Relationship Power,Sociodemographics, and Their Relative Influence on Sexual Agreements Among Gay Male Couples

Men who have sex with men (MSM) in primary relationships engage in condomless sex both within and outside their relationships and a majority of HIV transmission risk may actually occur within primary relationships. Sexual agreements regarding non-monogamy are a critical component to understanding HIV prevention in male couples. Relationship factors have been associated with how sexual agreements function and power is one dyadic construct likely to affect couple’s maintenance of non-monogamy agreements. Multilevel modeling was used in a cross-sectional study of gay male couples (N = 566 couples) to examine associations between partners’ demographic characteristics traditionally used to define relationship power, a scale of decision-making power, and outcomes related to sexual agreements, including investment, agreement breaks, and break disclosure. Results indicated that decision-making power relative to one’s partner was not associated with any agreement outcome, contrary to hypotheses. However, controlling for decision-making power, demographic bases of power were variably associated with sexual agreements’ functioning. Younger partners were less invested in and more frequently broke their agreements. Lower-earning partners broke their agreements more frequently, but also disclosed breaks more often. White men in white-minority relationships broke their agreement more often than their partners. Concordant HIV-positive couples were less invested in their agreements and HIV-positive men disclosed breaks more frequently. HIV prevention efforts for same-sex couples must attend to the social, developmental, and cultural influences that affect their agreements around non-monogamy.     

Relationship Factors Associated with HIV Risk Among a Sample of Gay Male Couples

More HIV prevention research is needed to better understand how relationship factors may affect sexual risk behaviors among gay male couples. Our cross-sectional study collected dyadic data from 144 gay male couples to examine which relationship factors and characteristics were associated with men having UAI with a secondary sex partner. We targeted male couples by using a variety of recruitment strategies. Multilevel random-effects logistic regression modeling was used to examine which factors were predictive of men in gay couples who had UAI with a secondary sex partner. Analyses revealed that men were less likely to have had UAI with a secondary sex partner if they reported being in a strictly monogamous relationship, receiving an HIV test within the previous 3 months, and being committed to their sexual agreement. Future HIV prevention interventions must consider how relationship factors may influence sexual risk behaviors among gay male couples.     

Relationship-Based Predictors of Sexual Risk for HIV Among MSM Couples: A Systematic Review of the Literature

Behavioral and epidemiological studies report high risk for HIV among MSM couples. Over the last decade, studies have examined relationship dynamics associated with sexual risk for HIV. It is important to examine the impact this research has had on HIV prevention and what is still needed. We conducted a review of the literature focusing on relationship dynamics associated with sexual risk for HIV among MSM couples. Procedures used for this review were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses established to provide a framework for collecting, reviewing and reporting studies systematically (Mohler et al. in Ann Intern Med 151(4):264-269, 2009). We found that positive relationship dynamics are associated with less risk with partners outside the relationship, but were associated with greater odds of unprotected anal intercourse with primary partners. We also discuss other factors including sexual agreements about outside partners and make recommendations for next steps in HIV prevention research among MSM couples.     

Substance Use During Sex and Sensation Seeking as Predictors of Sexual Risk Behavior Among HIV+ and HIV− Gay Men

Substance use (i.e., use of recreational drugs and alcohol) has been associated with HIV-related sexual risk behavior in several studies involving gay men. One explanatory hypothesis proposes that substance use and sexual risk behavior are both a function of underlying personality traits. This paper examines sensation seeking and alcohol and drug use during sex as predictors of unprotected anal and oral sex and of a sexual risk index. The sample includes 117 predominantly gay-identified men (73 HIV+ and 44 HIV–) who participated in a 5-year natural history study of HIV disease in New York City. Repeated measures regression analyses tested predictor variables individually and in models including all predictor variables simultaneously. Alcohol use, drug use, and sensation seeking were each significantly associated with all sexual risk behavior variables when entered individually. When predictor variables were entered simultaneously in analyses involving unprotected receptive and insertive anal sex, sensation seeking remained a significant predictor, with substance use typically falling to marginal significance. However, significant associations between substance use and the other sexual risk behavior variables (oral sex and a risk index) are maintained even when controlling for sensation seeking. The results suggest that sensation seeking may partially account for the association between substance use and sexual risk behavior, but substantial independent associations also exist.     

