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Lisa Bond, PhD, Darrell P. Wheeler, PhD, MPH, Gregorio A. Millett, MPH, Archana Bodas LaPollo, MPH, Lee F. Carson, MSW, and also Adrian Liau, PhD
Lisa Bond, Archana LaPollo, and Lee Carchild are with the Public Health Management Corporation, Philadelphia, PA. Darrell Wheeler is through the Hunter College School of Social Work, City College of New York, New York, NY. Gregorio Millett and also Adrian Liau are with the Centers for Disease Control and Prevention, Atlanta, GA.

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Corresponding writer.
Repursuits for reprints should be sent out to Lisa Bond, Public Health Management Corporation, 260 South Broad St, Philadelphia, PA 19102-5085 (gro.cmhp
Contributors

L. Bond initiated and completed analyses of all data and also led the creating of the write-up. D. P. Wheeler added to conceptualizing the article, interpreting the findings, and also editing and enhancing the write-up. G. A. Millett added to conceptualizing the post, interpreting the findings, and editing and enhancing the post. A. B. LaPollo added to analyzing the information, interpreting the findings, and also editing the post. L. F. Carboy helped via collecting information and also modifying the article. A. Liau assisted via interpreting the findings and also editing and enhancing the write-up. All authors were associated in research design, reviewing drafts of the short article, and also offering approval of the final version.


Babsence men “on the dvery own low” have actually been taken into consideration prime agents of HIV transmission in the Black neighborhood despite little empirical proof. We assessed the connection in between down-low identification and also sexual hazard outcomes among 1151 Black MSM. Down-low Identification was not linked via unprotected anal or vaginal sex through male or female partners. Future HIV prevention programs and also research should targain sexual hazard behaviors of Black guys, irrespective of identification, and not focus on the “down low.”


The term “on the dvery own low” has actually been provided to explain Black males that identify as heterosex-related yet put their female partners at danger for HIV infection by privately having actually homosexual sex.1–7 Black guys on the dvery own low have been implicated in the popular push as prime agents of HIV transmission in the Black neighborhood.1,8–10 However before, the degree to which the dvery own low is connected via HIV danger habits has actually never been quantitatively examined among a large sample of Babsence guys who have actually sex through men (MSM). We sneed to assess whether or not dvery own low identity is linked with higher sexual threat behavior with male or female partners of Black MSM.


METHODS

File were collected as part of a examine funded by the Centers for Disease Control and also Prevention. The Brothers y Hermanos research recruited Babsence and Latino MSM to research components associated with HIV threat behavior and also HIV infection. Men were enrolled from May 2005 to April 2006 in Philadelphia, Los Angeles, and New York City. Candidates had actually to be male (and also recognize as such); be 18 years or older; self-recognize as Black, Afrideserve to Amerihave the right to, or Latino; and also report sexual intercourse (oral, anal sex, or shared masturbation) via a man in the past 12 months. Participation was open to guys who were HIV positive, HIV negative, or of unrecognized serostanding. Respondent-driven sampling11,12 was used to recruit participants. Participants completed an audio computer-assisted self-intersee adhered to by HIV testing. All participants, except those that disclosed in the time of screening that they had formerly been diagnosed as HIV positive, got pretest counseling and were tested for HIV antibodies utilizing a rapid, dental fluid HIV antibody test. Participants that preliminarily tested positive on the rapid test and also those who disclosed during screening that they were HIV positive gave a blood specimen for confirmatory testing via Western blot assay. Our analysis was restricted to data collected from 1151 Black MSM in New York City and also Philadelphia.

Identification via “down low” was assessed by the question “Do you recognize with any of the following terms? (check all that apply): queer; same-gender loving; in the life; on the dvery own low; none.” Men that checked “on the dvery own low” were categorized as “identify through the dvery own low”; all various other guys were categorized as “carry out not determine via the down low.” The interpretation of down low was additionally asked of respondents and worded as follows: “Recently human being have been talking even more around the dvery own low or DL, however this may mean different things to different human being. We would certainly favor to know what DL indicates to you. Which of the following do you feel ideal defines men that are DL or on the dvery own low? (check all that apply): exceptionally masculine; constantly tops (men who pass through throughout anal or oral sex); less likely to have actually HIV; have fewer male sex partners than gay identified men; DL just describes Babsence men; have wives or girlfriends; only have male sex partners; I do not agree with any of these; I never heard of the term dvery own low or DL.”

