Spousal Communication about HIV Prevention in Kenya

High HIV rates among cohabiting couples in many African countries have led to greater programmatic emphasis on spousal communication in HIV prevention. This study examines how demographic and socioeconomic characteristics of cohabiting adults influence their dyadic communication about HIV. A central focus of this research is on how the position of women relative to their male partners influences spousal communication about HIV prevention. The authors analyze gaps in spousal age and education and females' participation in household decision making as key factors influencing spousal communication about HIV, while controlling for sexual behaviors of both partners as well as other individual and contextual factors. Data were obtained from the 2003 Kenya Demographic and Health Survey for 1,388 cohabiting couples. Information regarding spousal communication was self-reported, assessing whether both, either, or neither partner ever discussed HIV prevention with the other. Analyses showed higher levels of education for the female partner and participation in household decision making are positively associated with spousal communication about HIV prevention. With females' education and other factors controlled, couples with more educated male partners were more likely to have discussed HIV prevention than couples in which both partners have the same level of education. Spousal communication was also positively associated with household wealth status and exposure to the mass media, but couples in which male partners reported having nonspousal sex in the past year were less likely to have discussed HIV prevention with their spouses. Findings suggest HIV prevention programs should promote female empowerment and encourage male participation in sexual health discussion.     

Better Communication Regarding Sexual Agreements Within Serodiscordant Male Couples Leads to Improved Antiretroviral Therapy Adherence Among the HIV-Positive Partner

Sexual agreements (SAs)—guidelines that outline what type of sexual behaviors are permissible with sexual partners outside of their primary relationship—are often negotiated within same-sex male relationships to reduce their risk for HIV infection. However, HIV risk is not only a function of sexual behavior, but is also affected by factors such as antiretroviral therapy (ART) adherence. We examined whether HIV-positive partners in serodiscordant male couples who have better communication about SAs and report concordant SAs with their partners have greater odds of being adherent to ART to not only improve their health, but to also reduce the risk of transmitting HIV to partners. We analyzed longitudinal data from 135 HIV-positive partners in serodiscordant male couples recruited from Atlanta, GA, Boston, MA, and Chicago, IL to examine the relationship between optimal ART adherence and two independent variables: communication about SAs and if the couples have discrepant SAs. HIV-positive male partners who reported high levels of communication regarding SAs had nearly three times the odds of optimal adherence to ART compared to those who reported lower levels. The HIV-positive partners with discrepant SAs with their male partner had approximately half the odds of optimal adherence to ART compared to those with concordant SAs. Our findings suggest that integrating communication skills training into dyad-level HIV interventions to improve communication regarding HIV may provide more opportunities for couples to discuss ways of reducing the risk of HIV transmission. Couples may benefit from interventions that assist them in composing SAs.

     

Actor–Partner Effects of Demographic and Relationship Factors Associated with HIV Risk Within Gay Male Couples

Recent research has investigated the association of relationship factors and dynamics with sexual behaviors and HIV risk among gay male couples. However, few studies with gay male couples have used the Actor–Partner Interdependence Model framework to examine whether factors influence an individual and his partner’s sexual risk behaviors. None of these studies analyzed whether relationship factors had influenced the sexual risk behaviors of both partners within the couple. Our cross-sectional study used dyadic data from 142 gay male couples to assess actor–partner effects of relationship commitment, trust, and investment in one’s sexual agreement for HIV risk. Multilevel modeling was used to examine which actor–partner effects of these factors were predictive of individuals and their partners having had UAI within and outside the relationship. Results indicated that participants’ likelihood of having had UAI within and outside of the relationship significantly decreased with: (1) actor effects of value in and commitment to a sexual agreement, and quality of alternatives to the relationship and (2) partner effects of participant’s age, dependability of trust, quality of alternatives to the relationship, and investment of relationship commitment. No significant actor–partner effects were detected for having had UAI within the relationship. Our findings suggest that future HIV prevention strategies should take into account how relationship factors influence an individual and his main partners’ sexual risk behaviors and in turn, the couple’s risk for HIV. However, more research is needed to examine how actor–partner effects of relationship factors influence a variety of sexual risk behaviors within gay male couples.     

