Trends in agreements between regular partners among gay men in Sydney, Melbourne and Brisbane, Australia

Stronger Together: Results from a Randomized Controlled Efficacy Trial of a Dyadic Intervention to Improve Engagement in HIV Care Among Serodiscordant Male Couples in Three US Cities

Engagement in HIV care and a high level of antiretroviral therapy (ART) adherence for people living with HIV is crucial to treatment success and can minimize the population burden of the disease. Despite this, there is a critical gap in HIV prevention science around the development of interventions for serodiscordant male couples. This paper reports on the results of a randomized controlled trial to assess the efficacy of Stronger Together, a dyadic counseling intervention aimed at increasing engagement in and optimizing HIV care among serodiscordant male couples in Atlanta, GA, Boston, MA, and Chicago, IL. Between 2014 and 2017, 159 male serodiscordant couples (total N = 318) in Atlanta, GA, Boston, MA, and Chicago, IL were enrolled and equally randomized to either the Stronger Together intervention arm (a three-session dyadic intervention involving HIV testing and adherence counseling) or a standard of care (SOC) control arm. Couples completed individual study assessments via an audio computer assisted self-interviewing (ACASI) system at baseline, 6, 12 and 18 months. Primary outcomes included being prescribed and currently taking ART, and fewer missed doses of ART in the past 30 days; because the trial was not powered to examine viral suppression, we examined this as an exploratory outcome. Longitudinal data analysis was by an intention-to-treat approach. Participants ages ranged from 18 to 69 (mean = 35.9), and are predominantly white (77.5%), and college educated (68.4% earned a college degree or higher). Participants randomized to the Stronger Together arm had a significantly greater odds of being prescribed and currently taking ART over time than those in the SOC arm (at 12 months OR 2.75, 95%CI 1.35-4.67, p-value 0.020, and at 18 months OR 2.91, 95%CI 1.61-4.88, p-value 0.013). Similarly, those in the Stronger Together arm had a significantly lower odds of missing a dose of ART in the past 30 days over time compared to those in the SOC arm (at 12 months OR 0.28, 95%CI 0.09-0.81, p-value 0.019, and at 18 months OR 0.25, 95%CI 0.07-0.82, p-value 0.023). Among male couples in serodiscordant relationships, the Stronger Together intervention resulted in significantly improved HIV treatment outcomes at both 12 and 18 months of follow-up. This trial is the first to date to demonstrate evidence of efficacy for a dyadic counseling intervention and has the potential to fill a critical gap in secondary HIV prevention interventions for serodiscordant male couples.

Communication Patterns Among Male Couples with Open and Monogamous Agreements

Male couples in open relationships tend to have as equally fulfilling relationships as monogamous male couples; however, less is known about communication differences between monogamous and open couples. Because couples with open agreements permit sex with outside partners, they must navigate different relationship issues than monogamous couples, and this can translate to differences in communication. We therefore examined differences between cisgender men in monogamous versus open relationships regarding communication about sexual agreements, safety agreements, breaking of sexual and safety agreements, the disclosure of broken sexual and safety agreements, and general relationship communication. Using a sample of 395 couples, we found that while certain aspects of communication are different for monogamous couples compared to open couples, similarities also exist. Specifically, we identified no differences in how explicitly couples discussed their sexual and safety agreements, attitudes toward communication about safety agreements, and mutual avoidance and withholding communication. However, monogamous couples had more positive attitudes toward communication about sexual agreements. The results were mixed on the perceived impact that broken safety agreements had on communication with the primary partner. Our results are interpreted with attention to relationship well-being and implications for safer sex practices.

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.

A Dyadic Perspective on Sexual Agreements Among Same-Sex Male Couples in the United States

Sexual agreements are an important HIV risk reduction strategy enacted by men in male-male partnerships. Greater levels of relationship quality have been associated with sexual agreement formation and adherence. However, current evidence supporting the associations between relationship quality and sexual agreements for male dyads is based primarily on the responses of just one partner. Understanding that relationship quality and decisions about sexual agreements are inherently influenced by both partners, the present analysis uses dyadic-level data to examine the sexual agreements among 199 HIV serodiscordant and seroconcordant male dyads (n = 398 individuals). Specifically, the analysis examines measures of love, trust, and conflict style as they relate to (1) the type of agreement established, (2) concordance in agreement reporting, (3) satisfaction with the agreement, and (4) broken agreements. A discrepancy in love between partners was associated with the type of agreement established, whether they reported the same agreement type, and whether one of the partners reported a broken agreement, but it was not associated with either partner's satisfaction with the agreement. A discrepancy in trust was associated with agreement concordance and agreement breaks, but it was not associated with the type of agreement established or satisfaction with the agreement. Lastly, a discrepancy in conflict style was associated with each of the agreement outcomes. Future research and intervention efforts should focus on understanding the behavioral and communication skills necessary for couples to make successful sexual agreements.

Comparing Australian gay and bisexual men with undiagnosed and recently diagnosed HIV infection to those in the National HIV Registry

Background Gay and bisexual men (GBM) with recent HIV infection are a key population to inform HIV-prevention. The National HIV Registry (NHR) provides details about all individuals diagnosed with HIV, but it is unclear how.

METHODS

Basic sociodemographic characteristics of GBM in the NHR who were diagnosed between 2010 and 2014 were compared with three samples of GBM: men with undiagnosed HIV infection from the Community-Based Study of Undiagnosed HIV and Testing (COUNT) study of HIV prevalence and undiagnosed infection that was conducted during 2013-14; men in the Australian Gay Community Periodic Surveys (GCPS) who were diagnosed with HIV between 2010 and 2014; and men in the HIV Seroconversion Study (SCS) who were also diagnosed in those years.

RESULTS

The NHR identified 3629 men who reported male-to-male sex as the exposure risk for their diagnosis between 2010 and 2014. COUNT identified 19 (8.9% of all men who tested HIV positive) men as having undiagnosed HIV. In the GCPS sample, 185 (2.5%) reported being diagnosed with HIV in 2010-14. In total, 367 men in the SCS received their diagnosis during 2010-14. The mean age of men in the NHR (36.8 years) was similar to that in GCPS (36.3 years) and SCS (35.1 years), while undiagnosed men in COUNT were younger (32.6 years), with no other significant differences between the samples.