Risk habits outcomes (yes or no) had insertive undefended anal intercourse via a male in the past 3 months, receptive unprotected anal intercourse with a male in the past 3 months, or undefended anal or vaginal intercourse with a female in the past 3 months.

Descriptive analyses and the χ2 test were used to compare demographic and also sex-related risks of the complete sample of down-low MSM and nondown-low MSM. For all analyses, unreadjusted bivariate relationships were examined first to test for distinctions in between down-low–determined and also nondown-low–figured out MSM. Variables consisted of in multivariate models were those found to be statistically significant in bivariate analyses (P ≤ .10) or relevant based on a priori knowledge. Multivariate logistic regression assessed the contribution of dvery own low identification to each of the sex-related threat habits outcomes among MSM reporting sex with male or female partners in the past 3 months, while adjusting for age, sexual orientation, HIV serostatus, study site, sex profession, revenue, and also form of sexual partners.


RESULTS

One 3rd of participants (31%) identified via the term “on the down low.” Down-low MSM were even more most likely than were nondown-low MSM to report their sex-related identity as bisexual and also to report that it was “incredibly important” to store their same-sex habits secret (Table 1). One fourth of down-low MSM additionally reported a gay sex-related identity, and 11.1% reported being straight or heterosexual. Regarding the meaning of “dvery own low,” equivalent proportions of down-low MSM and nondown-low MSM schosen equivalent features that “best describe” guys who are dvery own low. Half of the men (ircorresponding of down-low identity) did not characterize the down low as having actually a wife or a girlfrifinish.


Demographic, HIV Status, and also Risk Behavior Comparikid of Babsence MSM Who Do and also Do Not Identify With the Term “Dvery own Low”: Philadelphia and also New York City, 2005–2006 (N = 1151)


Do Not Identify With Dvery own Low, No. (%) (n = 790)Identify With Dvery own Low, No. (%) (n = 361)P
Age.353
    18–29111 (14.1)47 (13.1)
    30–39174 (22.1)65 (18.1)
    40–49364 (46.1)175 (48.6)
    ≥ 50140 (17.7)73 (20.3)
Gross annual income.680
    < $5,000264 (34.4)131 (36.8)
    $5,000–$9,999183 (23.8)85 (23.9)
    $10,000–$19,999163 (21.2)66 (18.5)
    $20,000–$29,99972 (9.4)39 (11.0)
    ≥ $30,00086 (11.2)35 (9.8)
Sexual identity<.001
    Homosex-related or gay443 (56.2)101 (28.1)
    Bisexual225 (28.6)200 (55.6)
    Heterosex-related or straight83 (10.5)40 (11.1)
    Other37 (4.7)19 (5.3)
What best describes guys on the down lowa
    Have wives or girlfriends400 (51.0)176 (48.8).489
    Extremely masculine142 (18.1)87 (24.1).018
    Always the height partner131 (16.7)82 (22.7).015
    Have fewer male partners than gay men152 (19.4)82 (22.7).191
    Don"t agree through any kind of of above statements119 (15.2)48 (13.3).406
    Never before heard of the “DL”b25 (3.2) …
Ever tested for HIV726 (92.0)324 (89.8).206
HIV status<.001
    Negative343 (43.8)202 (56.3)
    Hopeful (infected, aware)c362 (46.2)124 (34.5)
    Hopeful (infected, unaware)c79 (10.1)33 (9.2)
Type of sexual intercourse, previous 3 months
    Traded sex through a male160 (20.3)106 (29.4).001
    Any anal intercourse via male555 (70.3)265 (73.4).273
    Insertive UAI via male (n = 820)d263 (47.4)138 (52.1).209
    Receptive UAI with male (n = 820)d205 (36.9)74 (27.9).011
    Any vaginal/anal intercourse via female182 (23.0)167 (46.3)<.001
    Unsafeguarded vaginal or anal intercourse through female (n = 349)e108 (59.3)98 (58.7).901
Importance of keeping sex through men secret.001
    Not at all important273 (34.7)50 (13.9)
    Somewhat/bit important328 (41.3)145 (40.2)
    Very important188 (23.9)166 (46.0)

