Unreported Male Sex Partners Among Men with Newly Diagnosed HIV Infection — North Carolina, 2011–2013

Hsiu Wu, MD1; Lisa B. Hightow-Weidman, MD2; Cynthia L. Gay, MD2; Xinjian Zhang, PhD1; Steve Beagle2; Laura Hall, MPH1,3; Tonyka Jackson, MPH1,3; Jenni Marmorino, PhD2; Ann N. Do, MD1; Philip J. Peters, MD1

Human immunodeficiency virus (HIV) prevention interventions, such as preexposure prophylaxis (PrEP), are often targeted to men who have sex with men (MSM) who self-report high-risk behaviors (1). Data from a prospective study evaluating methods to detect acute HIV infection among a primarily young (aged <25 years) and black or African American (African American) population from North Carolina were analyzed (2). In the study, participants were asked about risk behaviors during pretest counseling (at the time of testing) and then during a partner services (3) interview (at HIV diagnosis). Participants whose disclosure of sexual risk behaviors during pretest counseling was different from their disclosure of sexual risk behaviors during their partner services interview were identified, and factors associated with these discordant responses were examined. Among 113 HIV-infected men, 26 (23.0%) did not disclose male sex partners at pretest counseling, but subsequently did disclose this information during their partner services interview. When compared with men who disclosed having male partners at pretest counseling, these 26 MSM who did not disclose male partners during pretest counseling were found to have a similar number of male partners during contact tracing, but were more likely to have a female partner (30.8% versus 6.9%). In addition, the proportions of MSM found to have at least one HIV-infected partner were similar for both groups (MSM who disclosed having male partners during pretest counseling and those who did not). To better customize HIV prevention interventions for MSM, HIV prevention programs might consider using novel strategies to accurately assess risk in this population.

The Screening Targeted Populations to Interrupt Ongoing Chains of HIV Transmission with Enhanced Partner Notification (STOP) project was a prospective study evaluating acute HIV infection diagnosis linked to partner services at 12 HIV testing venues in North Carolina, New York City, New York, and San Francisco, California (2,4). Participants were asked about sex partners during pretest counseling, and those diagnosed with HIV infection were asked again during a partner services interview following diagnosis. During pretest counseling a counselor recorded demographics and risk behaviors within the past 12 months. After HIV diagnosis, HIV-infected participants were offered partner notification services. Contact information was elicited for sex partners from the previous 3 months for participants receiving a diagnosis of acute HIV infection and from the previous 12 months for participants receiving a diagnosis of established HIV infection (3). Disease intervention specialists contacted sex partners by telephone or internet-based communication (e.g., e-mail and social network messaging) and text messaging when available. HIV testing was offered to notified partners.

This analysis included participants from three sexually transmitted disease (STD) clinics in North Carolina. MSM were defined as male participants with newly diagnosed HIV infection (either acute or established) who reported a male sex partner during the partner services interview. Factors associated with not reporting male sex partners during pretest counseling were determined among MSM who did not report a male sex partner during pretest counseling but subsequently did during the partner services interview. Sexual networks for MSM who named at least one sex partner during partner services interviews were also reviewed to evaluate their connections to other MSM. Data were analyzed using Chi-squared tests, t-tests, and Fisher's exact tests to compare groups; statistical significance was defined as two-sided p<0.05.

Among 16,892 male participants tested during September 2011–October 2013 in North Carolina, 179 (1.1%) received a diagnosis of HIV infection; 145 of the 179 (81.0%) participated in partner services interviews. Among 113 HIV-infected men (median age = 24 years; 85.0% African American) who reported having male sex partners during their partner services interviews, 26 (23.0%) had not disclosed male sex partners at the time of HIV testing (pretest counseling) (Figure). Compared with MSM who reported male sex partners during pretest counseling, those who did not had a similar number of male sex partners (median three versus four male sex partners, p = 0.41), but were more likely to have at least one female sex partner (30.8% versus 6.9%, p = 0.001) (Table). Among all MSM participants who tested positive for HIV, 23 (20.4%) reported sex with an HIV-infected partner during pretest counseling; however, partner services determined that 70 (61.9%) had one or more HIV-infected sex partners. Among 14 MSM who reported male and female sex partners during partner services interviews, three had also accurately reported male and female sex partners during pretest counseling. Sexual networks were diagrammed for 86 MSM who provided contact information for at least one sex partner (available at http://www.cdc.gov/hiv/pdf/cdc-hiv-msm-risk-behavior.pdf). Among 17 HIV-infected MSM who did not report male sex partners during pretest counseling and provided contact information for at least one sex partner, nine (52.9%) shared sexual networks with other participants who did report male sex partners and who also had newly diagnosed HIV infection.