CONCLUSIONS

The undiagnosed men were somewhat younger than diagnosed men. To achieve earlier diagnosis of new HIV infections, improved HIV testing frequency is needed among younger men.

Sexual Agreements: A Scoping Review of Measurement, Prevalence and Links to Health Outcomes

A sexual agreement is a mutual understanding between two partners regarding sexual and relational behaviors both within and outside of their relationship. Sexual agreements have been central to research and programming efforts around HIV prevention, primarily for male couples. A comprehensive scoping review of the primary literature on sexual agreements, including negotiated safety, was performed to identify what is known about sexual agreements among couples (n = 66). Results indicate a wide range of prevalence of agreements and measurements used to characterize sexual agreements. Findings also report associations between sexual agreements and health and relational outcomes. Several knowledge gaps were identified; specifically, the need to expand sexual agreements research beyond MSM populations and the need to better understand agreement breaks, break disclosure, and how variation in agreement categorization may impact reported prevalence. This review demonstrates the importance of broadening the evidence-base of sexual agreements research and programmatic focus.

Project Stronger Together: Protocol to Test a Dyadic Intervention to Improve Engagement in HIV Care Among Sero-Discordant Male Couples in Three US Cities

BACKGROUND

An estimated one- to-two-thirds of new human immunodeficiency virus (HIV) infections among US men who have sex with men (MSM) occur within the context of primary partnerships. Despite this fact, there remains a lack of prevention interventions that focus on male sero-discordant dyads. Interventions that provide male couples with skills to manage HIV risk, and to support each other towards active engagement in HIV prevention and care, are urgently needed.

OBJECTIVE

The objective of this paper is to describe the protocol for an innovative dyadic intervention (Stronger Together) that combines couples' HIV testing and dyadic adherence counseling to improve treatment adherence and engagement in care among HIV sero-discordant male couples in the United States.

METHODS

The research activities involve a prospective randomized controlled trial (RCT) of approximately 165 venue- and clinic-recruited sero-discordant male couples (330 individuals: 165 HIV sero-negative and 165 HIV sero-positive). Couples randomized into the intervention arm receive couples' HIV counseling and testing plus dyadic adherence counseling, while those randomized to the control arm receive individual HIV counseling and testing. The study takes place in three cities: Atlanta, GA (study site Emory University); Boston, MA (study site The Fenway Institute); and Chicago, IL (study site Ann & Robert H. Lurie Children's Hospital of Chicago). Cohort recruitment began in 2015. Couples are followed prospectively for 24 months, with study assessments at baseline, 6, 12, 18, and 24 months.

RESULTS

Stronger Together was launched in August 2014. To date, 160 couples (97% of the target enrollment) have been enrolled and randomized. The average retention rate across the three sites is 95%. Relationship dissolution has been relatively low, with only 13 couples breaking up during the RCT. Of the 13 couples who have broken up, 10 of the 13 HIV-positive partners have been retained in the cohort; none of these HIV-positive partners have enrolled new partners into the RCT.

CONCLUSIONS

The intervention offers a unique opportunity for sero-discordant couples to support each other towards common HIV management goals by facilitating their development of tailored prevention plans via couples-based HIV testing and counseling, as well as problem-solving skills in Partner Strategies to Enhance Problem-solving Skills (STEPS).

TRIAL REGISTRATION

ClinicalTrials.gov NCT01772992; https://clinicaltrials.gov/ct2/show/NCT01772992 (Archived by WebCite at http://www.webcitation.org/6szFBVk1R).

In Australia, Most HIV Infections Among Gay and Bisexual Men are Attributable to Sex with 'New' Partners

It has been estimated that the majority of global HIV infections among gay and bisexual men (GBM) can be attributed to sex within a committed relationship. In Australia, however, negotiated safety, whereby HIV-negative regular partners agree to discard condoms with each other but commit to consistent condom use with other partners, has been promoted as a key component of the HIV prevention response. We asked GBM recently diagnosed with HIV to describe their relationship to the person they believed to be the source of their infection ('source person'). The majority (66.1%) ascribed their infection to a casual partner. A further 23.3% ascribed their infection to a non-committed and non-romantic partner (or 'fuckbuddy'). Only 10.6% believed they had acquired their HIV from a 'boyfriend' in the context of a committed romantic relationship, and 51.7% of these occurred within the first 3 months following their first sexual contact. Most men (61.5%) believed they had acquired their HIV infection on the first occasion they had sex with the source person. In the Australian context, negotiated safety appears to have minimised infections between regular partners. However, many HIV infections between regular partners may not be in the context of a romantic committed relationship, and yet this distinction between types of regular partners has been all but ignored. Furthermore, in this sample, most infections occurred on the occasion of first meeting, suggesting that the most useful indicators of risk may be the characteristics, contexts, and lengths of sexual partnerships and how sex is negotiated, rather than how GBM categorize their partner. Findings suggest more new HIV infections occur in new partnerships, than in established relationships.

Home-Based HIV Testing and Counseling for Male Couples (Project Nexus): A Protocol for a Randomized Controlled Trial

BACKGROUND

HIV prevalence remains high among men who have sex with men (MSM) in the United States, yet the majority of research has focused on MSM as individuals, not as dyads, and has discussed HIV risks primarily in the context of casual sex. Nexus is an online prevention program that combines home-based HIV testing and couples HIV testing and counseling (CHTC). It allows partners in dyadic MSM relationships to receive HIV testing and care in the comfort of their designated residence, via video-based chat. By using video-based technologies (eg, VSee video chat), male couples receive counseling and support from a remote online counselor, while testing for HIV at home.

OBJECTIVE

This randomized control trial (RCT) aims to examine the effects of video-based counseling combined with home-based HIV testing on couples' management of HIV risk, formation and adherence to explicit sexual agreements, and sexual risk-taking.

METHODS

The research implements a prospective RCT of 400 online-recruited male couples: 200 self-reported concordant-negative couples and 200 self-reported discordant couples. Couples in the control arm will receive one or two home-based HIV self-testing kits and will be asked to report their results via the study's website. Couples in the experimental arm will receive one or two home-based HIV self-testing kits and will conduct these tests together under the facilitation of a remotely located counselor during a prescheduled VSee-based video CHTC session. Study assessments are taken at baseline, as well as at 3- and 6-month follow-up sessions.

