Objectives: The purpose of this study was to compare the social network characteristics of men who have sex with men (MSM) to men who did not have sex with men (NMSM) in a sample of predominately African-American drug users. Specifically, we were interested in examining the differences in structure of the networks and drug and sexual risk partners within the network.
Methods: Data came from 481 male participants who reported having ⩾1 sex partner in the past 90 days. MSM were defined as having sex with a male. Data on social network composition were collected using a Social Network Inventory.
Results: Of 481 men, 7% (n = 32) were categorised as MSM. Nearly two-thirds of MSM did not identify as gay. MSM were more likely to be HIV positive compared with NMSM. Social networks of MSM were younger and a greater proportion was HIV positive. After adjusting for HIV status, networks of MSM were less dense indicating fewer connections among network members. Among injection drug using men in the sample, MSM reported a greater number of needle sharing networks than NMSM.
Conclusions: These findings underscore the importance of including social network factors in investigations of HIV risk among MSM. Further studies should focus on dynamics within a network and how they may operate to affect behaviour and health.
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Male to male sexual contact remains the most prominent route of HIV transmission in the USA1 and African-American men who have sex with men (MSM) experience disproportionate rates of HIV infection compared with white MSM.2–6 Several studies of MSM have identified individual-level factors associated with HIV risk.7–9 Few studies, however, have examined characteristics of the social networks of MSM and the risk partners within these networks.
Social networks are a powerful source of influence on a number of HIV risk behaviours, including drug use and needle sharing10–12 and sexual partnerships.13 Network members may include multiple social spheres of influence, such as sex or drug partners, friends, family, neighbours and co-workers.14 Structural characteristics of personal networks include size of total network, racial composition, number of sex partners, density and overlap of function. Miller and colleagues conducted in-depth interviews with African-American MSM and inquired about the composition of their social networks.15 They found that MSM nominated twice as many men who do not have sex with men (NMSM) male friends and more female sex partners compared with MSM friends. Few MSM in this study nominated MSM friends with whom they do not have sex with indicating overlap in function of networks. Smith et al16 reported that among a predominantly white MSM sample, a higher density network was associated with lower sex risk, which may be attributable to social monitoring of network members’ behaviours or to peer norms that favour safer behaviour. The purpose of this study was to compare the social network characteristics of MSM with NMSM in a sample of predominately African-American drug users. Specifically, we were interested in examining the differences in structure of the networks and drug and sexual risk partners within the network.
The STEP into Action study was an experimental, longitudinal social network oriented HIV prevention intervention study. The study sample included active injection drug users (referred to as “index” participants) and behavioural risk partners (referred to as “networks”) who the indexes invited to enrol in the study. Index participants were recruited from March 2004 through to March 2006 using advertisements placed at needle exchange locations, drug treatment centres and through participant word-of-mouth. Additionally, trained recruiters distributed fliers in areas that had been identified by ethnographers as active with drug users. Inclusion criteria for the index participants were aged ⩾18 years and self-report of injection drug use in the past 6 months. Eligible index participants met with study staff in private offices at the research clinic for their baseline visit, which included providing written informed consent, behavioural risk assessment and social network survey. After completion of the index baseline visit, the index participant was asked to invite their network members to enrol into the study. The index was provided with a network recruitment flyer to use as an invitation. The network recruitment flyer included information about the study but did not identify the index as a drug user. Inclusion criteria for the network participants were aged ⩾18 years and nominated by an index participant. Injection drug use was not inclusion criteria for the network participants. After providing written informed consent, network participants completed similar risk behaviour assessment surveys and social network inventories. All participants (index and network) were offered HIV testing using Orasure (Orasure Technologies Inc, Bethlehem, Pennsylvania, USA) specimen collection and received $35 for completing the baseline visit.
For the current study, data were from 481 male participants (300 index; 181 networks) who completed the baseline visit of the STEP Into Action study.
Data were based on self-reported gender, age, race/ethnicity, drug and alcohol use in the past 6 months. Sexual identity was assessed using the question “Do you consider yourself gay, heterosexual (straight) or bisexual”. All participants were offered HIV testing during their study visit and these results were used to indicate their HIV status. There were 74 who did not provide a specimen for testing or whose test results were indeterminate. Of these, 71 self-reported HIV negative status and were coded as HIV negative and 3 self-reported HIV positive status and were coded HIV positive.