Sexual Health Risks Among Young Thai Women: Implications for HIV/STD Prevention and Contraception

This paper examines factors that may place female Thai adolescents and young adults at risk for HIV, sexually transmitted diseases (STDs), and unintended pregnancies. A total of 832 female vocational students participated in a cross-sectional audio-computer-assisted self-interview (ACASI) survey after providing informed consent. The questionnaire covered: sociodemographic characteristics; knowledge, attitudes, and beliefs related to HIV and STDs; contraceptive practices; sexual experiences and behaviors; and drug use. Oral fluid was tested for HIV antibodies and urine was tested for illicit drugs and for the presence of gonococcal or chlamydial nucleic acids. A total of 359 women (43.1%) reported sexual intercourse history, with an average age at first sex of 17.6 years, and a 2.6 mean number of lifetime sex partners. Twenty-one percent of the entire sample reported coerced sexual contact or intercourse. Among those with sexual intercourse experience, 27.3% (n = 98) had been pregnant and the majority of their most recent pregnancies were terminated. Three tested positive for HIV antibodies. Sexually active young Thai women report behaviors or experiences that may expose them to HIV/STD infection and unintended pregnancy in the future. These include unprotected intercourse, sexual coercion, low levels of contraceptive use, and drug and alcohol use. Culturally appropriate interventions that increase their awareness of and ability to respond to these sexual health risks are needed.     

Sexual and Physical Victimization as Predictors of HIV Risk Among Felony Drug Offenders

Injection and other drug use and high-risk sexual behaviors put criminal offenders at increased risk for HIV infection. Studies in other populations, especially females, have found that a history of sexual or physical victimization increases engagement in HIV-risk behaviors, and drug-involved offenders have high rates of such prior victimization. However, there has been little research among male offenders. In a sample of 247 male felony drug offenders in New York City, prior sexual victimization was related to a higher number of sex partners and lower proportion of protected sex acts in the 30 days before arrest. Prior physical abuse was related to cocaine injection, but not heroin injection or high-risk sex behaviors. These results suggest a complex relationship between sexual and physical abuse and HIV risk among male offenders. Assessing for specific prior abuse histories of offenders and providing targeted interventions may be useful for developing more effective primary and secondary HIV prevention services for this high-risk population.     

Attitude and Behavior Changes Among Gay and Bisexual Men After Use of Rapid Home HIV Tests to Screen Sexual Partners

HIV testing can now be self-administered outside clinical settings through the purchase of home testing (HT) kits. Individuals also can use the kits to perform a test on a potential sexual partner prior to intercourse. We provided a 3-month supply of HT kits to men who reported multiple male partners and little or no condom use for anal intercourse. Participants used the test kits with partners in over 100 occasions. At the end of the study, approximately half of the participants described shifts in their attitudes and/or behaviors related to sexual risk. Reported changes included increased awareness of risk, increased discussion of STI/HIV safety measures, changes in partner choice and heightened consciousness of partner thinking. Easy access to HT kits may be a risk-reduction strategy for men with a high risk profile because their regular use could have an impact beyond the specific sexual encounter.     

Other-Sensitive Motivation for Safer Sex Among Gay Men: Expanding Paradigms for HIV Prevention

Self-interest is not the only motivator to sexual safety among sexually active gay men. Indeed, limits to a self-interest prevention paradigm are significant, and growing. Semi-structured qualitative interviews in two cities with an ethnically diverse cohort of mixed-status, sexually active gay men reveal a wide range of other-sensitive motivators beyond self-interest whose roles in men's HIV safety decisions have not been recognized. Other-sensitive motivations fall into several categories: altruistic concern for sex partners, personal ethical/moral values, expressed desire for communal/collective survival, concerns about self-definition, and elaborate concerns over the effects of potential HIV infection on family and friends. Other-focused concerns seem to operate as key motivators among these men, lowering risk. Implications of other-sensitive concerns for a new generation of prevention strategies are discussed.     

