Sexual concurrency and its potential contribution to HIV transmission within racial/ethnic groups among men who have sex with men in the United States Open Access

Rosenberg, Eli S (2012)

Permanent URL: https://etd.library.emory.edu/concern/etds/9w032358w?locale=en
Published

Abstract

Individual-level risk behaviors have failed to explain this disparity and network
factors have been suggested. Sexual concurrency, or the overlapping on one's sexual
partnerships in time, catalyzes HIV transmission in networks and remains little studied
among MSM. In populations where concurrency has been studied, methodological
limitations have resulted in inconsistent estimates of its prevalence and relationship to
HIV transmission.

For this dissertation, three studies were conducted to understand the occurrence
and potential impact of concurrency in an online cohort of MSM in the US.
Simultaneously, three methodological issues were addressed: accurate measurement,
inference at the appropriate levels of analysis, and the measurement of biologically
relevant concurrency.

In the first study we evaluated existing methods and a novel partnership timing
module for measuring concurrency. The module had strong concurrency detection ability
and agreement with previous measures, at the individual-, dyad-, and triad-levels,
suggesting it may be well-suited to quantifying concurrency among MSM.

In the second study we assessed concurrency and concurrent unprotected anal
intercourse (UAI) at the individual and triad levels. Forty-five percent of individuals
indicated concurrent partnerships and 16% indicated concurrent UAI in the previous 6
months, with no significant heterogeneity by race/ethnicity. Respondents had a two-fold
odds of UAI with two partners when they were concurrent.

In the third study we implemented a new technique for quantifying the indirect
exposure imparted to sex partners attributable to concurrency and concurrent UAI. Levels
of indirect exposure to other partners were high among repeat sex-partners: 58% were
exposed by concurrency and 37% of UAI partners were exposed by concurrent UAI.
Black non-Hispanic and casual partners were more likely to be exposed.

Concurrency is highly prevalent among MSM, potentially contributing to high
HIV incidence, and may place black and casual partners at greater risk. The methods
developed may aid in the understanding of concurrency in other contexts where
concurrency is thought to play a role in HIV transmission, such as sub-Saharan Africa.

Table of Contents



Table of Contents

Chapter 1: Background and significance .............................................................................1

Chapter 2: Research study and instruments .......................................................................33

Chapter 3: Manuscript 1.....................................................................................................49

Chapter 4: Manuscript 2.....................................................................................................80

Chapter 5: Manuscript 3 ..................................................................................................104

Chapter 6: Conclusion......................................................................................................129

Appendices

1. Checking In Study Sexual Behavior Inventory .............................................142

2. SurveyGizmo PHP scripting language
Partnership timing module algorithm code ....................................................188

3. SAS
A. Code for processing of partnership module response data
into triadic and individual concurrency outcomes ...................................193

B. print_sex_cal.sas .....................................................................................240

4. Manuscript 2, press copy:
High prevalence of sexual concurrency and concurrent unprotected anal
intercourse across racial/ethnic groups among a national, web-based study of
men who have sex with men in the United States. Sexually Transmitted
Diseases.
October 2012; 39(10):741-6. .........................................................242








List of Tables

Ch.2, Table 2.1 Page Layout of the Checking In Study Sexual Behavior Inventory ........36
Ch.2, Table 2.2 Summary of responses evaluating the partnership timing module ..........47
Ch.2, Table 2.3 Key themes and representative quotes from the qualitative evaluation of
the partnership timing module ...........................................................................................47
Ch. 3, Table 1 Individual-level concurrency, by partnership timing module and
alternative measures of concurrency, among 2,737 men who have sex with men ...........77
Ch. 3, Table 2 Individual-level concurrency, by partnership timing module and
alternative measures of concurrency, among subsets of men who have sex with men ....78
Ch. 3, Table 3 Dyad- and triad-level concurrency, by partnership timing module and
alternative measures of concurrency, among subsets of men who have sex with men .....79

Ch. 4, Table 1 Participant-level concurrency and concurrent UAI in the previous 6
months among 2,940 MSM, by participant race/ethnicity ...............................................100

Ch. 4, Table 2 Triad-level concurrency and concurrent UAI in the previous 6 months
among 12,812 partner triads, involving 2,114 MSM participants with multiple partners in
the previous 6 months, by participant race/ethnicity .......................................................101

Ch. 4, Supplementary Digital Content Table 1 Participant-level concurrency and
concurrent UAI in the previous 6 months among 2,940 MSM, by participant age .........102

Ch. 4, Supplementary Digital Content Table 2 Triad-level concurrency and concurrent
UAI in the previous 6 months among 12,812 partner triads, involving 2,114 MSM
participants with multiple partners in the previous 6 months, by participant age ...........103

Ch. 5, Table 1 Characteristics of and indirect exposure among 4,060 sex partners with
repeated contact to HIV-negative/unknown study participants .......................................127

Ch. 5, Table 2 Characteristics of and indirect unprotected anal intercourse (UAI)
exposure among 1,885 UAI partners with repeated contact to HIV-negative/ unknown
study participants .............................................................................................................128

Ch. 5, Table 3 Multivariable models of the relationships between partner race/ethnicity
and type with indirect exposure .......................................................................................128


List of Figures

Ch.1, Figure 1.1 Serially monogamous and concurrent partner arrangements ....................6

Ch.1, Figure 1.2 Point prevalence measures of concurrency underestimate the
phenomenon among MSM .................................................................................................18

Ch.1, Figure 1.3 Triads, the fundamental unit of concurrency ..........................................21

Ch.2, Figure 2.1. Implementation of calendar-based partnership timing module in
SurveyGizmo ver 2.6, illustrating follow-up clarification questions .................................38

Ch.2, Figure 2.2. Hypothetical partner calendar responses and concurrency
determinations ....................................................................................................................39

Ch.2, Figure 2.3. Schematic of SAS processing of concurrency calendar data and
implementation of concurrency determination algorithm ..................................................44

Ch.3, Figure 1. Partnership timing module ........................................................................76

Ch.4, Figure 1. Partnership timing module ........................................................................98

Ch.4, Figure 2. Triads ........................................................................................................99

Ch.4, Figure 1. Contribution of triadic partnership configurations to indirect exposure
outcomes for a Partner A .................................................................................................125

Ch.4, Figure 2. Flowchart for the inclusion of individuals and their reported partners
(dyads) in an analysis of partner-perspective concurrency in a national online study of
men who have sex with men ............................................................................................126

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