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HIV/STD Risks in Young Men Who Have Sex with Men Who Do Not Disclose
Their Sexual Orientation --- Six U.S. Cities, 1994--2000
To avoid social isolation, discrimination, or verbal or physical abuse,
many men who have sex with men (MSM), especially young and minority MSM,
do not disclose their sexual orientation (1--3). Young MSM who do
not disclose their sexual orientation (nondisclosers) are thought to be at
particularly high risk for human immunodeficiency virus (HIV) infection
because of low self-esteem, depression, or lack of peer support and
prevention services that are available to MSM who are more open about
their sexuality (disclosers) (1--3). However, the risks for HIV
infection and other sexually transmitted diseases (STDs) are unknown for
nondisclosers. To better understand the prevention needs of young MSM, CDC
analyzed data from the Young Men's Survey (YMS) to compare HIV/STD risk
differences between nondisclosers and disclosers. This report summarizes
the results of that analysis, which indicate that 8% of 637 nondisclosers
were infected with HIV compared with 11% of 4,952 disclosers. Among
blacks, the prevalence of HIV infection was 14% among 199 nondisclosers
compared with 24% among 910 disclosers. Compared with disclosers,
nondisclosers had similar high risks for other STDs, reported less sexual
behavior with men and more sexual behavior with women, reported less use
of HIV testing services, and, among those who were HIV infected, were less
likely to be aware of their infection. To reduce HIV/STD transmission
among young MSM and their female sex partners, comprehensive HIV/STD
testing and prevention programs for young nondisclosers, especially for
those who are black, should be developed or expanded.
YMS was a cross-sectional survey conducted during 1994--2000 of men
aged 15--29 years who attended MSM-identified venues in six U.S.
metropolitan areas (Baltimore, Maryland; Dallas, Texas; Los Angeles,
California; Miami, Florida; New York, New York; and Seattle, Washington) (4,5).
Participants were interviewed with a standard questionnaire, had blood
drawn for testing, and were provided HIV/STD prevention counseling and
referral for care. Specimens were tested for HIV and hepatitis B virus (HBV)
with standard assays. HBV infection was defined as the presence of HBV
surface antigen or antibodies to HBV core antigen.
Disclosure was assessed with the following measure: "Using this
card, choose the number that best describes how `out' you currently are
about having sex with men. By `out,' we mean you let others know that you
are sexually attracted to men." Responses were measured on a 7-point
scale (e.g., 1, "Not out to anyone;" 4, "Out to half the
people I know;" 7, "Out to everyone"). Participants who
answered 1 or 2 were defined as nondisclosers, and participants who
answered 3--7 were defined as disclosers. Participants who answered 1 or 2
were grouped together because of similarities in their demographic
characteristics, reported risk behaviors, and prevalence of HIV infection.
Differences between nondisclosers and disclosers were evaluated by using
the Cochran-Mantel-Haenszel chi-square test controlling for city, age
group, and race/ethnicity (if applicable). Analyses were stratified by
race/ethnicity for those groups that had >50 nondisclosers. Some
analyses were restricted to men aged 15--22 years because YMS was
conducted in two different phases, and some questions were not repeated in
the second phase, which was conducted among men aged 23--29 years.
In the six cities, 5,589 MSM participated in YMS (range by city:
815--1,060). The participation rate among eligible men was 59% (range:
54%--66%). A total of 637 (11%) MSM were defined as nondisclosers (range:
7%--14%); of these, 349 (55%) were aged 15--22 years (median: 22 years;
interquartile range: 19--25 years). Black (18%), mixed-race (14%),
Hispanic (13%), and Asian/Pacific Islander (10%) MSM were more likely to
be nondisclosers than were white MSM (8%) (p<0.05). Among racial/ethnic
minorities, age was not associated with nondisclosure. However, among
white MSM, the proportion of nondisclosers decreased with age: 12% among
those aged 15--19 years, 8% among those aged 20--24 years, and 5% among
those aged 25--29 years (p<0.01).
