Safer sex decision-making among men with haemophilia and HIV and their female partners

An exploratory qualitative study of adult heterosexual men with haemophilia and HIV and women who were their sexual partners was conducted as formative research to better understand cognitive factors involved in behavioural intentions and practices which comprise HIV risk-reduction for sexual transmission. The study sought to generate hypotheses, uncover themes, and develop a broad perspective on possible determinants of behaviours related to HIV transmission risk reduction. Qualitative analysis of these data served as a basis for developing a subsequent quantitative, hypothesis-testing survey and an intervention. Face-to-face interviews were conducted with 23 single men and 28 married men with haemophilia and HIV infection, and 28 married women partners selected through stratified, purposeful sampling. The interviews identified beliefs, attitudes, and values underlying decisions regarding target behaviours related to preventing sexual transmission of HIV, including (1) using condoms consistently during vaginal intercourse and (2) talking to partners about risk reduction. The interviews elicited information about perceived advantages and disadvantages of performing each of the targeted behaviours, and factors that facilitate or prevent performing them. Qualitative analysis of coded responses yielded important themes regarding how choices are made about sexual activity and safer sex. Most notably, communication between partners (1) plays a direct, key role in facilitating condom use and (2) forms the basis for maintaining emotional intimacy in these relationships. The link between condom use and communicating about safer sex was viewed as pivotal in achieving HIV prevention for individuals in serodiscordant couples. Recommendations for risk reduction intervention development are discussed.     

Understanding Heterosexual Condom Use among Homeless Men

This study uses an event-based approach to examine individual, relationship, and contextual correlates of heterosexual condom use among homeless men. Structured interviews were conducted with a predominantly African American sample of 305 men recruited from meal lines in the Skid Row area of Los Angeles. Men reported on their most recent heterosexual event involving vaginal or anal intercourse. Adjusting for demographic characteristics only, condom use was more likely when men had higher condom use self-efficacy, greater HIV knowledge, or talked to their partner about condoms prior to sex. Condom use was less likely when men held more negative attitudes towards condoms, the partner was considered to be a primary/serious partner, hard drug use preceded sex, or sex occurred in a public setting. Condom attitudes, self-efficacy, partner type, and communication were the strongest predictors of condom use in a multivariate model that included all of the above-mentioned factors. Associations of unprotected sex with hard drug use prior to sex and having sex in public settings could be accounted for by lower condom self-efficacy and/or less positive condom attitudes among men having sex under these conditions. Results suggest that it may be promising to adapt existing, evidence-based IMB interventions for delivery in non-traditional settings that are frequented by men experiencing homelessness to achieve HIV risk reduction and thus reduce a significant point of disparity for the largely African American population of homeless men.     

Sex partner support,drug use and sex risk among HIV-negative non-injecting heroin users

HIV prevention efforts among drug users have incorporated social support to reinforce risk reduction. We examine the extent to which sex partner characteristics, including partner support, influence HIV sex risk practices among a little studied population of non-injecting heroin users, 257 of whom were recruited in New York City between 1996 and 2001. The sample was racially/ethnically diverse (26% African American, 43% Latino, 31% white or other ethnicity) and 65% male. Three-quarters reported having unprotected intercourse within 30 days; 27% had sex with partners at known risk of being HIV infected. There were no gender differences in terms of sex or drug use practices; however, gender differences in sex partner characteristics were apparent. Men were significantly less likely than women to have partners who used drugs (OR = 0.5, 95% CI = 0.3, 0.9), receive support from their partners (OR = 0.5, 95% CI = 0.3, 0.8), use heroin with their partners (OR = 0.5, 95% CI = 0.3, 0.8) and have partners at known risk of being HIV infected (OR = 0.4, 95% CI = 0.2, 0.7). For men, increased sex risk was independently associated with sex partner support, and for women, increased sex risk was independently associated with having used heroin with sex partners. Social support may have detrimental, as well as beneficial, consequences on HIV risk.     

