Bisexual Men and Heterosexual Women: How Big Is the Bridge? How Can We Know?

RECENTLY, MUCH ATTENTION HAS BEEN paid to bisexually active men, who are perceived as constituting a possible “bridge” allowing HIV to cross from men who have sex with men (MSM) to women who have sex with men (WSM). The article in this issue by Hightow and colleagues1 describes results of a study following up an investigation of an HIV outbreak among young black men in North Carolina, a significant number of whom were college students. Health department data were retrospectively reviewed to compare HIV-positive men who have sex with men and women (MSM/W) with other HIV-positive MSM and men who have sex with women (MSW) on a variety of demographic characteristics and sexual behaviors. The majority of subjects were black. Additionally, information from disease intervention specialist (DIS) reports regarding HIV contacts (sex partners) was used to construct 2 sexual network patterns: one with all subjects except the MSM/W and one that included the MSM/W. The addition of this subgroup produced a much denser network and increased connections between colleges and individuals. The number of colleges in the network increased to from 17 to 26, and the number of individuals increased from 58 to 95. These data were interpreted to suggest that the contribution of MSM/W to the HIV epidemic may be substantial because they increase the number of possible exposures among members of their sexual networks. A key question is whether these data are representative of the black community and whether MSM/W behavior truly constitutes a transmission bridge to women. HIV is more prevalent among MSM than any other risk group. If bisexual activity is more common among black MSM than those from other ethnic groups—and there are substantial data to indicate that it is2–7—then it may partly explain the burgeoning HIV epidemic among black women.8 Unfortunately, the comparisons and analyses that would be required to show that MSM/W substantially alter sexual networks are not presented in the report. What might have been more revealing would have been a comparison of the sexual network that did not include female partners with one that did rather than using as the comparison the network without the MSM/W individuals at all. Whether sexual networks that have MSM/W are different in kind from strictly MSM networks is a worthwhile research goal that could be investigated through more sophisticated network analyses. Strengthening the claim of a transmission bridge from MSM/W to WSM, however, is MSM/W’s secretive MSM behavior that was evident in the study. The term “down low” was popularized by a best-selling book9 whose author appeared to widespread attention in popular print and electronic media. It has been depicted as being a black phenomenon, although the behavior denoted by the term is not bounded by race (in fact, even men who describe themselves as “on the down low” come from a variety of racial/ethnic groups10). In the Hightow et al study, 37% of white men and 17% of black men concealed their MSM risk behavior from health professionals during HIV counseling sessions but later revealed this information to DIS who were informing them of their HIV-positive test result. This concealment of MSM behavior may be fueled by perceived or actual homophobia in the community at large, family of origin, or religious ministry (Jones et al., under review).11–13 Indeed, studies have shown bisexual behavior and nongay self-identification to be associated with internalized homophobia (O’Leary et al., under review).6,11,13 Secrecy may also result from men’s desire to have children because this is an element of cultural definitions of masculinity.14 A critical remaining unanswered question is whether we can trust the information obtained by the DIS, which was the basis for all of the analyses reported here. DISs are highly trained interviewers who are aware that information offered by respondents may not always be accurate as a result of “social desirability” bias, and they are trained to detect this. Nonetheless, respondents who had previously reported MSW as their sole risk factor, even those who were strictly homosexually active, might have found it difficult to retract the MSW risk factor even in the context of disclosing previously unreported MSM activity. Among men for whom gender roles and sexual norms are felt to be important, the naming of female partners might have been done to present the image of a near-heterosexual lifestyle rather than an exclusively homosexual one. Thus, female partners may have been named solely to “save face” in the interview. In such cases, these men would not have served as an HIV transmission bridge to WSM. Unfortunately, data from this retrospective study were limited, and records were not adequate to follow the reported female contacts of those reporting MSM/W risk behavior. Another reason for this lack of disclosure may have been legitimate mistrust of individual DIS officers’ confidentiality or the healthcare system more generally. Mistrust found among blacks is a natural legacy of the U.S. Public Health Service Tuskegee Syphilis Study on Untreated Syphilis in the black male, in which investigators withheld widely available medical treatment from black male study participants.15 For men in the Hightow et al study, failure to disclose activity may have been products of societal stigma against MSM behavior and stigma associated with HIV in combination with concern that data would not be kept confidential. Nonetheless, credit must be given to those men who later disclosed their MSM sexual histories. These men understood the gravity of testing HIV-positive and the importance of their responsibility to ensure that their partners be informed. It is likely that men vary along a continuum in their degree of “outness” to others regarding their MSM behavior.16 Men whose MSM activity is highly secretive—i.e., who withhold this information from wives, families, their faith communities, and so on—may not be most effectively reached through standard outreach efforts. Some may be avoidant of mainstream gay venues such as gay pride cultural celebrations or bars and nightclubs,10 restricting their search for male sex partners to the Internet or public sex environments, where the secrecy may be acknowledged and honored.17 Unfortunately, these men may avoid condom use with male partners when attributions involving substance use or seduction are necessary to ease guilt. With female partners, condom use may also be avoided as a result of fear that the female partner may suspect MSM behavior or some other infidelity. Accurately ascertaining the prevalence of highly secretive MSM activity may be intrinsically impossible. If so, we will never know the true magnitude of its contribution to the HIV epidemic. However, intervention to facilitate behavior change remains an urgent priority. To date, no intervention with effectiveness exists specifically for bisexually active men, especially for those who engage in secretive MSM behavior (or even for black MSM in whom reported bisexuality is the greatest). However, the need to reach these men with effective behavioral interventions that promote abstinence, monogamy, and condom use and confer skills in negotiating these strategies with all partners is great. These interventions must also seek to reduce internalized homophobia that serves as a barrier to risk disclosure and to increase men’s skills to cope with perceived homophobia. One promising strategy for reaching these men may be through the use of respondent-driven sampling (RDS).18,19 The Centers for Disease Control and Prevention is supporting a formative feasibility study to use RDS to recruit bisexually active men for interviews, to offer HIV testing, and to assess the feasibility of using social networks to disseminate interventions and prevention messages for this important population. Until we gain a better understanding of men who engage in secretive MSM behavior, and the factors that contribute to it, there remain more questions than answers.