The current study examines risk behaviors in a case-control study of 90 HIV-infected and 272 uninfected African American men in Los Angeles County who self-identified as heterosexual. Thirty-one percent of the infected men and sixteen percent of the uninfected men reported having anal sex with men. Among that group, 100 percent of the infected men and 67 percent of the uninfected men reported inconsistent condom use during anal sex with men. Few of the infected (12 percent) or uninfected (2 percent) men reported oral sex with other men. Forty-six percent of the HIV-positive men and 37 percent of the HIV-negative heterosexuals reported anal sex with women with infrequent condom use.

Many theories have been put forth to explain why African American men who self-identify as heterosexual and have sex with men are at a particularly high risk for HIV. One hypothesis suggests that heterosexual African American men are not reached by the prevention messages directed at gay and bisexual communities. Another postulates that, unlike gay and bisexual men, heterosexual men do not normally circulate in social networks that reinforce sexual norms of risk reduction. Furthermore, many African American men who identify themselves as heterosexual and have sex with men are not comfortable with homosexuality or its perceived reception in the African American community. Evidence suggests that self-homophobia is linked with high-risk behavior among men who have sex with men.

Researchers found increased odds for HIV infection were associated with a decreasing age at first sexual experience and a history of injection drug use. They caution that the percentage of heterosexually identified men reporting anal sex with other men in this study is likely to be an underestimate due to the subjects' underreporting. Low condom use among this cohort could mean that self-identified heterosexual men do not consider themselves at risk for HIV infection and thus do not heed public messages about the importance of condom use.

Female partners of the men in the study are at risk for HIV transmission, given that the men in the study reported a high frequency of unprotected anal sex with women. Moreover, female partners may not know about the men's risk behavior or HIV status.

The data provide support for expanding the prevention model beyond the traditional gay/straight dichotomy. The authors suggest crafting media messages not exclusively targeted to gay- and bisexually-identified men, and interventions such as the promotion of a positive view of condoms through outreach at heterosexual venues.

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