Human immunodeficiency virus (HIV) infection

o r i g i n a l c o m m u n i c a t i o n Sex With Bisexual Men Among Black Female Students at Historically Black Colleges and Universities Andrew C. Voetsch, PhD; Peter E. Thomas, PhD, MPH; Anna Satcher Johnson, MPH; Gregorio A. Millett, MPH; Lynette Mundey, MD; Carolyn Goode, PhD; Joanne Nobles, RN, MPH; Kaye Sly, PhD; Michelle R. Smith, PhD; Mattie Shiloh, RN, MSN; Binwei Song, MS; Kathleen Green, PhD, MS; Hazel D. Dean, ScD, MPH; James D. Heffelfinger, MD, MPH Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC), Atlanta, Georgia. Background: Human immunodeficiency virus (HIV) disproportionately affects black women. Nearly two-thirds of all female HIV cases reported to the CDC are black, and HIV is the leading cause of death among black women aged 25 to 34 years. The greatest HIV transmission risk among black women is sexual intercourse with a man, although the role of bisexual men is not clear. Methods: The CDC and collaborating partners conducted behavioral surveys at 7 historically black colleges and universities from January 2005 to April 2007. Results: Of the 2705 black female students aged 18 to 29 years who were surveyed, 2040 (75%) reported being sexually active in the previous 12 months and, among sexually active women, 291 (14%) reported having sex with a bisexual man in the previous 12 months. Women who reported sex with a bisexual man were more likely than women who did not to report having at least 2 sex partners in the previous 12 months, having male and female sex partners, not using a condom at last intercourse, being in a committed relationship, never or infrequently attending church, and believing they were at increased risk for HIV infection. Conclusion: Heterosexually active black women who have engaged in sexual intercourse with bisexual men have a different HIV risk profile than other heterosexually active black women. Keywords: HIV/AIDS n risk behaviors n African Americans J Natl Med Assoc. 2010;102:1198-1205 Author Affiliations: National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Disease, and Tuberculosis Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia (Drs Voetsch, Thomas, Johnson, Millett, Green, Dean, and Heffelfinger and Ms Song); Howard University, Washington, DC (Drs Mundey, and Goode); Fort Valley State University, Georgia (Ms Nobles); Jackson State University, Mississippi (Dr Sly); Jefferson Comprehensive Care Inc, Pine Bluff, Arkansas (Dr Smith); Albany State University, Georgia (Ms Shiloh). Correspondence: Andrew C. Voetsch, PhD, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Mailstop E46, Atlanta, GA 30333 (aav6@cdc.gov). INTRODUCTION Human immunodeficiency virus (HIV) infection disproportionately impacts women of color in the United States. 1 The 2006 estimated HIV prevalence rate (diagnoses per 100 000 women) for black women was nearly 18 times as high 2 as that for white women (1122 vs 62.7). In the 1999-2002 National Health and Nutrition Examination Surveys, HIV prevalence was 1% among black women aged 18 to 39 years and 2.8% among black women aged 40 to 49 years, compared with an overall HIV prevalence among women in these age groups of 0.1% and 0.4%, respectively. 3 Black women represented 63% of all female HIV cases reported 4 to the Centers for Disease Control and Prevention (CDC) in 2007 and an estimated 61% of new HIV infections among women 5 in 2006. High-risk heterosexual contact is the predominant risk factor for HIV transmission among HIV-infected black women, although in most of these cases the HIV risk factors for the male partners remain unknown. For example, of the 8119 HIV cases among non-hispanic black women reported to the CDC in 2007, the mode of transmission for 3561 (44%) was high-risk heterosexual contact. Of these heterosexually transmitted cases, the risk factor of the sex partner was not specified for 3054 (86%) cases, and sex with a bisexual male accounted for 123 (3%) cases. 4 However, in a study of CDC AIDS surveillance data from 2000 to 2004, the AIDS rate attributed to heterosexual sex with a bisexual man for black women was 13 times as high as the rate for white women and 4 times as high as that of Hispanic women. 6 Although the reported percentage of female HIV 1198 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 102, NO. 12, DECEMBER 2010