Social network data
The Social Network Inventory, was used to delineate social network composition.11 The first part of this assessment asks participants to list individuals who provide emotional support with who they socialise, use drugs or depend on for drugs, and those who they have sex with. The individuals listed were referred to as networks. After the name elicitation section, the participant was asked about each of the networks such as their age, race, gender, relationship (for example, family, friend, professional), HIV status, employment status, drug use and injection risk behaviours. Participants were asked to identify those networks with whom they do not get along with or often disagree with, which was coded as a conflictual relationship. Density was measured by asking participants to indicate which networks know other networks and was calculated as a score from 0–1.00 indicating high to low density, such that a score of 0 means that 100% of the networks know each other and a score of 1.00 means that none of their networks know each other. Needle sharing was assessed among participants who reported injection drug use in the past 6 months by asking which networks they shared needles.
Data were analysed using STATA (version 8). Bivariate comparisons of sociodemographic and drug history variables with MSM were calculated using Fishers exact χ2 test for categorical variables. For continuous variables, two-sample Wilcoxon rank-sum (Mann-Whitney) test was used to compare means. Given sample size limitations, a maximum of two variables were entered simultaneously into the regression models. Variables for the regressions were chosen based on their statistical significance level in the bivariate comparisons (p<0.10) and relevance to the literature.
The majority of the sample was African-American (82%), unemployed (88%) and had injected drugs in the past 6 months (89%) (table 1). Of 481 men who reported having at least one sex partner in the past 90 days, 32 (7%) reported sex with a male and were categorised as MSM. Among MSM, 34% identified as gay, 41% “straight” or heterosexual and 25% bisexual compared with 99% of NMSM who identified as heterosexual. There were no differences in the proportions of participants who smoked crack or injected in the past 6 months. In bivariate analysis, being MSM was associated with younger age (38 years vs 44 years; p<0.001) and HIV positive status compared with NMSM.
Social network characteristics
No differences were observed between MSM and NMSM in total size of network or number of females. The networks of MSM were on average younger, HIV positive and experienced greater conflict (table 2). MSM had on average more networks with which they received emotional support. However, MSM networks were less dense compared with NMSM indicating that fewer members within the network knew other members.
Drug and sex network
There were no differences in the mean number of drug users, injectors or crack smokers in the social networks of MSM and NMSM. Among participants who reported injecting drugs in the past 6 months (402 NMSM; 28 MSM), MSM reported sharing needles with more networks compared with NMSM. There were no statistical differences in the number of sex partners or number of drug users who are sex partners. Less than 100% condom use was reported among both MSM and NMSM.
Associations between social network characteristics and MSM
Tables 3, 4 and 5 present associations of social network factors and MSM adjusting for HIV status. Decreasing density was associated with a nearly fivefold increase in odds of being MSM (adjusted odds ratio (AOR) 4.85; 95% CI 1.20 to 19.7) controlling for HIV status. MSM was associated with having greater number of networks who provide emotional support (AOR 1.30; 95% CI 1.06 to 1.61). Among injection drug users, sharing needles with more networks was marginally associated with greater odds of MSM (p = 0.07) after adjusting for HIV status.
We sought to describe and compare social network characteristics of a sample of predominately African-American MSM and NMSM. We acknowledge the small number of MSM in this study, which limits our statistical power and ability to detect differences between groups. However, we did find that MSM in the sample were younger and a greater proportion was HIV positive compared with NMSM. The social networks of MSM were younger and had a greater number of HIV positive networks compared with NMSM. These data support the concept of differential affiliation—that is, people who are similar tend to affiliate. Consequently, HIV positive MSMs may be able to recruit similar network members and may serve as an avenue for promoting access to HIV care and prevention of HIV transmission.