Sexual assault, sexual risks and gender attitudes in a community sample of South African men

Sexual assault against women and HIV infection are both prevalent and related social problems in South Africa. The current study examined hostile attitudes toward women, acceptance of violence against women and masculine ideological beliefs in relation to sexual assault history among men in a Cape Town township in South African. Men (n=435) completed anonymous surveys of sexual assault history, HIV risk history and gender-based attitudes. More than one in five men in this community sample reported that they had either threatened to use force or used force to gain sexual access to a woman in their lifetime. Men with a history of sexual assault were at significantly higher risk for HIV transmission than their non-sexually assaultive counterparts. Men with a history of sexual assault were also more likely to endorse hostile attitudes toward women and were more likely to accept violence against women, although these attitudes and beliefs were prevalent and pervasive across men with and without histories of sexual assault. These findings extend previous research to show that men who have a history of sexual assault also exhibit elevated risks for HIV infection and transmission. Interventions are needed to address hostile attitudes toward women, sexual assault and sexual risks for HIV among South African men.     

HIV testing is associated with increased knowledge and reductions in sexual risk behaviours among men in Cape Town,South Africa

HIV testing benefits those who test positive, allowing them to receive treatment, but the benefits for those who test negative remain controversial. We evaluated the impact of testing on HIV knowledge and sexual risk among men in South Africa. Men were recruited from townships outside Cape Town and completed a survey that assessed testing history, knowledge, and sexual behaviours. Among the 820 participants, 516 (63%) reported being tested (82% tested negative, 6% tested positive, and 12% unknown). Compared to those who had never been tested for HIV, men who tested for HIV were more knowledgeable about HIV transmission, but did not differ on sexual risk behaviour. Knowledge moderated the effect of testing on sexual risk such that men reported fewer sexual partners (incidence rate ratio (IRR) = 0.91, 95% CI = 0.84, 0.98) and fewer unprotected anal sex events (IRR = 0.81, 95% CI = 0.66, 1.00) if they had been tested for HIV and were knowledgeable about HIV transmission. For men testing HIV-negative, knowledge predicted fewer sexual risk behaviours. Previous HIV testing is associated with enhanced knowledge, which moderates sexual risk behaviour among South African men living in Cape Town. Results suggest that HIV testing may increase knowledge and lead to reductions in sexual risk even when results are negative.     

Gender attitudes, sexual power, HIV risk: a model for understanding HIV risk behavior of South African men

The Gender Attitudes-Power-Risk (GAPR) model of HIV risk behavior was tested using survey data collected from among 309 men who were attending STI services in a primary health care clinic in Cape Town, South Africa. Results showed that negative attitudes towards women were significantly positively associated with a high level of HIV risk behavior, and that endorsement of traditional male roles was negatively associated with HIV risk behavior. Endorsement of traditional male gender roles was also inversely related to relationship control but positively to a high degree of decision-making dominance in one's relationship. Sexual relationship power did not significantly mediate the relationships between gender attitudes and HIV risk behavior. A better understanding of gender roles and ideologies in combination with one's power in sexual relationships as they relate to HIV risk behavior among men could better inform future HIV prevention interventions.     

Partners of men with HIV infection and haemophilia: controlled investigation of factors associated with psychological morbidity.

The study was concerned with determining the prevalence of psychosocial problems in partners of men with haemophilia and HIV infection, and with identifying factors associated with psychological morbidity. Partners of 17 HIV positive and partners of 19 HIV negative men with haemophilia were assessed in a cross-sectional controlled investigation. Outcome measures included current psychological status and psychiatric history; coping and health beliefs; and social and sexual functioning. Partners of HIV positive men with haemophilia, the majority of whom were asymptomatic, were not found to suffer more psychological difficulties than the partners of HIV negative men with haemophilia. However, partners of haemophiliacs regardless of HIV status suffer from higher levels of psychological distress than comparable women in the community, and those with past psychiatric history and current social difficulties are particularly at risk. The sexual relationships of couples with HIV positive men were more adversely affected than those of HIV negative couples.     

