Is the experience of hunger associated with risk of engaging in condomless anal sex among minority young men who have sex with men?

Abstract

Although emerging evidence suggests that hunger may be a risk factor for engaging in risk behaviors that lead to HIV acquisition, this has rarely been explored for young minority men who have sex with men (YMSM). This study explored a range of sexual risk behaviors for associations with a measure of hunger, assessed among 448 YMSM residing in Los Angeles, CA. Forty-five percent experienced hunger (past 12 months). Hunger was significantly associated with engaging in any condomless anal receptive sex (CARS) (adjusted odds ratio = 1.74; 95% confidence interval = 1.01–3.01; P = .049). Further, hunger was also significantly associated with a greater percentage of CARS (Beta = .12; t = 2.18; P = .03). Parallel effects were not observed relative to condomless anal insertive sex. Findings suggest that the experience of hunger among young minority MSM is generally not associated with a milieu of sexual risk. One important exception is that hunger may lead to having CARS. This suggests a potential ‘trade off’ for receptive partners experiencing hunger and partially supports the idea that at hunger may predispose minority YMSM to partner demands not to use condoms.

Keywords

HIV infections food security hunger sexual risk

Introduction

Broadly, nationally representative evidence suggests that food insecurity is causally related to a host of negative health outcomes such as diabetes, heart disease, hypertension, and mental illness.¹ Hunger is a specific form of food insecurity, one that has a focus on the experience of ongoing lack of food as opposed to ample food of very poor quality.² Hunger has been associated with chronic disease and psychological distress.^1,3,4 Further, hunger has been associated with poor adherence to antiretroviral medications among persons living with HIV, including young men who have sex with men (YMSM).^2,5–8

Emerging evidence suggests that hunger may be a risk factor for engaging in behaviors that lead to HIV acquisition.^9–11 Given disproportionate burden of HIV experienced by minority YMSM, and the corresponding prioritization of this population for intervention research, it becomes important for initial studies to focus on Black and Hispanic YMSM. To the extent that hunger may influence risk of HIV acquisition among people in this priority population, study findings may provide valuable insights pertaining to policy and practice regarding food security.

To the best of our knowledge, only one study investigation on hunger and HIV risk has been conducted among minority YMSM. A recent study of Black YMSM found that a single-item measure of hunger was associated with a broad range of sexual risk behaviors, including concurrent sex partners, serosorting as a prevention alternative, and testing positive at the time of being surveyed for chlamydia/gonorrhea.¹¹ The last of these findings was not supported by a corresponding increase in either condomless anal receptive sex (CARS) or condomless anal insertive sex (CAIS), thus leaving open the question of whether condomless sex is more likely among young Black MSM recently experiencing hunger. The question is important because resolving hunger is clearly within the realm of public health intervention efforts. If hunger is ultimately demonstrated as a causal factor in condomless anal sex among young minority MSM not living with HIV, then a reasonable prevention option is to provide adequate access to food, as is currently a common practice for people living with HIV.^12–14

Two plausible explanations for associations between hunger and sexual risk behaviors among HIV-uninfected minority MSM exist. First, it is possible that hunger is a part of a larger social milieu characterized by poverty, discrimination, and unmet needs – with this milieu not having social norms prioritizing safer sex. Second, it is possible that hunger simply places some MSM at-risk of acquiescing to partner-based demands to forego condom use. Of note, this second possibility would not imply a general increase in risky sexual behaviors (e.g. accumulating more partners, exchanging sex for drugs, money, etc.). Accordingly, the purpose of the study was to test a range of sexual risk behaviors for associations with a measure of hunger, assessed among a sample of minority MSM residing in Los Angeles, California, USA.

Methods

Population studied

Data were from an ongoing study conducted with a cohort of 448 Black and Latino YMSM. The study recruited YMSM in Los Angeles, CA, using both venue-based and social media recruitment strategies. Young men were eligible to participate if they: (1) were 16–24 years old; (2) were assigned a male sex at birth; (3) self-identified as gay, bisexual, or uncertain about their sexual orientation; (4) reported a sexual encounter with a man within the previous 12 months; (5) self-identified as Black/African American, Latino, or multiethnic/racial; and (6) lived in Los Angeles or a surrounding county, with no expectation of moving outside this area for at least six months. The recruitment strategy resulted in a geographically dispersed cohort recruited from throughout Los Angeles County. Recruitment strategies followed methods used in previous studies conducted by the Los Angeles-based research team.^15–17

This study was reviewed and approved by Children’s Hospital Los Angeles’ Institutional Review Board (IRB# 14-00279). All participants were identified, screened for eligibility, and if eligible, invited to participate in the study. They also provided written informed consent during a face-to-face consenting session.