cases attributed to heterosexual sex with a bisexual man is low, black women may be at increased risk for HIV infection for several reasons. Black men have a higher HIV prevalence than men of other races and ethnicities, 2,3 and black women are more likely to choose sex partners of the same race than white or Hispanic women. 7,8 In addition, there is evidence that black men are more likely to engage in concurrent sexual relationships. 9 Black men who have sex with men (MSM) may be more likely than MSM of other races and ethnicities to also have sex with women 10 and less likely to disclose their sexual behavior or identity, 10-13 thereby acting as a bridging population for HIV transmission to black women. 14-16 Black men who have sex with men and women may also be less likely to use condoms with female partners than with male partners. 15,17 In addition, social factors such as poverty and incarceration in the black community may also contribute to the disparity in HIV rates among black women. 18,19 Young black women may be at a higher risk for HIV infection than young women of other races and ethnicities. From 1999 to 2005, HIV was the leading cause of death among black women aged 25 to 34 years. 20 Approximately one-third of new HIV infections among black women are estimated to occur among adolescents and young adults aged 13 to 29 years. 5 Most of the infections among young women are from high-risk heterosexual contact. 21 In a recent outbreak of HIV infection, predominantly among young black MSM in North Carolina, 33% of HIV-infected male college students had sex with both male and female partners in the 1 year prior to their HIV diagnosis. 22 Further, bisexual men in this outbreak had a greater number of sexual partners and were more likely to have exchanged sex or drugs for money compared with men who only had sex with men. 23 In a study of HIV-infected black women in North Carolina, half of their male sex partners who were interviewed reported having had sex with a man in the 12 months prior to their female partners diagnosis. 24 Few studies have addressed black women s knowledge of male-male sex among their sex partners. A 1992 survey of predominantly African American women living in low-income housing showed that 16% knew or believed that their male sex partners had sex with men. 25 We used data from a recent CDC-funded demonstration project to conduct a secondary analysis that describes the proportion of black female students at historically black colleges and universities (HBCUs) who reported having had sex with bisexual men and compares their characteristics and behaviors with black female students at HBCUs who did not report sex with bisexual men. METHODS The methods of the CDC demonstration project in HBCU settings have been previously described. 26 Briefly, the CDC and collaborating partners conducted rapid HIV testing and behavioral surveys at 7 HBCUs in 3 states (Arkansas, Georgia, and Mississippi) and Washington, DC, from January 2005 to April 2007. Staff recruited participants using convenience sampling methods on or near participating HBCU campuses. Students and nonstudents were eligible to participate if they met the age requirement for consent to HIV testing in the state where the HBCU was located. Surveys were conducted in a variety of venues on campuses, including student health centers, dormitories, student activity centers, gymnasiums, and during large campus social or academic events. Respondents completed a brief (<10 minutes) self-administered survey. Small nonmonetary incentives (<$5 in value) were offered to participants who completed the surveys in some sites. Information about demographic characteristics, participation in campus activities, living situation, religiosity, spirituality, church attendance, sexual orientation, sexual behaviors with men and women, alcohol and drug use, attitudes and beliefs about HIV, and history of testing for HIV and other sexually transmitted diseases was collected. Surveys were completed on paper forms and data were entered into a QDS database (Questionnaire Development System, Nova Research, Bethesda, Maryland) at project sites. Sex