mental health AIDS

Spring 2005 Newsletter

HIV Prevention News

About Men Who Have Sex with Men

In Puerto Rico , Toro-Alfonso and Rodríguez-Madera (2004) surveyed a convenience sample of 302 gay men, 49% of whom reported that they had a steady relationship partner. Many respondents reported violence in their relationships (48% reported emotional violence, 26% physical violence, 27% sexual violence), and there was "a positive correlation between being anally penetrated without a condom, the need to please the partner, and being HIV positive" (p. 47). The authors suggest that "the manner in which violence is constructed and perceived in men may be related to vulnerability for violence and possibly HIV infection" (p. 47). Consequently, "[i]nterventions for domestic violence among gay men and men who have sex with men [MSM] should ... [be] addressing issues of power, examining intergenerational violence and problem-solving skills. Interpersonal and structural obstacles for the development of healthy relationships should be carefully considered and include[d] in all prevention interventions ..." (p. 55).

Denning and Campsmith (2005) analyzed multistate interview data from a diverse sample of 970 HIV-positive MSM who had a single steady male sex partner with negative or unknown serostatus. They found that 278 (29%) reported unprotected anal intercourse (UAI) in the year prior to the interview. While the vast majority of men reduced their sexual risk behavior following an HIV-positive test result, among the 674 men in the total sample who knew their positive serostatus for the full year before their interview, 144 (21%) had UAI. In this latter group, factors associated with UAI were heterosexual self-identification, use of crack cocaine, no education after high school, and having a partner with unknown serostatus. According to Denning and Campsmith, these findings underscore the need to incorporate prevention activities

into all health services that HIV-positive MSM routinely receive, such as primary care, case management, mental health counseling, and substance abuse treatment. ... Prevention programs should also help HIV-positive MSM develop the communication skills needed to disclose their HIV serostatus to their partner and to negotiate safe[r] sex with him. In addition, interventions should emphasize the importance of counseling and voluntary HIV testing for an HIV-positive man's steady sex partner. MSM who have lower educational levels or who identify as heterosexual require more intensive prevention outreach and intervention. This is true for some racial/ethnic minority MSM as well. Although race and ethnicity were not independent predictors of UAI in our study population, the factors found to be predictive of UAI were much more prevalent among Black, Hispanic, and American Indian/Alaska Native men. (p. 156)

To learn more about disclosure practices, Gorbach et al. (2004) interviewed 55 MSM living with HIV (24 in Seattle , 31 in Los Angeles ) who attended a sexually transmitted disease (STD) clinic and reported either a recent STD or UAI with a partner whose serostatus is negative or unknown. They found that "disclosing one's HIV status to sexual partners is complicated and dependent on multiple and often competing emotional, situational, and legal factors; consequently few men ... had a consistent pattern of disclosing. The themes identified suggest ... avenues for potential intervention, but also illustrate how complex promoting disclosure is likely to be among MSM" (p. 516). Regarding disclosure,

• Those who were "unlikely to disclose" saw HIV as "nobody's business," were in denial about their own HIV status, had a low viral load, feared rejection by HIV-negative partners, saw sex as "just sex," used drugs, and had sex in public places.

• Those who "might disclose" considered the type of sex that was practiced and whether partners asked about serostatus or disclosed first.

• Those who were "likely to disclose" had feelings for their partner, felt responsibility for their partner's health, and feared legal prosecution if they did not disclose and their partner became infected.

It should be noted that many reported the use of nonverbal or indirect disclosure methods (e.g., leaving HIV medications where a partner could see them; sporting tattoos with a "+" symbol). Also important was men's subscribing to the "don't ask, don't tell" doctrine (i.e., placing responsibility on the partner to inquire about HIV status and presuming that those who do not ask must also be positive).

Gorbach and colleagues conclude that "HIV positive MSM's decision to disclose their HIV status to sex partners is ... influenced by a sense of responsibility to partners, acceptance of being HIV positive, the perceived transmission risk, and the context and meaning of sex. Efforts to promote disclosure will need to address these complex issues" (p. 512).

