Older Sexual Partners May Contribute to Racial Disparities in HIV Among Young Men Who Have Sex With Men

In 2008, young men who have sex with men (YMSM) had more than 2.5 times as many HIV diagnoses as young women across all risk groups, despite the fact that they are a small proportion of the youth population [1, 2]. Black YMSM are being particularly hard hit, with emerging adults having an estimated prevalence of 16.5% [3]. Troubling trends exist in the rate of diagnoses, which went up by 48% from 2006 to 2009 among Black YMSM—the only population to show an increase [4]. Paradoxically, Black MSM have not been found to engage in more HIV risk behaviors; compared to other racial groups, they report similar or higher rates of condom use, fewer sexual partners, and less substance use [5–9]. As such, disparities in HIV incidence cannot be explained by individual risk behaviors. Older partners in the sexual networks of Black YMSM have been hypothesized as one source of the disparity [10]. The role of older partners in HIV infection among youth has long been described among heterosexual girls. For example, one study of U.S. girls found that those with an older first partner had a younger sexual debut, a lower likelihood of condom use, and higher pregnancy rate [11]. In countries where HIV prevalence is significantly higher among girls than boys (e.g., sub-Saharan Africa), it has been suggested that transmission from older male partners to girls may explain the gender disparity [12]. In South Africa, girls have three times the rate of HIV as boys, are much more likely to have older partners, and these older partners increased the odds of being infected with HIV by 60%[13]. Similar results have been reported in other countries [e.g., 14, 15]. Some HIV prevention programs for girls directly discourage sex with “sugar daddies” [16]. Given that older male partners appear to drive gender disparities in HIV among heterosexual youth, it is plausible they also drive racial disparities among YMSM in the U.S. Dyadic research has shown that YMSM are most likely to have same-race partnerships (sexual homophily) [7], and that sexual homophily is highest among Black YMSM [8]. The mechanisms behind the elevated same-race sexual homophily in Black YMSM have not been widely studied, but evidence suggests that this phenomenon may by partially explained by race-based sexual stereotypes [17, 18]. These sexual homophily statistics suggest that when Black YMSM have older partners, these partners are most likely to also be Black. And Black MSM have the high HIV prevalence (28%)[19]. Unprotected sex with older partners from high prevalence groups produces the unsurprising, but distressing, result that such sexual couplings are associated with HIV seroconversion in Black YMSM [8, 10, 20–22]. Essentially these dyadic and network phenomena set up a dynamic where the high prevalence in adults increases the incidence in youth. As the virus enters the youth networks, it can then spread through the smaller more racially homophilous sexual networks of Black YMSM more efficiently than the larger less homophilous networks of other racial groups. This dynamic makes Black YMSM particularly vulnerable to HIV acquisition, but of course other structural factors must also be considered (e.g., lack of access to healthcare). Very little is known about the motivations for some Black YMSM to have sex with older men, which highlights the value of an article in this issue of Journal of Adolescent Health that explores this topic using qualitative methods [23]. The results suggest that Black YMSM seek older partners because of their emotional maturity and their ability to expose them to the LGBT community. Because Black YMSM are less “out” on average than YMSM of other racial groups [24, 25], they have less access to LGBT-identified spaces with diverse peers and potential romantic partners. As such, they may have greater need for brokers who can help connect them to these communities; a function that older men appear to be playing. The Black YMSM in this study also reported being attracted to older men because of emotional, financial, and instrumental support. Our prior research has shown that Black YMSM are more likely to receive a rejecting response from their families or origin [24], which creates a real need for emotional and instrumental support outside the family. Older men can sometimes provide such emotional and physical resources, but doing so can engender power over younger men in vulnerable situations. Power imbalances in partnerships with older MSM can have important implications for condom use, which is corroborated by a recent finding that YMSM were more likely to have unprotected sex when they perceived their partner to have more power in the relationship [26]. More research is needed on the role older sexual partners play in unprotected sex and HIV infection amongst Black YMSM. Longitudinal designs and mediation analyses would be particularly helpful in determining whether certain variables associated with having older partners (e.g., power differentials) are causal predictors of unprotected sex and/or infection. Network science is particularly well-poised to examine how the presence of older partners in the sexual networks of YMSM influence risk in concert with other important drivers of HIV disparities, including size and density of the sexual network, sexual concurrency within the network (i.e., multiple overlapping sexual partnerships), and network structures (e.g., are older partners more likely to be “key players” in Black YMSM networks). Further investigation of these effects should also inform prevention efforts and services. If data clearly demonstrate that older partners play a central role in HIV disparities in YMSM, the incorporation of this phenomenon into an intervention must be done with great sensitivity to issues of stigma, culture, and resources. For example, a simplistic approach to eliminating agediscordant relationships could withdraw needed resources from Black YMSM [23]. Social marketing campaigns addressing age discordant relationships among MSM could further drive anti-gay stigma. We agree with the suggestions of Arrington-Sanders and colleagues [23] that the best interventions are those that provide safety net, family, and community resources to Black YMSM so they do not need to rely on older men to access the LGBT community or to get basic needs met. If we are to create health equity for Black YMSM we must begin to holistically address the constellation of dyadic, network, and structural factors that drive these disparities.