More effort needed with down low’ males

CDC expert discusses issue in Q & A

[Editor’s note: AIDS Alert asked Greg Millett, MPH, a behavioral scientist in the Division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention (CDC) in Atlanta to discuss the phenomenon and impact on the HIV epidemic of the population of men who have sex with men (MSM) who also have sex with women. Millett spoke about this topic at the 11th Conference on Retroviruses and Opportunistic Infections (CROI), held in February in San Francisco.]

AIDS Alert: What have been the results of any interventions — sponsored by the CDC or not — that have been tailored specifically to reduce risk behavior among MSM who also have sex with women but do not identify as gay or bisexual?

Millett: There have been interventions for non-gay-identified men that have been sponsored by community-based organizations, but I am not aware of any that have been scientifically evaluated for effectiveness. CDC has several studies that recruit gay and nongay-identified MSM, including one study that is devoted to determining HIV risk behavior of nongay-identified MSM. However, the point of my talk was that we need to first determine where heterosexually identified MSM fit on the spectrum of HIV risk and then develop appropriate interventions for the population.

AIDS Alert: Does the CDC have any data suggesting how much this particular population has contributed to the increases in women HIV cases in recent years?

Millett: No. The CDC does not have specific data to show the impact of bisexual behavior on HIV rates in women. We have studies that touch on the risk, but none that specifically link the two.

The AIDS Care study shows that 45% of black MSM were reported to also be having sex with women. A series of studies headed by Linda Valleroy of CDC found that young MSM may serve as a bridge for HIV transmission to women.

That study of MSM found that one in six of them recently had sex with women. A CDC study on young men who have sex with men who do not disclose their sexual orientation was released last year. One of the main findings was that HIV-infected nondisclosures were less likely to know their HIV status and more likely to have had recent female partners. However, these studies mostly recruited gay- or bisexually-identified men. There is limited data on heterosexually identified men who have sex with women.

The CDC’s most current AIDS data for women show 42% reported being exposed heterosexually and 36% did not know or did not report their risk. These women possibly could have become infected because their male partner had engaged in a risk behavior such as IDU [intravenous drug user], or sex with another man.

AIDS Alert: Are there any interventions aimed at women who may or may not know whether their partners are "on the down low" and therefore at higher risk for HIV?

Millett: To clarify, the term come to be known as the "down low" is defined as heterosexually identified bisexually active black men who do not disclose their same-sex behavior to their female partners.

There are no interventions or programs I’m aware of that specifically target women who have partners in the particular segment defined previously, but there are a few studies that look at why some women might be at increased risk of HIV.

A study from Morehouse School of Medicine in Atlanta found among a sample of 250 African-American women that 70% perceived themselves at little or no risk for HIV, 45% had unprotected sex in the past two months, and 60% did not ask their partners about their HIV status.

There are clear prevention steps we can take to reduce the risk of HIV infection among men on the down low and their male and female partners. Some of these tactics are to develop and deliver prevention efforts for MSM regardless of their sexual identity; ensure prevention messages for women remind them to use protection during sexual encounters; make testing a more routine part of medical care; and expand HIV testing beyond traditional medical settings into churches, community centers, and nightclubs.

AIDS Alert: Under the CDC’s new initiative to increase HIV testing, counseling, and prevention for positives, there is a push to get partners of HIV-positive people in for testing and counseling, as well. How effective might these new strategies be with this specific population of men who may be hiding their sexual activity from wives, girlfriends, and sometimes even from male lovers? And how could community-based organizations adapt this new strategy that focuses more on documentation and outcomes to suit the nuances of culturally sensitive issues, such as the down low black man?

Millett: It is difficult to reach MSM with HIV prevention messages when they do not identify as gay or bisexual. We must come up with ways to aim messages at men, regardless of their sexual identity, and assume some are having sex with both men and women. Making HIV testing a routine part of medical care will help identify those becoming infected, and partner notification will help identify who is infecting who.

AIDS Alert: What are some of your other thoughts about this subset of MSM and how health care professionals best can reach them and convince them to be tested and receive prevention education?

Millett: We hope health care professionals will adopt routine HIV testing. If patients are identified as positive, they should be linked to counseling that can help them take steps to reduce their risky behavior. Providers also can work within the community to help test people outside traditional medical settings, who might not be able to afford or have access to health care services.