The sexual relationships of many African American men who have sex with men are largely shaped by economic insecurity, housing instability and stigma, according to a new study. These structural inequalities influence the kinds of relationships and sexual behaviour that men have.
While most HIV prevention interventions and studies focus on the individual, “our research underlines the continued need to attend to the structural drivers of HIV among Black gay, bisexual and other men who have sex with men,” writes Caroline Parker of Columbia University in an article published online in the journal Culture, Health and Sexuality.
A separate study, published in BMC Public Health, also highlights similar issues for women at high risk of HIV in urban areas of the United States.
Explaining high infection rates
Black men who have sex with men (MSM) have a disproportionate burden of HIV in the United States. It’s estimated that 1 in 2 black MSM will acquire HIV in their lifetime, whereas 1 in 11 white MSM are likely to do so.
Numerous quantitative studies have demonstrated that in comparison with MSM of other ethnic groups, partner numbers and rates of risky sexual behaviour are no higher. But due to a lack of racial mixing, black men may be more likely to have sexual partners who already have HIV. And they are much more likely to report poverty, housing problems and barriers accessing medical care.
In order to better understand how such issues might impact on health-related behaviours, Parker and colleagues conducted a qualitative, ethnographic study in New York City in 2013 and 2014. In-depth interviews were conducted with 31 black MSM and participant observation was conducted in locations frequented by black MSM (such as parks, community organisations and house parties). In addition, 17 community advocates and healthcare professionals were interviewed.
Amongst the men interviewed, whose average age was 29, social problems were common. Ten had spent time in prison, 15 were unemployed, 16 had housing problems, and nine had no health insurance. Five men told the researchers that they were living with HIV. Whereas half identified as ‘gay’, the others described themselves in a variety of ways, including bisexual, straight, discreet and having no sexual identity.
Unstably housed and unemployed men sometimes used sex to satisfy material needs. They described exchanging sex for food, shelter, alcohol, drugs, clothing, and the payment of phone bills and taxis. Some men used profiles on dating apps to sell sex.
Economic insecurity and housing instability constrained these men’s ability to negotiate condoms, as one man explained:
“Okay. If you are eating and you have clothing, you have shelter, you’re probably going to resist it and a very blatant resistance. But if you are hungry, that’s a different ballgame. I can sit here and tell you I’m a very proud person but you let my stomach rumble for more than three days, okay, you can call me.”
While sex without a condom put men at risk of HIV, a lack of food or shelter might have a more immediate impact. Men made choices which made sense to them in their current circumstances (for example, having multiple partners to access temporary housing and other resources).
Interviewees with fewer economic problems had different approaches to sexual relationships which did not reflect these pressing economic considerations.
The researchers paid particular attention to the way in which different places and environments shaped men’s sexual relationships.
Family homes were places in which many men had experienced disapproval or homophobia, with four men being made homeless as a direct result. Many men avoided introducing male sexual partners to family members; sex was more likely to happen at a partner’s home or in a public space. One man recalled:
“I was a gay man and figuring out that my mum wasn’t too happy about it…. I couldn’t bring any company over or they couldn’t stay overnight or whatever, [but my brother] could bring girls over and there was discrimination towards me with my mum.”
Some men who lived independently also avoided bringing male partners home because of homophobic reactions from landlords or neighbours. Men sometimes felt unsafe in their own homes.
Many respondents met partners and had sex with them in parks, streets, sports clubs, trains, supermarkets and restaurants. This was particularly the case for men with unstable or no housing, and for men who identified as straight or discreet. These meetings might be arranged on apps like Jack’d and Grindr.
These interactions were usually rushed – men were afraid of being observed by other people, being assaulted or being arrested. The rush meant that condoms were less likely to be used.
In addition, several men thought that carrying condoms was dangerous as police might consider condoms to be evidence of sex work (this was New York police practice until 2014). Police are more likely to stop and search black men than other people and interviewees expressed considerable mistrust and fear of the police.
Respondents also went to gay bars and nightclubs, particularly those which were predominantly used by black and Latino men. These spaces were often felt to be safer places to socialise with and meet other men who have sex with men.
For men who sold sex, bars provided some protection against the police. Men with housing difficulties sometimes went to clubs to find ‘a generous friend’ with a place to stay. However commercial venues did not always feel welcoming to men who did not have money for drinks or the right clothes to wear.
And men who did not present themselves in a conventionally masculine way could experience insults, violence and ‘drama’. One interviewee was assaulted outside a club for being ‘faggoty’. One community advocate felt this hostility could have an impact on sexual risk taking:
“It’s really bad at times. I see it all the time, the fighting, the arguments and the putdowns and yeah, so if you feel like you’re being put down all the time about your weight or about your financial situation or housing situation, sometimes you submit to someone who’s waving $10 to $20 and have their own place.”
“Among most of the men in this sample, the pursuit of same-sex relationships took place in a social context characterised by economic insecurity, housing instability, and widespread stigma and discrimination,” the researchers conclude. “We draw attention to how men’s position in a social structure configures their opportunities, restrictions and priorities in sexual relationships and how these shape their choices and behaviours in health-relevant ways.”
A separate study highlights similar issues for women at high risk of HIV in ‘hot spot’ communities in New York, Washington DC, Atlanta and Raleigh. This qualitative analysis is a sub-study of HPTN 064, a cohort study which established that among some groups of women in the US, the annual rate of new HIV infections is 0.3%, which is comparable to that in the general population in many African countries.
The 247 women who took part in interviews and focus groups were mostly black (86%) and single (67%). Poverty, incarceration and substance use were frequently reported.
Women described living in neighbourhoods dominated by unemployment, violence and drug use. The environments were chaotic and stressful, but interviewees did not have the possibility of living elsewhere. Economic necessity sometimes pushed women to sell sex.
“There's girls out here that I know that you would never imagine in your wildest dreams that they would do the type of things they do. But crunch times, you got your kids, you got to feed your baby. You got to feed yourself.”
Women’s own drug use was sometimes explained as a response to difficult circumstances. It was understood to affect their sexual choices.
“I used to say it was self-medicating. Cause I was going through like a lot and then it was like I got depressed real bad and my son went to live with his father. So I just my attitudes like, I just couldn’t cope. So it’s just when I got high I didn’t think about nothing.”
Due to the large numbers of men who were imprisoned, there were far more women than men in the communities studied. This imbalance reduced women’s power to negotiate the terms of relationships.
“There’s so many women available and there’s so many men that’s not available. So many men incarcerated. So many men in mental facilities. So many men at war. They’re [women] limited and they don’t think that they could find something maybe half as good as what they have …So they’d rather settle.”
Women accepted men who had multiple partners and concurrent relationships. Many experienced intimate partner violence, but found it difficult to leave those relationships.
“Our findings support the fundamental role that financial insecurity plays in HIV risk among women in certain communities in the US,” the researchers say.
Parker CM et al. Social risk, stigma and space: key concepts for understanding HIV vulnerability among black men who have sex men in New York City. Culture, Health & Sexuality, online ahead of print, 2016.
Frew PM et al. Socioecological factors influencing women's HIV risk in the United States: qualitative findings from the women's HIV SeroIncidence study (HPTN 064). BMC Public Health 16:803, 2016.