Discussion

Approximately 23% of newly identified HIV-infected MSM tested at STD clinics in North Carolina did not report male partners at the time of HIV testing, despite having been asked about male and female sex partners. Nondisclosure of same-sex sexual contact was not associated with number of male partners but was associated with reporting at least one female sex partner during partner services; these men also often shared sexual networks with other MSM with newly diagnosed HIV infection.

Nondisclosure of risk for HIV infection (including same-sex sexual contacts) to health care providers has been previously reported (5,6). In a survey in New York City, 39% of MSM did not disclose their sexual orientation to health care providers (5), and in a study evaluating HIV screening strategies in an emergency department, 51% of newly diagnosed patients reported no HIV risk factors (6). Participants in this analysis were recruited from STD clinics, where staff members were experienced in taking a sexual history; participants in this study, who were seeking STD evaluation, might also have been more prepared to discuss their sexual history with their providers, compared with those recruited from the community or in an emergency department. Despite the apparent advantages of the STD clinic setting, nearly a quarter of HIV-infected MSM did not report their male sex partners during pretest counseling.

Health care providers often assess the need for HIV and STD prevention services on the basis of clients' self-reported risk behaviors, which might be underreported. MSM might misreport risk behaviors for several reasons. First, clients might not be aware of the importance and potential benefits of reporting risk behaviors accurately (e.g., that PrEP is recommended for persons, especially MSM, at high risk for HIV acquisition). Second, concerns about privacy, confidentiality, fear of being judged, and perceived or experienced homophobia might interfere with accurate reporting of sexual risk behavior (7). Third, although risk for HIV acquisition is more closely correlated with sexual behavior than with sexual orientation, mistaking sexual orientation or identity (8) as sexual behavior can contribute to misreporting. Reporting at least one female sex partner during partner services interviews was associated with nondisclosure of male sex partners during pretest counseling in this study. Other studies have also noted that MSM who self-identified as bisexual or heterosexual were less likely than those who self-identified as gay to report same-sex behaviors (5,7). Bisexual-identifying MSM might have additional barriers to accurately reporting risk behavior. A qualitative study conducted in New York City reported that society often views bisexuality as non-monogamous and indicative of infidelity (9). This additional stigma might play a role in misreporting sex behaviors.

Numbers of male sex partners and HIV-infected partners were similar among HIV-infected MSM who did and did not disclose male sex partners during pretest counseling. More than half of HIV-infected MSM who did not report male sex partners during pretest counseling shared sexual networks with those who reported male sex partners. Taken together, these observations suggest similar levels of risk for HIV acquisition across the two groups (10). This potential for missed opportunities to deliver effective prevention services to MSM highlights the importance of accurately identifying risks among this population, which remains the population most affected by HIV infection.

The findings in this report are subject to at least three limitations. First, only HIV-infected participants who accepted partner services were included. Those who had the greatest concerns about stigma or privacy might have been less likely to participate in partner services (19% did not participate) resulting in an underestimate in the frequency of men not accurately reporting male sex partners. In addition, the proportion of HIV negative MSM who did not report male partners could not be estimated. Second, barriers to accurately reporting risk behaviors were not assessed. Third, the results were observed among clients (most of whom were African American) at three STD clinics in North Carolina and might not be generalizable.

A substantial proportion of MSM with newly diagnosed HIV infection (predominately young and African American) at three STD clinics in North Carolina did not disclose their male sex partners during HIV testing. To customize HIV prevention interventions effectively in disproportionately affected persons such as young African American MSM, HIV prevention programs might consider implementing novel strategies to accurately assess risk. Examples of potential strategies include increased access to testing venues that are customized for young African American MSM, increased use of technology to administer risk screening privately (e.g., a risk screening tool that can be completed on a mobile device or a clinic's tablet computer), and increased education regarding the benefits of new HIV prevention interventions, such as PrEP, that can be offered if the patient's risk for HIV infection is accurately ascertained.

1CDC; 2University of North Carolina, Chapel Hill, North Carolina; 3ICF International, Atlanta, Georgia.

Corresponding author: Philip J. Peters, pjpeters@cdc.gov, 404-639-6158.

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