HIV knowledge,disclosure and sexual risk among pregnant women and their partners in rural South Africa

Abstract

Partner involvement has been deemed fundamental for the prevention of mother-to-child transmission (PMTCT) of HIV, although it remains difficult to achieve. This study aimed to explore the attitudes and behaviours of pregnant women and their partners who participated in a behavioural risk reduction intervention in six community health centres in the Mpumalanga province of South Africa. Qualitative methods only were used in this study. Women and their partners took part in four gender-concordant groups that addressed HIV, PMTCT, disclosure of HIV status and safer sex practices. The results indicate that men value and understand the importance of being involved in women's reproductive health, although some components of the PMTCT programme such as condom use were still met with some resistance. Participants demonstrated high levels of HIV- and sexually transmitted infection-related knowledge. Men lacked knowledge about PMTCT but were interested in acquiring information so that they could support their partners. All groups highlighted the emotional and physical benefits of disclosing one's HIV status. The involvement of men in antenatal care has the potential to prevent women from becoming infected with HIV both during pregnancy and post-partum when they are more vulnerable to infection and have a high risk of transmission to the infant. There is a need for interventions that focus on both increasing male involvement and promoting condom use during pregnancy.     

HIV vaccine efficacy trial participation: men who have sex with men's experiences of risk reduction counselling and perceptions of risk behaviour change

Qualitative interviews were conducted with 35 men who have sex with men, enrolled in the world's first phase III HIV vaccine efficacy trial at five US sites, regarding their risk reduction counselling experiences and their perceptions of its impact on risk behaviour. Respondents ranged in age from 20 to 58 years and were predominately white (71.4%) in racial/ethnic origin. Systematic qualitative analysis revealed that a positive counselling experience meant having good rapport with clinic staff. Differences in attitudes toward counselling were related to either a personal approach of balancing an enjoyable sex life with safe sex behaviours (balancing risks) or accepting the consequences of risky sexual behaviour rather than making changes (risk homeostasis). Respondents seeking to balance risks indicated that they saw themselves engaging in safer sexual behaviour almost twice as often as in riskier behaviours. They perceived counselling and behavioural risk assessments to help increase their awareness of personal risk-taking behaviours. Conversely, those with a risk homeostasis approach reported that they had established sexual boundaries prior to trial participation that had thus far proven to be effective in avoiding HIV infection, and that they were comfortable with the level of risk taken. Thus, risk reduction counselling had little to no influence on their sexual practices. Some of these men also indicated that while they had not found the risk reduction information imparted to them by clinic staff to be novel, counselling was beneficial in reinforcing their HIV/AIDS and safe sex knowledge base.     

The influence of male circumcision for HIV prevention on sexual behaviour among traditionally circumcised men in Cape Town, South Africa

We examined the relationship between HIV prevention beliefs related to male circumcision and sexual behaviour/sexually transmitted infection (STI) acquisition among traditionally circumcised men in Cape Town, South Africa. HIV-negative men (n = 304), circumcised for cultural/religious reasons, attending a health clinic in Cape Town, South Africa, completed cross-sectional surveys. Generalized linear models were used to analyse the relationships between unprotected vaginal sex acts, number of female sexual partners, STI diagnoses and male circumcision-related beliefs and risk perceptions. Men who were aware that circumcision offers protection against HIV (relative risk [RR] = 1.19, 95% confidence interval [CI] = 1.06-1.32, P < 0.01), endorsed risk compensation related to male circumcision (RR = 1.15, 95% CI = 1.11-1.12, P < 0.01) and perceived lower risk of HIV infection when circumcised (RR = 1.08, 95% CI = 1.04-1.12, P < 0.01) were more likely to report unprotected vaginal sex acts. Similar patterns were also identified when predicting number of female sexual partners. Men who were more likely to endorse risk compensation related to male circumcision were also more likely to be diagnosed with a chronic STI (odds ratio [OR] = 1.64, 95% CI = 1.06-2.53, P < 0.05). Our findings suggest that we must not overlook the effects of beliefs towards male circumcision for HIV prevention among men traditionally circumcised; doing so may undermine current efforts to reduce HIV transmission through male circumcision.     

