Linking Syndemic Stress and Behavioral Indicators of Main Partner HIV Transmission Risk in Gay Male Couples

Healthcare worker perspectives on HIV status sharing intervention components for partnered, Black sexual minority men in South Africa

BACKGROUND

Globally, there is suboptimal coverage of antiretroviral treatment to treat and prevent HIV. It is crucial for individuals to know their partner's HIV status so they may use all appropriate and available prevention tools. For sexual minority men in South Africa, a population known to face intersecting forms of marginalization including a disparate burden of HIV incidence, there are challenges to status sharing.

OBJECTIVE

We explore perspectives of healthcare workers (HCW) with expertise providing services to sexual minority men to identify strategies to support HIV status sharing.

METHODS

As part of a larger study designed to improve HIV-related health outcomes for sexual minority men, we conducted one focus group discussion (participant n = 4) and two in-depth-interviews with HCW. We used thematic analysis to synthesize qualitative themes and identify corresponding implications for interventions.

RESULTS

HCW each had 5-23 years of experience. We identified three implementation considerations to support sharing of HIV status: (1) ensuring partner support for sharing status while circumventing risk of personal harms, (2) facilitating concordant couple-based peer support and belonging, and (3) leveraging the strengths of mass media as educational tools.

CONCLUSION

HCW highlighted that sharing that one is living with HIV is a sensitive and potentially dangerous process that can be managed by involving both partners in the process. This process may be supported by incorporating HIV status sharing narratives in popular media.

Assessment of Sexual Violence Risk Perception in Men Who Have Sex With Men: Proposal for the Development and Validation of "G-Date"

BACKGROUND

Sexual violence (SV) is a significant problem for sexual minorities, including men who have sex with men (MSM). The limited research suggests SV is associated with a host of syndemic conditions. These factors tend to cluster and interact to worsen one another. Unfortunately, while much work has been conducted to examine these factors in heterosexual women, there is a lack of research examining MSM, especially their SV risk perception. Further, MSM are active users of dating and sexual networking (DSN) mobile apps, and this technology has demonstrated usefulness for creating safe spaces for MSM to meet and engage partners. However, mounting data demonstrate that DSN app use is associated with an increased risk for SV, especially given the higher likelihood of using alcohol and other drugs before sex. By contrast, some researchers have demonstrated that DSN technology can be harnessed as a prevention tool for HIV; unfortunately, no such work has progressed regarding SV.

OBJECTIVE

This study aims to (1) use qualitative and quantitative methods to tailor an existing laboratory paradigm of SV risk perception in women for MSM using a DSN mobile app framework and (2) subject this novel paradigm to a rigorous validation study to confirm its usefulness in predicting SV, with the potential for use in future prevention endeavors.

METHODS

To tailor the paradigm for MSM, a team of computer scientists created an initial DSN app (G-Date) and incorporated ongoing feedback about the usability, feasibility, and realism of this tool from a representative sample of MSM. We used focus groups and interviews to assist in the development of G-Date, including by identifying relevant stimuli, developing the cover story, and establishing the appropriate study language. To confirm the paradigm's usefulness, we are conducting an experimental study with web-based and face-to-face participants to determine the content, concurrent, and predictive validities of G-Date. We will evaluate whether certain correlates of SV informed by syndemics and minority stress theories (eg, history of SV and alcohol and drug use) affect the ability of MSM to detect SV risk within G-Date and how paradigm engagement influences behavior in actual DSN app use contexts.

RESULTS

This study received funding from the National Institute on Alcohol Abuse and Alcoholism on September 10, 2020, and ethics approval on October 19, 2020, and we began app development for aim 1 immediately thereafter. We began data collection for the aim 2 validation study in December 2022. Initial results from the validation study are expected to be available after December 2025.

CONCLUSIONS

We hope that G-Date will enhance our understanding of factors associated with SV risk and serve as a useful step in creating prevention programs for this susceptible population.