Measures

The study used a six-month recall period. Nine outcome measures were assessed, with four of these capturing condomless anal sex: (1) any CARS, (2) any CAIS, (3) the percent of anal receptive sex not including condom use, and (4) the percent of anal insertive sex not including condom use. Three outcomes pertained to exchanging sex: (1) exchange for drugs, (2) exchange for money, and (3) not exchanging sex for anything. Two outcomes pertained to the number of male partners: (1) number of partners when the study participant was a receptive partner and (2) number of partners when the study participant was an insertive partner.

Adapting questionnaire items from the U.S. Census Bureau,¹⁸ the measure of recently experiencing hunger was arrived at by using a 4-item index. Items were prefaced by the statement ‘In the past 12 months…’ and were worded as follows: (1) … did you ever eat less than you felt you should due to lack of money?, (2) … the food I bought just did not last because I didn’t have money to get more, (3) … were you ever hungry but did not eat due to lack of money, and (4) … did you or others adults in your household ever eat less or skip meals due to lack of money. This index was used to fully ascertain a complete absence of hunger among those answering no to each of the questions; the remainder were classified as recently experiencing hunger.

Finally, based on previous studies, two possible covariates were selected: (1) recently having penile–vaginal sex (PVS) (past six months) and (2) identification as Black/African American. The former covariate was selected based on evidence that minority MSM having sex with females may take fewer sexual risks with males.¹⁹ The latter was based on overwhelming evidence demonstrating extremities of HIV risk for Black YMSM.²⁰

Data analysis

First, bivariate associations between the two selected covariates and the study measures were conducted. Next, bivariate associations between the dichotomously assessed outcomes and the measure of hunger were assessed using Chi square tests, with t-tests being used for the outcomes assessed on a continuous level. A series of regression models (logistic regression for the dichotomous outcomes and linear regression for the continuous outcomes) assessed the strength of associations between hunger and each outcome, in the presence of the two selected covariates. Significance for the model was defined by a P-value of <.05.

Of note, although age was significantly associated with both CARS and with CAIS, the role of age in safer sex among YMSM is well established in the literature thus prompting us not to include age in the models, as doing so overwhelms the models and thus masks important information about hunger. For interested readers, the mean age among those not reporting CARS was 21.2 years versus 21.8 years among those reporting CARS, (t = 2.19, P = .03), and the mean age among those not reporting CAIS was 21.3 years versus 21.8 years among those reporting CAIS, (t = 1.80, P = .03).

Results

Characteristics of the sample

The mean age of the sample was 21.7 years (sd = 2.00). Table 1 presents a summary of descriptive information for the sample of 448 YMSM. As shown, one-third had not received education beyond the level of high school. This, however, is a function of age – among those 18 years of age or younger, 25.6% had not yet completed high school; however, among those older than 18 only 24% reported not completing high school. Noteworthy is that the majority of the sample identified as Hispanic, and that very few (7%) reported PVS. Most noteworthy is that 45% were classified as experiencing hunger.

Table 1.

Characteristics of the sample.

Characteristic	Percent
Did not complete education past high school	33
Current employment	67
Currently attending school	48
Identification as Hispanic	59
Identification as Black	21
Identification as mixed race	20
Had penile–vaginal sex at least once, past six months	7
Classified as currently experiencing hunger	45

Bivariate screening of covariates

To begin, screening tests of the two potential covariates (recent PVS and Black race) were conducted regarding the measure of hunger, CARS, and CAIS. The purpose of these tests was to determine which of two covariates (if either) should be entered as covariates into the regression models. Of these six screening tests (see Table 2), four produced P-values meeting the screening criterion of <.25. First, among those not reporting PVS, 85.9% reported CARS versus 73.3% among those indicating PVS. Similarly, among those not reporting PVS, 82.3% reported CAIS versus 73.2% among those indicating PVS. Further, of those identifying as Black, CAIS was reported by 86.0% versus 79.9% among those not making this identification. Finally, of those identifying as Black, 55.0% experienced hunger versus 44.1% among those not identifying as Black.

Table 2.

Bivariate associations of tested covariates.

Tested covariate	Percent
Condomless anal receptive sex
… among those not reporting any penile–vaginal sex	85.9^a
… among those reporting penile–vaginal sex	73.3
… among those not self-identifying as Black	51.7
… among those self-identifying as Black	48.4
Condomless anal insertive sex
… among those not reporting any penile–vaginal sex	82.3^b
… among those reporting penile–vaginal sex	73.2
… among those not self-identifying as Black	79.9
… among those self-identifying as Black	86.0^c
Classified as experiencing hunger
… among those not reporting any penile–vaginal sex	44.7
… among those reporting penile–vaginal sex	50.0
… among those not self-identifying as Black	44.1
… among those self-identifying as Black	55.0^d

^aThis value was greater than the compared value of 73.3, at the screening level of .06.