HIV Transmission Risk among HIV Seroconcordant and Serodiscordant Couples: Dyadic Processes of Partner Selection

Selecting sex partners of the same HIV status or serosorting is a sexual risk reduction strategy used by many men who have sex with men. However, the effectiveness of serosorting for protection against HIV is potentially limited. We sought to examine how men perceive the protective benefits of factors related to serosorting including beliefs about engaging in serosorting, sexual communication, and perceptions of risk for HIV. Participants were 94 HIV negative seroconcordant (same HIV status) couples, 20 HIV serodiscordant (discrepant HIV status) couples, and 13 HIV positive seroconcordant (same HIV status) couples recruited from a large gay pride festival in the southeastern US. To account for nonindependence found in the couple-level data, we used multilevel modeling which includes dyad in the analysis. Findings demonstrated that participants in seroconcordant relationships were more likely to believe that serosorting reduces concerns for condom use. HIV negative participants in seroconcordant relationships viewed themselves at relatively low risk for HIV transmission even though monogamy within relationships and HIV testing were infrequent. Dyadic analyses demonstrated that partners have a substantial effect on an individual’s beliefs and number of unprotected sex partners. We conclude that relationship partners are an important source of influence and, thus, intervening with partners is necessary to reduce HIV transmission risks.     

Stigma,Health Care Access,and HIV Knowledge Among Men Who Have Sex With Men in Malawi,Namibia, and Botswana

Same-sex practices are stigmatized in much of sub-Saharan Africa. Cross-sectional relationships between discrimination, access to and use of health care services, and HIV knowledge among men who have sex with men (MSM) were assessed in Malawi, Namibia, and Botswana. A survey and HIV screening were used to explore these variables and the prevalence of HIV. Overall, 19% of men screened positive for HIV infection. Ninety-three percent knew HIV is transmitted through anal sex with men, however, only 67% had ever received information of how to prevent this transmission. Few (17%) reported ever disclosing same sex practices to a health professional and 19% reported ever being afraid to seek health care. Men reported ever been denied health care services (5%) and 21% had ever been blackmailed because of their sexuality. Strong associations were observed between experiences of discrimination and fear of seeking health care services. Characterizing the relationship between stigma and health care seeking practices and attitudes can inform the development and implementation of HIV interventions for African MSM.     

Prospective Study of Attitudinal and Relationship Predictors of Sexual Risk in the Multicenter AIDS Cohort Study

We examined the influence of attitudes concerning HIV transmission, safe sex, and sexual sensation seeking, as well as negotiated risk reduction with primary partners, on the proportion of unprotected sexual partners (%UASP) among men who have sex with men (MSM). Participants were 263 HIV-seropositive and 238 HIV-seronegative MSM in the Multicenter AIDS Cohort Study between 1999 and 2003 who completed a 20-item attitude survey twice. Behavioral data were collected concurrently and 6–12 months after each survey. Among seropositives, decreased HIV concern and increased safer sex fatigue were associated with higher %UASP at 6 and 12 months. Among seronegatives, increased %UASP at 12 months was associated with safer sex fatigue. At 6 months and 12 months, risk reduction agreements were associated with increased %UASP among seronegatives in seroconcordant monogamous relationships, reflecting their abandonment of condoms in such partnerships. We conclude that HIV prevention efforts should target modifiable attitudes (reduced concern about HIV and safer sex fatigue) and increases in sexual risk-taking of MSM, particularly among HIV+ men having sex with serodiscordant partners.     