Expanding on this complexity, van Kesteren, Hospers, Kok, and van Empelen (2005) summarize interviews conducted with 30 Dutch gay men living with HIV in an effort to understand more about their perspectives on sexuality and sexual risk behavior . They found that most of their sample engaged in less sexual activity following HIV diagnosis for several reasons.

First, most [men] struggled with the altered meaning and consequences of unprotected sex. Whereas unprotected sex before diagnosis was directly related to risks to their own health, after diagnosis unprotected sex is mainly associated with the risk of transmitting the virus during sexual intercourse. This realization diminished the enjoyment of sex for most [men] and left them feeling anxious and tense. Second, many ... suffered from sexual problems because of physical complaints brought on by the treatment regime or HIV itself. Third, some [men] reported that sexual problems were related to negative feelings about their physical appearance ... . Personal HIV-related risk seemed to play a less important role in sexual problems ... . Although most were aware of the risk of HIV superinfection and STDs for their own health, only half ... reported that they were motivated to practice safer sex to protect themselves. (p. 162)

van Kesteren and colleagues go on to observe that "the majority of participants ... felt responsible for the health of their sex partners. It seemed that both moral concerns ('unprotected sex is wrong') and social concerns (avoidance of blame by others) played a key role in their resolve to practice safer sex with both steady and casual or anonymous sex partners. Only a small minority ... claimed to take no personal responsibility for safer sex and reported that engaging in safer sex practices depended on what a sex partner wanted" (p. 162).

Importantly, while most men articulated a sense of personal responsibility to engage in safer sex, contextual factors seem to influence the consistency of their actual sexual behavior. These included:

• Partner type, with men feeling less personal responsibility for safer sex with casual or anonymous partners who are "aware of the risks they might be taking" (p. 163) or with a seroconcordant partner, either steady or casual;

• Perception of the partner's behavior (i.e., feeling less responsibility toward partners who do not initiate condom use or exert pressure for unprotected sex); and

• Partner characteristics, with partner attractiveness enhancing feelings of responsibility and partner similarity in appearance and background diluting feelings of responsibility.

van Kesteren and colleagues offer these recommendations to clinicians serving MSM living with HIV:

First, because many [men] reported sexual problems after diagnosis with HIV, it is crucial that HIV-preventive interventions for HIV-positive MSM not only target the health-promoting behavior of using a condom every time during anal intercourse but also address ... sexual dysfunction in HIV-positive MSM . . Moreover, HIV prevention programs should include clear and specific information about ... the risk of HIV superinfection and the relationship between undetectable viral load and HIV transmissibility. Failure to meet the information needs of HIV-positive MSM might result in continued confusion about HIV-related risk and might lead some people to discount the relevance of prevention messages . . In addition, specific attention should be paid to the issue of personal responsibility for safer sex. . It seems essential to enhance skills and self-efficacy to handle risk pressure and to negotiate condom use by means of, for example, instruction and modeling . . A possible way to address sexuality and safer sexual behavior in practice [is] brief counseling techniques that have been effective in improving sexual functioning in cancer patients. Typically those interventions focus on (a) assessing sexual problems; (b) providing information on the impact of the illness on sexual drive, behavior, body functioning, and body image; and (c) giving reassurance to the participant (and his partner), improving their communication and finding alternative ways of expressing affection . . The techniques of motivational interviewing . can [also] be useful to target safer sexual practices of HIV-positive MSM.

