately for MSM of color (n = 343) and White MSM (n = 462). Among MSM of color, 7% were assortative while 93% were disassortative. White MSM were evenly split between assortative and disassortative. For White MSM being 26–45 years old (v 2 10.26, p \ 0.01), having all/most friends of the same race (v 2 21.78, p \ 0.01), preferring partners of the same race (v 2 29.28, p \ 0.01), and perceiving it easier to meet men of the same race (v 2 23.14, p \ 0.01) were associated with assortative partnering. Only having all/most friends of the same race (v 2 13.83, p \ 0.01) and preferring the same race (v 2 8.05, p \ 0.01) were associated with assortative partnering among MSM of color.

 

Discusión

Nuestros datos describen un patron de facgtores en San Francisco que potencialmente reflejan en la segregación sexual relativa de los HSH negros de otros grupos de HSH. Como en nuestra encuesta previa, conducida en 2004 (Berry et al. 2007), encontramos que los HSH negros hacen pareja con otros HSH negros en tasas varias veces más altas que lo que debería esperarse si fuera simple casualidad. Como en nuestra encuesta previa, documentamos rezones potenciales para que esto ocurriera. Primero, los HSH negros son los menos preferido como parejas sexuales por otros HSH. Segundo, de los HSH negros se percibe que son los que están en mayor riesgo de VIH comparados con otras parejas, lo que puede conducir a hombres de otras razas a evitar a los HSH negros en calidad de parejas sexuales. Tercero, los HSH negros son los que menos a menudo se cuentan entre las amistades de otros HSH. Cuatro, los HSH negros son ranqueados como los menos fáciles de conocer por otros HSH. Quinto, de los HSH negros se percibe que son los menos bien recibidos en los lugares de reunión communes de socialización entre los HSH de San Francisco. Algo nuevo de este estudio fue el descubrimiento de que los HSH blancos tenían significativamente menos probabilidades de tener parejas sexuales de razas/etnicidades no negras. Sacamos la conclusion de que la combinación de actitudes de parte de los HSH no negros, las redes de amistad y sociales que tienen menos probabilidades de incluir HSH negros, y los ambientes encontrados en los lugares de reunion gay sirven para separar a los HSH negros de los otros grupos. Si bien los números de asociaciones intrarraciales de los HSH negros aparecen modestamente elevados del 8.5% que se esperaría al 29% observado, este efecto triple puede server para intensificar las interconexciones dentro de esta población minoritaria en relación con otras poblaciones HSH, lo suficiente para acelerar la difusión del VIH hasta el apreciable grado testimoniado.

While this pattern may tempt one to conclude that racism towards Black MSM is prevalent among MSM in our city, we call for extreme caution before using this label. Inherent to a definition of overt racism are beliefs that qualities are particular to certain races and that these qualities make one race superior or inferior to another. We purposely did not include questions on these aspects of racism in an effort to avoid the social desirability response bias that this line of questioning is likely to engender. Our first goal was to confirm the level of same race partnering among Black MSM seen 4 years earlier. Second, if still apparent, to explore whether the phenomenon was associated with the stated preferences of Black or non-Black MSM, perceptions on the epidemiology of HIV, prevailing social networks, the environment of the venues where MSM meet sexual part­ners, or combinations of these factors. We also wish to point to the quite high level of interracial partnering in our sample. Overall, 46% of partnerships described were interracial. Moreover, the interpretation of racism would be unfair without comparable data from other populations. While population-based data on the race/ethnicity of sexual partners are rare, the US Census estimated around 2% of marriages were interracial from 1970 through 1992 (US Census Bureau 1998). More recent estimates raise this to only 7% (Cary 2007). While same sex marriage is currently illegal in California, therefore precluding truly comparable figures for MSM, these estimates are many-fold lower than the interracial partnering we observed in our study. We do not believe our data should be bluntly interpreted as evi­dence of racism among MSM. Rather, we do interpret that our data capture less overt, more subtle factors stemming from the history and legacy of racism towards Blacks and segregation of Blacks in the US. Moreover, we acknowl­edge that our analyses only address racism towards Black MSM and does not address racism towards other racial groups.