Feasibility and Acceptability Pilot Test of Connecting Latinos en Parejas: A Couples-Based HIV Prevention Intervention for Latino Male Couples

Despite recent emphasis on couples-based HIV prevention interventions, efficacious interventions for Latino male couples have yet to be tested. The study examined the feasibility and acceptability of the Connecting Latinos en Pareja (CLP) intervention, a couples-based HIV prevention intervention for Latino male couples. This pilot demonstrated high feasibility, meeting targets for recruitment, retention, and intervention completion. We recruited a diverse cohort of 46 individuals/23 couples with a retention rate of 80% over 6 months and a 100% intervention completion rate in both conditions (four structured couple sessions in each condition). This pilot RCT was not powered to detect significant intervention impact on the primary outcome; however, there was a significant increase in relationship functioning among couples in the intervention group relative to controls and promising trends in changes in several key outcome and mediating variables. Secondary analysis documented trends in the expected directions for several other key hypothesized mechanisms of action (stimulant use, psychological symptoms, quality of life) as well as the primary outcome of proportion of protected sex acts (overall and broken out by main vs. outside partners). Qualitative exit interviews revealed high levels of acceptability of the CLP intervention. Participants highlighted affective component of the intervention and perceived effectiveness in improving dyadic communication skills and safer sex practices. Our findings show that a pilot trial of CLP is highly feasible and acceptable, with CLP demonstrating promising evidence of changes in key intervention mechanisms.

Hidden cues for approach and avoidance motivation: implicit cognitive associations among patients with Nonadherence to HIV treatment

Although patient motivation related to HIV treatment is widely acknowledged as a key factor related to consistent adherence and engagement with medical care, research has predominantly focused on explicit rather than implicit cognitive processes that underlie motivation. This study identified and examined implicit cognitive processes that influence approach and avoidance treatment motivation in a sample of 30 HIV patients with suboptimal adherence and poor engagement with medical care. Study participants were predominantly African American (87%) and gay/bisexual (63%). We examined 173 thought statements about treatment collected from patients during two previous studies. Thematic analysis described how implicit cognitive associations influenced patients to approach or avoid treatment and medical care. Findings revealed three major contextual categories of treatment-related thoughts: links with routines and habits, connections to physical changes and reactions, and interpersonal associations. Within each category, implicit cognitive associations about treatment in terms of these daily life events and experiences cued approach and avoidance motivational tendencies without the patient's awareness. Findings from this study support the need for interventions that use implicit, less effortful approaches aimed at promoting adherence and improving the retention of patients with poor engagement.

Inter-partner Agreement of Condom Use and Sexual Positioning in Male Couples

Accurate, reliable self-reports of sexual behavior are a crucial component of valid HIV risk-estimation and behavioral intervention evaluation, yet this data's reliability remains understudied. The goal of this study was to describe interpartner agreement on recent receptive anal intercourse (AI) and condomless receptive AI frequencies, among a sample of male couples. We quantified interpartner agreement on self-reported receptive AI and condomless receptive AI (absolute and relative to AI frequency), and position and condom use during a couple's most recent AI, using cross-sectional data from male partners (US, 2016-2017; N = 718 individuals). Proportional and statistical agreement (intraclass correlation coefficients (ICC), kappa (k)) were assessed. Observed agreement for receptive AI frequency was 49.44% (ICC (95% CI): 0.82(0.79, 0.84)) and for relative receptive frequency, 59.05% (ICC: 0.96 (0.85, 0.96). Agreement on condomless receptive AI was 90.21% (ICC: 0.78 (0.75, 0.82), and for relative condomless receptive AI, 91.15% (ICC: 0.80 (0.77, 0.83). Most recent AI position agreement was 89.42% (k (95% CI): 0.84 (0.80, 0.88)), and condom use, 98.89% (k: 0.82 (0.87, 0.98)). Observed agreement was higher among those who reported consistent positioning and condom use. Further research on self-reported sexual behavior data is needed to improve research validity and intervention effectiveness.

Relationship Power and Intimate Partner Violence in Sexual Minority Male Couples

Objective: The objective of the present study was to test pathways implied by Disempowerment Theory to predict intimate partner violence (IPV) among men in a same-sex relationship. Background: Sexual minority men in relationships experience rates of IPV comparable with heterosexual women, yet most research on IPV focuses on heterosexual couples. Disempowerment Theory suggests that a range of individual, family-of-origin, and intimate relationship risk factors predict the use of violence to re-establish power in a relationship. Method: Data for the present study were gathered from an online survey completed by sexual minority men currently in a same-sex relationship (n = 339). Analysis of data included two steps: (a) we tested the direct effect of individual, family, and relational predictors on the odds of IPV and (b) we calculated a path model that included relationship power as a link between the predictors (individual, family, and relational) and IPV. Results: In line with Disempowerment Theory, relationship power was negatively associated with IPV. Bivariate analysis indicated an association between childhood sexual abuse and IPV, but childhood sexual abuse was not predictive of IPV through relationship power. Other individual (depression) and relationship-specific (sexual communication and relationship satisfaction) risk factors were associated with IPV indirectly through relationship power. Conclusion: Disempowerment Theory may provide a useful framework for understanding the occurrence of IPV in sexual minority male couples. It may also provide a starting point for the development of multi-component interventions to reduce violence in these couples.

