February 7, 2003
YMS was a cross-sectional survey conducted during 1994-2000 of men aged 15-29 years who attended MSM-identified venues in six U.S. metropolitan areas (Baltimore, Maryland; Dallas, Texas; Los Angeles, California; Miami, Florida; New York, New York; and Seattle, Washington) 4,5. Participants were interviewed with a standard questionnaire, had blood drawn for testing, and were provided HIV/STD prevention counseling and referral for care. Specimens were tested for HIV and hepatitis B virus (HBV) with standard assays. HBV infection was defined as the presence of HBV surface antigen or antibodies to HBV core antigen.
Disclosure was assessed with the following measure: "Using this card, choose the number that best describes how 'out' you currently are about having sex with men. By 'out,' we mean you let others know that you are sexually attracted to men." Responses were measured on a 7-point scale (e.g., 1, "Not out to anyone;" 4, "Out to half the people I know;" 7, "Out to everyone"). Participants who answered 1 or 2 were defined as nondisclosers, and participants who answered 3-7 were defined as disclosers. Participants who answered 1 or 2 were grouped together because of similarities in their demographic characteristics, reported risk behaviors, and prevalence of HIV infection. Differences between nondisclosers and disclosers were evaluated by using the Cochran-Mantel-Haenszel chi-square test controlling for city, age group, and race/ethnicity (if applicable). Analyses were stratified by race/ethnicity for those groups that had >50 nondisclosers. Some analyses were restricted to men aged 15-22 years because YMS was conducted in two different phases, and some questions were not repeated in the second phase, which was conducted among men aged 23-29 years.
In the six cities, 5,589 MSM participated in YMS (range by city: 815-1,060). The participation rate among eligible men was 59% (range: 54%-66%). A total of 637 (11%) MSM were defined as nondisclosers (range: 7%-14%); of these, 349 (55%) were aged 15-22 years (median: 22 years; interquartile range: 19-25 years). Black (18%), mixed-race (14%), Hispanic (13%), and Asian/Pacific Islander (10%) MSM were more likely to be nondisclosers than were white MSM (8%) (p<0.05). Among racial/ethnic minorities, age was not associated with nondisclosure. However, among white MSM, the proportion of nondisclosers decreased with age: 12% among those aged 15-19 years, 8% among those aged 20-24 years, and 5% among those aged 25-29 years (p<0.01).
Nondisclosers were less likely than disclosers to identify themselves as homosexual and to attend homosexually identified bars and dance clubs (p<0.05), although 64% of nondisclosers attended these venues at least monthly (Table 1). Among MSM aged 15-22 years, nondisclosers were more likely to report that being homosexual or bisexual or having homosexual or bisexual friends was not important, that they sometimes disliked themselves for being homosexual or bisexual, that they felt isolated from others, and that the majority of persons in their racial/ethnic group disapproved of homosexuals (p<0.05) (Table 1).
The 637 nondisclosing MSM reported a median of five male (interquartile range: 2-13) and three female (interquartile range: 1-12) sex partners during their lifetime. During the preceding 6 months, 212 (33%) reported having unprotected anal intercourse (UAI) with men, and 169 (27%) reported having unprotected vaginal or anal intercourse (UI) with women. For all racial/ethnic groups, nondisclosers reported less sexual behavior with men and more sexual behavior with women (p<0.05) (Table 2). Similar high proportions of disclosers and nondisclosers reported perceiving themselves to be at low risk for HIV infection and using a regular source of health care; however, proportionally fewer (p<0.05) nondisclosers had ever or repeatedly (>3 times) tested for HIV (Table 1). Nondisclosers reported a median of only one previous HIV test (interquartile range: 0-2); 60% had either never tested previously or had not tested in >1 year.
No differences were observed in the high prevalence of HBV infection and self-reported previous STDs between disclosers and nondisclosers; however, the prevalence of HIV infection was lower among nondisclosers than disclosers (adjusted odds ratio [AOR] = 0.5; confidence interval [CI] = 0.4-0.7) (Table 1). Among nondisclosers, the prevalence of HIV infection was higher among blacks than all other racial/ethnic groups combined (14% versus 5% [AOR = 2.9; CI = 1.5-5.6]). However, black nondisclosers were more likely to perceive themselves to be at low risk for ever acquiring HIV compared with all other nondisclosers (68% versus 56%; p<0.01). Similar proportions of HIV-infected nondisclosers (n = 51) and disclosers (n = 522) reported engaging in UAI with male partners during the preceding 6 months (51% versus 50%) and injecting drugs during their lifetime (8% versus 12%). HIV-infected nondisclosers were more likely than disclosers to report being unaware of their infection (98% versus 75%; p<0.01), and during the preceding 6 months, having one or more female sex partners (35% versus 10%; p<0.01) and engaging in UI with female sex partners (20% versus 5%; p = 0.01).