with a bisexual man was assessed using the question, In the past 12 months [have you] had sex with a man who has sex with other men? Respondents were asked about the sex of their sex partners in the past 12 months (response categories = all male, mostly male, equally male and female, mostly female, all female ). Women who reported the sex of their sex partners as mostly male, equally male and female, or mostly female were categorized as having both male and female sex partners in the analysis. Women who reported being married/partnered when asked, How would you describe your relationship status? or women who answered yes when asked, Is there currently someone that you are involved with sexually and committed to above anyone else? were categorized as being in a committed relationship in the analysis. Respondents were asked their agreement with the following statement, The biggest cause for the spread of HIV is the black men who are living on the down low on campus. Responses were captured on a 5-point scale (completely agreed, 5; agreed somewhat, 4; neither agreed nor disagreed, 3; disagreed somewhat, 2; or completely disagreed, 1). To measure religiosity and spirituality, respondents were asked How often do you attend religious services? (responses were 1, never; 2, less than once a year; 3, several times a year; 4, once a month; 5, 2-3 times a month; 6, nearly every week; 7, every week; and 8, more than once a week), and were asked their agreement with the following statements: I consider myself to be a religious person, and I consider myself to be a spiritual person (responses were captured on a 5-point scale with 3 labeled points: 1, do not agree at all; 3, agree somewhat; 5, very much agree). Respondents were also asked about discussions of HIV testing with JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 102, NO. 12, DECEMBER 2010 1199

partners using 2 questions, Has a sexual or romantic partner ever asked you to get tested for HIV? and Did you ask your last sexual partner whether he/she had been tested for HIV before you engaged in sex with him/ her? Respondents were asked to assess their risk of HIV infection using the question, What do you think your chances are of getting infected with HIV, the virus that causes AIDS? Responses were captured on a 4-point scale (1, high; 2, medium; 3, low; 4, none). In this analysis, we included data from all black female survey respondents aged 18 to 29 years who were enrolled as a part- or full-time student at an HBCU. Data were analyzed using SAS version 9.1 (SAS Institute, Cary, North Carolina) at the CDC. Bivariate analyses were conducted to describe characteristics and behaviors of women who reported having sex with a bisexual male. Logistic regression modeling was used to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for factors identified in the bivariate analysis (p <.05), weighted by sample size for each site. This project was determined to be a public health program activity by the CDC and therefore review by the CDC s institutional review board was not required. The project was approved by the institutional review boards at the participating HBCUs. RESULTS Of the 6620 persons surveyed, 4298 (65%) were women, of which 3856 (90%) respondents were black. Among black women, we included 2705 (70%) respondents who were students aged 18 to 29 years in this analysis. Of these, 1177 (43.5%) women were surveyed in Washington, DC; 749 (27.7%) in Mississippi; 405 (15.0%) in Georgia; and 374 (13.8%) in Arkansas (Table 1). The median age was 20 years. Most (88%) women had never married, but half reported being in a committed relationship (Table 1). Sixty-four percent of women lived on campus and 60% lived with a roommate or housemate who was not related to them. Of the 2705 women in the analysis, 2672 (98.9%) received rapid HIV testing on the day they were surveyed, and 3 (0.1%) had a reactive rapid HIV test result. Confirmatory testing showed that none of the 3 women was HIV positive. Of the 2705 women in the analysis, 2315 (86%) women reported having at least 1 sex partner in the previous 12 months. Eight (0.3%) women reported having sex with a person whom they knew was HIV infected, yet 481 (18%) reported having sex with someone