Relationship Characteristics and HIV Transmission Risk in Same-Sex Male Couples in HIV Serodiscordant Relationships

Unprotected anal intercourse (UAI) remains a main risk factor for HIV among men who have sex with men (MSM) and this is of particular concern for partners of HIV serodiscordant status. However, HIV transmission risk has been demonstrated to vary by the sexual position adopted among partners. Guided by interdependence theory, this study examined how relational factors were differentially associated with risk taking (HIV-positive/insertive and HIV-negative/receptive) and strategic positioning (HIV-positive/receptive and HIV-negative/insertive) UAI within serodiscordant same-sex male couples. HIV-positive men and their HIV-negative partners (n _couples = 91; n _individuals = 182) simultaneously but independently completed computerized questionnaires and HIV-positive men had blood drawn for viral load. A minority of couples (30 %) engaged in risk taking and/or strategic positioning unprotected anal sex. Results of multinomial logistic regression indicated that HIV-negative partners’ levels of relationship commitment were positively associated with the odds of engaging in strategic positioning sexual behaviors. For HIV-negative partners, reports of relationship intimacy, and sexual satisfaction were negatively associated with odds of reporting risk taking behavior. In contrast, HIV-positive partners’ reported sexual satisfaction was positively associated with odds of engaging in risk taking behavior. Findings suggested that aspects of relational quality may be differentially associated with sexual decision making for same-sex male couples in serodiscordant relationships. Study findings lend support for the incorporation of discussions of HIV risk reduction strategies, enhancing communication between partners, and support for general relationship functioning in HIV care.     

Sexual communication among married couples in the context of a microbicide clinical trial and acceptability study in Pune,India

Previous research in India indicates that there is little communication within marriage about sex. Lack of communication about safe sexual behaviours may increase couples' vulnerability to HIV. This study explores couple level sexual communication and socio-cultural norms that influence couples' communication about sex and its implications for HIV prevention. Data derive from in-depth interviews at two points in time with 10 couples. Secondary qualitative analyses of the interviews were conducted using inductive and deductive coding techniques. Half of the couples described improved communication about sex and HIV and AIDS after participation in the clinical trial and/or acceptability study, as well as increased sexual activity, improved relationships by alleviating doubts about their partner's fidelity and forgiving their partners. The findings show that creating safe spaces for couples where they can ask frank questions about HIV and AIDS, sex and sexuality potentially can improve couples' communication about sex and reduce their risk for HIV infection.     

Interpersonal issues surrounding HIV counseling and testing, and the phenomenon of "testing by proxy"

This multimethod study explored challenges faced by women in close heterosexual relationships who decided to test for HIV, and their experiences with instituting safer sexual practices and partner testing. Eighty-one women who sought HIV counseling and testing and had a regular male sexual partner were interviewed on five occasions, and 18 of these women and 15 men later took part in one of four focus groups (women only, men only, or couples). Findings identified difficulty understanding the unpredictability of HIV transmission, gender differences in how partners interpret their susceptibility to HIV, and male resistance to safer sex and testing. We also identified a pervasive phenomenon of "testing by proxy"--the belief that if one partner tests negative for HIV after having unprotected intercourse, the untested partner's serostatus is deemed to be negative. This dangerous practice must be addressed in public health prevention efforts. Programs aiming to reduce heterosexual HIV risk for women must include their male partners and incorporate effective interpersonal communication skills.     