We also interpret serious consequences of this legacy on the HIV epidemic through their effects on the sexual net­works of Black MSM. Previous research highlighting the paradox of higher HIV prevalence among Black MSM despite lower levels of individual risk behavior suggest that the sexual networks of Black MSM create the circum­stances for high incidence and prevalence of HIV. Our data are consistent with this hypothesis in that the sexual net­works of Black MSM are constrained to smaller numbers and are therefore potentially more highly interconnected than other groups. Once HIV enters one part of such tightly connected network, it is likely to spread rapidly through­out. This rapid spread could also easily be greater if reports of sexual risk are lower than what is actually occurring and if the rates of partner change are greater. If the networks persist over time or across age groups, then the high prevalence of HIV could be sustained for a long time.

A major limitation to our study is that we do not char­acterize the complete sexual networks and their intercon­nections, rather our conclusions are inferred from individuals’ responses about their partnerships. We also note potential limitations in the representativeness of the sample. There is no true Census of MSM populations in the US and therefore no gold standard to which to compare the make up of our sample. Nonetheless, the sampling method employed in our study is identical to our previous survey and to that used by the CDC for National HIV Behavioral Surveillance among MSM (MacKellar et al. 2007). Our data may therefore be reasonably consistent over time and could be compared to other cities included in the national system. Another limitation on interpretation is that some findings will be influenced by the relative numbers of MSM of different race/ethnicities. For example, the rela­tive numbers of friends of different race/ethnicities and the ease in meeting such friends can be expected to be influ­enced by the relative numbers in each group. However, the analysis of partnerships corrects for these relative propor­tions, and this bias should not be the case for preferences, welcoming of venues, or perception of risk (the latter actually appears to mirrored the relative prevalence of HIV). Moreover, despite being the most predominant in numbers, Whites were not in fact counted most frequently among the friendships of Asian and Latino MSM. An additional limitation is our lack of measures that probed mediators and moderators of partner selection (e.g. fear of rejection, stigma, availability of partners of different races) thus we are limited to the current analyses. Future research on the topic of partner selection will need to include these types of measures. Finally, we also note the limitations in self-reported data. In American culture, questions on race are very sensitive and answers may be biased against responses that might be construed as ‘‘racist’’. Such a bias may have resulted in diminishing or under-estimating many of the effects described here.

Such limitations and potential biases should not thwart the investigation of the factors that have created the unacceptable disparity in HIV incidence and prevalence by race/ethnicity in the US today. Given their potential rele­vance to HIV transmission, epidemiological surveys need to track questions on race/ethnicity that are, strangely, considered too sensitive or intrusive in such surveys. Fur­ther investigations will need to draw upon social-behav­ioral theories that will help frame and explain complex patterns of sexual mixing. For example, researchers might use social cognitive theory as a framework to better understand the interactions between individuals and those around them and those interactions’ effect on sexual mix­ing (Bandura 2004). Social capital concepts may also be a useful framework to quantify the resources of individuals and their social networks and to explore how those resources influence sexual partnering (Bourdieu 1986). More difficult than describing such factors will be the means to intervene upon them. One finding, that social spaces are not welcoming to MSM of color raises the possibility of structural interventions to address the dis­parities in HIV infection. Group level interventions to reduce negative attitudes based on race might be imple­mented but these interventions to change preferences and attitudes will not be easy. Progress in interracial relation­ships in the US has been painstakingly slow, even since the decades following civil rights legislation. A starting point is to raise awareness among MSM that social barriers are having serious effects on the health and well-being on different parts the community. We believe that such a dialog needs to be infused with rigorous data rather than stereotypes and misperceptions.

 

Acknowledgments We wish to thank John Newsome for his thoughtful feedback to earlier versions of this manuscript.

 

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Última actualización el Lunes, 27 de Julio de 2009 15:56