Sexual HIV Risk Behavior Levels Among Young and Older Gay Men Outside of AIDS Epicenters: Findings of a 16-City Sample

Although AIDS rates have leveled among older gay men in large original epicenters, HIV seroincidence remains high among young men who have sex with men (MSM) in many areas of the country. This research examined patterns of risk behavior among young (age 25 years or less) and older (age 26 years and over) MSM. Nearly 2,000 men entering gay bars in 16 small U.S. cities completed an anonymous survey of their sexual practices in the past 2 months and of psychosocial risk-related characteristics. Young men were more likely than older men to have engaged in unprotected anal intercourse and, specifically, receptive intercourse in the past 2 months. Younger men also reported more frequent occurrences of unprotected anal intercourse. A progressive decline in risk behavior levels was associated with increasing age. Young men less often personally knew someone who had died of AIDS, and deaths were not primarily within their close social networks. Continued HIV prevention efforts directed toward young MSM are needed, including cities traditionally considered as second tier with respect to AIDS.     

Asking and Telling: Communication About HIV Status Among Latino HIV-Positive Gay Men

Communication about HIV status—that is, asking about a sex partner's status as well as disclosing one's own status—was examined in a sample of 129 Latino HIV-positive gay men interviewed as part of a larger study conducted in New York, Miami, and Los Angeles. Asking and telling were strongly related to each other; however, participants were more likely to disclose their positive serostatus to sex partners than to solicit information about their partners' serostatus. Region of birth was associated with both asking and telling. Participants with bilingual friendship networks reported more communication with partners. Higher levels of social isolation were related to lower levels of communication, and perceived negative consequences—beliefs that disclosure would result in negative consequences or rejection—were related to less telling. Contrary to expectations, reported experiences of gay discrimination were positively associated with communication of serostatus.     

Sexual Risk Behaviors Among HIV-Infected South African Men and Women with Their Partners in a Primary Care Program: Implications for Couples-Based Prevention

We studied 1163 sexually-active HIV-infected South African men and women in an urban primary care program to understand patterns of sexual behaviors and whether these behaviors differed by partner HIV status. Overall, 40% reported a HIV-positive partner and 60% a HIV-negative or status unknown partner; and 17.5% reported >2 sex acts in the last 2 weeks, 16.4% unprotected sex in the last 6 months, and 3.7% >1 sex partner in the last 6 months. Antiretroviral therapy (ART) was consistently associated with decreased sexual risk behaviors, as well as with reporting a HIV-negative or status unknown partner. The odds of sexual risk behaviors differed by sex; and were generally higher among participants reporting a HIV-positive partner, but continued among those with a HIV-negative or status unknown partner. These data support ART as a means of HIV prevention. Engaging in sexual risk behaviors primarily with HIV-positive partners was not widely practiced in this setting, emphasizing the need for couples-based prevention.     

Deconstructing the Relationship Between Intimate Partner Violence and Sexual HIV Risk Among Drug-Involved Men and Their Female Partners

This study, based on data from a random sample of 322 men on methadone, examines whether traditional male gender role beliefs, male substance use, and couple drug-involvement lead to male psychological dominance, which in turn leads to perpetration of intimate partner violence (IPV) and sexual HIV risk behavior. Structural equation modelingindicated that male psychological dominance is directly associated with perpetrating both physical IPV and sexual HIV risk; however, physical IPV did not lead to sexual HIV risk as predicted originally. Stronger endorsement of traditional male gender role beliefs was associated with male psychological dominance. Couple drug-involvement was also directly associated with male psychological dominance as well as sexual HIV risk. Male substance use led to couple drug-involvement, but not to physical or sexual HIV risk as hypothesized. Study findings highlight the significance of couple drug-involvement and male psychological dominance as pathways leading to physical IPV and sexual HIV risk behavior. Implications for HIV prevention efforts targeting drug-involved men and their sexual partners are discussed.     

Alcohol and Sexual Risk Behaviors Among Male Central Asian Labor Migrants and Non-migrants in Kazakhstan: Implications for HIV Prevention

This paper examines the association between alcohol consumption and sexual risk behaviors (unprotected sex, multiple sex partners, sex under influence of drugs or alcohol and commercial sex) in a sample of Central Asian migrant and non-migrant laborers in the largest marketplace in Kazakhstan. We used data from The Silk Road Health Project, conducted from 2010 to 2013 with 1342 male migrant and non-migrant market workers. Participants were selected through respondent driven sampling at the Baraholka Market in Almaty, Kazakhstan. We used regression analyses adjusting for potential confounders to examine the relationship between alcohol consumption and sexual risk behavior. We found that hazardous drinking was associated with an increase in the odds of sex under the influence of drugs (aOR = 6.09, 95% CI 3.48, 10.65; p < .001) and purchasing commercial sex (aOR = 2.02, 95% CI 1.02, 4.02; p < .05). We identified potential targets for HIV interventions to reduce sexual risk behaviors among this key population.     

