References
1. Montgomery JP,
Mokotoff ED, Gentry
AC, et al. The extent
of bisexual behavior
in HIV-infected men
and implications for
transmission to their
female sex partners.
AIDS Care. 2003;
15(6): 829–837.
2. Buehler JW, Diaz T,
Hersch BS, et al. The
Supplement to HIV-AIDS
Surveillance Project: An
approach for monitoring
HIV risk behaviors.
Public Health Report.
1996; 111(Suppl. 1):
133–137.
3. Centers for Disease
Control and Prevention
(CDC). HIV/AIDS
Surveillance Report.
1999; 11(2).
4. Harrison PF, Rosenberg
Z, Bowcut J. Topical
microbicides for
disease prevention:
Status and challenges.
Clinical Infectious
Diseases. 2003;
36(15): 1290–1294.
5. Microbicides: A new
weapon against HIV.
American Foundation
of AIDS Research. 2000;
http://www.amfar.org/binary-data/AMFAR_PUBLICATION/
download_file/9.pdf .
6. N-9 call and
resources. Global Campaign
for Microbicides.
2002; http://www.global-
campaign.org .

Authors
Eve Mokotoff, MPH is
the HIV/AIDS Epidemiology
Manager at the
Michigan Department
of Community Health.
Loretta Davis-Satterla,
MSA is the Director of
the Division of HIV/
AIDS-STD at the Michigan
Department of
Community Health.
References

In the Black and Hispanic communities in the United States, there is a significant proportion of men who have sex with both men and women but who do not tell their female partners about their bisexual behavior. Much has been written recently about this group of men, their HIV related risks, and the failure of gay-focused and heterosexually focused prevention interventions to reach them. But little has been said about the risks their female partners face. This article reviews a recent U.S. study on this topic.1

Survey of HIV-Positive People

Researchers from the MDCH and the CDC analyzed supplemental HIV/AIDS surveillance data collected between January 1, 1995 and June 30, 2000.2 Health department staff from 12 sites across the country—Arizona, Colorado, Connecticut, Delaware, Florida, Georgia, New Jersey, New Mexico, South Carolina, Washington, and Los Angeles interviewed HIV-positive people who were reported to the public health department.

Among the interview questions were: “Have you had sex with a man in the last five years?” and “Have you had sex with a woman in the last five years?” Answers given by the 5,156 male respondents were stratified by race and ethnicity and used to assign men to one of two mutually exclusive behavioral groups: men who have sex with men only or men who have sex with both men and women.

The study also examined self-reported sexual behavior among women who reported that they had sex with a man in the last five years. These women were asked “Have you had sex with a bisexual man in the last five years?” This information was stratified by race and ethnicity and measured the extent to which women were aware of bisexual identity or behavior in male partners. These women were not the matched sex partners of HIV-infected behaviorally bisexual men. Among 3,139 interviewed women, 240 reported having sex with a bisexual man.

Partner Knowledge of Male Bisexual Behavior

The study found that the proportion of HIV-positive men who have sex with men who also reported having sex with women in the previous five years varied by race and ethnicity: 34 percent among Black respondents, 26 percent among Hispanic respondents, and 13 percent among White respondents. These racial and ethnic differences, which were statistically significant, are consistent with previous studies measuring the prevalence of bisexual behavior among HIV positive men who have sex with men.

The proportion of women who contracted HIV through heterosexual sex and who knew that one or more of their male sex partners were behaviorally bisexual also varied by race and ethnicity: Black and Hispanic women were statistically significantly less likely (6 percent each) than White women (14 percent) to be aware that their partners were bisexually active. Again, the published literature is consistent with these findings. The study did not measure the proportion of HIV transmission that occurs between bisexually active HIV-positive men and their female sex partners, but the study’s data suggest that it may be greater than the small proportion reported in the Centers for Disease Control and Prevention’s HIV/AIDS surveillance statistics.3

This suggests that more men, particularly men of color, are behaviorally bisexual than disclose this fact to their female partners, leaving female partners with incomplete information on which to base their risk reduction decisions.

Microbicides: Protection Against Nondisclosure

These findings underscore the urgent need to develop female-controlled methods of HIV prevention, methods that do not require women to acknowledge the use of HIV protection to their sexual partners. A number of societal norms come into play to prevent open and honest communication on this topic. Societal scorn about homosexuality and bisexuality on the part of both men and women make it a difficult topic to discuss. Many women may still hold to the myths that a “manly man” could not possibly be having sex with other men, or that a woman would somehow know if her man also desired other men. Even in the best of circumstances, issues of trust, betrayal, responsibility, and gender roles make this a difficult topic for couples to discuss, especially within the context of a long-term relationship.

While waiting for society to become more accepting of same sex relationships, prevention providers need to give heterosexually active women tools to protect themselves. Topical microbicides are often cited as a solution. Microbicides, several of which are in development, can be applied in the vagina or the rectum and may not be apparent to sexual partners.4 Some microbicides have anti-microbial activity that does not kill sperm, making them appropriate for the broadest population of women, including those who may want to get pregnant while preventing HIV transmission. In these ways, microbicides have distinct advantages over both the male and female condoms. They have the potential to decrease both male-to female and male-to-male HIV transmission.

Although several microbicides are in various stages of development, many barriers impede their widespread use.4,5 Experience with nonoxynol-9 underscores the need for thorough testing. Although nonoxynol-9 demonstrated in-vitro anti-HIV activity, clinical trials showed that prolonged use was associated with lesions and epithelial disruption, actually increasing the risk of HIV transmission.6 There has been minimal financial support, either through the government or pharmaceutical companies, to advance microbicide research. Additionally, clinical trials that are deemed ethical, safe, and which have measurable outcomes are a challenge to structure.

Conclusion

While the data from this study suggest that the lack of disclosure about homosexual behavior may increase the risk of HIV transmission to heterosexual partners, it is crucial that behaviorally bisexual men, particularly those in the Black and Hispanic communities, not be vilified for their secrecy. Until society accepts the full range of human sexuality as normal, many people will not disclose this behavior. Where do we start to change the cultural norm that views same-sex behavior as deviant? Everywhere and anywhere. In conversations with our children and the attitudes we pass on to them. In conversations with friends. In our houses of worship, where so many turn for support. We must all make efforts to promote more open discussions of sexuality and sexual orientation in all of our communities.