RESULTS

Project Nexus was launched in April 2016 and is ongoing. To date, 219 eligible couples have been enrolled and randomized.

CONCLUSIONS

Combining home-based HIV testing with video-based counseling creates an opportunity to expand CHTC to male couples who (1) live outside metro areas, (2) live in rural areas without access to testing services or LGBTQ resources, or (3) feel that current clinic-based testing is not for them (eg, due to fears of discrimination associated with HIV and/or sexuality).

TRIAL REGISTRATION

ClinicalTrials.gov NCT02335138; https://clinicaltrials.gov/ct2/show/NCT02335138 (Archived by WebCite at http://www.webcitation.org/6qHxtNIdW).

Negotiated safety - components, context and use: an integrative literature review

AIM

The aim of this study was to examine the components and use of negotiated safety in the context of HIV prevention and to identify reported factors associated with the concept.

BACKGROUND

There is an emerging interest in dyadic approaches to address HIV transmission. Although there are theoretical foundations for how interpersonal relationships influence individual behaviour, how these dyadic processes influence on health is still not wholly understood.

DESIGN

Integrative review of empirical and theoretical literature.

DATA SOURCES

The Cumulative Index for Nursing and Allied Health Literature (CINAHL) MEDLINE and PsychINFO electronic databases were accessed.

REVIEW METHODS

Articles were read to gain a historical context of the term and identify varying interpretations of the concept. Factors warranting consideration in association with NS were identified and clinical and public health implications were noted.

RESULTS

Forty-eight studies were reviewed. Negotiated safety included the following components: (i) HIV sero-negative concordant men within a primary relationship; (ii) joint HIV screening and mutual disclosure of their HIV status; (iii) explicit relationship boundaries which establish either nonexclusively that allows for the dispensing of condoms within the primary relationship and consistent condom use for extra-dyadic sex; or dispensing of condoms within a primary partnership and exclusivity; and (iv) a breach clause that allows communication to re-establish the agreement if needed.

CONCLUSION

Negotiated safety is a prescriptive approach to HIV risk reduction among couples. Researchers and practitioners could benefit from promoting this approach to HIV prevention.

A Dyadic Behavioral Intervention to Optimize Same Sex Male Couples' Engagement Across the HIV Care Continuum: Development of and Protocol for an Innovative Couples-based Approach (Partner Steps)

Background

An estimated one- to two-thirds of new human immunodeficiency virus (HIV) infections among US men who have sex with men (MSM) occur within the context of primary partnerships. Thus, HIV interventions that recognize and harness the power of relationships are needed. Increasingly, HIV prevention efforts are being directed toward improving engagement across the HIV care continuum from testing to linkage to care, antiretroviral therapy (ART) adherence, engagement in care, and viral suppression. However, to our knowledge, no behavioral interventions have attempted to address the HIV care continuum using a dyadic approach.

Objective

The objective of this paper is to describe the development of and protocol for an innovative couples-based approach to improving treatment adherence and engagement in care among HIV serodiscordant and concordant HIV-positive same sex male couples in the United States.

Methods

We developed the Partner Steps intervention by drawing from relationship-oriented theory, existing efficacious individual-level ART adherence interventions, couple-focused HIV prevention interventions, and expert consultation. We incorporated new content to address all aspects of the HIV care continuum (eg, linkage to and retention in care) and to draw on relationship strengths through interactive activities.

Results

The resulting theory-based Partner Steps intervention is delivered by a trained bachelors-level counselor (interventionist) over 2 in-person sessions with male-male dyads in which at least 1 partner has recent suboptimal engagement in HIV care. Each session is designed to use relationship strengths to increase motivation for HIV care and treatment, and cover sequential intervention “steps” relating to specific challenges in HIV care engagement and barriers to ART adherence. For each step, couples work with a trained interventionist to identify their unique challenges, actively problem-solve with the interventionist, and articulate and commit to working together to implement a plan in which each partner agrees to complete specific tasks.

Conclusions

We drew on theory and evidence to develop novel intervention strategies that leverage strengths of relationships to address engagement across the entire HIV care continuum. We provide details on intervention development and content that may be of use to researchers as well as medical and mental health professionals for whom a dyadic approach to HIV prevention and care may best suit their patient population.

Perceived Challenges and Rewards of Forming a Sexual Agreement Among HIV-Negative Male Couples

Sexual agreements, explicit mutual understandings made between two partners about which sexual and related behaviors they agree to engage in within and/or outside of their relationship, are common among male couples. However, little is known about the perceived rewards and challenges partnered men face in the process of forming a sexual agreement. Such knowledge may be useful for the development of future HIV preventive and sexual health programs that encourage male couples to establish a sexual agreement in their relationship. By using qualitative dyadic data from a sample of 29 self-reported concordant HIV-negative male couples who had a sexual agreement, the present qualitative study sought to assess partnered men's perceived rewards and challenges of forming a sexual agreement in their relationship and examine whether both men in the couple concurred about their perceived rewards and challenges of forming a sexual agreement. Themes for perceived rewards were (1) being honest, (2) improving communication, (3) increasing understanding about expectations and permitted behaviors, (4) enhancing intimacy and relational bond, and (5) building trust. Themes for perceived challenges were: (1) stigma about having an open agreement; (2) awkwardness about the topic and talking about it; (3) jealousy; and (4) no perceived challenges. Few couples had both partners concur about their perceived rewards or challenges toward establishing a sexual agreement. The variety of perceived rewards and challenges highlight the need for tailoring given that a variety of factors may influence partnered men's establishment of a sexual agreement in their relationship.

Illuminating the Context and Circumstances of Male Couples Establishing a Sexual Agreement in Their Relationship

A sexual agreement is an explicit mutual understanding made between two partners about which sexual and relational behaviors they agree to engage in within and/or outside of their relationship. Factors that prompt male couples to form a sexual agreement and under what circumstances remain underinvestigated, yet are important considerations for development of couples-based sexual health and HIV prevention interventions. By using thematic analysis with qualitative dyadic data from a convenience sample of 29 HIV-negative male couples, the present study sought to describe the timing and investigate the context and circumstances that led male couples to establish a sexual agreement in their relationship at both the individual and couple levels, and by agreement type. Themes identified for when a sexual agreement was formed included within the first 6 months, and after 6 months in the relationship. Themes related to context and circumstances of couples' sexual agreement formation were as follows: (a) desire for sexual exploration, (b) arisen circumstances or events with other men, (c) influences from past relationship(s) and/or other couples (i.e., peers), (d) to protect against HIV, and (e) purposeful conversations versus understood. Findings suggest HIV prevention efforts should include skill-building exercises to help improve communication and promote sex positivity within male couples' relationships.