Partner Support and Communication for Pre-exposure Prophylaxis (PrEP) Use Among Male Couples

Between one to two-thirds of HIV infections among gay, bisexual, and other men who have sex with men are from primary partners, and there has been increased research attention focused on strategies to increase PrEP adoption among male couples. While there is evidence that partner support is a strong correlate of pre-exposure prophylaxis (PrEP) adoption, there has been a lack of attention on PrEP communication dynamics among male couples. In this paper, we build upon this literature through analysis of dyadic data from a large cross-sectional survey of 543 concordant sero-negative and serodiscordant male couples to examine individual and relationship factors associated with reports of partner communication around PrEP, comfort in discussing PrEP, and perceived partner-level support for PrEP use. PrEP use was relatively low (16.2%), and although 87.5% of men reported their partners would support their PrEP use, only 26.3% had talked to their partner recently about PrEP. PrEP communication and perceived support for PrEP were significantly negatively associated with PrEP stigma and stigma based on sexuality (i.e., internalized homophobia and enacted external stigma based on sexuality), while men with sexual agreements were more comfortable talking about PrEP with their partner. There is a need to adapt current interventions, or develop new dyadic interventions, that provide opportunities for male couples to talk and learn about PrEP together, as a potential pathway to engage them toward PrEP use.

     

BOOK REVIEWS

This multimethod study explored challenges faced by women in close heterosexual relationships who decided to test for HIV, and their experiences with instituting safer sexual practices and partner testing. Eighty-one women who sought HIV counseling and testing and had a regular male sexual partner were interviewed on five occasions, and 18 of these women and 15 men later took part in one of four focus groups (women only, men only, or couples). Findings identified difficulty understanding the unpredictability of HIV transmission, gender differences in how partners interpret their susceptibility to HIV, and male resistance to safer sex and testing. We also identified a pervasive phenomenon of “testing by proxy”—the belief that if one partner tests negative for HIV after having unprotected intercourse, the untested partner's serostatus is deemed to be negative. This dangerous practice must be addressed in public health prevention efforts. Programs aiming to reduce heterosexual HIV risk for women must include their male partners and incorporate effective interpersonal communication skills.     

Gay Male Couples’ Attitudes Toward Using Couples-Based Voluntary HIV Counseling and Testing

Many men who have sex with men acquire HIV from their primary male partners while in a relationship. Studies with gay couples have demonstrated that relationship characteristics and testing behaviors are important to examine for HIV prevention. Recently, couples-based voluntary HIV counseling and testing (CVCT) has become available to male couples throughout the U.S. However, HIV-negative couples’ attitudes toward using CVCT and how their relationship characteristics may affect their use of CVCT remain largely unknown. This information is particularly relevant for organizations that offer CVCT. To assess couples’ attitudes, and associated factors toward using CVCT, a cross-sectional study design was used with a novel Internet-based recruitment method to collect dyadic data from a national sample of 275 HIV-negative gay couples. Multivariate multilevel modeling was used to identify factors associated with differences between and within couples about their attitudes towards using CVCT. Findings revealed that couples were “somewhat” to “very likely” to use CVCT. More positive attitudes toward using CVCT were associated with couples who had higher levels of relationship satisfaction and commitment toward their sexual agreement and among those who had at least one partner having had sex outside of the relationship. Less positive attitude toward using CVCT was associated with couples who had higher levels of trust toward their partners being dependable. Differences within couples, including age between partners, whether sex had occurred outside of the relationship, and value toward a sexual agreement also affected their attitudes toward using CVCT. Providing additional testing methods may help HIV-negative gay couples better manage their HIV risk.     