Communication about safer sex and serostatus disclosure in HIV-positive adolescents with haemophilia

Objectives . To assess the attitudes, beliefs and feelings of adolscents and young men with severe haemophilia with respect to discussing safer sex and disclosing their human immunodeficiency virus (HIV) seropositivity to potential sex partners.
Methods . Fifty-nine males with haemophilia from throughout the US answered open-ended questions.
Results . Talking about avoidance of transmitting AIDS and disclosing one's seropositivity was beneficial, moral and wise. Nevertheless, this was exceedingly, difficult, unpleasant, and fraught with fear of rejection and alienation. Communication was approved by family, friends, and health-care providers. Facilitators of communication were: knowledge and an accepting attitude about persons with HIV, a supportive person to assist with discussion, and environmental cues.
Conclusion . This first report of HIV-infected adolescents and young adults reveals that although they endorse discussing safer sex and disclosing their HIV seropositivity, they are painfully aware of the social and interpersonal risks of such extremely difficult communications.     

HIV risk and communication between regular partners in a cohort of HIV-negative gay men

This paper reports on the breaking of agreements between regular partners among HIV-negative gay men in Sydney. Data were from the 1333 men completing face-to-face interviews through December 2003 for the Health in Men (HIM) open cohort of HIV-negative gay men in Sydney.822 men had a primary regular partner during the six month period before their 2003 interview. Most of these men had entered into agreements with their partners about sex either with each other or with other partners (87.2%). They most commonly agreed not to use condoms with each other (50.6%). Regarding casual sex, they most commonly agreed to always use condoms (34.2%) or to have no sex with men outside their relationships (28.6%). 48.8% reported some discomfort discussing with their partner their sex outside the relationship. Among those with agreements with their partners, 27.7% reported ever breaking those agreements. Those who found it more difficult to discuss issues of HIV serostatus and sexuality were more likely to report having broken their agreements (p<.001; p=.021 at one-year follow-up) and were more likely to have engaged in unprotected anal intercourse with casual partners (p<.001). A third of those men who broke their agreements did not inform their partner. A substantial proportion of gay men with agreements with their regular partners report some discomfort discussing sexuality and HIV serostatus with their partners. Difficulty discussing these issues may place these men at increased risk of breaking their agreements and may place both themselves and their partners at increased risk of infection.     

HIV risk behaviour among gay and bisexual men in Budapest, Hungary

HIV is a growing public health threat in Central and Eastern Europe. In Hungary and a number of other countries, men who have sex with men (MSM) account for a high proportion of HIV infections. However, there has been very little systematic study of the sexual risk practices and characteristics of MSM in this region. This study surveyed 469 MSM recruited in Budapest gay community venues in June 2001. Half the men (50%) engaged in unprotected anal intercourse (UAI) in the past 3 months. Of these, 40% of men's insertive and 50% of their receptive acts were unprotected, and 25% had multiple AI partners in the past 3 months. 17% of MSM exchanged sex for money, 26% had female partners in the past year, and condoms were used in only 23% of their vaginal intercourse occasions. Multivariate analyses showed that high-risk behaviour was predicted by not having condoms available when needed, weak risk reduction intentions, negative attitudes toward safer sex, being in a steady relationship, and having a bisexual orientation. Community-based HIV prevention programmes focused on the needs of gay or bisexual men in Central and Eastern Europe are urgently needed.     

Demographic and attitudinal variables related to high-risk behaviors in Asian males who have sex with other men

Although AIDS is spreading rapidly in minority communities, little is known about attitudes, knowledge, and behavior related to AIDS and HIV in the Asian community. The purpose of this study was to examine these variables in a sample of gay Asian males, as well as to investigate the relationship between knowledge, sources of information, culturally influenced attitudes and high-risk behaviors in this population. Results from a sample of 60 young Asian men who self-identified as "having sex with other men" indicated they were generally knowledgeable about methods of transmission and prevention, and appeared linked to a large information network that included informal sources such as peers and formal sources. However, significant percentages held culturally biased views of AIDS, such as believing race of partner or one's own gender role in the sexual encounter determined level of risk; and one third of the sample did not use condoms regularly. Having been tested for HIV was associated with holding less traditional cultural beliefs and a higher sexual activity level. Open communication about safer sexual practices was associated with monogamous as opposed to multiple relationships and with decreased tendency to engage in alcohol-related unprotected sex. Variance in overall risk was predicted by demographic variables such as education, age, and level of sexual activity, rather than by the attitudinal factors measured. Limitations of this exploratory study include a time-limited subject recruitment period and consequent small sample size, a homogeneous sample weighted toward young, well-educated, and middle-class respondents, and the exclusion of non-English speaking individuals. Nevertheless, study findings suggest that educational outreach targeting Asians who have sex with other men needs to address inaccurate cultural beliefs about HIV/AIDS, emphasize consistent condom use, and encourage models of open communication with partners about safer sexual practices.     