Younger Gay and Bisexual Men's Condom Use With Main Regular Sexual Partner in New Zealand

Main partners are a common source of new HIV infections among men who have sex with men (MSM). National behavioral surveillance data (2006-2011) for younger MSM (YMSM, aged 16-29) in New Zealand were analyzed to investigate condom use during anal intercourse with a regular partner (boyfriend/fuckbuddy) by sexual position (insertive/receptive). Backward-stepwise multivariate multinomial logistic regression was used to identify demographic, relational, behavioral, and cognitive factors associated with condom use frequency (high, medium, low). Most YMSM who reported a current regular partner (n=1,221) classified them as a boyfriend (59.5%) versus fuckbuddy (40.5%), though condom use was higher with the latter partner type. Condom use or nonuse was habitual across partners, although insertive sexual position was positively associated with condom use. YMSM who believed condoms reduce sensitivity reported lower condom use. Condoms remain the leading HIV/STI prevention tool for YMSM; efforts to improve condom use must consider sexual position and relationship factors.

Stimulant use patterns and HIV transmission risk among HIV-serodiscordant male couples

BACKGROUND

Substance use is strongly linked to HIV risk, and members of couples can have a powerful influence on each other's health behaviors. We examined whether couple-level patterns of stimulant use were differentially associated with engaging in condomless anal intercourse with primary partners and outside partners.

METHODS

Members of HIV serodiscordant male couples (N = 117 couples, 232 men) completed surveys, and HIV-positive men had blood drawn for viral load.

RESULTS

Results revealed that stimulant use by only one partner in the couple was associated with a decrease in the odds of engaging in condomless anal sex with one's primary partner (AOR = 0.09, 95% CI: 0.01, 0.89). When both partners reported stimulant use, the HIV-negative partner had an increase in the odds of condomless sex with outside partners (AOR = 6.68, 95% CI: 1.09, 8.01).

CONCLUSIONS

Understanding the role of couples' stimulant use patterns in HIV transmission risk is an important area for future research and intervention.

A scoping review and thematic analysis of social and behavioural research among HIV-serodiscordant couples in high-income settings

BACKGROUND

While HIV incidence has stabilized in many settings, increases in health and wellbeing among many people living with HIV/AIDS suggest that the number of HIV-serodiscordant relationships is growing. Given the deficit of reviews addressing social and behavioural characteristics of HIV-serodiscordant couples within high-income settings, our objective was to understand the scope of the published literature, identify evidence gaps, and suggest future research needs.

METHODS

Ten electronic databases were searched. Studies were included if they were reported in English, used primary data, were from the combination antiretroviral (cART) era (>1996), reported on social or behavioural aspects, included any fraction of primary (i.e., stable) relationships, and were conducted in high-income settings. Studies that identified their unit of analysis as either the dyad or individual member of the couple were included. Studies were coded according to a thematic framework.

RESULTS

Included studies (n = 154) clustered into eight themes: risk behaviours (29%), risk management (26%), reproductive issues (12%), relationship quality (9%), serostatus disclosure (7%), adherence to antiretroviral therapy (7%), vulnerability (5%), and social support (3%). The proportion of studies conducted among heterosexual couples, same-sex male couples, and mixed cohorts were 42%, 34%, and 24%, respectively. Most studies (70%) were conducted in the United States, 70% of all studies were quantitative (including interventions), but only one-third were focused on couples (dyads) where both partners are recruited to a study. Over 25% of studies focused on sexual risk among same-sex male couples.

CONCLUSIONS

Future research efforts should focus on the interrelationship of risk management strategies and relationship quality, social determinants of health and wellbeing, HIV testing, vulnerable populations, reproductive issues among same-sex couples, disclosure of serodiscordant status to social networks, dyadic studies, population-based studies, and interventions to support risk management within couples. Additional population-based studies and studies among marginalized groups would be helpful for targeting research and interventions to couples that are most in need. As HIV-positive partners are typically the link to services and research, innovative ways are needed for reaching out to HIV-negative partners. Our review suggests that significantly more research is needed to understand the social and behavioural contexts of HIV-serodiscordant relationships.

Motivations to test for HIV among partners in concordant HIV-negative and HIV-discordant gay male couples

Previous studies of HIV testing among gay men describe the motivations, facilitators and barriers, behaviors, and demographic characteristics of individuals who test. What little research focuses on HIV testing among gay men in relationships shows that they do not test regularly or, in some cases, at all-their motivations to test have not been investigated. With so little data on HIV testing for this population, and the continued privileging of individually focused approaches, gay men in relationships fall into a blind spot of research and prevention efforts. This study examined motivations to test for HIV using qualitative data from both partners in 20 gay male couples. Analysis revealed that the partners' motivations were either event-related (e.g., participants testing at the beginning of their relationship or HIV-negative participants in an HIV-discordant relationship testing after risky episode with their discordant primary partner) or partner-related (e.g., participants testing in response to a request or suggestion to test from their primary partner or participants testing out of concern for their primary partner's health and well-being). These data provide insight into relationship-oriented motivations to test for HIV for gay men in relationships and, in doing so, evidence their commitment to their primary partner and relationship. These motivations can be leveraged to increase HIV testing among gay men in relationships, a population that tests less often than single gay men, yet, until recently, has been underserved by prevention efforts.

Between and within couple-level factors associated with gay male couples' investment in a sexual agreement

Sexual agreements are common among gay male couples, and between one-third and two-thirds of gay men acquire HIV while in a same-sex relationship. Studies have assessed whether agreements could be used for HIV prevention yet additional research is needed. By using dyadic data collected from 361 U.S. gay male couples, the present cross-sectional study sought to assess whether certain between and within couple-level relationship characteristics predict a partner's value in, commitment to, and satisfaction with an agreement. On average, couples with higher levels of constructive communication and relationship satisfaction and commitment were associated with partners who had higher levels of investment in the agreement. Within the couple, differences in commitment and investment of the relationship were also found to be negatively associated with partners' investment toward an agreement. Implications are discussed for how sexual agreements may be used to develop new HIV prevention efforts for gay male couples.