The findings in this report are consistent with previous research suggesting that among MSM, nondisclosure of sexual orientation is associated with being a member of a racial/ethnic minority group, identifying as bisexual or heterosexual, having greater perceived community and internalized homophobia, and being less integrated socially within homosexual communities 1-3,6. Although this study did not find that nondisclosing MSM were at higher risk for HIV infection than MSM who are more open about their sexuality 1-3, the data suggest that a substantial proportion of nondisclosers are infected with HIV and other STDs and are at high risk for transmitting these infections to their male and female sex partners.
The finding that more than one in three nondisclosers reported having recent female sex partners suggests that nondisclosing MSM might have an important role in HIV/STD transmission to women. This might be particularly true for black nondisclosing MSM, of whom approximately one in five was infected with HBV and one in seven was infected with HIV. To help prevent further HIV/STD transmission among young MSM and their female sex partners, greater efforts are needed to increase public awareness and to develop or expand HIV/STD testing and prevention programs to meet the needs of nondisclosers, particularly those who are black.
The findings in this report suggest that public-awareness and prevention programs should be developed for nondisclosing MSM to reduce internalized homophobia and other factors that influence nondisclosure, barriers to HIV/STD testing and prevention services, low-risk perception, and high-risk behavior, including the risk for transmission to male and female sex partners. Corresponding efforts also should be developed for women to increase knowledge of HIV/STD acquisition risks from partners who might be bisexual and of where to obtain confidential testing and prevention services for themselves and their partners.
Prevention managers should intensify outreach efforts to provide HIV/STD testing, risk reduction, and health-care referral services to nondisclosers who avoid homosexually identified prevention organizations. Because this report and others 6 suggest that many nondisclosers have regular male and female sex partners, prevention managers should consider combining outreach efforts with partner counseling and referral services 7 and community network development strategies 8 to increase the availability of HIV/STD prevention services to sex partners of nondisclosing MSM.
In accordance with recently revised guidelines, health-care providers should routinely assess the HIV/STD risks of their patients and encourage at-risk MSM to test annually for HIV, syphilis, gonorrhea, and chlamydia, and to accept or seek vaccination against hepatitis A and B 9. To facilitate risk disclosure from young MSM, health-care providers should create discrete and nonjudgmental environments and ensure that patients are aware of confidentiality safeguards and of the importance of disclosing accurate risk information 3.
The findings in this report are subject to at least three limitations. First, information about the types of persons to whom disclosure was provided or withheld was not collected routinely. Second, the percentage of young MSM defined as nondisclosers in this report should be considered a minimum estimate because young MSM who are reluctant to disclose their sexual orientation were probably less likely to participate or report sexual behavior with men. Finally, findings might not be applicable to nondisclosing MSM aged >29 years or to MSM aged 15-29 years who do not attend MSM-identified venues or reside in one of the six participating cities.
The finding that all but one HIV-infected nondiscloser were unaware of their infection is consistent with a recent report suggesting that the majority of young HIV-infected MSM do not know they are infected 10. For more young HIV-infected MSM to realize the benefits of early diagnosis and care, and to help prevent further HIV transmission among young MSM and their female partners, health-care providers and federal, state, and local HIV-prevention managers should expand and improve HIV testing and prevention practices to meet the needs of diverse MSM, including those who do not disclose their sexual orientation.
Reported by: DA Shehan, Univ of Texas Southwestern Medical Center at Dallas, Texas. M LaLota, MPH, Florida Dept of Health. DF Johnson, MPH, Los Angeles County Dept of Health Svcs, California. DD Celentano, ScD, Johns Hopkins Univ School of Hygiene and Public Health, Baltimore, Maryland. BA Koblin, PhD, New York Blood Center, New York; LV Torian, PhD, New York City Dept of Health, New York. H Thiede, DVM, Public Health -- Seattle and King County, Seattle, Washington. DA MacKellar, MPH, GS Secura, MPH, S Behel, LA Valleroy, PhD, GW Roberts, PhD, Div of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, CDC.