^bThis value was greater than the compared value of 73.2, at the screening level of .22.

^cThis value was greater than the compared value of 79.9, at the screening level of .13.

^dThis value was greater than the compared value of 44.1, at the screening level of .007.

Bivariate associations

Table 3 presents the bivariate association between hunger and the outcomes assessed at a dichotomous level. As shown, only CARS and not exchanging sex for money, drugs, etc. approached, but did not obtain, significance. Table 3 also presents the bivariate association between hunger and the outcomes assessed at a continuous level. As shown, only the percent of CARS obtained significance.

Table 3.

Bivariate associations between food insecurity and selected outcomes, over a six-month recall period (N = 488).

Dichotomous outcomes	Percent of secure	Percent of insecure	P-value
Any condomless anal receptive sex, past six months	82.1	88.6	.055
Any condomless anal insertive sex, past six months	80.1	83.7	.33
Exchanged sex for money	11.8	16.3	.16
Exchanged sex for drugs	2.8	6.4	.07
Did not engage in any form of sexual exchange	87.0	80.2	.051
Continuous outcomes	Mean FS^a	Mean FI^b	t	P
Percent condom use as an anal receptive partner^a	60.84	52.09	1.98	.048
Percent condom use as an anal insertive partner^b	56.22	54.32	.42	.67
Number of male partners for anal receptive sex	26.91	36.62	.61	.54
Number of male partners for anal insertive sex	27.54	36.89	.59	.56

FI: food insecure; FS: food secure.

^aAmong 325 men reporting any anal receptive sex.

^bAmong 334 men reporting any anal insertive sex with males.

Regression model findings

Table 4 presents findings from the binary logistic regression models. As shown, CARS was the only significant outcome associated with hunger, with the odds being 1.74 times greater (95% confidence interval = 1.01–3.01) for persons classified as experiencing hunger. However, it is well worth noting that persons experiencing hunger were marginally less likely to report an absence of exchanging sex for other things, such as money and drugs.

Table 4.

Logistic regression models findings for selected outcomes of hunger.

Binary outcomes	AOR	95% CI	P
Condomless anal receptive sex^a	1.74	1.01–3.01	.049
Condomless anal insertive sex^b	1.23	.75–2.02	.41
Exchanged sex for drugs^c	2.28	.89–5.88	.09
Exchanged sex for money^d	1.41	.83–2.44	.21
Did not exchange sex for anything^e	.61	.37–1.01	.06
Continuous outcomes	Beta value	t	P
Percent of anal receptive sex without condoms^f	.12	2.18	.03
Percent of insertive sex without condoms^g	.03	.55	.58
Number of partners during receptive sex^h	.019	.41	.68
Number of partners during insertive sexⁱ	.02	.37	.71

AOR: adjusted odds ratio; CI: confidence interval.

^aPVS yielded a P-value of .06; Black/African American identity yielded a P-value of .85.

^bPVS yielded a P-value of .22; Black/African American identity yielded a P-value of .16.

^cPVS could not be calculated due to an empty cell; Black/African American identity yielded a P-value of .76.

^dPVS yielded a P-value of .43; Black/African American identity yielded a P-value of .66.

^ePVS yielded a P-value of .58; Black/African American identity yielded a P-value of .90.

^fAmong 324 men having any anal receptive sex in the past six months, P-values for any PVS and identification as Black/African American were .08, and .33, respectively.

^gAmong 335 men having any anal insertive sex in the past six months, P-values for any PVS and identification as Black/African American were .08, and .65, respectively.

^hAmong 324 men having any anal receptive sex in the past six months, P-values for any PVS and identification as Black/African American were .19, and .21, respectively.

ⁱAmong 335 men having any anal insertive sex in the past six months, P-values for any PVS and identification as Black/African American were .16, and .29, respectively.

Table 4 also presents the findings from the linear regression models. As shown, only the percent of condom use for anal receptive sex was significantly associated with experiencing hunger.