whose HIV status they did not know. Although only 450 (17%) reported having unprotected vaginal intercourse and only 91 (3%) reported having unprotected anal intercourse Table 1. Demographic and Behavioral Characteristics of Female Black Students at 7 Historically Black Colleges and Universities, January 2005 to April 2007 Arkansas Georgia Mississippi Washington, DC Total n (%) n (%) n (%) n (%) n (%) Age, y 18-20 237 (63.4) 298 (73.6) 435 (58.1) 707 (60.1) 1677 (62.0) 21-24 116 (31.0) 99 (24.4) 250 (33.4) 354 (30.1) 819 (30.3) 25-29 21 (5.6) 8 (2.0) 64 (8.5) 116 (9.9) 116 (7.7) In a committed relationship a Yes 192 (51.3) 208 (51.4) 369 (49.3) 585 (49.7) 1354 (50.1) No 179 (47.9) 196 (48.4) 376 (50.2) 588 (50.0) 1339 (49.5) Missing 3 (0.8) 1 (0.3) 4 (0.5) 4 (0.3) 12 (0.4) Attend religious services Never/infrequently 41 (11.0) 107 (26.4) 179 (23.9) 433 (36.8) 760 (28.1) Monthly 63 (16.8) 126 (31.1) 233 (31.1) 314 (26.7) 736 (27.2) Weekly 145 (38.8) 139 (34.3) 290 (38.7) 290 (24.6) 864 (31.9) Missing 125 (33.4) 33 (8.2) 47 (6.3) 140 (11.9) 345 (12.8) Sexual identity Heterosexual 327 (87.4) 375 (92.6) 661 (88.3) 1041 (88.5) 2404 (88.9) Bisexual 10 (2.7) 4 (1.0) 26 (3.5) 16 (1.4) 56 (2.1) Lesbian 12 (3.2) 4 (1.0) 24 (3.2) 14 (1.2) 54 (2.0) Missing 25 (6.7) 22 (5.4) 38 (5.1) 106 (9.0) 106 (7.1) No. of sex partners in the previous 12 mo (vaginal or anal) No partners 35 (9.4) 24 (5.9) 35 (4.7) 91 (7.7) 185 (6.8) 1 partner 128 (34.2) 176 (43.5) 318 (42.5) 404 (34.3) 1026 (37.9) 2 partners 186 (49.7) 184 (45.4) 338 (45.1) 581 (49.4) 1289 (47.7) Missing 25 (6.7) 21 (5.2) 58 (7.7) 101 (8.6) 205 (7.6) Total 374 405 749 1177 2705 a Married, partnered, or involved with sexually and committed to above anyone else. 1200 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 102, NO. 12, DECEMBER 2010

with a man in the past 12 months, 962 (36%) reported not using a condom at last vaginal or anal intercourse. Overall, 300 (11%) women reported having sex with a bisexual man in the previous 12 months. The proportion of women who reported having had sex with a bisexual male was highest among women surveyed in Washington, DC (20%), followed by those in Arkansas (6%), Mississippi (5%), and Georgia (0%). History of diagnosis with a sexually transmitted disease was reported by 251 (9%) women. Overall, 1617 (60%) women reported Table 2. Demographic and Behavioral Characteristics Associated With Self-Reported Sex With a Bisexual Man Among 2040 Black Female Students at 7 Historically Black Colleges and Universities, January 2005 to April 2007 Sex With a Bisexual Man a Yes No Crude n (%) n (%) OR (95% CI) Site Arkansas 23 (7.9) 246 (14.1) 1.0 Georgia 0 (0) 323 (18.5) 0 0 Mississippi 36 (12.4) 559 (32.0) 0.60 (0.35-1.0) Washington, DC 232 (79.7) 621 (35.5) 3.4 (2.1-5.3) Age, y 18-20 159 (54.6) 1092 (62.4) 1.0 21-24 101 (34.7) 536 (30.7) 1.3 (0.99-1.7) 25-29 31 (10.7) 121 (6.9) 1.8 (1.1-2.7) In a committed relationship b Yes 184 (63.2) 952 (54.4) 1.4 (1.1-1.8) No 107 (36.8) 791 (45.2) 1.0 Missing 0 (0) 6 (0.3) Agree that I consider myself to be a religious person Very much/somewhat agree 229 (78.7) 1519 (86.9) 1.0 DoNot agree at all 32 (11.0) 122 (7.0) 1.7 (1.2-2.6) Missing 30 (10.3) 108 (6.2) Agree that I consider myself to be a spiritual person Very much/somewhat agree 223 (76.6) 1476 (84.4) 1.0 DoNot agree at all 12 (4.1) 98 (5.6) 0.81 (0.44-1.5) Missing 56 (19.2) 175 (10.0) Attend religious services Never/Infrequently 110 (37.8) 495 (28.3) 2.0 (1.4-2.7) Monthly 75 (25.8) 512 (29.3) 1.3 (0.91-1.8) Weekly 64 (22.0) 567 (32.4) 1.0 Missing 42 (14.4) 175 (10.0) Sexual identity Heterosexual 247 (94.2) 1640 (93.8) 1.0 Bisexual 4 (1.4) 38 (2.2) 0.63 (0.22-1.8) Lesbian 7 (2.4) 8 0.5 5.2 (1.9-15) Missing 6 (2.1) 63 (3.6) No. of sex partners in the previous 12 months (vaginal or anal) 1 partner 102 (35.1) 807 (46.1) 1.0 2 partners 189 (64.9) 942 (53.9) 1.6 (1.2-2.1) Male and female sex partners in the previous 12 mo Yes 19 (6.5) 53 (3.0) 2.2 (1.3-3.8) No 271 (93.1) 1658 (94.8) 1.0 Missing 1 (0.3) 38 (2.2) Sexual behavior in the previous 12 mo Sex with person of unknown HIV status Yes 61 (21.0) 398 (22.8) 0.90 (0.66-1.2) No 230 (79.0) 1351 (77.2) 1.0 Sex while high, on drugs, or drunk Yes 53 (18.2) 203 (11.6) 1.7 (1.2-2.4) No 238 (81.8) 1546 (88.4) 1.0 Sex with person you don t know Yes 8 (2.8) 50 (2.9) 0.96 (0.45-2.0) No 283 (97.3) 1699 (97.1) 1.0 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 102, NO. 12, DECEMBER 2010 1201