Trust, commitment, love and sex: HIV, monogamy, and gay men

Research on gay men's relationships has neglected monogamy. Instead, it has tended to (a) emphasize HIV risk and relationship agreements between partners regarding sex and condom use with outside partners or (b) focus on nonmonogamous relationships as emblematic of relationship innovation. On the basis of qualitative interviews with 36 gay Australian men who favored a monogamous relationship as ideal, this article explores the meaning and practice of monogamy and its association with HIV risk. The authors present themes that include men's use of condoms in monogamous relationships, expectations of fidelity, and understandings of trust and security as the basis to meaningful and satisfying relationships.

Australian gay men's satisfaction with sexual agreements: the roles of relationship quality, jealousy, and monogamy attitudes

This study examined whether relationship quality, dispositional jealousy, and attitudes towards monogamy were associated with gay men's satisfaction with the agreements they have in their relationships about extra-dyadic sex. Three types of sexual agreement were examined: closed (no extra-dyadic sex is allowed), monogamish (extra-dyadic sex is allowed only when both members of the couple are present), and open (extra-dyadic sex is allowed). Results from a 2010 survey of 772 gay men in relationships indicated that sexual agreement satisfaction was positively associated with levels of intimacy and commitment for all three types of sexual agreement, but was differentially associated with sexual satisfaction within the relationship, jealousy, and monogamy attitudes as a function of sexual agreement type. Mean levels of sexual satisfaction, jealousy, and monogamy attitudes also differed between types of agreement. These findings provided preliminary evidence that sexual agreement satisfaction may be influenced by different factors depending on the type of agreement, which has useful implications for professionals with gay male clients experiencing dissatisfaction with their agreement or with their relationship more generally.

Aspects of gay male couples' sexual agreements vary by their relationship length

Few HIV-preventing interventions exist for gay male couples in the USA, yet estimates indicate that between one- and two-thirds of US men who have sex with men acquire HIV while in a primary relationship (e.g., gay male couples). In response to these statistics, research has been conducted to better understand gay male couples' relationships, including their sexual agreements. Many gay male couples in the USA establish a sexual agreement, which is an explicit mutual understanding between two main partners about what sexual and other behaviors they agree to engage in and with whom while in the relationship. Although some research about sexual agreements has been conducted, little is known on whether aspects of gay male couples' sexual agreements (e.g., establishment, type, and adherence) vary as a function of their relationship length. The present study aimed to fulfill this gap of knowledge, which may lead to a better understanding of how agreements can be used for developing HIV/sexually transmitted infection (STI) prevention interventions. A national, cross-sectional, Internet-based study was used to collect dyadic data from 361 US gay male couples. Men in each couple completed the questionnaire independently. All analyses were employed at the couple level. Our findings showed that the longer the couples had been in their relationship, the more likely they would concur about having a sexual agreement. As relationship length increased, the proportion of couples who disagreed about their current agreement type increased. No direct trend was found for recent adherence to an agreement; however, the likelihood of ever breaking an agreement increased as relationship length increased. Findings from this study indicate there is a need to help gay male couples' establish and maintain their agreements, particularly for those who are in their early formative stages, as well as, for those who are experiencing challenges and/or changes in their relationships.

Sexual risk for HIV among gay male couples: a longitudinal study of the impact of relationship dynamics

While the relationship context itself is increasingly being examined to understand sexual risk behavior among gay male couples, few studies have examined relationship dynamics and HIV risk longitudinally. We aimed to investigate relationship dynamics and psychosocial predictors of unprotected anal intercourse (UAI) with outside partners of serodiscordant or unknown HIV serostatus (UAIOUT) over time as well as UAI with primary partner in serodiscordant couples (UAIPP). We recruited a sample of 566 ethnically diverse, seroconcordant and serodiscordant couples and interviewed them six times over the course of 3 years. The surveys encompassed relationship dynamics between the partners and sexual behavior with primary and outside partners. We fit generalized linear mixed models for both the UAI outcomes with time and relationship dynamics as predictors while controlling for relationship length. Analyses of the longitudinal data revealed that, in both categories of couples, those with higher levels of positive relationship dynamics (e.g., commitment, satisfaction) were less likely to engage in UAIOUT. Higher investment in sexual agreement and communication were among the factors that significantly predicted less UAIOUT for seroconcordant couples, but not for the serodiscordant couples. For serodiscordant couples, greater levels of attachment and intimacy were associated with greater odds of UAIPP while increased HIV-specific social support was associated with lower odds of UAIPP. These results underscore the importance of creating and tailoring interventions for gay couples that help maintain and strengthen positive relationship dynamics as they have the potential to produce significant changes in HIV risk behavior and thereby in HIV transmission.

Personal or relational? Examining sexual health in the context of HIV serodiscordant same-sex male couples

Couples' ability to adopt a "we" orientation has been associated with optimal health outcomes. This study examined how personal and relational motivations are uniquely associated with unprotected anal intercourse (UAI), protected anal intercourse (PAI), and the absence of sexual activity within HIV-serodiscordant same-sex male couples. HIV-positive men and their HIV-negative partners (N = 116 couples, 232 men) completed questionnaires and HIV-positive men had blood drawn for viral load. Results of a multinomial logistic regression illustrated that sexual satisfaction was positively associated with PAI among HIV-negative partners and negatively associated with PAI among HIV-positive partners. Endorsing a "we" orientation was positively associated with PAI among HIV-positive partners. Findings suggest that HIV-positive partners who espouse a "we" orientation may be willing to forgo their personal interests to protect their HIV-negative partners from HIV transmission. Couples-based interventions are warranted to help strengthen relationship dynamics to enhance the sexual health of serodiscordant couples.

Intimacy, monogamy, and condom problems drive unprotected sex among young men in serious relationships with other men: a mixed methods dyadic study

This mixed methods study aimed to examine partner and relationship characteristics associated with HIV risk among young men who have sex with men (YMSM). A sub-sample of YMSM (18-25 years) who were involved in serious relationships with other men were recruited from two on-going longitudinal studies, Project Q2 and Crew450 (N = 20 couples). The mean age of the dyadic sample was 22.5 years (SD = 5.33, range 18-46 years) and participants were racially and ethnically diverse, with the largest percentage of the sample identifying as African American (47.5 %), followed by Hispanic (20 %). Participants completed individual self-report measures using computer-assisted self-interview technology and engaged in couples-based interviews. Mixed methods analyses indicated three global reasons for unprotected sex among YMSM in serious relationships: (1) the desire to achieve emotional intimacy; (2) the perception of being in a monogamous relationship; and (3) the difficulties associated with accessing and/or using condoms. Couples' decision-making processes, including decisions made "in the heat of the moment," have implications for HIV prevention interventions.

