July 13, 2004 -- Men who have sex with men and women are a "significant bridge for HIV to women," the CDC's new data suggest.
The findings come in a presentation to the XV International AIDS Conference in Bangkok by CDC researcher Linda Valleroy, PhD. The CDC's Young Men's Survey shows that about one in 10 men reporting sex with men also has sex with women. And more than one in four of these bisexual men has unsafe sex with both kinds of partners.
"Men who also had sex with women had similar levels of HIV and STDs [as exclusively homosexual men] and higher levels of many risk behaviors," Valleroy and colleagues note in their presentation abstract.
Another study presented at the AIDS conference -- based on interviews with nearly 2,500 bisexual men by the San Francisco Department of Health -- shows that 14% of men who have sex with men also has sex with women. But the study, led by Willi McFarland, MD, PhD, suggests that these men may have fewer risk behaviors than exclusively homosexual men.
"In San Francisco a few years back, we detected this rise in risk behavior in men who have sex with men," McFarland tells WebMD. "That raises the question of whether this will spill over into the general population, with the bridge being men who have sex with men and women. Despite dire predictions, San Francisco does not have a large heterosexual HIV epidemic."
What's going on? The reality is that nobody really knows.
The Down Low: Not Just Black Men
Black men call it the DL: the down low. Fearing loss of community support, men living this lifestyle keep their bisexuality -- and their sexual relationships with other men -- secret from their female partners.
Whether they call it the DL or not, many white and Latino men also keep their sexual affairs with men secret from their female sex partners.
"Most people believe this is only something happening with black men," CDC scientist Greg Millet, MPH, tells WebMD. "We see it in Latino and white men, too. They say they are heterosexual but report sex with other men in the last three months, in the last year, in the last five years. Sexual identity is not destiny."
John Peterson, PhD, professor of psychology at Atlanta's Georgia State University, has studied the issue for a long time.
"The DL is a new name for an old issue," Peterson tells WebMD. "Bisexual men not telling their female partners about their male relationships takes place across all races and ethnicities. But what we really don't know is how these men behave when they have primary male or female partners."
Sex, Risky Sex, and Very Risky Sex
What is known about bisexual men suggests that those who have long-term relationships with women may have different HIV risks than those who do not.
"In previous studies, those with mainly female partners engaged in far fewer sex behaviors with men than men with no female partners," Millet says. "So we have to be careful about how we characterize these men. The little data we have is that is not the case -- they don't have the same risks."
Secret affairs put the unwary partner at risk of HIV and STDs. But there are different levels of risk. Not all sex behaviors carry the same risk of spreading HIV, says Joseph P. Stokes, PhD, professor emeritus at the University of Illinois in Chicago. Stokes is well known for his studies of bisexual men.
"We found a long time ago that two-thirds of the time, the female was not aware of the extracurricular sex the behaviorally bisexual man was doing," Stokes tells WebMD. "But it is a stretch to say this always puts the women at risk of HIV infection."
Stokes says not all bisexual men engage in high-risk sex with both their male and female partners.
"We have to ask what kind of sex are these men having, or to what risk factors are they exposing their partners?" he says. "Are they doing unprotected anal and vaginal sex? There's little reliable information, but I doubt that this is common. Most of these guys aren't having receptive anal sex with a man and insertive vaginal sex with a woman. The degree to which they engage in anal sex with men isn't known, but with a lot of these guys, when there is anal sex, it is insertive, and probably safer than receptive anal intercourse."
The trouble with this information is that it's not definitive. And it's not comforting either to women or to health professionals working in AIDS and STD prevention.
New Studies, New Ideas, New Generation
The problem is that too little is known. Men who have sex with men and women may see themselves as bisexual, as heterosexual, or as homosexual. Black and Latino men face particular stigma from their communities if they admit to having sex with other men. This makes it difficult to reach them with HIV/STD prevention messages -- and to study them.
"The perfect study would be one just done with heterosexual-identified black men, on a large scale, where the premise is not just HIV or STDs but black men's health in general," Millet says. "It would look at diabetes testing and cancer: HIV would be just one component. A study like that would be far less threatening to men not identified as gay. There's a lot of interest in a study like this to reach non-gay men who have sex with men."
Meanwhile, people like Raymond Perez are working with bisexual men who don't see themselves as gay. Perez is assistant director of the counseling and support center at the Michael Palm Center for AIDS Care in New York.
"What we assume is these people exist everywhere you go," Perez tells WebMD. "In all walks of society men who have sex with men are rearing children; they are weightlifting; they are tough guys."
When these men get HIV infection, Perez is there. They tell him that it is their shame and fear of stigma that drives them to secrecy. Support is the key.
"When you create a private and comfortable space for people, they can address the underlying issues that put them and their loved ones at risk," he says. "If you can build trust and confidence, men come in here. Providing those opportunities for people in a nonjudgmental and supportive way, that is very important."