Oral versus anal sex at last encounter -- behavioral differences among men who have sex with men in the District of Columbia

Oral sex may be used as a form of harm reduction against HIV transmission. We compared characteristics of men who have sex with men (MSM) in Washington, DC having oral sex versus those having anal sex at last encounter. Data collected through National HIV Behavioral Surveillance in 2008 using venue-based sampling were used. Men ≥18 years old disclosing MSM behavior in the past year were analyzed (n=500); OraQuick and Western Blot confirmation were used to assess HIV status. Multivariable methods were used for data analyses by type of sex at last encounter. A total of 71.8% of MSM had anal sex and 28.2% reported oral sex at last encounter. Men reporting oral sex were more likely to be white, older, insured, HIV-negative, unaware of last partner's HIV status, have a main partner, and not be HIV tested in the previous year. Significant demographic and behavioral differences exist between MSM reporting oral or anal sex; further studies should assess whether oral sex is being used as HIV prevention among MSM.     

Predictors of HIV risk behavior among Russian men who have sex with men: an emerging epidemic

BACKGROUND: Russia is experiencing one of the sharpest increases in HIV incidence in the world. Almost no research has examined patterns of risk behavior among Russian men who have sex with men (MSM). DESIGN AND METHODS: A total of 434 MSM were surveyed in all of St. Petersburg's gay-identified clubs during June 2000. Men completed questionnaires about their sexual practices, AIDS risk knowledge, safer sex attitudes, behavior change intentions, perceived safer sex norms, and fatalism. RESULTS: Most MSM were bisexual; 79% had female partners in their lives and 37% had female partners in the previous 3 months. Sexually transmitted disease treatment was reported by 32% of the men, 23% had sold sex to gain money, and knowledge about critical HIV risk-reduction steps was low. Of all men surveyed, 38% had unprotected anal sex in the previous 3 months, consistent condom use was reported by only 30% of men, and most recent anal intercourse occasions 37% of particpants'. Regression analyses showed that high-risk behavior was predicted by poor safer sex attitudes, weak behavior change intentions, low knowledge about AIDS risk, perceived peer norms that did not support safer sex, and having a boyfriend. CONCLUSION: To avert a widespread epidemic, HIV prevention interventions for Russian MSM are critically needed. Factors predicting risk were consistent with those found among MSM in other countries early in the HIV epidemic. However, unique cultural factors, including frequent bisexual behavior, the 'newness' of openly gay communities in Russia and lack of community experience in dealing with AIDS, require HIV prevention program tailoring.     

Male polyurethane condoms do not enhance brief HIV-STD risk reduction interventions for heterosexually active men: results from a randomized test of concept.

The current study examined the effects of a brief HIV risk reduction intervention for men. Participants were recruited (n = 108) from an urban public health clinic and randomly assigned to one of 3 experimental intervention conditions: (1) 3 h HIV-STD risk reduction behavioural skills building latex condom intervention; (2) the same 3 h skills workshop but focused on male polyurethane condoms; or (3) a 3 h HIV education workshop. Results showed all 3 interventions increased AIDS knowledge and positively influenced attitudes, but men who received the polyurethane condom skills intervention were more likely to request condoms at follow ups. In addition, men who received either of the 2 skills interventions evidenced increased condom use at the one-month follow up, with no differences at 3-month follow up. This study is among the first to test a brief HIV risk reduction intervention for men and is the first to test whether polyurethane male condoms enhance HIV risk reduction efforts.