Understanding Consistent Condom Use Among Homeless Men Who Have Sex With Women and Who Engage in Multiple Sexual Partnerships: A Path Analysis
Purpose: Homeless persons are at heightened risk of STI and HIV transmission. HIV risk behavior among homeless men who have sex with women (MSW) and who engage in multiple partnerships has been understudied, exposing both men and their female partners to higher risk of acquiring and transmitting HIV. An improved understanding of sexual risk in this population will enhance HIV prevention among homeless men and their female partners. Informed by Social Cognitive Theory, this study aims to explore the pathways to consistent condom use in homeless MSW who have multiple sexual partners. Specifically, we hypothesize that, for homeless MSW who engage in multiple sexual partnerships, condom efficacy will serve as the intervening mechanism through which condom attitudes, social network characteristics, and personal mental health status will have influence on consistent condom use.
Method: A probability sample of 182 homeless adult MSW who engaged in multiple sex partnering was interviewed in Los Angeles. Data were collected through computer-assisted face-to-face structured interviews with men. Consistent condom use is defined as “always use a condom during sexual intercourse in the past six months”. Egocentric social network data were gathered by asking each participant to nominate 20 members with whom they had contact in the past six months. We focus on member HIV risk-related behaviors. Chi-square or T-Tests were conducted to investigate bivariate associations of independent variables with condom efficacy (hypothesized intervening mechanism) and consistent condom use. A justified recursive path analysis was then conducted to investigate the hypothesized model controlling for the other variables’ influence on condom efficacy and the outcome simultaneously.
Result: Inconsistent condom use among the homeless MSW was highly prevalent; over two-thirds of the participants reported inconsistent condom use. In the final path model, condom efficacy and having more members who talk about HIV prevention had direct positive effects on consistent condom use (β=0.630; p<0.001; β=0.051; p=0.006, respectively). Negative condom attitudes and depression had indirect effects on consistent condom use through condom efficacy (β=-0.199; p=0.005; β=-0.156; p=0.029, respectively).
Implication: The results suggest that condom efficacy is a critical intervening mechanism in consistent condom use for MSW who engage in multiple partnering. Currently, there are no evidence-based HIV prevention interventions targeting homeless MSW in the study area. Future intervention development should identify and adopt HIV prevention interventions that include promoting condom efficacy as a critical focus for homeless MSW. The protective effect of having peers who talk about HIV prevention also suggests the potential application of network-based HIV interventions in this population. Considering high utilization of shelter services, staff at shelter settings can serve as network members facilitating HIV prevention.