Nondisclosers were less likely than disclosers to identify themselves
as homosexual and to attend homosexually identified bars and dance clubs
(p<0.05), although 64% of nondisclosers attended these venues at least
monthly (Table
1). Among MSM aged 15--22 years, nondisclosers were more likely to
report that being homosexual or bisexual or having homosexual or bisexual
friends was not important, that they sometimes disliked themselves for
being homosexual or bisexual, that they felt isolated from others, and
that the majority of persons in their racial/ethnic group disapproved of
homosexuals (p<0.05) (Table
1).
The 637 nondisclosing MSM reported a median of five male (interquartile
range: 2--13) and three female (interquartile range: 1--12) sex partners
during their lifetime. During the preceding 6 months, 212 (33%) reported
having unprotected anal intercourse (UAI) with men, and 169 (27%) reported
having unprotected vaginal or anal intercourse (UI) with women. For all
racial/ethnic groups, nondisclosers reported less sexual behavior with men
and more sexual behavior with women (p<0.05) (Table
2). Similar high proportions of disclosers and nondisclosers reported
perceiving themselves to be at low risk for HIV infection and using a
regular source of health care; however, proportionally fewer (p<0.05)
nondisclosers had ever or repeatedly (>3 times) tested for HIV (Table
1). Nondisclosers reported a median of only one previous HIV test (interquartile
range: 0--2); 60% had either never tested previously or had not tested in
>1 year.
No differences were observed in the high prevalence of HBV infection
and self-reported previous STDs between disclosers and nondisclosers;
however, the prevalence of HIV infection was lower among nondisclosers
than disclosers (adjusted odds ratio [AOR] = 0.5; confidence interval [CI]
= 0.4--0.7) (Table
1). Among nondisclosers, the prevalence of HIV infection was higher
among blacks than all other racial/ethnic groups combined (14% versus 5% [AOR
= 2.9; CI = 1.5--5.6]). However, black nondisclosers were more likely to
perceive themselves to be at low risk for ever acquiring HIV compared with
all other nondisclosers (68% versus 56%; p<0.01). Similar proportions
of HIV-infected nondisclosers (n = 51) and disclosers (n = 522) reported
engaging in UAI with male partners during the preceding 6 months (51%
versus 50%) and injecting drugs during their lifetime (8% versus 12%).
HIV-infected nondisclosers were more likely than disclosers to report
being unaware of their infection (98% versus 75%; p<0.01), and during
the preceding 6 months, having one or more female sex partners (35% versus
10%; p<0.01) and engaging in UI with female sex partners (20% versus
5%; p = 0.01).
Reported by: DA Shehan, Univ of Texas Southwestern Medical
Center at Dallas, Texas. M LaLota, MPH, Florida Dept of Health. DF
Johnson, MPH, Los Angeles County Dept of Health Svcs, California. DD
Celentano, ScD, Johns Hopkins Univ School of Hygiene and Public Health,
Baltimore, Maryland. BA Koblin, PhD, New York Blood Center, New York; LV
Torian, PhD, New York City Dept of Health, New York. H Thiede, DVM, Public
Health--Seattle and King County, Seattle, Washington. DA MacKellar, MPH,
GS Secura, MPH, S Behel, LA Valleroy, PhD, GW Roberts, PhD, Div of
HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, CDC.
Editorial Note:
The findings in this report are consistent with previous research
suggesting that among MSM, nondisclosure of sexual orientation is
associated with being a member of a racial/ethnic minority group,
identifying as bisexual or heterosexual, having greater perceived
community and internalized homophobia, and being less integrated socially
within homosexual communities (1--3,6). Although this study did not
find that nondisclosing MSM were at higher risk for HIV infection than MSM
who are more open about their sexuality (1--3), the data suggest
that a substantial proportion of nondisclosers are infected with HIV and
other STDs and are at high risk for transmitting these infections to their
male and female sex partners.
