The Role of Race and Criminal Justice Involvement at the Individual, Network, and Community Levels on the Prevalence of Sexually Transmitted Infections among Men Who Have Sex with Men in Atlanta, GA Open Access
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Sexually transmitted infections (STIs) disproportionately affect men who have sex with men (MSM) and black/African American men in the United States. The incarceration rate among black men was six times that of white men in 2013, and higher rates of incarceration may be an important factor that contributes to racial disparities in STIs. The purpose of this study was to assess differences in criminal justice involvement comparing black and white MSM, examine the association between STIs with race at the individual, dyadic, and community levels, and to assess the associations between STIs and criminal justice involvement at the individual, dyadic, and community levels with STIs, adjusting for race. Cross-sectional data collected from 803 black and white MSM recruited in Atlanta were analyzed. Black MSM more frequently reported that they had a lifetime history of arrest (42.5%) as compare to white MSM (33.5%, p<.01) and lived in census tracts with significantly higher incarceration rates among 18-39 year old men (median of 1.7 person-years per 100 population as compared to 0.3 among white MSM, p<.001). There was no statistically significant difference by race in the percent reporting that they had a partner who had been arrested in the previous six months. Black MSM in this study sample more frequently tested positive for HIV (43.4% compared to 13.2%, p<.001). With respect to HIV/STI risk factors assessed, black MSM more frequently reported unemployment (20.0% compared to 10.6%, p<.001), homelessness in the last 12 months (15.3% compared to 6.9%, p<.001), currently homeless (3.8% compared to 0.6%, p<.01), and more frequently tested positive for marijuana (26.7% compared to 19.2%, p<.05) as compared to white MSM. White MSM more frequently reported having sex without a condom in the last 12 months (80.2% compared to 69.6%, p<.001) or the last six months (74.0% compared to 61.5%, p<.001) and having sex without a condom with multiple partners in the last six months (40.2% compared to 33.0%, p<.05). White MSM also more frequently reported having health insurance (72.9% compared to 48.9%, p<.001). Upon assessing arrest history as a mediator for the relationship between race and HIV seropositivity or HIV/STI risk factors, no mediation was observed. Overall, a significantly higher percent of black MSM tested positive for one or more of urethral chlamydia, urethral gonorrhea, or syphilis RPR (26.3% compared to 8.1%, p<.001). When individual STIs were assessed, black MSM as compared to white MSM more frequently tested positive for urethral gonorrhea (2.7% compared to 0%, p<.01) and syphilis RPR (26.3% compared to 8.1%, p<.001), but not for urethral chlamydia. Partner race was found to partially mediate the relationship between individual race and STI positivity. After adjustment for partner race, individual race was still significantly associated with STIs but the association was closer to the null. In a path analysis individual race, partner race, drug positivity (excluding marijuana), and reporting multiple condomless sex partners were significantly associated with positivity for one or more STI. Criminal justice involvement at the individual and partner levels were associated with STIs in bivariate analyses, but no significant association with community-level incarceration rates was observed. When stratified by race, no significant associations were observed for black MSM. For white MSM, lifetime arrest (OR=2.90, p<.01), arrest in the past year (OR=3.36, p<.05), and partner arrest in the past six months (OR=6.78, p<.001) were associated with higher STI positivity. When examining individual STIs, partner arrest was associated with higher urethral chlamydia (OR=7.31, p<.01) and Syphilis RPR (OR=6.12, p<.01). Upon entering criminal justice at all three levels into a multivariable model with race, significant interactions between individual race with individual lifetime history of arrest and partner arrest in the last six months were observed, so the multivariable model was run separately for black and white MSM. Among black MSM, criminal justice involvement was not significantly associated with STI positivity, but among white MSM, partner arrest in the last six months was associated with higher positivity with one or more STI (OR=5.53, p<.01). This study sought to assess the relationship between STIs with race and criminal justice involvement at the individual, partner, and community levels, and to examine the potential role of criminal justice involvement in contributing to racial disparities in STIs. Our results identified arrest history as a correlate of HIV, STIs, and STI risk factors. The results from the multi-level assessment of race highlight the value of including partner-level risk factors in future studies. Because partner arrest was only associated with STI positivity among white MSM, our findings did not support that the prevention of incarceration-related risk will directly address racial disparities in HIV and STIs. Additional research may be needed to establish how criminal justice involvement at multiple levels and STI risk are associated over time.