Negotiating sexual safety in the era of biomedical HIV prevention: relationship dynamics among male couples using pre-exposure prophylaxis

Up to two-thirds of new cases of HIV transmission between gay, bisexual and other men who have sex with men in the USA are attributed to primary relationships. Understanding the relationship dynamics and sexual agreements of male-male couples can provide insight into HIV transmission patterns and prevention needs in this population. The daily use of antiretroviral pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV, but its negotiation and use within social and intimate relationship contexts remain understudied. We conducted semi-structured qualitative interviews with 20 male couples (n = 40 men) in which at least one partner was either using or in the process of initiating PrEP. Congruent with a theoretical focus on social theories of relationships and negotiated risk, couples were interviewed about relationship dynamics, trust, communication and sexual health practices, including their perception and use of PrEP. Overall, we found that couples showed heightened trust and communication when establishing open, sexual agreements and demonstrated high awareness of sexual risks and health practices in the context of PrEP use. This study demonstrates how understanding relationship dynamics can better inform HIV prevention and sexual health promotion efforts for male couples at risk of HIV.     

Changes in Couples' Communication as a Result of a Male-Involvement Family Planning Intervention

Research suggests that spousal communication and male involvement in decision making can positively influence family-planning use and continuation. However, few existing studies explore the dynamics of this communication and how they factor into family-planning decision making. Building upon a recent evaluation of a theory-based male-involvement intervention in Malawi, this study aimed to fill this gap by examining the role of communication in the intervention's success, through semi-structured in-depth interviews with male participants and female partners of study participants. Results support the idea that communication is an integral component of successful interventions to increase male involvement in family planning. Participants reported improvements in spousal communication, increased frequency of communication, and an increase in shared decision making as a result of the study, which directly contributed to their family-planning use. This effect was often mediated through increased knowledge or reduced male opposition to family planning. Further analysis of communication and decision-making dynamics revealed shifts in gendered communication norms, leading to improvements in spousal relationships in addition to contraceptive uptake. This study shows that interventions can and should encourage spousal communication and shared decision making, and it provides an effective model for involving men in family-planning use.     

Changes in couples' communication as a result of a male-involvement family planning intervention

Research suggests that spousal communication and male involvement in decision making can positively influence family-planning use and continuation. However, few existing studies explore the dynamics of this communication and how they factor into family-planning decision making. Building upon a recent evaluation of a theory-based male-involvement intervention in Malawi, this study aimed to fill this gap by examining the role of communication in the intervention's success, through semi-structured in-depth interviews with male participants and female partners of study participants. Results support the idea that communication is an integral component of successful interventions to increase male involvement in family planning. Participants reported improvements in spousal communication, increased frequency of communication, and an increase in shared decision making as a result of the study, which directly contributed to their family-planning use. This effect was often mediated through increased knowledge or reduced male opposition to family planning. Further analysis of communication and decision-making dynamics revealed shifts in gendered communication norms, leading to improvements in spousal relationships in addition to contraceptive uptake. This study shows that interventions can and should encourage spousal communication and shared decision making, and it provides an effective model for involving men in family-planning use.     

Extrarelational sex among Mexican men and their partners' risk of HIV and other sexually transmitted diseases

OBJECTIVES: This study explored the risk of HIV and other sexually transmitted diseases (STDs) among married and cohabiting women in Mexico City, Mexico, derived from their partners' sexual behaviors. METHODS: Results were derived from the first population-based household survey in Mexico that investigated male sexual behavior. Analyses were restricted to sexually active married or cohabiting men (n = 3990). RESULTS: Fifteen percent of the men reported extrarelational sex during the past year, 9% reported condom use during last intercourse, and 80% perceived no HIV risk. Most secondary partners were coworkers, mistresses, or friends. CONCLUSIONS: Targeted HIV and STD prevention efforts appear necessary because a substantial number of women may be at risk.     