Prevalence of Intimate Partner Violence and Associated Factors Among Men Who Have Sex with Men in China

Intimate partner violence (IPV) in the heterosexual population has gained increasing public concern in China, but little is known about it among men who have sex with men (MSM).¹ This study aimed to investigate the prevalence of IPV and associated factors among MSM in Chengdu, China. Participants were recruited from a local MSM-friendly health consulting center. This study used the adjusted Intimate Partner Violence Scale among Gay and Bisexual Men (IPV-GBM scale) to capture lifetime IPV experiences including physical, sexual and emotional violence, monitoring, and controlling behaviors. Among 431 participants, 153 (35.5%) reported any IPV experiences, and 119 (27.6%) reported themselves as being the perpetrator. Adjusted logistic regression models revealed that having been engaged in transactional sex was positively associated with victimization through monitoring behaviors (adjusted odds ratio [ORa] = 2.7, 95% confidence interval CI = [1.7, 7.4]) and perpetration of monitoring behaviors (ORa = 3.9, 95% CI = [1.5, 13.3]); drug use was positively associated with victimization through controlling behaviors (unadjusted odds ratio [ORu] = 2.5, 95% CI = [1.2, 5.0]) and emotional violence (ORa = 1.9, 95% CI = [1.0, 3.5]); older age (≥18 years) of first homosexual intercourse was negatively associated with perpetration of physical violence (ORu = 0.3, 95% CI = [0.2, 0.7]) and sexual violence (ORu = 0.4, 95% CI = [0.2, 1.0]); higher self-esteem was negatively associated with both victimization and perpetration of sexual and emotional violence. We found that victimization and perpetration experiences were correlated in all dimensions of IPV. Violence was prevalent among MSM and merits public attention. This study provides more evidence about IPV among Chinese MSM and identifies two significant factors contributing to IPV (self-esteem and age of first homosexual intercourse), which have been overlooked in previous studies. Researchers should take these factors into consideration for interventions developments.

Prevalence and Correlates of Sexual Violence Experienced by Young Adult Black Men Who Have Sex with Men

Men who have sex with men (MSM) experience high prevalence of sexual violence (SV), and SV has well-documented effects on health. Research gaps are especially evident for young Black MSM (YBMSM), who experience significant HIV disparities and syndemics, including multiple forms of violence victimization. We examined lifetime prevalence of SV (having been forced or frightened into sexual activity) in a cross-sectional sample of YBMSM (N = 1732), and tested associations of demographic, psychosocial, and structural factors using multivariable regression. YBMSM were recruited between 2013 and 2015 using modified venue-based time-location sampling (e.g., at bars and clubs) in Dallas and Houston, Texas. Approximately 17% of YBMSM experienced any SV in their lifetimes. SV was associated with high school non-completion (OR 1.78; 95% CI 1.15-2.77), lower psychological resilience (OR 0.84; 95% CI 0.71-0.98), lifetime history of homelessness (OR 5.52; 95% CI 3.80-8.02), recent financial hardship (OR 2.16; 95% CI 1.48-3.14), and recent transactional sex (OR 3.87; 95% CI 2.43-6.15). We also examined differences by age of SV onset (childhood versus adulthood). YBMSM with adolescent/emerging adult-onset SV may have been more ambivalent in reporting lifetime SV experience, compared to men with childhood-onset SV, and correlates differed by age of onset. Childhood-onset SV was associated with high school non-completion, lower levels of psychological resilience, history of homelessness, recent financial hardship, and recent transactional sex. Adolescent/emerging adult-onset SV was associated with greater depressive symptoms, history of homelessness, and recent financial hardship. There is a need for multi-level approaches to SV prevention and treatment, including services and supports that are culturally-relevant and responsive to the needs of YBMSM.