having been tested for HIV in the previous 12 months, 666 (25%) reported having ever been asked by a partner to get tested for HIV, and 1328 (49%) asked their last partner to get tested for HIV. When asked to assess their risk for HIV infection, 463 (17%) believed they were at no risk, 1293 (48%) believed they were at low risk, 285 (11%) believed they were at medium risk, and only 97 (4%) believed they were at high risk for HIV infection. Of the 2266 (84%) women who reported vaginal or anal sex with at least 1 male partner in the previous 12 months, 2040 (90%) responded to the question regarding having sex with a bisexual male. Of these women, 291 (14%) reported having sex with a bisexual man. Women who had sex with a bisexual man were more likely than those who had not to report being older than 20 years, being in a committed relationship, never or infrequently attending church, not agreeing that they were a religious person, identifying as lesbian, having 2 or more sex partners in the previous 12 months, having both male and female sex partners in the previous 12 months, having sex while using drugs or alcohol in the previous 12 months, not using a condom at last vaginal Table 2. Demographic and Behavioral Characteristics Associated With Self-Reported Sex With a Bisexual Man Among 2040 Black Female Students at 7 Historically Black Colleges and Universities, January 2005 to April 2007 (contd) Sex With a Bisexual Man a Yes No Crude n (%) n (%) OR (95% CI) Receptive unprotected anal intercourse Yes 9 (3.1) 76 (4.4) 0.70 (0.35-1.4) No 282 (96.9) 1673 (95.7) 1.0 Used a condom at last intercourse (vaginal or anal) Yes 113 (38.8) 1054 (60.3) 1.0 No 172 (59.1) 630 (36.0) 2.5 (2.0-3.3) Missing 6 (2.1) 65 (3.7) Ever diagnosed with a sexually transmitted disease Yes 36 (12.4) 183 (10.5) 1.1 (0.77-1.7) No 222 (76.3) 1275 (72.9) 1.0 Missing 33 (11.3) 291 (16.6) Tested for HIV in previous 12 mo Yes 156 (53.6) 1055 (60.3) 0.79 (0.61-1.0) No 100 (34.4) 537 (30.7) 1.0 Missing 35 (12.0) 157 (9.0) Ever asked by a partner to get tested for HIV Yes 77 (26.5) 468 (26.8) 0.96 (0.72-1.3) No 203 (69.8) 1179 (67.4) 1.0 Missing 11 (3.8) 102 (5.8) Asked last partner to get tested for HIV Yes 175 (60.1) 923 (52.8) 1.2 (0.96-1.6) No 111 (38.1) 726 (41.5) 1.0 Missing 5 (1.7) 100 (5.7) Perception of HIV risk High 12 (4.1) 72 (4.1) 2.2 (1.0-4.5) Medium 48 (16.5) 189 (10.8) 3.3 (1.9-5.6) Low 164 (56.4) 891 (50.9) 2.4 (1.5-3.8) None 23 (7.9) 298 (17.0) 1.0 Missing 44 (15.1) 275 (17.2) Agree that men living on the down low are the biggest cause for the spread of HIV on campus Completely disagree 65 (22.3) 296 (16.9) 2.2 (1.4-3.5) Disagree somewhat 42 (14.4) 211 (12.1) 2.0 (1.2-3.2) Neutral 61 (21.0) 419 (24.0) 1.5 (0.93-2.3) Agree somewhat 37 (12.7) 239 (13.7) 1.5 (0.89-2.5) Completely agree 29 (10.0) 290 (16.6) 1.0 Missing 57 (19.6) 294 (16.8) Abbreviations: CI, confidence interval; OR, odds ratio. a Self-reported sex with a man who has sex with other men. b Married, partnered, or involved with sexually and committed to above anyone else. 1202 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 102, NO. 12, DECEMBER 2010

or anal intercourse, and believing they were at increased risk for HIV infection (Table 2). In a multivariable model, women who had sex with a bisexual man were more likely than those who had not to report being older than 20 years (OR, 1.8; 95% CI, 1.5-2.1), being in a committed relationship (OR, 1.7; 95% CI, 1.4-2.0), never or infrequently attending church (OR, 1.6; 95% CI, 1.3-1.8), having 2 or more sex partners in the previous 12 months (OR, 1.6; 95% CI, 1.4-1.9), having both male and female sex partners in the previous 12 months (OR, 1.8; 95% CI, 1.2-2.6), not using a condom at last vaginal or anal intercourse (OR, 2.0; 95% CI, 1.7-2.4), and believing they were at an increased risk for HIV infection (OR, 1.3; 95% CI, 1.2-1.4). Among the 2167 women who responded to the statement, The biggest cause for the spread of HIV is the black men who are living on the down-low on campus, 34% agreed somewhat