Importance of Women’s Relative Socioeconomic Status within Sexual Relationships in Communication about Safer Sex and HIV/STI Prevention

The socioeconomic status (SES) of women is increasingly considered an important factor for HIV/STI risk. The HIV/STI literature has largely focused on women’s absolute levels of SES, and therefore, the importance of their SES relative to their male sexual partners remains understudied. This paper examines the association between women’s relative SES and frequency of safer sex communication among heterosexual couples. A convenience sample of 342 couples (N = 684) recruited in New York City was asked about frequency of discussions with their partner about the need to use male condoms, about HIV prevention, and about STI prevention in the previous 90 days. Differences between partners in education, income, employment, housing, and incarceration history were combined using principal component analysis to form an index of women’s relative SES. Negative binomial regression models assessed associations between woman’s relative SES and communication frequency controlling for age, sex, race, ethnicity, education, and relationship type using a generalized estimating equation framework. On average, participants had 2.5, 4.2, and 4.8 discussions regarding the need to use male condoms, about HIV prevention, and about STI prevention, respectively. A one standard deviation increase in a woman’s relative SES score was associated with increased frequency of discussions about male condom use (adjusted rate ratio [aRR], 1.15; 95 % confidence interval [CI], 1.03–1.29), about HIV prevention (aRR, 1.25; CI, 1.14–1.37), and about STI prevention (aRR, 1.29; CI, 1.18–1.41). Women’s relative SES may be an important factor for sexual communication, and further research on its role in HIV/STI risk may uncover avenues for intervention.

Electronic supplementary material

The online version of this article (doi:10.1007/s11524-014-9935-y) contains supplementary material, which is available to authorized users.     

Power, Control, and Intimate Partner Sexual Violence in Haiti

This study sought to determine how power and control in intimate relationships influenced women's exposure to sexual violence. Multilevel modeling was used to determine the risk of partner sexual violence in the past 12 months among 2240 women aged 15–49 years who were currently married or cohabiting. The data were drawn from the 2000 Haiti Demographic and Health Survey. Strong positive effects on intimate partner sexual violence were found for husband's jealousy and perpetration of controlling behavior and women's endorsement of traditional norms concerning a husband's rights to beat his wife. Female dominance in decision making about purchases for daily household needs was positively associated with intimate partner sexual violence but its effects were mediated by relationship quality. The effect of wife's education on intimate partner violence was nonlinear. The analysis also showed that high community female headship rates were independently associated with higher risks of partner sexual violence. The findings highlight the importance of adopting a multidimensional approach to the measurement of power in sexual relationships and the need for programs to work at multiple levels to address gender-based norms and the structural factors that put women at increased risk of sexual violence.     

From prenatal HIV testing of the mother to prevention of sexual HIV transmission within the couple

The first step in preventing mother-to-child HIV transmission (PMTCT) programmes is offering HIV counselling and testing to pregnant women. In developing countries where HIV testing remains rare, it represents a unique opportunity for many women to learn their HIV status. This prenatal HIV testing is not only the entry point to prevention of mother-to-child HIV transmission, but also an occasion for women to sensitize their male partner to sexual risks. Here we explore if these women, HIV-tested as mothers, apply the prevention recommendations they also receive as women.In the Ditrame Plus PMTCT program in Abidjan, Côte d'Ivoire, two cohorts of women (475 HIV-infected women and 400 HIV-negative women) were followed up two years after the pregnancy when they were offered prenatal HIV testing. In each cohort, we compared the proportion of women who communicated with their regular partner on sexual risks, prior to and after prenatal HIV testing. We analysed socio-demographic factors related to this communication. We measured two potential conjugal outcomes of women HIV testing: the level of condom use at sex resumption after delivery and the risk of union break-up.Prenatal HIV testing increased conjugal communication regarding sexual risks, whatever the woman's serostatus. This communication was less frequent for women in a polygamous union or not residing with their partner. Around 30% of women systematically used condoms at sex resumption. Among HIV infected ones, conjugal talk on sexual risks was related to improved condom use. After HIV testing, more HIV-infected women separated from their partners than HIV-uninfected women, despite very few negative reactions from the notified partners.In conclusion, offering prenatal HIV counselling and testing is an efficient tool for sensitizing women and their partners to HIV prevention. But sexual prevention in a conjugal context remains difficult and need to be specifically addressed.