Past present: Relationship dynamics may differ among discordant gay male couples depending on HIV infection history

Discordant couples are unique because neither partner shares the same serostatus. Yet research overlooks how they became discordant, mistakenly assuming that they have always been that way and, by extension, that being discordant impacts the relationship in a similar manner. This study examines HIV infection history and its impact on relationship dynamics using qualitative data from 35 discordant gay male couples. Most couples met discordant (69%); however, many did not (31%). Those couples that met discordant felt being discordant had a lesser impact on their sexual and relational satisfaction, while those that did not meet discordant felt it had a greater impact, reporting sexual frustration and anxiety over seroconverting. This suggests that relationship dynamics may differ for discordant couples depending on HIV infection history. HIV prevention and counseling services for discordant couples can be better tailored and more effective when differences in HIV infection history are recognized.

Satisfaction with open sexual agreements in Australian gay men's relationships: the role of perceived discrepancies in benefit

This study investigated whether satisfaction with open sexual agreements in gay men's relationships was associated with perceptions of discrepancies in the benefit experienced from those agreements. Three types of perceived discrepancy between the self and the relationship partner were examined: frequency of casual sex, attractiveness of casual partners, and "overall" benefit. Results from a survey conducted in 2010 of 685 Australian gay men in relationships with open agreements showed that men perceiving discrepancies in benefit, particularly those representing "under-benefit", were less satisfied with their agreement than were men perceiving equal benefit. These results supported hypotheses derived from equity theory and provide insight into factors associated with gay men's satisfaction with open agreements. These findings also have important practical implications. Professionals counselling gay men or couples experiencing low satisfaction with open agreements may consider raising issues of unequal benefit and work with their clients towards achieving equality.

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.

Versatility and HIV vulnerability: patterns of insertive and receptive anal sex in a national sample of older Australian gay men

According to mathematical modeling, HIV is more likely to spread through a population of men who have sex with men when high numbers practice versatile anal sex roles, that is, engage in both insertive (IAI) and receptive anal intercourse (RAI). Yet, actual patterns of versatility remain largely unknown, particularly among older men who currently face growing rates of HIV. In this study, 1,135 Australian gay men aged 40 years and older completed a national online survey of their sexual health and behavior over the past 12 months. Of men who had anal intercourse, 62 % engaged in both IAI and RAI. Factors associated with being versatile included younger age (P = 0.01), higher income (P = 0.009), and larger numbers of sexual partners (P = 0.003). Among men with multiple sexual partners, 20 % were highly versatile, that is, reported similar numbers of IAI and RAI partners. Having HIV (P = 0.003) and living in a rural area (P = 0.04) were significantly associated with being highly versatile. These data point to high rates of versatility among older Australian gay men, with implications for mathematical predictions of change in HIV epidemics and for the design of future HIV prevention strategies.

Characteristics and allowed behaviors of gay male couples' sexual agreements

Research has shown that gay male couples' sexual agreements may affect their risk for HIV. Few U.S. studies have collected dyadic data nationally from gay male couples to assess what sexual behaviors they allow to occur by agreement type and the sequence of when certain behaviors occur within their relationships. In our cross-sectional study, dyadic data from a convenience sample of 361 male couples were collected electronically throughout the United States by using paid Facebook ads. Findings revealed that couples discussed their HIV status before having unprotected anal intercourse (UAI) but established their agreement some time after having UAI. About half of the couples (N = 207) concurred about having an agreement. Among these couples, 58% concurred about explicitly discussing their agreement, 84% concurred about having the same type of agreement, and 54% had both men adhering to it. A variety of sexual behaviors were endorsed and varied by agreement type. Concordance about aspects of couples' agreements varied, suggesting the need to engage couples to be more explicit and detailed when establishing and communicating about their agreements. The allowed behaviors and primary reasons for establishing and breaking sexual agreements further highlight the need to bolster HIV prevention for gay male couples.

Agreements about extra-dyadic sex in gay men's relationships: exploring differences in relationship quality by agreement type and rule-breaking behavior

Research comparing the quality of monogamous and non-monogamous ("open") relationships among gay men has produced mixed findings. In addition, little is known about the consequences of breaking the rules of relationship agreements about extra-dyadic sex. Results from a survey of 229 gay men in romantic relationships showed that open relationships were less passionate, but no less intimate or committed, than monogamous or "threesome-only" relationships. However, men who broke rules reported lower relationship quality overall, regardless of the relationship agreement. Thus, it is less the nature of the agreement itself than adhering to the conditions of it that influences relationship quality.

Relationship characteristics associated with sexual risk behavior among MSM in committed relationships

Understanding situations that increase HIV risk among men who have sex with men (MSM) requires consideration of the context in which risky behaviors occur. Relationships are one such context. This study examines the presence and predictors of unprotected anal intercourse (UAI) in the past 3 months among 566 MSM couples. A majority of couples allowed sex with outside partners. Overall, 65% of the sample engaged in UAI with primary partner, including nearly half of discordant couples. Positive relationship factors, such as attachment and intimacy, were associated with an increased likelihood of UAI with primary partner. Meanwhile, 22% of the sample engaged in at least one episode of UAI with an outside partner, half of whom were discordant or unknown HIV status outside partners. Higher levels of HIV-specific social support, equality, and sexual agreement investment were significantly associated with a decreased likelihood of engaging in UAI with a discordant or unknown HIV status outside partner. HIV-positive men in discordant relationships had two and one half times the odds of having UAI with a discordant or unknown HIV status outside partner as their HIV-negative partners. Many MSM in relationships, including some in serodiscordant ones, engage in UAI with primary partners. Potential explanations include relationship closeness, relationship length, and agreement type. In addition, relationship context appears to have a differential impact upon UAI with primary and outside partners, implying that prevention messages may need to be tailored for different types of couples. Prevention efforts involving MSM couples must take into account relationship characteristics as couples balance safer sex and HIV risk with intimacy and pleasure.