Armed conflict, HIV, and syndemic risk markers of mental distress, alcohol misuse, and intimate partner violence among couples in Uganda

Northeastern Uganda has suffered from protracted armed conflict and HIV/AIDS and has some of the highest rates of intimate partner violence (IPV) globally. Little is known about how exposure to conflict and HIV influence individuals' syndemic risk markers or those of their partners. We conducted a population-based study using multistage sampling across three districts in Northeastern Uganda. We randomly surveyed 605 women aged 13-49 years and estimated syndemic problems for currently partnered women (N = 561) who reported for their male partners. Syndemic problems were lower in the low-conflict district than the high-conflict district, p = .009. Conflict exposure was associated with couples' syndemic scores, respondent: β = 0.182, p < .001; partner: β = .181, p < .001. Problem scores were significantly higher among women whose partner was either HIV positive, p = .031, or had an unknown HIV status, p = .016, compared with those whose partner was HIV negative. The total effects of women's, β = .15, p = .034, and men's, β = .137, p = .038, armed conflict exposure on male-to-female IPV were significant. For male partners, there were significant total effects of having an unknown, β = .669, p < .001, or positive, β = 1.143, p < .001, HIV status on experiencing female-to-male IPV. These results suggest that syndemic problems and corresponding treatments should consider couple influences. Addressing mediating problems of mental distress and alcohol misuse may reduce the risk of male-to-female IPV. Providing couple-based HIV psychosocial interventions could reduce men's exposure to IPV.

Perceived facilitators of decision-making and usage of biomedical HIV prevention strategies: findings from an online, qualitative study with same-gender male couples in the United States

The early stages of gay and bisexual men's relationships are a critical period for communicating about HIV prevention strategies. This study sought to: (1) explore facilitators to decision-making to use prevention strategies and (2) describe the prevention strategies being used by same-gender male couples in new relationships. Individual interviews were conducted with 76 partnered men, representing 37 couples and 2 individuals. Couples had been together for one year or less, and varied by U.S. geographical region of residence and HIV serostatus: 8 seroconcordant positive, 17 seroconcordant negative, and 13 serodiscordant couples. Two overarching qualitative themes emerged: (1) communication and (2) information and resources. Notably, few couples had both partners mention the same facilitator. The most commonly used HIV prevention strategies were treatment as prevention for partners in seroconcordant positive and serodiscordant couple relationships, and HIV/STI testing for partners of seroconcordant negative couples. Compared to the other two couple groups, fewer seroconcrdant negative couples were aware of each other's use of strategies. Study findings suggest these facilitators are important to include in future interventions. Efforts are also needed to improve within-dyad awareness about which strategies partners are using and how they may best support one another toward their sexual health goals.

Longitudinal Associations of Syndemic Conditions with Antiretroviral Therapy Adherence and HIV Viral Suppression Among HIV-Infected Patients in Primary Care

Psychosocial syndemic conditions have received more attention regarding their deleterious effects on HIV acquisition risk than for their potential impact on HIV treatment and viral suppression. To examine syndemic conditions' impact on the HIV care continuum, we analyzed data collected from people living with HIV (N = 14,261) receiving care through The Centers for AIDS Research Network of Integrated Clinical Systems at seven sites from 2007 to 2017 who provided patient-reported outcomes ∼4-6 months apart. Syndemic condition count (depression, anxiety, substance use, and hazardous drinking), sexual risk group, and time in care were modeled to predict antiretroviral therapy (ART) adherence and viral suppression (HIV RNA <400 copies/mL) using multilevel logistic regression. Comparing patients with each other, odds of ART adherence were 61.6% lower per between-patient syndemic condition [adjusted odds ratio (AOR) = 0.384; 95% confidence interval (CI), 0.362-0.408]; comparing patients with themselves, odds of ART adherence were 36.4% lower per within-patient syndemic condition (AOR = 0.636 95% CI, 0.606-0.667). Odds of viral suppression were 29.3% lower per between-patient syndemic condition (AOR = 0.707; 95% CI, 0.644-0.778) and 27.7% lower per within-patient syndemic condition (AOR = 0.723; 95% CI, 0.671-0.780). Controlling for the effects of adherence (AOR = 5.522; 95% CI, 4.67-6.53), each additional clinic visit was associated with 1.296 times higher odds of viral suppression (AOR = 1.296; 95% CI, 1.22-1.38), but syndemic conditions were not significant. Deploying effective interventions within clinics to identify and treat syndemic conditions and bolster ART adherence and continued engagement in care can help control the HIV epidemic, even within academic medical settings in the era of increasingly potent ART.

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.

