Sunday, December 15, 2013

A Cautionary Tale: Risk Reduction Strategies among Urban American Indian/Alaska Native Men Who Have Sex with Men

American Indian/Alaska Native (AIAN) men who have sex with men (MSM) are at high risk for transmitting and contracting HIV,1 in part due to sexual risk behavior2 and drug injection among this population. Among urban AIAN MSM, HIV prevalence rates range from 18-34%.2-4 Though there is no empirically supported HIV prevention intervention intended for AIAN MSM,5 there are several risk reduction strategies that the general population of MSM use to protect against the transmission of HIV. Pearson and colleagues conceptualize these strategies as a hierarchy, from most to least effective:
  1. Not engaging in anal intercourse
  2. 100% condom use during anal intercourse
  3. Serosorting: Having unprotected anal intercourse (UAI) in a monogamous relationship with a partner who is of the same HIV status (seroconcordant)
  4. Serosorting: Engaging in UAI with a seroconcordant casual partner
  5. Strategic positioning:  HIV-seropositive partner practices receptive anal sex and HIV-seronegative partner practices insertive anal sex

Given that none of the existing studies addresses AIAN MSM specifically, Pearson and colleagues examined HIV risk reduction strategies among a sample of AIAN MSM, paying particular attention to sexual behavior and risks by serostatus.

Methods and Sample

The authors conducted a secondary data analysis using data from the HONOR project.2, 6-8 Between July 2005 and March 2007, researchers recruited AIAN MSM from seven disparate U.S. cities: Seattle-Tacoma, San Francisco-Oakland, Los Angeles, Denver, Tulsa-Oklahoma City, Minneapolis-St. Paul, and New York. Criteria for inclusion included: English-speaking adults (18 or older) residing, working, or socializing in one of the seven study sites. Additional eligibility criteria included identifying as 1) AI, AN, or First Nations and either be enrolled in their tribal nation or report 25% or more Indian blood; and 2) gay, lesbian, bisexual, transgender, or two-spirit (GLBT-TS) or have engaged in same-sex sexual behavior in the previous year. The final analytic sample included 174 anatomically male, AIAN MSM who knew their HIV serostatus. Measures included HIV status; sociodemographic characteristics (e.g., age, gender, partnership status); sexual behavior (e.g., sex trade, sexually transmitted infections, condom use); and risk reduction behaviors. Select sample demographics are as follows:
  • Age: M=39.3 year (SD=10.2)
  • 28.7% were in monogamous relationships
  • 87.9% had at least a high school diploma
  • 49.4% were employed
  • 52.3% earned less than $1,000 per month


Thirty-five percent of the total sample reported a HIV-seropositive status. Nearly 95% of the total sample reported engagement in some risk reduction strategy, including no anal sex (28%), 100% condom use (23%), and seroconcordant monogamous relationships (8%). Of the men who reported any type of anal sex in the past year, those in serodiscordant relationships (i.e., one partner is HIV-seropositive and the other is HIV-seronegative) were significantly less likely (52.4%) to share their HIV status to all partners than those in seroconcordant relationships (85.5%). Participants in serodiscordant relationships were also more likely than their seroconcordant counterparts to have ever had a sexually transmitted infection, have ever traded sex for money or drugs, be HIV-seropositive, and have more sexual partners.


Only approximately half of the present sample reported risk reduction strategies that are likely to protect against HIV transmission, such as condom use and monogamous seroconcordant relationships. While some MSM engage in sero-adaptive strategies, such as serosorting or strategic positioning, the protection these strategies offer is likely ineffective when other factors are taken into account. For example, only half of the sample shared their HIV status with partners and only 39% had an HIV test in the past three months; this may create a false confidence and, thus, reduce engagement in HIV prevention behaviors.9-11 Pearson and colleagues suggest public health messages targeted at AIAN MSM should not only include information about effective risk reduction behaviors, but also encourage both partners to keep abreast of their HIV statuses, including frequent testing and disclosure to partners.

For More Information

For a more in-depth discussion of these findings, refer to the full article, available in AIDS Education and Prevention. To read more about Dr. Beltrán’s work, check out her faculty page


Pearson, C. R., Walters, K. L., Simoni, J. M., Beltrán, R., & Nelson, K. M. (2013). A cautionary tale: Risk reduction strategies among urban American Indian/Alaska Native men who have sex with men. AIDS Education and Prevention, 25(1), 25-37.


1 Fauci, A. S. (2010). Statement for National Native HIV/AIDS Awareness Day. Retrieved from

2 Cassels, S., Pearson, C. R., Walters, K., Simoni, J. M., & Morris, M. (2010). Sexual partner concurrency and sexual risk among gay, lesbian, bisexual, and transgender American Indian/Alaska Natives. Sexually Transmitted Diseases, 37(4), 7.

3 Catania, J., Osmond, D., Stall, R., Pollack, L., Paul, J., Blower, S., Binson, D., Canchola, J. A., Mills, T. C., Fisher, L., Choi, K. H., Porco, T., Turner, C., Blaire, J., Henne, J., Bye, L. L., & Coates, T. (2001). The continuing HIV epidemic among men who have sex with men. American Journal of Public Health, 91(6), 907-914.

4 Centers for Disease Control and Prevention. (2010). Prevalence and awareness of HIV infection among men who have sex with men—21 cities, United States, 2008. Morbidity and Mortality Weekly Report, 59(37), 1201-1227.

5 Centers for Disease Control and Prevention. (2012). Risk reduction chapter. In Divisions of HIV/AIDS Prevention (Ed.), Compendium of evidence-based HIV behavioral interventions: Updated April 5, 2011. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

6 Chae, D. M., & Walters, K. M. (2009). Racial discrimination and racial identity attitudes in relation to self-rated health and physical pain and impairment among two-spirit American Indians/Alaska Natives. American Journal of Public Health, 99(Suppl. 1), S144-S151.

7 Lehavot, K., Walters, K. L., & Simoni, J. M. (2009). Abuse, mastery, and health among lesbian, bisexual, and two-spirit American Indian and Alaska Native women. Cultural Diversity & Ethnic Minority Psychology, 15(3), 275-284.

8 Nelson, K. M., Simoni, J. M., Pearson, C. R., & Walters, K. L. (2011). “I’ve ad unsafe sex so many times, why bother being safe now?”: The role of cognitions in sexual risk among American Indian/Alaska Native men who have sex with men. Annals of Behavioral Medicine, 42(3), 370-380.

9 Centers for Disease Control and Prevention. (2011). Serosorting among gay, bisexual and other men who have sex with men. Gay and Bisexual Men’s Health. Centers for Disease Control and Prevention

10 Eaton, L. A., Kalichman, S. C., & Cherry, C. (2010). Sexual partner selection and HIV risk reduction among Black and White men who have sex with men. American Journal of Public Health, 100(3), 503-509.

11 Zablotska, I. B., Imrie, J., Prestage, G., Crawford, J., Rawstorne, P., Grulich, A., Jin, F., & Kippax, S. (2009). Gay men’s current practice of HIV seroconcordant unprotected anal intercourse: Serosorting or seroguessing? AIDS Care, 21(4), 501-510.

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