Discussion

The weight of evidence clearly indicates that the experience of hunger among this sample of minority YMSM is generally not associated with a milieu of sexual risk behaviors. This is contrary to the few past studies that exist.^9–11 One important exception, however, was that those experiencing hunger were significantly more likely to report CARS (either any CARS or a greater percent of CARS). A previous study by Mena et al.¹¹ found that a single-item measure of food insecurity was also significantly associated with CARS, thus the current study collaborates this finding by the use of index measure of hunger. This single significant finding in the current study is important because CARS is the most important of all the possible sexual risk behaviors for the acquisition of HIV,²¹ as well as rectally-acquired sexually transmitted infections such a gonorrhea and chlamydia.^22,23 Thus, the study findings partially support the possibility that hunger may predispose minority YMSM to partner demands not to use condoms. If this were the case it would be quite consistent with the previously articulated case that persons experiencing hunger engage in ‘trade offs’ as part of their overall coping strategy.²⁴ In this case, the trade off may have been sacrificing the safety and psychological security of asking insertive partners to use condoms in favor of the sexual pleasures provided by barebacking or as a possible method of ‘keeping’ the partner as a source of dating/hooking up and the customary meals that often occur as part of some sexual interludes. Also, it is plausible that very act of ‘asking an insertive partner’ about condom use is one that requires a great deal of comfort relative to being out, and thus a minimal level of internalized homophobia. That this ‘asking’ may be sacrificed under the assumption of a trade off could therefore be more likely for young Black MSM compared to young White MSM if the often stated hypothesis about Black MSM having greater levels of internalized homophobia^25–29 is true. Whether this dynamic occurred among the YMSM in our study cannot be determined; qualitative studies are needed to investigate this possibility. Also, whether such trade offs are a form of exchange for food was not a testable hypothesis, as that specific form of exchange for sex was, unfortunately, not assessed. It is known from this study, however, that hunger was marginally associated with sexual exchange in that those classified as experiencing hunger were about 50% less likely to indicate not making sexual exchanges in the past six months.

Moreover, the two null findings regarding CAIS are noteworthy in that hunger had no discernible effect on condom use behaviors for men who were insertive partners. These null findings provide support for the ‘trade off hypothesis’ over the idea of a larger sexual milieu.

Several observations from the descriptive and null findings warrant attention. First, that ∼45% of the sample had recently experienced hunger is an important finding given that national estimates of hunger prevalence are ∼13%.¹⁸ However, we wish to note that one other national estimate appears to be much higher than 13%; this is a national estimate of adult men which yielded a point estimate of 22.3%.³⁰ Of course, great variation in local estimates is also likely. For instance, a recent study of San Francisco, CA youth living with HIV found that recent hunger was experienced by 36.3%.³¹ Clearly, however (regardless of the comparison) hunger was disproportionately common in this sample of minority MSM. Second, the number of male partners in the past six months was equally high regardless of hunger. This suggests that hunger is not a driver of seeking and/or accepting new male sex partners. The converse is also true in that men without hunger issues, who presumably have more money for going out to clubs etc., were no more likely to acquire new partners than those presumably having less discretionary money. Third, hunger was not associated with exchanging sex for money. This is intriguing as such an exchange would be a quick way to purchase food. One plausible explanation is that food may be an implied aspect of sexual hook-ups, dates, etc. Yet, as noted, those who experienced hunger acquired no fewer partners than those not with this recent experience. Finally, and perhaps most important, is that findings relative to CAIS were not significant. This suggests that ‘tops’ find a way to acquire condoms even if they are unable to purchase enough food to avoid hunger. This may speak to widespread availability of free and convenient access to condoms throughout the Los Angeles area.

Limitations

The measure of hunger was designed to ascertain that those not experiencing hunger were indeed classified as such; whether any misclassification bias occurred for those classified as experiencing hunger cannot be determined. Further, findings are limited by the accuracy and validity of the self-reported outcome data. It must also be noted that potentially important analytic covariates were not assessed, and that the relatively small sample size may have imposed statistical power issues. Also, several measurement-related limitations apply. Finally, the majority of our sample identified as non-Hispanic Black, thus the findings may not generalize to other racial/ethnic populations of YMSM.

Conclusion

Findings from this exploratory study provide initial evidence suggesting that the experience of hunger among young minority MSM may be a predisposing factor to engaging in CARS, but not CAIS. This seeming paradox supports the concept of receptive partners potentially sacrificing safety for pleasure and/or meals that may be part of the immediate sexual experience.

Footnotes

Acknowledgements

The authors would like to acknowledge the contributions of the many staff members who contributed to collection, management, analysis, and review of this data: James Aboyage, Ifedayo Akinyemi, MPH, Alex Aldana, Alicia Bolton, PhD, Wendy Hawkins, Ali Johnson, Lily Negash, MPH, Nicole Pereia, Yolo Akili Robinson, Aracely Rodriguez, Maral Shahanian, Choo Phei Wei, MS. The authors would also like to acknowledge the insightful and practical commentary of the members of The Community Advisory Board: Joaquin Gutierrez, Altamed Health Services, Daniel Nguyen, Asian Pacific AIDS Intervention Team, Ivan Daniels III, Los Angeles Black Pride, Steven Campos and Davon Crenshaw, AIDS Project Los Angeles, Andre Mollette, LA Gay and Lesbian Center, Miguel Martinez, Division of Adolescent Medicine, CHLA, Greg Wilson, Reach LA, and Jesse Medina, The LGBTQ Center Long Beach.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support for the original research was provided by a grant from the National Institute on Drug Abuse of the National Institutes of Health (U01DA036926). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

ORCID iD

Richard A Crosby

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