Note. MSM = males that have sex through men; DL = down low; UAI = unsafeguarded anal intercourse. Numbers may not add to totals as a result of absent information.


aThese statements were checked by participants as finest describing males who are dvery own low. Other statements not displayed were checked by much less than 15% of participants in the DL or non-DL samples.
bZero participants who identified via the term “down low” reported that they had actually “never before heard of the DL.”
cInfected-mindful males self-reported that they were HIV-positive at the moment of study enrollment, and also their positive status was evidenced via examine experimentation. At enrollment, infected-unaware males self-reported they were HIV-negative, did not understand their status, did not return for outcome of their last HIV test, or last test outcome was indeterminant. These males consequently tested HIV-positive through examine testing.
dIncludes only participants who had actually a male sex partner in the past 3 months (n = 820; 265 DL men; 555 non-DL men).
eIncludes only participants that had actually a female sex partner in the past 3 months (n = 349; 167 DL men; 182 non-DL men).

A majority of participants had previously been tested for HIV and there were no substantial distinctions between down-low MSM and nondown-low MSM in HIV trial and error background. Comparable proparts of down-low MSM and non down-low MSM tested HIV positive and also were unmindful of their infection, yet down-low MSM were significantly less likely to be HIV positive overall.

Similar proportions of dvery own low and nondown-low men had recent sex-related intercourse with a male partner. Among these participants, comparable proparts of down-low and also nondown-low MSM reported insertive unprotected anal intercourse, whereas down-low MSM were considerably much less most likely than were nondown-low MSM to report receptive unsafeguarded anal intercourse. Down-low MSM were more most likely to report sex profession tasks through males and even more likely than were nondown-low MSM to have actually sex-related intercourse with womales. However before, one fourth of nondown-low men also reported recent sex through a woguy, and also down-low MSM and nondown-low MSM reported equivalent prices of undefended sex via women.

Table 2 shows the outcomes of 3 multivariate logistic regression models for each threat actions outcome. Controlling for various other covariates, down-low identity was not substantially associated with any type of sexual threat outcome. In added analyses we performed (not shown) in which we restricted the sample to HIV-positive males, we discovered no significant differences in the proparts of down-low established and nondown-low determined males reporting undefended sex with female partners who were HIV negative or whose HIV condition was unrecognized (N= 72; χ2 = .937; P = .333) or male partners (N= 365; χ2 = .016; P = .898).


Multivariate Logistic Regression Models of the Association Between Down Low Identity and Undefended Intercourse through Male and Female Partners, Among Black MSM Recruited in New York City and also Philadelphia, 2005-2006