The social networks of MSM were less dense meaning that fewer people within the network knew each other. This finding is not surprising given the stigma associated with MSM behaviour. Density may be a proxy for levels of social monitoring within a network, which has been found in one study to be associated with HIV risk behaviour.16 We did not investigate the association between density and HIV risk behaviour within this report and do not intend to suggest that having a lower density network implies higher risk behaviour. Disconnection within the MSM social network may be a functional arrangement such that the MSM purposely fragments their network to prevent disclosure of their sexual behaviours and/or drug use. It is not clear from our data where the breaks in connection of the network occurred (for example, kin to drug user or drug user to sex partner); however, further research is warranted to explore how density of network may mediate or moderate risk among MSM.
Social networks of MSM injection drug users included a greater number of people with whom they shared needles compared with NMSM injection drug users. Given the high HIV prevalence among MSM, this level of sharing is of great concern. MSM who inject drugs have been described as a “bridge” population that warrant attention because of their dual risk of HIV infection and transmission via injection and sexual behaviours.17–22 This association was marginally significant after adjusting for serostatus suggesting that the finding is not likely due to serosorting. Further, no differences in lifetime use of needle exchange were observed between groups. Social desirability bias may explain some of these results whereby those individuals who admit to stigmatised same sex behaviour may also admit to the stigmatised behaviour of sharing syringes. Studies on norms of needle sharing and the social contexts within which the sharing occurs of MSM injection drug users may be useful to elucidate these findings.
MSM tended to report a greater number of conflictual ties within their network. Studies of HIV infected individuals have found that conflictual relationships to be significant and related to negative mood.23 This difference did not persist after adjusting for HIV status. In a separate analysis among MSM we found overlap between conflictual ties and HIV status, such that a greater number of conflictual ties were with HIV seropositive networks. After controlling for HIV status, networks of MSM had more members who were sources of emotional support. Given the stigma associated with MSM behaviour, this may reflect their efforts to select individuals to be in their social network who are supportive. Social support has been consistently identified as a protective health factor.24 25 Mitchell and colleagues26 describe the importance of social support to decreasing drug use and improving communication with healthcare providers on the basis of results from in-depth interviews conducted with HIV positive drug users. These findings underscore the importance of studying dynamics within a network and how they may operate to affect behaviour and health.
Nearly two-thirds of the MSM did not identify as gay. This may be a result of the recruitment strategy, which focused on drug use venues and not sex-based venues. African-American MSM are less likely to disclose their same sex behaviour and less likely to identify as gay compared with white MSM.27 28 It is unclear whether the social networks of non-gay identified MSM differ from gay-identified MSM. Further studies are needed to explore differences in the social networks of gay-identified versus non-gay identified MSM and how this is associated with HIV risk behaviours. Moreover, these results emphasise the need for culturally relevant interventions tailored to non-gay identified MSM.
There are a number of limitations to this study that should be acknowledged. Data for this study were drawn from a larger study in Baltimore, Maryland, whose main recruitment target was active drug users and their risk partners resulting in a sample of predominately African-American heroin users. Generalisations to MSM who may use other drugs, such as methamphetamine or MSM, who are not African-American should be made with caution. As previously mentioned, with a small sample size of MSM we had limited statistical power to detect correlations between all of the social network variables of interest. This limited our ability to control for multiple social network levels variables in statistical models. Finally, data for this study were collected in face-to-face interviews and were based on self-report, which introduce recall and social desirability bias.
Despite these limitations, our findings describe the characteristics of social networks of MSM and are an important contribution to the literature. Network-level approaches to HIV prevention have been successfully used with injection drug users29 and effective, culturally appropriate, models of HIV prevention intervention are urgently needed for African-American MSM to address their persistently high rates of HIV.
Social network characteristics should be included in future studies examining HIV risk among men who have sex with men (MSM). Social support or social conflict may be important factors associated with risk especially for MSM populations.
MSM injection drug users are a unique risk population and needle sharing risk behaviours warrant attention in the literature.
Interventions should include communications skills training so that MSM can talk with their networks about HIV. MSM may serve as an avenue for promoting access to HIV care and prevention of HIV transmission to their social networks who may not seek prevention services because of stigma.
Competing interests: None.
Funding: This research was funded through a grant from the National Institutes of Drug Abuse (R01 DA016555).
Ethics approval: This study was reviewed and approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.
Contributors: KT conceived the idea for the study, conducted the data analysis and took the lead in writing the manuscript. CL provided guidance and comment on the data analysis and assisted with writing the manuscript.