Assessing the Reliability of Self-Reported Sexual Behavior Among Male Couples

Coupled gay, bisexual, and other men who have sex with men (GBMSM) are at particularly high risk for HIV, and a clear understanding of behavioral risk is key to effective interventions. Accurate behavioral self-reports are a crucial component of valid sexual health research, yet reliability of these data remains understudied. This study aimed to quantify and identify predictors of dyadic discordance in reported 3-month anal intercourse (AI) occurrence and frequency. Using cross-sectional data from 407 male couples in the U.S. (2016-2017), we calculated proportional dyadic concordance and used dyad-level logistic and linear regression to identify demographic, behavioral, and relationship traits associated with the odds of discordant frequency reports and the relative difference between discordant partner reports. Couples had high levels of concordant reports of 3-month anal AI occurrence (97%) but low interpartner agreement in reported frequency (37%). After adjustment, the odds of discordance were significantly associated with dyadic employment and differences on the Communal Coping to Reduce HIV Threat Scale (CCS) (p < .05). Among frequency-discordant couples, the mean relative difference between partner reports was 52.80% ± 35.91% (M ± SD). After adjustment, relative differences between partners' reported AI frequencies were positively associated with interpartner differences in CCS (p < .05). These results indicate that among GBMSM couples in committed partnerships, self-reported sexual behavior data may be impacted by granularity, recall, and relationship characteristics. Further research in this area is warranted to better understand measurement error in self-reported sexual activity data.

Mini-review: Elucidating the psychological, physical, and sex-based interactions between HIV infection and stress

Stress is generally classified as any mental or emotional strain resulting from difficult circumstances, and can manifest in the form of depression, anxiety, post-traumatic stress disorder (PTSD), or other neurocognitive disorders. Neurocognitive disorders such as depression, anxiety, and PTSD are large contributors to disability worldwide, and continue to affect individuals and communities. Although these disorders affect men and women, women are disproportionately represented among those diagnosed with affective disorders, a result of both societal gender roles and physical differences. Furthermore, the incidence of these neurocognitive disorders is augmented among People Living with HIV (PLWH); the physical ramifications of stress increase the likelihood of HIV acquisition, pathogenesis, and treatment, as both stress and HIV infection are characterized by chronic inflammation, which creates a more opportunistic environment for HIV. Although the stress response is facilitated by the autonomic nervous system (ANS) and the hypothalamic pituitary adrenal (HPA) axis, when the response involves a psychological component, additional brain regions are engaged. The impact of chronic stress exposure and the origin of individual variation in stress responses and resilience are at least in part attributable to regions outside the primary stress circuity, including the amygdala, prefrontal cortex, and hippocampus. This review aims to elucidate the relationship between stress and HIV, how these interact with sex, and to understand the physical ramifications of these interactions.

Estimating HIV transmissions in a large U.S. clinic-based sample: effects of time and syndemic conditions

INTRODUCTION

Little is known about onward HIV transmissions from people living with HIV (PLWH) in care. Antiretroviral therapy (ART) has increased in potency, and treatment as prevention (TasP) is an important component of ending the epidemic. Syndemic theory has informed modelling of HIV risk but has yet to inform modelling of HIV transmissions.

METHODS

Data were from 61,198 primary HIV care visits for 14,261 PLWH receiving care through the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) at seven United States (U.S.) sites from 2007 to 2017. Patient-reported outcomes and measures (PROs) of syndemic conditions - depressive symptoms, anxiety symptoms, drug use (opiates, amphetamines, crack/cocaine) and alcohol use - were collected approximately four to six months apart along with sexual behaviours (mean = 4.3 observations). Counts of syndemic conditions, HIV sexual risk group and time in care were modelled to predict estimated HIV transmissions resulting from sexual behaviour and viral suppression status (HIV RNA < 400/mL) using hierarchical linear modelling.

RESULTS

Patients averaged 0.38 estimated HIV transmissions/100 patients/year for all visits with syndemic conditions measured (down from 0.83, first visit). The final multivariate model showed that per 100 patients, each care visit predicted 0.05 fewer estimated transmissions annually (95% confidence interval (CI): 0.03 to 0.06; p < 0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; p < 0.0005), 0.34 (95% CI: 0.20 to 0.49; p < 0.0005) and 0.22 (95% CI: 0.09 to 0.35; p < 0.005) fewer estimated HIV transmissions/100 patients/year than cisgender men who have sex with men (MSM). Each within-patient syndemic condition predicted 0.18 estimated transmissions/100 patients/year (95% CI: 0.12 to 0.24; p < 0.0005). Each between-syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; p < 0.0005).