Unsafeguarded Insertive Anal Intercourse With a Male in the Past 3 Monthsac (n = 801)Unsafeguarded Receptive Anal Intercourse With a Male in the Past 3 Monthsac (n = 801)Unsafeguarded Vaginal or Anal Intercourse With a Female in the Past 3 Monthsbc (n = 342)
AOR (95% CI)PAOR (95% CI)PAOR (95% CI)P
Identify as “down low”1.12 (0.80, 1.55).5110.87 (0.60, 1.27).4740.84 (0.53, 1.34).471
Age, y0.99 (0.98, 1.01).5170.99 (0.97, 1.00).0901.00 (0.97, 1.02).843
Sexual identity
    Heterosexual or straightRefRefRef
    Homosex-related or gay0.97 (0.50, 1.90).9387.36 (2.68, 20.22)<.0011.07 (0.40, 2.88).894
    Bisexual1.03 (0.54, 1.99).9212.27 (0.83, 6.22).1120.94 (0.53, 1.67).826
    Other0.59 (0.22, 1.54).2792.27 (0.62, 8.37).2180.85 (0.29, 2.47).763
HIV standing, self-reported
    NegativeRefRefRef
    Positive0.97 (0.69, 1.37).8701.42 (0.97, 2.07).0740.57 (0.31, 1.05).073
    Unknown1.09 (0.69, 1.70).7191.61 (0.98, 2.64).0580.94 (0.48, 1.83).853
Traded sex through a male past 3 months1.95 (1.36, 2.78)<.0012.11 (1.43, 3.13)<.0011.17 (0.69, 1.99).552
Type of sex partner(s) in past 3 monthsd
    Key companion onlyRefRefRef
    Casual companion only0.96 (0.65, 1.41).8360.64 (0.41, 0.99).0431.07 (0.65, 1.78).780
    Both main companion and casual partner2.16 (1.40, 3.31)<.0011.65 (1.05, 2.60).0303.93 (1.97, 7.85)<.001
Study site
    Philadelphia, PARefRefRef
    New York City, NY1.29 (0.94, 1.76).1141.08 (0.77, 1.53).6480.65 (0.39, 1.09).104

aParticipants reporting no sex in the previous 3 months with a male partner are excluded from this evaluation.
bParticipants reporting no sex in the past 3 months with a female partner are excluded from this evaluation.
dType of companion refers to male partners in models predicting insertive and receptive unprotected anal intercourse, and female partners in design predicting undefended vaginal and anal intercourse. Key partner was defined as a “committed relationship.”

DISCUSSION

Our examine suggests numerous crucial findings. First, contrary to what has been reported in the well-known push, down-low identity was not linked with engaging in better sex-related hazard habits with female or male partners. Black MSM who established through the dvery own low (irparticular of their HIV serostatus) involved in similar sexual risks with male and also female partners as nondown-low–determined MSM. Although down-low MSM were more likely than were nondown-low MSM to report a female sex companion, both groups of males engaged in similar sex-related risks with female partners. Second, identifying with the dvery own low did not constantly imply having actually female sex partners. Half of the down-low males in our research reported no current sex via a woman, whereas 23% of nondown-low guys reported a current female sex partner. Third, our examine challenges prevailing assumptions that men on the dvery own low generally identify as heterosex-related. Down-low MSM were a lot more most likely to recognize as bisex-related or homosexual than heterosexual, and also nondown-low MSM were just as likely as down-low MSM to report being heterosexual. Last, compared via nondown-low MSM, down-low–established MSM reported fewer instances of receptive undefended anal intercourse via male partners and also were much less likely to test HIV positive.

Our research has its restrictions. First, the survey did not differentiate main identification as down low from other identities that down-low males might have chosen. Second, the males in our sample were mainly low income and also were recruited in urban areas in the Northeast; they might not be representative of Babsence MSM overall. Third, we relied on self-reports to assess sexual danger behaviors, although use of audio computer-assisted self-interviews most likely decreased underreporting because of social desircapacity.

Findings from our examine underscore the limitations of making use of identification quite than sexual habits to predict sexual danger.13–17 Interventions that focus on males that recognize as dvery own low will certainly fail to reach substantial numbers of nondown-low–established guys who are sexually affiliated through womales. The clinical neighborhood should deal with more salient, and scientifically valid, contributors to sexual hazard among Babsence MSM than identifying as “dvery own low.”


The Brothers y Hermanos research was funded with a cooperative agreement from the US Centers for Disease Control and also Prevention.

The authors would like to say thanks to the entire Brothers y Hermanos research team, community-based partners in Philadelphia and also New York City for their participation on the research, and also volunteer members of local area advisory boards who guided the style and also implementation of the examine.

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This study was apshowed by the institutional testimonial boards of the Public Health Management Corporation, the New York City Department of Health and also Mental Hygiene, Hunter College, and also the Centers for Disease Control and also Prevention. All HIV trial and error information was gathered through signed increated consent out.


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