or completely agreed. Among women who had sex with a man in the past 12 months, women who had sex with a bisexual man were more likely to disagree completely or disagree somewhat with the statement compared to women who had not had sex with a bisexual man (Table 2). Discussion More than 14% of the sexually active young black women at HBCUs in our study reported having sex with a bisexual man in the previous 12 months. These women were more likely to report engaging in high-risk sexual activity, including having 2 or more sex partners in the previous year and having unprotected sex at last intercourse, even after adjusting for being in a committed relationship. Because of the high prevalence of HIV among black MSM, women who have sex with bisexual men are at an increased risk of HIV infection. However, more than half of the women surveyed who reported having had sex with a bisexual man believed that they were at low risk for HIV. Nearly 80% of the women in our study who reported having had sex with a bisexual man were surveyed in Washington, DC. Women surveyed in our study in the 6 other HBCUs in 3 states in the southern United States were less likely to report having had sex with bisexual men in the past year, and at 1 HBCU, no women reported having had sex with a bisexual man. The variation in the prevalence of reported bisexual sex by men and women may reflect regional differences in disclosure of sexual behavior rather than variations in behaviors. Previous surveys of students at HBCUs have shown regional differences in sexual behavior. 27 A survey of 459 female African American students at 3 HBCUs and 3 predominantly white colleges showed that 75% of women asked potential sex partners about their sexual history, but only 48% asked potential sex partners about a history of bisexual behavior. 28 Men who do not disclose that they have male sex partners are at risk for HIV transmission and acquisition. 29,30 Disclosing male-male sex to female partners is important because it allows both men and women to make more informed decisions about risks and actions to reduce the risk of HIV transmission and acquisition. In addition, because disclosure of malemale sex may not occur, interventions that focus on consistent condom use, rather than risk-based condom use, are needed. Women who reported having both male and female sex partners were more likely to report having sex with bisexual men. Previous surveys of young women who had both male and female sex partners have shown that they were more likely to report having sex at an earlier age, an increased number of sex partners, selling sex, and illegal drug use. 31-33 Decisions about sex partner selection have implications for the riskiness of sex activity and for decisions that can be made to reduce the risk of HIV transmission. Sex partner selection may be affected by a number of factors, including perceptions about the scarcity of eligible male sex partners at HBCUs. 34 The lack of available male sex partners may negatively affect a woman s ability to negotiate safe-sex behaviors such as condom use or HIV testing. The nature of a person s emotional commitment to his or her sex partner may also affect the decision to use condoms. 35 Women who reported attending church regularly were also less likely to report having sex with bisexual men. This result may be explained by research showing that religiosity has increased communication with sex partners regarding HIV and other STDs, the use of condoms with sex partners, and the perception of risk for HIV infection. 36-38 Alternatively, homophobia and stigma in black churches may inhibit discussions of sexuality, including history of male-male sex, among women who attend church regularly. 39 The results of our analysis support the need to explore further the role of church attendance, religiosity, and spirituality in HIV prevention efforts. Although more than half of the respondents had been tested for HIV in the previous 12 months, women who had sex with a bisexual man were slightly less likely to have been tested. However, women who reported bisexual male partners were also slightly more likely to ask their partners to be tested for HIV. Nevertheless, 40% of our overall sample had not been tested for HIV in the past year, and 51% did not ask their last partner to be tested for HIV. Young black women should be encouraged to be tested, encourage their male partners to be tested, and acquire skills to negotiate sexual practices that protect both partners when the HIV status of either is unknown. 