The finding that more than one in three nondisclosers reported having
recent female sex partners suggests that nondisclosing MSM might have an
important role in HIV/STD transmission to women. This might be
particularly true for black nondisclosing MSM, of whom approximately one
in five was infected with HBV and one in seven was infected with HIV. To
help prevent further HIV/STD transmission among young MSM and their female
sex partners, greater efforts are needed to increase public awareness and
to develop or expand HIV/STD testing and prevention programs to meet the
needs of nondisclosers, particularly those who are black.
The findings in this report suggest that public-awareness and
prevention programs should be developed for nondisclosing MSM to reduce
internalized homophobia and other factors that influence nondisclosure,
barriers to HIV/STD testing and prevention services, low-risk perception,
and high-risk behavior, including the risk for transmission to male and
female sex partners. Corresponding efforts also should be developed for
women to increase knowledge of HIV/STD acquisition risks from partners who
might be bisexual and of where to obtain confidential testing and
prevention services for themselves and their partners.
Prevention managers should intensify outreach efforts to provide
HIV/STD testing, risk reduction, and health-care referral services to
nondisclosers who avoid homosexually identified prevention organizations.
Because this report and others (6) suggest that many nondisclosers
have regular male and female sex partners, prevention managers should
consider combining outreach efforts with partner counseling and referral
services (7) and community network development strategies (8)
to increase the availability of HIV/STD prevention services to sex
partners of nondisclosing MSM.
In accordance with recently revised guidelines, health-care providers
should routinely assess the HIV/STD risks of their patients and encourage
at-risk MSM to test annually for HIV, syphilis, gonorrhea, and chlamydia,
and to accept or seek vaccination against hepatitis A and B (9).
To facilitate risk disclosure from young MSM, health-care providers should
create discrete and nonjudgmental environments and ensure that patients
are aware of confidentiality safeguards and of the importance of
disclosing accurate risk information (3).
The findings in this report are subject to at least three limitations.
First, information about the types of persons to whom disclosure was
provided or withheld was not collected routinely. Second, the percentage
of young MSM defined as nondisclosers in this report should be considered
a minimum estimate because young MSM who are reluctant to disclose their
sexual orientation were probably less likely to participate or report
sexual behavior with men. Finally, findings might not be applicable to
nondisclosing MSM aged >29 years or to MSM aged 15--29 years who do not
attend MSM-identified venues or reside in one of the six participating
cities.
The finding that all but one HIV-infected nondiscloser were unaware of
their infection is consistent with a recent report suggesting that the
majority of young HIV-infected MSM do not know they are infected (10).
For more young HIV-infected MSM to realize the benefits of early diagnosis
and care, and to help prevent further HIV transmission among young MSM and
their female partners, health-care providers and federal, state, and local
HIV-prevention managers should expand and improve HIV testing and
prevention practices to meet the needs of diverse MSM, including those who
do not disclose their sexual orientation.
References
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disclosure of sexuality among African American and white gay/bisexual
men: implications for HIV/AIDS prevention. AIDS Educ Prev
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- Stokes JP, Peterson JL. Homophobia, self-esteem, and risk for HIV
among African American men who have sex with men. AIDS Educ Prev
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- Ryan C, Futterman D. Lesbian and Gay Youth Care and Counseling: The
First Comprehensive Guide to Health and Mental Health Care. New York,
New York: Columbia University Press, 1998:9--91.
- MacKellar DA, Valleroy LA, Karon J, Lemp G, Janssen R. The Young
Men's Survey: methods for estimating HIV seroprevalence and risk
factors among young men who have sex with men. Public Health Rep
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- Valleroy LA, MacKellar DA, Karon JM, et al. HIV prevalence and
associated risks in young men who have sex with men. JAMA
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- Doll LS, Beeker C. Male bisexual behavior and HIV risk in the United
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- CDC. HIV partner counseling and referral services: guidance.
Atlanta, Georgia: U.S. Department of Health and Human Services, CDC,
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community networks to deliver HIV prevention interventions. AIDS Educ
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- CDC.
Sexually transmitted diseases treatment guidelines 2002. MMWR
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- CDC.
Unrecognized HIV infection, risk behaviors, and perceptions of risk
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