Sexual agreements among gay male couples

A Narrative Study of Sexual Agreements and HIV Prevention Strategies Among Emerging Adult Sexual Minority Men

Qualitative content analysis of an HIV testing and communication skill-building session explored the development of sexual agreements and HIV risk prevention strategies among emerging adult (18 to 24 years old) sexual minority men (SMM) to inform HIV testing services for younger SMM in relationships. In total, 29 intervention sessions were transcribed and coded for analysis. Most youth identified as cisgender male (86.2%), gay (72.4%), and as Latino/x (41.4%) or non-Hispanic White (37.9%). Results revealed that the process of forming a sexual agreement with one's main partner, as well as the composition of sexual agreements, was generally similar to those found in studies of adult SMM. HIV transmission risk reduction was not a central goal for establishing a sexual agreement for SMM emerging adults in this study; however, behavioral strategies for managing HIV risk did vary across casual partner types. SMM frequently used condoms with anonymous or new non-primary partners but relied on other HIV prevention strategies (e.g., sexual history, disclosing HIV status, pre-exposure prophylaxis) with regular non-primary partners. Sexual health service providers should assess for risk separately across non-primary partner types and collaborate with clients to discuss appropriate preventative strategies.

Diversity in Partner Number Sexuality via Sexual Configurations Theory

"Partner number sexuality" (P#S) refers to how many partners individuals have/are interested in having. Those with P#S outside of monogamous desires and/or practices commonly face stigma in North America and elsewhere. Yet theories of sexuality do not always make room for diverse P#S. One theory that does is sexual configurations theory (SCT), which visually models gender/sex and sexuality (van Anders, 2015). In this study, we investigated what insights SCT could provide into P#S, whether SCT was useful to those with minoritized P#S, and how those with minoritized P#S made use of SCT. To do so, we conducted online interviews, asking participants (N = 26) to complete two SCT diagrams and report on their experience. We used template analysis to analyze transcripts and compiled "SCT heatmaps," aggregates of SCT diagrams. We constructed 11 major themes, including diverse understandings of eroticism and romantic/platonic relationships, the impacts of hermeneutical injustice (the injustice of knowledge systems) on participants' abilities to conceptualize and discuss their P#S, and how SCT facilitated conversations about P#S. The heatmaps showed that participants made use of most of both SCT diagrams, showing branchedness in P#S between "eroticism" and "nurturance," and between status, identity, and orientation. Our study highlights that the lived experience of partnering, especially of those with minoritized P#S, extends far beyond commonly understood categories, and that SCT is a useful tool that can accurately reflect diversity in P#S.

Relationship Inclusivity in Sexual and Gender Minority Psychology

Despite critical overlap between sexual and gender minority (SGM) and consensually non-monogamous (CNM) communities, relationship diversity remains a largely unaddressed domain of SGM people's wellbeing. We write to the readership of PSOGD as members of the LGBTQIA+ workgroup within the APA Division 44 Committee on Consensual Non-Monogamy and call for relationship diversity (i.e., CNM) to be meaningfully included within SGM-focused psychological science and practice.

Impact of Awareness of Sexual Partners' HIV Serostatus on the HIV Acquisition among Men Who Have Sex with Men in Guangzhou, China: A Nested Case-Control Study

This study aimed to investigate the impact of sexual partners' HIV serostatus awareness on the HIV acquisition among men who have sex with men (MSM) in Guangzhou, China. A nested case-control study was conducted based on a prospective cohort of MSM in Guangzhou. Within the cohort, individuals who underwent HIV seroconversion were identified as the case group, and each case was matched with four controls from the non-seroconverted participants. Information regarding the awareness of sexual partners' HIV serostatus over the preceding 6 months was gathered. Of the 161 participants, 36.0% were aware of the HIV serostatus of all their sexual partners. The practice of engaging in condomless anal sex with partners of unknown HIV serostatus and being aware of the HIV serostatus of only some casual partners were positively correlated with an elevated risk of acquiring HIV. Conversely, being fully aware of the HIV serostatus of all sexual partners, including regular ones, was associated with a diminished risk of HIV incidence. Regular communication with sexual partners regarding HIV testing outcomes, honest disclosure of one's own HIV serostatus, and refusal of sexual contact with partners of unknown HIV serostatus can potentially mitigate the risk of acquiring HIV among MSM.

Romantic relationship configurations and their correlates among LGBTQ+ persons: A latent class analysis

Research comparing monogamous and non-monogamous relationships on well-being indicators across diverse populations have yielded inconsistent findings. The present study investigates sociodemographic characteristics, as well as personal and relational outcomes, across different relationship configurations. Data were drawn from an online community-based sample of 1,528 LGBTQ+ persons aged 18 years and older in Quebec, Canada. A latent class analysis was performed based on legal relationship status, relationship agreement, cohabitation status, and the seeking of extradyadic sexual and romantic partners on the internet. Class differences on sociodemographic characteristics and well-being and relationship quality indicators were examined. A five-class solution best fit the data, highlighting five distinct relationship configurations: Formalized monogamy (59%), Free monogamy (20%), Formalized open relationship (11%), Monogamous considering alternatives (7%) and Free consensual non-monogamies (3%). Cisgender women were more likely to engage in monogamous relationships than cisgender men, who were overrepresented in open relationships. Lower levels of perceived partner support were observed in both free monogamous and consensually non-monogamous relationships, the latter of which also showed lower levels of well-being. Consensual non-monogamy researchers exploring relationship outcomes should examine relationship facets that go beyond relationship structure or agreement. Variations in monogamies and non-monogamies, both consensual and non-consensual, may be present within each broad relationship configuration, as reflected in different personal and relational needs, which can then translate to better or poorer outcomes.