CONCLUSIONS

Estimated HIV transmissions among PLWH receiving care in well-resourced U.S. clinical settings varied by HIV sexual risk group and decreased with time in care, highlighting the importance of TasP efforts. Syndemic conditions remained a significant predictor of estimated HIV transmissions notwithstanding the effects of HIV sexual risk group and time in care.

Testing the drug use and condomless anal sex link among sexual minority men: The predictive utility of marijuana and interactions with relationship status

BACKGROUND

The association between drug use and condomless anal sex (CAS) is well documented among sexual minority men (SMM). Less is known about whether this association generalizes to marijuana and across relationship status and sexual agreements groups (single, partnered monogamous, partnered open -outside partners permitted, and partnered monogamish -outside partners permitted when main partners are together).

METHODS

A nationwide sample of SMM (N = 65,707) were recruited through a geosocial networking app between November 2017 and November 2019. Participants reported on drug use and instances of CAS with casual partners in the previous 30 days.

RESULTS

Both marijuana and club drug use were associated with the occurrence of CAS with casual partners among single men. Only club drug use was associated with CAS frequency in this group. The association between marijuana and the occurrence of CAS did not differ significantly among monogamous men, while the associations between club drug use and the occurrence as well as frequency of CAS were significantly weaker. Meanwhile, the associations between club drug use and the occurrence as well as frequency of CAS did not differ significantly between single and non-monogamous (open and monogamish) subgroups; however, the association between marijuana and the occurrence of CAS was significantly weaker.

CONCLUSIONS

Findings largely replicated the robust association between club drug use and CAS with casual partners. They support the assertion that marijuana use predicts sexual risk for some SMM subgroups. Finally, they illustrate the potential for relationship status - and sexual agreements - to contextualize associations between drug use and CAS.

Timing and Sequence of Events: HIV Status Disclosure, Condomless Anal Sex, and Sexual Agreement Formation Among Same-Sex Male Couples

Despite the implications for human immunodeficiency virus (HIV) prevention and sexual health, little is known about the timing and chronological order of when same-sex male couples disclose their HIV serostatus, establish a sexual agreement, and first engage in condomless anal sex (CAS) in their relationships. Dyadic data from 357 dyads were used to describe when these respective events occurred; whether members of a couple concurred about when the events happened; and the chronological order of these events. For many, disclosure and CAS happened within the first month, whereas an agreement tended to occur much later (if at all). Couples' concordance of when disclosure and agreement formation happened differed by their serostatus, whereas there was little difference by serostatus for CAS. The chronological order of these events revealed interesting patterns and varied substantially. Although two-thirds of partners reported disclosure had occurred first, some reported events happening on the same day. These findings reveal that the first few months in a same-sex male couple's relationship is a critical time period for when information and decisions about sexual health occur. Suggestions are provided for how current and future HIV prevention efforts could assist couples with their sexual health needs.

Couple Interdependence Impacts Alcohol Use and Adherence to Antiretroviral Therapy in Malawi

In sub-Saharan Africa, harmful alcohol use among male drinkers is high and has deleterious consequences on adherence to antiretroviral therapy (ART), HIV clinical outcomes, and couple relationship dynamics. We conducted in-depth qualitative interviews with 25 Malawian couples on ART to understand how relationships influence adherence to ART, in which alcohol use emerged as a major theme. Almost half of men (40%) reported current or past alcohol use. Although alcohol use was linked to men's non-adherence, women buffered this harm by encouraging husbands to reduce alcohol use and by offering adherence support when men were drinking. Men's drinking interfered with being an effective treatment guardian for wives on ART and also weakened couple support systems needed for adherence. Relationship challenges including food insecurity, intimate partner violence, and extramarital relationships appeared to exacerbate the negative consequences of alcohol use on ART adherence. In this setting, alcohol may be best understood as a couple-level issue. Alcohol interventions for people living with HIV should consider approaches that jointly engage both partners.

