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)
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
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
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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