mental health AIDS

Fall 2004 Newsletter / Volume 6, Issue 1

HIV Prevention News

Dutch investigators (Davidovich, de Wit, & Stroebe, 2004) examined the first incident of unprotected anal intercourse (UAI) occurring within the steady relationships of 324 gay men in Amsterdam, as well as related cognitions."Of the men who had UAI with their steady partners, 55%. .. did so within the first 3 months of the relationship, and 46% did not discuss having UAI with their partner before it occurred.. .. [P]erceiving UAI as a symbol of trust and believing that the partner desired UAI were associated with less condom use but also with a higher likelihood that men established HIV-negative seroconcordance and. .. practiced negotiated safety. ... Perceiving UAI as more gratifying was [also] associated with having. .. UAI" (p. 304).

As for reducing sexual risk-taking within steady male relationships, Davidovich and colleagues suggest that clinicians utilize beliefs related to trust and to a partner's desire for UAI as leverage to promote negotiated safety.² In those relationships in which negotiated safety cannot be established (e.g., relationships that have only just begun), these beliefs and, in particular, the perception that UAI is more gratifying may, indeed, function as barriers to safer sex. Moreover, the rapid initiation of risk behavior within steady relationships suggests that clinicians must intervene early with couples and could, by logical extension, target single gay men in an effort to promote safer sex within future steady relationships.

In a related study, Dudley, Rostosky, Korfhage, and Zimmerman (2004) surveyed 154 young men who have sex with men (MSM; ages 13 to 21) in five mid-sized, Midwestern U.S. cities and found that, in addition to number of reported anal sex partners and relationship status (i.e., having a dating partner), impulsive decision making was positively associated with the self-reported frequency of UAI. Dudley and colleagues urge clinicians to teach young, impulsive decision-makers"to carry condoms with them at all times, to keep condoms stored in a place where they are most likely to have sexual intercourse (next to the bed), and to proactively identify and avoid situations that are likely to lead to unprotected sex. Other psychoeducational interventions. .. include increasing awareness of impulsive tendencies, overrehearsing responses to sexual pressure, and overrehearsing decision-making steps" (p. 336).

Contributing to the ongoing investigation of the role of alcohol in unsafe sexual behavior, Vanable et al. (2004) analyzed event-level data from a three-city sample of 1,712 HIV-negative MSM and discerned that, in encounters that involved a primary partner, rates of UAI did not vary in accordance with the use of alcohol. In fact,

[a]cross the entire sample, [UAI] was just as likely for nondrinking events as for events that included alcohol consumption. However, alcohol use prior to sex was strongly related to unsafe sex for encounters involving nonprimary partners. Indeed, among participants who reported consuming four or more drinks prior to a recent sexual encounter with a nonprimary partner, rates of [UAI] were nearly three times those reported by men who did not drink or who reported consuming less than four drinks.. .. Results also indicate that alcohol use relates to sexual risk taking in a dose-response fashion: For events involving a nonprimary partner, rates of unsafe sex were elevated only for events involving heavier alcohol use (four or more drinks). Taken together, findings highlight the importance of the social context for sexual activity, both in determining whether alcohol is consumed at all and with regard to whether alcohol consumption (and level of intoxication) is related to sexual risk taking. (p. 530)

Vanable and colleagues reason that"alcohol use may be related to increased sexual risk primarily in situations involving desirable behaviors that are most strongly proscribed or avoided under sober conditions" (p. 530; see also Parsons et al., 2004a, 2004b below). With regard to intervention, they recommend strengthening"self-management strategies for reducing alcohol use and improving safer sex negotiation skills for encounters involving new or nonprimary partners" (p. 531).

Deepening this focus on the context of alcohol use, Parsons et al. (2004b) interviewed 48 gay and bisexual men living with HIV who were diagnosed with alcohol use disorders (81% men of color) for the purpose of describing"the role participants assigned to alcohol before or during sexual activity.. .. The time at which men drank, for how long, where, why, and to what extent was related to the role they assigned to alcohol. Moreover, the role alcohol played in the sexual activity structure impacted its role in sexual risk behavior" (p. 168).

Parsons and colleagues observe that

[a]lcohol does not play a direct or dominant role in the sexual risk behaviors for the HIV-positive MSM in [this] sample. Rather, the intoxication is one aspect of a sexual script, which includes particular settings, partners, and sexual behaviors. The sexual scripts themselves are somewhat automatic and become more so under the influence of alcohol. Alcohol acts on these scripts by deceasing self-monitoring and increasing the reliance on default scripts, which are driven by environmental stimuli and situational cues. .. The default scripts that participants used could be seen as routine, spontaneous (alcohol enabled), or taboo. (pp. 168-169)

Within this same sample, Parsons et al. (2004a) delved further into interviews with those men engaging in"stigmatized" sexual practices (i.e., enacting a taboo sexual script) while using alcohol.

For these men, alcohol facilitated engagement in behaviors that elicited shame or guilt based on internalized social norms and proscriptions. For some men, alcohol and sex became so coupled that they did not or could not engage in sexual activity when they were sober.

