Beyond Sexual Partnerships: The Lack of Condom Use during Vaginal Sex with Steady Partners.

IntroductionAfrican Americans, specifically those belonging to the lower socioeconomic strata and who typically live in disadvantaged urban neighborhoods, have been impacted disproportionately by HIV (1). In 2009, African Americans comprised 14% of the United States population, but 44% of new HIV infections occurred among them (2). Between 2005 and 2008, African Americans experienced the largest increase in rate of HIV diagnoses as compared to members of other racial groups (2). In addition, African Americans were found to have the highest lifetime risk for a diagnosis of HIV infection of all racial/ethnic groups. Specifically, the rate among African Americans was one in 22 as compared to a rate of one in 170 among whites, and one in 52 among Hispanics/Latinos (3). These data also show that, by region in the U.S., African Americans accounted for the majority of HIV cases in the South (55.7%) (3).Since the 1990s, social scientists have called for a "syndemic" approach to the HIV epidemic and associated disparities (4-7). In the public health community, the increasing need for recognizing such an approach is reflected in the emerging body of literature on multi-level approaches to the HIV/AIDS epidemic, including an emphasis on the social determinants of health and health disparities (8-10). By placing individual behaviors in the larger context of poverty, unequal access to health care, uneven criminal justice involvement, and residence in crumbling neighborhoods with limited social capital, tailored prevention and intervention efforts may be more likely to be effective in curtailing the devastating impact of the HIV/AIDS epidemic on African Americans. As one of its main goals, the National HIV/AIDS Strategy calls for prioritizing the reduction of HIV-related health disparities (11). Given that condom use as a safer sex strategy remains one of the most effective risk-reduction strategies among African Americans, especially in the U.S. South where much of the epidemic is driven by heterosexual transmission (3), in this paper, we focus on condom use during vaginal sex with steady partners. Specifically, we aim to gain a better understanding of distal and proximal factors that influence the use of condoms during vaginal sex with steady partners. Examples of proximal factors include relationships and sexual partnerships and in the more distal domain, socioeconomic status and neighborhood social capital.Partner type and condom useThe way in which a person categorizes a sex partner may determine condom use behavior. In this inquiry, we limit the focus to male condoms because the use of female condoms is relatively low in the United States (12). Among women, researchers have found condom use with new or casual partners to be more common than condom use with regular partners (13). In addition, study findings show condom use to be least consistent with steady partners and explanations given for this include the notion that a steady partnership, beyond a sexual engagement, also involves emotional connectedness and trust (14, 15). The identification of the nature of a partner type (e.g., steady and casual) typically is left to study participants. Consequently, researchers as well as prevention and intervention experts may be applying definitions that do not capture everyday complexities of steady and casual partnerships, with the latter including transactional sex for which one partner is paid and the other pays. Having sex with a steady partner has been associated with a decrease in the odds of protected vaginal sex among women (16,17), while having sex with a casual partner has been associated with an increased likelihood of condom use among women as well as men (18). Among the barriers to condom use identified in the context of sex with steady partners are the perceived distraction from sexual intimacy and a possible reduction of sexual pleasure, its association with distrust in a partner and the assumption of unfaithfulness, and inadequate communication and negotiation skills (14,19,20). …