Relationship factors associated with gay male couples' concordance on aspects of their sexual agreements: establishment, type, and adherence

Factors associated with gay male couples' concordance on aspects of sexual agreements remain understudied. The present study examined which relationship factors, self-reports of UAI, and patterns of HIV testing may be associated with men who were concordant about having a sexual agreement, the same type of sexual agreement, and adhering to their sexual agreement with their main partner. Various recruitment strategies were used to collect dyadic data from 142 gay male couples. Concordance on aspects of sexual agreements varied within the sample. Results indicated that relationship satisfaction was significantly associated with couples who were concordant about having and adhering to their sexual agreement. Predictability and faith of trusting a partner, and value in one's sexual agreement were also positively associated with couples' adhering to their sexual agreement. More research is needed to better understand how relationship dynamics, including sexual agreements, affect HIV risk among gay male couples in the U.S.

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.

Risks worth taking: safety agreements among discordant gay couples

As HIV research and prevention efforts increasingly target gay men in relationships, situational factors such as couple serostatus and agreements about sex become central to examinations of risk. Discordant gay couples are of particular interest because the risk of HIV infection is seemingly near-at-hand. Yet, little is known about their sexual behaviors, agreements about sex, and safer sex efforts. The present study utilized longitudinal semi-structured, qualitative interviews to explore these issues among 12 discordant couples. Findings show that nearly every couple had agreements about reducing the likelihood of HIV transmission from one partner to the other. Negotiating these agreements involved establishing a level of acceptable risk, determining condom use, and employing other risk-reduction techniques, such as seropositioning and withdrawal. For half of the couples, these agreements did not involve using condoms; only two couples reported consistent condom use. Despite forgoing condoms, however, none reported seroconversion over the course of data collection. Additional issues are raised where long-term HIV prevention is concerned. Future prevention efforts with discordant couples should work with, rather than fight against, the couple's decision to use condoms and endeavor to complement and accentuate their other safer sex efforts.

Partner-provided social support influences choice of risk reduction strategies in gay male couples

We investigated the influence of partner-provided HIV-specific and general social support on the sexual risk behavior of gay male couples with concordant, discordant, or serostatus-unknown outside partners. Participants were 566 gay male couples from the San Francisco Bay Area. HIV-specific social support was a consistent predictor for reduced unprotected anal intercourse (UAI) with both concordant outside partners (all couple types) and outside partners of discordant or unknown serostatus (concordant negative and discordant couples). General social support was associated with increased UAI with concordant outside partners for concordant negative and concordant positive couples (i.e., serosorting). Our findings suggest that prevention efforts should target couples and identify the level of HIV-specific support that partners provide. Partner-provided support for HIV-related behaviors could be an additional construct to consider in gay male relationships, akin to relationship satisfaction and commitment, as well as an important component of future HIV prevention interventions.

The impact of parenting on gay male couples' relationships, sexuality, and HIV risk

Parenthood changes couples' relationships across multiple domains, generally decreasing relationship quality, sexual satisfaction, and sexual frequency. Emerging research suggests that gay couples who are parenting might experience similar challenges. However, such changes might have even more profound implications for gay couples' health, and in particular their HIV risk, given the somewhat different ways in which they negotiate and tolerate sexual behaviors with outside partners. We aimed to examine these issues in a qualitative analysis of interviews from 48 gay male couples who were actively parenting children. Findings suggest that parenthood increases men's commitment to their primary relationship while simultaneously decreasing time and energy for relationship maintenance, and generally decreasing sexual satisfaction. These challenges alone did not generally result in greater infidelity or HIV risk, as most men reported successfully coping with such changes through a combination of acceptance and revaluing what is important in their relationships. Additionally, couples reported negotiating agreements regarding sex with outside partners that closely resemble those documented in studies of gay couples who are not parents. Men reported that parenthood typically decreased their opportunities to engage in sex with outside partners, but also posed barriers to talking about these behaviors with their partners and healthcare providers. HIV-related sexual risk behavior was relatively rare, but nevertheless present in some men. Providers should assess sexual function as a regular part of their work with gay couples who parent, and facilitate opportunities for men to discuss their sexual agreements both with their primary partners and with relevant healthcare providers.

Behavioural surveillance among gay men in Australia: methods, findings and policy implications for the prevention of HIV and other sexually transmissible infections

BACKGROUND

The Australian HIV and sexually transmissible infection (STI) behavioural surveillance system (the repeated cross-sectional Gay Community Periodic Surveys, GCPS) has been conducted since 1998 and covers six main Australian jurisdictions. In this paper, we review its history and methodology, and the available indicators, their trends and their use.

METHODS

We describe the design and history of GCPS. For analyses of indicators, we use Pearson's χ²-test and test for trend where appropriate.

RESULTS

About 90% of gay men in Australia have been tested for HIV (60% to 70% of men who were not HIV-positive) have been tested as recommended in the preceding 12 months. STI testing levels (≈ 70% in the preceding 12 months) are high, but remain insufficient for STI prevention. In general, unprotected anal intercourse with regular (UAIR) and casual (UAIC) sex partners has increased over time. The prevalence and increasing trends in UAIR were similar across jurisdictions (P-trend <0.01), while trends in UAIC differed across the states: during 2001-08, UAIC declined in NSW (P-trend <0.01) and increased elsewhere (P-trend <0.01). Trends in UAIC were associated with HIV diagnoses.

CONCLUSION

This review of the design, implementation and findings of the Australian HIV/STI behavioural surveillance highlights important lessons for HIV/STI behavioural surveillance among homosexual men, particularly the need for consistent data collection over time and across jurisdictions. Investment in systematic behavioural surveillance appears to result in a better understanding of the HIV epidemic, the availability of a warning system and a better targeted HIV prevention strategy.