The Prevalence and Correlates of Sexual Arrangements in a National Cohort of HIV-Negative Gay and Bisexual Men in the United States

Sexual agreements have received considerable attention as an aspect of dyadic functioning associated with HIV risk. To date, this research has primarily utilized convenience samples which overrepresented men from large urban areas and with higher HIV risk. The current study utilized a national cohort of 1061 HIV-negative gay and bisexual men recruited to be geographically diverse within the U.S. The sample included 531 (50.0%) men who identified as single. Of the 530 partnered men, 240 (45.3%) were monogamous; 238 (44.9%) were in open relationships (where sex with outside partners was permitted); and 52 (9.8%) were in monogamish relationships (where sex with outside partners was limited to instances where both primary partners were present). Regardless of urban (vs. non-urban) residence, men in monogamous relationships engaged in less anal sex generally and condomless anal sex (CAS) specifically with casual partners. Single men reported significantly more frequent anal sex with casual partners compared to open and monogamish men; however, there were no significant differences among these three groups with respect to CAS with casual partners. In multivariable models, monogamish men reported significantly more frequent marijuana use and alcohol consumption compared to all other groups. Urban (vs. non-urban) residence moderated associations between sexual arrangements and depression as well as the use of illicit drugs other than marijuana. These findings point to the need to better examine the potentially unique mechanisms which confer risk and resilience for gay male couples in urban versus non-urban settings. The observed association between sexual arrangements and substance use suggests interventions which facilitate the negotiation of sexual agreements may present an opportunity to engage in dyadic substance use intervention.

A cross-sectional study of the relationship between sexual compulsivity and unprotected anal intercourse among men who have sex with men in shanghai, China

Background

HIV prevalence among men who have sex with men (MSM) in China is rising rapidly, and unprotected anal intercourse (UAI) is associated with HIV transmission. Recent research has shown that associations between UAI and other factors can differ according to the type of sex partners, including regular partners and casual partners. This study aimed to explore the relationship between sexual compulsivity and UAI according to partner type among MSM in Shanghai, China.

Methods

A cross-sectional study was conducted among 547 MSM from four districts in Shanghai, China. All participants were recruited using snowball sampling. The Sexual Compulsivity Scale was used to evaluate participants’ sexual compulsivity. Multivariable logistic regression was used to identify factors associated with sexual compulsivity and UAI. The mediation effects of substance use before sex on the relationship between sexual compulsivity and UAI were tested through mediation analyses.

Results

After adjusting for sociodemographic variables, sexual compulsivity was associated with overall UAI (adjusted odds ratios [AOR] = 1.039, 95% confidence intervals [CI] = 1.004–1.075), UAI with non-regular sex partners (AOR = 1.089, 95% CI = 1.033–1.148) and UAI with commercial sex partners (AOR = 1.185, 95% CI = 1.042–1.349). No significant association was found between sexual compulsivity and UAI with regular sex partners (AOR = 1.029, 95% CI = 0.984–1.077). Mediation analyses indicated that the relationship between sexual compulsivity and UAI was not mediated by either alcohol use before sex or drug use before sex.

Conclusions

The association between sexual compulsivity and UAI varies depending on the type of UAI partner. Therefore, individuals may engage in different types of UAI for different reasons, and tailored HIV cognitive–behavioral intervention programs are needed.

Dyadic Qualitative Analysis of Condom Use Scripts Among Emerging Adult Gay Male Couples

Sexual risk reduction among gay male couples has received increasing attention in light of evidence that primary partners account for many-and possibly most-new HIV infections. This study examined the content of condom use scripts in interviews conducted with both members of 17 HIV-negative gay male couples. In each couple, at least one partner was an emerging adult (aged 18 to 29). Three scripts were identified: romantic love, unanticipated condomless anal intercourse (CAI), and negotiated safety. Scripts varied in their emphasis on emotional factors versus HIV risk reduction, the salience of sexual agreements, and the presence of an explicit communication goal. Results indicated that condom use may vary for couples as a result of script content and from the fluid adoption of scripts across contexts. Results highlighted potential tensions between emotional closeness and HIV prevention. Condom use cessation and sexual agreements-a potential mechanism for HIV risk reduction-may also serve as expressions of intimacy. This implies interventions that facilitate direct communication about sexual and relational goals-as well as those that expand couples' repertoires for expressing emotional closeness-may enhance sexual health for gay couples, particularly during the period of emerging adulthood.

Intimate relationship characteristics as determinants of HIV risk among men who have sex with regular male sex partners: a cross-sectional study in Guangzhou, China

Background

China faces a serious HIV epidemic among men who have sex with men (MSM), and a large proportion of new infections are attributed to their regular male sex partners (RP). The objective of this study was to investigate the association between intimate relationship characteristics and HIV-related behaviors among MSM with RP in Guangzhou, China.