Factors Associated with Men in HIV-Negative Gay Couples Who Practiced UAI Within and Outside of Their Relationship

Despite recent advances in research with gay male couples, less data exists about men who have had UAI within and outside of their HIV-negative seroconcordant relationship. Multilevel modeling with dyadic data from 142 couples was used to identify the characteristics associated with men who have had UAI with both their main partner and a casual MSM partner within the same timeframe. Analyses revealed that men were more likely to have had UAI within and outside of their relationship if they perceived their main partner has had a recent HIV test. Men were less likely to have had UAI within and outside of their relationship if they valued their sexual agreement and reported having a sexual agreement that does not allow sex outside of their relationship. Research with a more diverse sample of couples is warranted. Future interventions must consider the complexity of relationships and sexual behaviors among gay male couples.     

Enhancing Acceptability and Use of Sexual Barrier Products Among HIV Concordant and Discordant Couples

Strategies to prevent HIV transmission may benefit from addressing both individual and dyadic factors. This study compared the impact of group and individual interventions on the acceptability of sexual barrier products among HIV sero-concordant and discordant couples, and evaluated the contribution of couple members’ perceived product acceptability to their sexual barrier use. Participants (n = 216 couples) were multicultural couples in Miami, Florida. Longitudinal multilevel modeling and the actor–partner interdependence model were used for analyses. Product acceptability increased more among female group participants, and acceptability of male condoms increased more among sero-discordant couples in the group. Additionally, acceptability of products associated with prevention of STDS/HIV and pregnancy increased more among sero-concordant couples in the group condition. Both actor and partner product acceptability predicted use. Results support the use of group interventions targeting both partners in relationships in prevention programs designed to enhance sexual barrier use.     

Predictors of High-Risk Sexual Behavior Among People Living With HIV/AIDS

Several recent studies have found that a significant number of HIV+ individuals are engaging in unsafe sexual practices. This study was conducted to explore the correlates of high-risk sex among a sample of 360 HIV+ adults recruited from outpatient medical care facilities. The study showed that 34% of all respondents reported at least 1 occasion of unprotected anal or vaginal intercourse in the previous 6 months. Consistent with other research, there were multiple correlates of high-risk sex: lower income, an elevated number of sexual partners, negative attitudes about condoms, lack of risk avoidance strategies, and recreational and intravenous drug use prior to sex. However, contrary to other research, no association was found between low self-esteem, depression/anxiety, or the use of alcohol with unprotected sex. Unlike most studies that have focused exclusively on gay and bisexual men, this study included an additional sample of women and poorer, ethnically diverse individuals. Although there were some gender and ethnic differences, neither gender nor ethnicity moderated any of the significant relationships between psychosocial variables and sexual behavior, suggesting the commonality of issues confronting people living with HIV/AIDS in maintaining safer sex practices. Implications for designing interventions for HIV+ persons are discussed.     

HIV Knowledge and Sexual Risk Behavior Among Pregnant Couples in South Africa: The PartnerPlus Project

In sub-Saharan Africa, 60 % of people living with HIV are women and most are of childbearing age. Alarmingly, seroconversion rates during pregnancy are high and increase as pregnancy progresses, highlighting the importance of increasing HIV-knowledge among pregnant women and their partners. This study compared sexual risk behavior, HIV knowledge and condom use pre- to post-partum among South African couples (n = 239 couples) randomly assigned to an intervention or an enhanced standard of care with the PMTCT protocol at rural community health antenatal clinics. Consistent condom use and HIV-related knowledge increased baseline to post-intervention and was maintained at long term follow up post-partum among participants in the intervention condition. HIV knowledge mediated the relationship between the intervention and consistent condom use. Results from this pilot study provide support for the integration of HIV risk reduction interventions for both women and men into existing PMTCT services during and following pregnancy.