For bisexual men, alcohol enabled them to have sex with other men while temporarily postponing a reconciliation of their behavior with their sexual identity. Alcohol also facilitated atypical sexual behaviors for men who experienced anxiety around anal receptive sex. Alcohol played a role in the violation of sexual parameters for those. .. who were in monogamous relationships. Finally, often due to its role in enabling stigmatized sexual behaviors, alcohol played a role in unsafe sex for some participants. (p. 1050)

With regard to interventions, Parsons and colleagues observe that

[b]ehavioral interventions designed to reduce the HIV sexual risk practices of HIV-seropositive MSM who abuse alcohol should consider the implications of sexual scripts and their role in sexual experiences. Cognitive or motivational interventions may be useful in helping HIV-positive MSM to understand their sexual scripts and the role that alcohol plays in scripting their sexual activities. Such approaches, which are designed to facilitate cognitive restructuring, amplify discrepancy, and increase self-monitoring, may benefit men through enabling script modifications. (Parsons et al., 2004b, p. 171)

Enriching this focus on contextual factors associated with unsafe sex, Díaz, Ayala, and Bein (2004) used data drawn from a probability sample of 912 Latino gay men in three U.S. cities to identify ways in which social discrimination (i.e., homophobia and racism) and financial hardship may be linked to risky sexual behavior:

First, individuals' experiences of social oppression on account of race/ethnicity, class, and sexual orientation are strongly correlated to sexual practices that place individuals at risk for HIV transmission. Second,. .. social oppression and psychological distress predict participation in sexual situations of risk. Third, social oppression affects sexual risk by increasing the likelihood that individuals participate in situations that make it difficult to practice safer sex. Men who were more discriminated [against] and psychologically distressed were more likely to participate in sexual situations under the influence of drugs or alcohol, to engage in sex. .. to alleviate anxiety and stress, and to be with partners who resisted condom use, among others. Participation in these"difficult" situations mediates the impact of social oppression on risky sexual behavior. (p. 265)

Simply stated, these findings, in combination with earlier work,"suggest that discrimination increases isolation, undermines a sense of self-worth, and produces psychological distress. Those who are oppressed and distressed, in turn, participate more often in sexual situations in which risk behavior is likely to occur" (p. 265).

Among the interventions suggested by these findings, the authors encourage clinicians to help Latino gay men"discover and understand that the risk for HIV is not simply an individual characteristic related to some kind of personal or moral deficiency. Rather, HIV education and prevention must be focused on the fact that 'risk' is often a property of situations or the product of person-situation interactions in which personal and contextual factors interact making it difficult to practice safer sex" (p. 266).

Continuing with this theme, Williams, Wyatt, Resell, Peterson, and Asuan-O'Brien (2004) conducted four focus groups involving 23 men (five gay-identifying African-American men, seven non-gay-identifying African-American men, five gay-identifying Mexican/Mexican-American men, and six non-gay-identifying Mexican/Mexican-American men) living with HIV, all of whom reported a history of sexual abuse, in an effort to better understand sexual risk among MSM of color. The data were organized into a matrix of seven domains to assist in developing interventions. The domain were:"(a) sex with men, (b) sex with women, (c) the importance of family including having children, (d) gender roles and social expectations, (e) sex or 'partying' with drugs and alcohol, (f) church and religion, and (g) living with HIV" (p. 272).³ Williams and colleagues observe that this investigation

described many of the issues and conflicts. .. for MSM of color and highlighted the need to better understand what it means to be African American or Latino, gay, male, and to live with HIV and a history of sexual abuse.. .. The seven domains identified in these focus groups should be prioritized to help men address the conflicts and challenges they reported. The primary focus should be the importance of personal identifications and acceptance as an African American or Latino [MSM]. Once the sociocultural and gender conflicts are addressed, the second area of focus should be on the behaviors and experiences that may influence these men's sexuality, namely, their HIV status, past and current abuse, and resultant sexual risk-taking practices that increase current HIV-related risks. Future interventions should also include sociocultural, religious, and alternative resources to minimize social isolation and rejection. These factors must be considered as basic to behavior change because they build on personal strengths while helping men to redefine themselves as critical members of their ethnic, cultural, and religious communities. The health and well-being of [MSM] is as essential to them as it is to the people who care about and depend on them. (p. 283)

Finally, the EXPLORE Study Team (2004) reported on its multisite RCT testing the efficacy of a behavioral intervention designed to prevent HIV infection in a sample of 4,295 MSM at high risk for infection and living in six U.S. cities. Study participants received either ten intensive, one-to-one counseling sessions, followed by quarterly, client-centered maintenance sessions, or twice-yearly standard, voluntary HIV counseling. All participants were assessed behaviorally and tested for HIV every six months over the four years of the study. The team found that the rate of receptive UAI with serodiscordant or unknown-status partners was 20.5% lower in the intervention group in comparison with the standard condition group over the course of the study. They also found that fewer men in the experimental group became infected with HIV during the study period in comparison with men in the standard condition (115 vs. 144; 18.2% lower in the intervention group, attenuated to 15.7% when adjusting for baseline covariates), although this difference was not statistically significant; moreover, the effect appeared to be more favorable during the first 12-18 months of follow-up than later. Nevertheless, the investigators suggest that" a behavioural intervention can prevent HIV infection, not just reduce the frequency of self-reported risk behaviours. Further analyses of [the] data are under way with the aim of generating hypotheses to help develop more effective behavioural interventions" (p. 47).

² When gay men negotiate safety, it most often means that they ascertain (through HIV testing) that they are both HIV-negative and agree to have UAI only with their steady partner and to use condoms when having sex with casual partners.

³ The richness of this data set cannot be easily summarized; readers are referred to the original text for an expanded discussion of these seven domains.

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