Heterosexual, lesbian, and gay male relationships: a comparison of couples in 1975 and 2000

This study examined the differences among lesbians, gay men, and heterosexuals at two points in time (1975 and 2000) using responses of 6,864 participants from two archival data sets. Groups were compared on variables representing equality of behaviors between partners in seven realms: traditionally "feminine" housework, traditionally "masculine" housework, finances, support, communication, requesting/refusing sex, and decision-making. In addition, the current study compared monogamy agreements and monogamy behaviors reported by the two cohorts of couple types. Overall, the results indicate that on the equality variables, there have been many statistically significant behavioral shifts among the different sexual orientations across 25 years. In addition, all couple types reported substantially greater rates of monogamy in the year 2000 than in 1975. The present study has important clinical implications for therapists working with couples because it provides new baseline evidence regarding how couples now interact with one another (especially about monogamy) and how this has shifted over time. In addition, it elucidates the differences that still exist between different couple types, which could serve to inform couple therapists as they strive to become more culturally competent working with same-sex couples.

Sexual agreement classifications for gay and bisexual men and implications for harm reduction HIV prevention

HIV prevention educators frequently encourage gay and bisexual men (GBM) to negotiate condom use prior to sexual engagement. Identifying groups of GBM based on their presexual agreements can aid efforts to tailor interventions. Using cross-sectional data from 1,188 GBM who reported having sex with a nonprimary sex partner in the 90 days prior to the survey, the authors identified presexual agreement patterns. For both HIV-positive and HIV-negative GBM, two groups existed: men agreeing to no anal sex and men agreeing to anal sex with condoms. Among HIV-negative participants, there was a group agreeing to anal sex without specifying condom use. Among HIV-positive participants, there was a group agreeing to anal sex without condoms; this was the largest group of HIV-positive participants. Despite a presexual agreement to use condoms, substance use during sex increased the risk of unprotected anal sex. Suggestions for applying harm reduction to HIV prevention based on agreement classifications are discussed.

Casual sexual encounters among gay men: familiarity, trust and unprotected anal intercourse

Familiarity with and a history of prior sex with casual partners is associated with unprotected anal intercourse and may increase the risk of HIV transmission among gay men. Using data from the Sydney Gay Community Periodic Survey 2007, we explored the relationship between familiarity and unprotected anal intercourse with the last casual partner (UAI-LC). 51% of the men knew their last casual partner and 49% had previously had sex with him. Men were more inclined to engage in UAI-LC if they had previously had sex with this partner. HIV-negative men were more likely to have UAI-LC with a more familiar partner independent of his serostatus. Familiarity with and a previous history of sex between casual partners may result in a false sense of trust and may increase the risk of HIV transmission. HIV prevention services should address this issue and develop programs to improve men's skills in negotiating safer sex.

Masculinity and relationship agreements among male same-sex couples

Extradyadic sex is a significant source of risk for sexually transmitted infections (STIs) among men in same-sex relationships. Nonmonogamous sexual agreements are common among male same-sex couples and may serve as effective targets for risk reduction interventions; however, there is a dearth of research reporting on the social and cultural determinants of explicit nonmonogamous agreements. In this study, it was hypothesized that attitudes toward dominant cultural standards of masculinity (i.e., normative masculinity) would be associated with the types of sexual agreements negotiated among gay male couples. An Internet-based survey was used to collect data from 931 men for this analysis. Results indicated that men who reported high endorsement of normative masculinity were more likely to be in nonmonogamous relationships. Furthermore, high endorsement of normative masculinity was predictive of relationship agreements characterized as the most sexually permissive. These findings indicate that rather than simply predicting nonmonogamy in gay male couples, attitudes toward masculinity may be indirectly related to increased risk of STIs by influencing the types of sexual agreements negotiated. This is the first empirical study to emphasize the role of masculinity as an explanatory factor of same-sex relationship agreements.

Relationship characteristics and motivations behind agreements among gay male couples: differences by agreement type and couple serostatus

Gay men in relationships are often overlooked in HIV prevention efforts, yet many engage in sexual behaviors that increase their HIV risk and some seroconvert as a result. While different aspects of gay male relationships have been studied, such as sexual agreements, relationship characteristics, and couple serostatus, little research combines these elements to examine HIV risk for this population. The present study recruited 566 gay male couples from the San Francisco Bay Area to study their sexual agreements, motivations behind making agreements, and other relationship characteristics, such as agreement investment, relationship satisfaction, intimacy, and communication. Participants rated their level of concurrence with a set of reasons for making their agreements. They were also measured on relationship characteristics using standard instruments. Analyses were conducted by agreement type (monogamous, open, and discrepant) and couple serostatus (concordant negative, concordant positive, and discordant). A majority reported explicitly discussing their agreements and nearly equal numbers reported being in monogamous and open relationships. A small number (8%) reported discrepant agreements. Across all agreement type and serostatus groups, HIV prevention as a motivator for agreements fell behind every motivator oriented toward relationship-based factors. Only concordant negative couples endorsed HIV and STD prevention among their top motivators for making an agreement. Mean scores on several relationship characteristics varied significantly. Couples with monogamous agreements had higher scores on most relationship characteristics, although there was no difference in relationship satisfaction between couples with monogamous and open agreements. Scores for concordant positive couples were distinctly lower compared to concordant negative and discordant couples. Agreements, the motivations behind them, and the relationship characteristics associated with them are an important part of gay male relationships. When examined by agreement type and couple serostatus, important differences emerge that must be taken into account to improve the effectiveness of future HIV prevention efforts with gay couples.

Sexual agreements among gay male couples

Many gay male couples make agreements about whether or not to permit sex with outside partners, yet little is known about the development and maintenance of these agreements, their impact on relationships, and whether they are an effective HIV prevention strategy. Using semi-structured, qualitative interviews, 39 gay male couples were asked about their sexual agreements and about other relationship dynamics that might affect their agreements. Analysis revealed a wide range of agreement types, all of which are presented along a continuum rather than as discrete categories. For couples with open agreements, most placed rules or conditions limiting when, where, how often, and with whom outside sex was permitted. Although motivations for having agreements varied, HIV prevention did not rank as a primary factor for any couple. Most couples had congruous agreements; however, a small number reported discrepancies which may increase HIV transmission risk. How couples handled breaks in their agreements also varied, depending on what condition was broken, whether it was disclosed, and the partner's reaction. Additional results include differences in agreement type and motivations for having an agreement based on couple serostatus. Overall, agreements benefited couples by providing boundaries for the relationship, supporting a non-heteronormative identity, and fulfilling the sexual needs of the couple. Future prevention efforts involving gay couples must address the range of agreement types and the meanings couples ascribe to them, in addition to tempering safety messages with the relationship issues that are important to and faced by gay couples.