40 Our analysis focused on behaviors of black female college students at HBCUs. Black female high school students are more likely than other female students to report being currently sexually active, having 4 or more sex partners and having sex before age 13 years, indicating that there are opportunities for intervention before JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 102, NO. 12, DECEMBER 2010 1203

college to encourage safe sexual behaviors. 41 Prevention programs designed for young black women should provide awareness of HIV transmission and acquisition risks and encourage improved communication with all sex partners. Evidence-based behavioral interventions should be used to encourage delays in sexual activity, consistent condom use, mutually monogamous relationships, and improved sex partner communication. 42 Our survey is one of the largest studies of sexual risk behavior of students who attend an HBCU, and to our knowledge the first to compare differences between black women who report recent sex with a bisexual man with those who do not. Despite these strengths, there were several limitations to the analysis. The questionnaire did not capture information specific to sex with bisexual male partners, including the nature of the woman s relationship with the bisexual male partner (eg, spouse, main partner, or casual partner) or demographic or contextual factors (eg, condom use during sex, drug or alcohol use before or during sex, concurrent sex partners, prior knowledge of male partner s bisexual behavior). In addition, women in our survey may have only suspected that a male sex partner was bisexual. Moreover, some women who did not report having sex with a bisexual man may have been unaware that their male sex partner had sex with men. There also may be confounding due to differences in sexual risk behavior between women who knew that their male partner was bisexually active before having sex compared with women who discovered or suspected their partner was bisexual afterward. Finally, we did not use probabilitybased methods to recruit women and therefore our data are not generalizable to black women aged less than 30 years who attend an HBCU. Future research on black women and sex with bisexual males should be expanded to include women outside of HBCU settings, including nonstudents, and should capture more specific information regarding bisexual male partners. In March 2007, the CDC, along with public health partners and community leaders, announced the Heightened National Response to the HIV/AIDS Crisis among African Americans to reduce the toll of HIV/AIDS in African American communities. 43 The CDC has expanded its partnerships with academic institutions, other federal agencies, state and local health departments, and community-based organizations to enhance research, policy, prevention services, testing, and linkage to care for African Americans. HBCUs are in a position to play a pivotal role in the success of HIV prevention initiatives targeted to young African Americans. A collective response involving multiple sectors of society will be required to reduce HIV infections among African Americans in the United States. Understanding the dynamics of sexual partner selection, communication with sexual partners, and high-risk sexual behaviors among young African American women; and providing opportunities for HIV testing, diagnosis, and access to early treatment and prevention services are important to reducing the number of new infections in this population. REFERENCES 1. Centers for Disease Control and Prevention. Racial/ethnic disparities in diagnoses of HIV/AIDS 33 states, 2001-2005. MMWR Morb Mortal Wkly Rep. 2007;56(9):189-193. 2. Centers for Disease Control and Prevention. HIV Prevalence Estimates United States, 2006. MMWR Morb Mortal Wkly Rep. 2008;57(39):1073-1076. 3. McQuillan GM, Kruszon-Moran D, Kottiri BJ, et al. 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