Methods

A convenience-sampling method was used in data collection. A total of 608 MSM were screened, of whom 406 HIV negative MSM with at least one RP in the past six months were used for data analysis. Three-step logistic regressions were used to analyze the data.

Results

The prevalence of unprotected anal intercourse (UAI) with regular male sex partners, non-regular male sex partners, and concurrent UAI in the past six months was 53.9%, 23.6%, 20.7%, respectively. Variables associated with UAI with regular male sex partners included expectations for this relationship (adjusted odds ratio in multiple forward stepwise logistic regression, OR_m = 1.66) and open communication about the sexual relationship (OR_m = 1.79), while expectations for the relationship (OR_m = 0.46 to 0.54) and conflicts of interest (OR_m = 5.46 to 5.97) were associated with concurrent UAI and UAI with non-regular male sex partners.

Conclusion

Intimate relationship characteristics were related to HIV-related risk behaviors. Future HIV prevention interventions should take MSM couples into consideration, include a focus on the quality of their intimate relationships, and encourage open communication about their sexual relationships.

Electronic supplementary material

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Psychosocial Syndemic Correlates of Sexual Compulsivity Among Men Who Have Sex with Men: A Meta-Analysis

Efforts have been made to better understand sexual compulsivity by examining salient psychosocial syndemic correlates, though examination of such factors has yielded inconclusive results. Given that research on sexual compulsivity has predominately involved men who have sex with men (MSM), the aims of the current study were to establish the mean effect sizes of seven psychosocial syndemic indicators with sexual compulsivity, to determine if the effect varied as a function of the type of psychosocial syndemic, and investigate the potential moderating effects using MSM samples. A total of 95 studies were included for analyses among the psychosocial syndemic indicators of interest (i.e., depression, anxiety, alcohol use, drug use, intimate partner violence, childhood sexual abuse, and sexual risk behavior). Results revealed a medium mean effect size of sexual compulsivity, the strength of which was significantly moderated by type of psychosocial syndemic indicator. Significant mean effect sizes for all syndemic indicators on sexual compulsivity were found, with depression and anxiety having the strongest relationships; significant moderating effects were found and are discussed. Findings highlight clinical considerations regarding sexual compulsivity and its role within the HIV syndemic framework among MSM.

Number of Psychosocial Strengths Predicts Reduced HIV Sexual Risk Behaviors Above and Beyond Syndemic Problems Among Gay and Bisexual Men

Syndemics research shows the additive effect of psychosocial problems on high-risk sexual behavior among gay and bisexual men (GBM). Psychosocial strengths may predict less engagement in high-risk sexual behavior. In a study of 470 ethnically diverse HIV-negative GBM, regression models were computed using number of syndemic psychosocial problems, number of psychosocial strengths, and serodiscordant condomless anal sex (CAS). The number of syndemic psychosocial problems correlated with serodiscordant CAS (RR = 1.51, 95% CI 1.18-1.92; p = 0.001). When adding the number of psychosocial strengths to the model, the effect of syndemic psychosocial problems became non-significant, but the number of strengths-based factors remained significant (RR = 0.67, 95% CI 0.53-0.86; p = 0.002). Psychosocial strengths may operate additively in the same way as syndemic psychosocial problems, but in the opposite direction. Consistent with theories of resilience, psychosocial strengths may be an important set of variables predicting sexual risk behavior that is largely missing from the current HIV behavioral literature.

Receipt and Perpetration of Intimate Partner Violence and Condomless Anal Intercourse Among Gay and Bisexual Men in Atlanta

Intimate partner violence (IPV) rates are disproportionately high among sexual minority populations, with increasing evident that gay men experience IPV at the same rates as heterosexual women. This study examines the relationship between self-reported condomless anal intercourse (CAI) and IPV among a sample of 750 gay and bisexual men. Participants answered questions regarding recent receipt and perpetration of IPV using the IPV-GBM Scale (Cronbach Alpha 0.90). Of the sample, 46.1% reported recent receipt of any type of IPV and 33.6% reported recent perpetration of any type of IPV. Overall, 55.1% of participants reported CAI at last sex. Significant associations were determined between several forms of IPV and increased odds of reporting CAI at last sex. These findings suggest that IPV may be a risk factor for CAI among men who have sex with men, and highlight the need to understand the IPV prevention and care needs of this population.