[Additionally, s]timulating the development of social networks by encouraging helpful relationships that enhance safer sex norms might be a very powerful tool in promoting safer sexual behavior... .(pp. 164-165)

Lightfoot, Song, Rotheram-Borus, and Newman (2005) assessed the influence of partner characteristics and risk status on sexual behavior among 217 young MSM receiving HIV care in New York , Los Angeles , Miami , or San Francisco . Of these young men, 62% reported multiple partners during the preceding 3 months and 34% engaged in unprotected sex during the same period. The investigators found that study participants generally decide whether to use a condom on the basis of their perception of their partner's risk for infection (i.e., they practice safer sex with partners not known to be HIV-positive and do not use condoms with partners they believe to be infected). A similar decision-making process was noted among the 26% of study participants with only one sexual partner, 28% of whom engaged in unprotected sex. These findings concern the authors, "because it is questionable whether the youth can truly know a partner's risk or HIV status or rely on a regular partner to be monogamous. Furthermore, these young men are putting themselves at significant risk for infection with an STD, which could have detrimental effects on their own disease progression" (p. 67).

Lightfoot and colleagues contend that interventions targeting young MSM living with HIV "need to focus on techniques of acquiring information from sexual partners to make a more informed decision [regarding condom use]. Interventions should also reinforce the altruism that [these men] feel toward protecting their partners. Consequently, there is a need to develop prevention strategies that involve couple-oriented and social network models" (p. 67). For those having unprotected sex with seroconcordant partners, "interventions ... must include education about transmission risk for STDs and the detrimental impact of other STDs on their own disease progression" (p. 67). The authors conclude that, "although these young men continue to have unprotected sex, they are making important decisions to protect themselves and others. Prevention programs must focus on promoting good decisions" (p. 67).

This advice extends to negotiated safety (NS), investigated by Guzman et al. (2005) in their survey of a diverse community sample of 340 HIV-negative MSM in San Francisco . "NS relationships were defined as those in which HIV-negative men were in seroconcordant primary relationships for > 6 months, had [UAI] together, and had rules prohibiting [UAI] with others. Adherence to NS was determined from self-reported sexual behavior in the prior 3 months. Presence of an agreement with NS partners to disclose rule breaking was also determined" (p. 82). Within this sample, Guzman and colleagues found that 22% of men were engaged in a seroconcordant primary relationship of at least 6 months' duration. Of this group, 50% had a relationship including NS; 39% had no UAI with primary partners; and 11% engaged in UAI with primary partners, but had no rules proscribing UAI with other men. Among the 38 men in an NS relationship, "29% violated their NS-defining rule in the prior 3 months, including 18% who reported [UAI] with others, and 18% reported [an STD] in the prior year. Only 61% of NS men adhered fully to rules and agreed to disclose rule breaking" (p. 82).

Guzman and colleagues conclude that, "[a]lthough NS was commonly practiced among HIV-negative men in seroconcordant relationships, some men violated NS-defining rules, placing themselves and potentially their primary partners at risk for HIV infection. Prevention efforts regarding NS should emphasize the importance of agreement adherence, disclosure of rule breaking, and routine [STD] testing" (p. 82). They further concede that "[u]ntil further data are collected from studies of US MSM regarding their NS relationships, including factors associated with agreement rule breaking, caution should be used in endorsing NS as an alterative risk reduction strategy to condom use for US HIV-negative men in seroconcordant relationships" (p. 85).

Finally, Huebner, Rebchook, and Kegeles (2004) surveyed a convenience sample of 538 young adult gay and bisexual men who were HIV-negative or untested and not engaged in monogamous relationships at baseline, and surveyed them again 18 months later. "In the cross-sectional data, treatment optimism [about highly active antiretroviral therapy (HAART)] was associated with the 2-month cumulative incidence of [UAI] with nonprimary partners; however, this effect was observed only among men who felt highly susceptible to HIV infection. Longitudinal analyses revealed that treatment optimism did not predict subsequent UAI, but UAI did predict later treatment optimism" (p. 1514). The authors conclude from their findings that "although risk and treatment optimism are related, the association may be more complex than previously thought. Whereas some prior research has implied that optimism drives subsequent risky sexual behavior, [these] data indicate that optimism is just as likely to follow from past risk behavior" (p. 1518).

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