Sexual Agreement Discussions Among Adolescent Sexual Minority Men in the USA

Nearly two-thirds of new HIV infections are attributed to primary partners, necessitating a greater understanding of relationship context of HIV transmission among sexual minority men. Sexual agreements, which are the explicit decisions couples make about sexual behaviors allowed inside and outside of their relationship, have been primarily studied among adult sexual minority men. Little work has sought to understand how adolescent sexual minority men utilize and navigate sexual agreement conversations. In this qualitative study, we explored adolescent sexual minority men's motivations for having these conversations, how they define different types of agreements (e.g., monogamous, non-monogamous), and the topics most commonly discussed in their conversations. We conducted thematic analysis of in-depth interviews with 30 partnered, HIV-negative, adolescent sexual minority men ages 15-19 years. Participants reported similar reasons, definitions, and desires for creating sexual agreements as those reported in the adult literature. Novel to this population was the influence of stigma and heterosexism on the participants' choice of sexual agreement type. Like adult sexual minority men, participants used sexual agreement conversations to respond to life events; however, the adolescents in our sample, when talking with their partners, led with the context of developmentally specific events such as leaving for college or attending a school dance. Those with more relationship experience often described having intentional, explicit sexual agreement conversations. Study findings suggest that content focused on sexual agreements is important for HIV prevention interventions designed with adolescent sexual minority men, especially young men who have less relationship experiences.

Optimizing Individual HIV Testing and Counseling for Emerging Adult Sexual Minority Men (Aged 18 to 24) in Relationships: A Pilot Randomized Controlled Trial of Adjunct Communication Components

The majority of new HIV infections in the US occur among sexual minority men (SMM) with older adolescent and emerging adult SMM at the highest risk. Those in relationships face unique HIV prevention challenges. Existing sexual HIV transmission risk interventions for male couples often encounter implementation challenges and engaging younger SMM early in relationships may be particularly difficult. This pilot randomized controlled trial evaluated the acceptibility and feasibility of We Test HIV testing - a behavioral health intervention tailored for younger SMM in realtionships - and generated preliminary estimates of effect size. The intervention comprises two adjunct moduls - video-based communication skills training as well as communication goal setting and planning - delivered in conjunction with routine HIV testing and counseling in individual or dyadic formats. A sample of 69 SMM aged 17 to 24 were recruited online. Following baseline assessment, youth were randomized to receive either the experimental, We Test, intervention or routine HIV testing (the control condition). Follow-up assessments were completed 3 and 6 months post-baseline. Results suggested the study was feasible and the individually delivered format was acceptible. We Test HIV testing was associated with significant improvements in communication skills. In addition, youth who remained in a relationship experienced an increase in communal coping to reduce HIV infection risk and relationship power. While groups did not differ with respect to condomless anal sex with casual partners, these psycho-social constructs (communication, communal coping with HIV prevention, and relationship power) may serve as mediators of intervention effects on sexual risk reduction in a larger study.

Dyadic Moderators of the Minority Stress-HIV Risk Association in Male Couples

Minority stressors have been linked to HIV risk behaviors among gay, bisexual, queer, and other men who have sex with men (MSM). Committed partnerships are a key context for new HIV infections and coping with minority stress among MSM, but very little work has tested the minority stress-HIV risk link among male couples, and little is known about how processes within one's relationship may exacerbate or buffer this association. The present study examined links between minority stress (i.e., internalized stigma, microaggressions) and HIV transmission risk behaviors (i.e., condomless anal sex with outside partners, breaks in relationship agreements) among male couples, as well as relationship-based moderators (i.e., social support, dyadic coping) of these associations. An analytic sample of male couples from a large cohort study (analytic N = 410 individuals, 205 dyads) completed self-report measures of minority stress, relationship-based moderators, and HIV transmission risk behaviors which were submitted to moderated actor-partner interdependence models (APIMs). In many cases, coping with stress with one's partner buffered the minority stress-HIV transmission link risk. However, findings also suggested situations in which partners may overburden one another with coping, thus exacerbating HIV-related risk behaviors.

Patterns and Factors of the Sexual Agreement for Extra-Dyadic Sex Among Men Who Have Sex with Men in Hong Kong, China: A Cross-Sectional Survey

This study investigated patterns of sexual agreement for extra-dyadic sex and their associations with sexual risk behaviors among men who have sex with men (MSM) having a regular male sex partner (RP) in China. A cross-sectional telephone survey was conducted among 530 MSM recruited through multiple sources in Hong Kong, China, between April and December 2020. This study was based on a subsample of 368 participants who had an RP in the past 6 months. Logistic regression models were fitted. Among the participants, 27.2%, 13.0%, and 3.0% had a closed agreement, an in-between agreement, and an open agreement, respectively. Compared to no agreement, a closed agreement was associated with fewer extra-dyadic partners and fewer instances of condomless sex with extra-dyadic partners. Those who had more positive attitudes toward a closed agreement, perceived more support from significant others to create a closed agreement, and perceived higher behavioral control of refraining from sex with extra-dyadic partners were more likely to have a closed agreement with RP. Those who were concerned that a closed agreement would impair freedom and sexual desire were less likely to have such an agreement. A closed agreement is a potentially useful risk reduction strategy for Chinese MSM with an RP.

Sex and Sexual Agreement Negotiation among Trans Women and Trans Men Partnered with Cis Men

Though trans individuals have some of the highest rates of HIV in the U.S., little is known about how trans couples navigate these risks within committed relationships. Thirty-nine couples, composed of one trans partner and one cis male partner, were asked about their relationship agreements, including sexual negotiations, in semi-structured, qualitative interviews. Couples reported definitions of monogamy and non-monogamy that were inconsistent with previous literature, each ranging as if on a continuum. While agreements varied, most non-monogamous couples reported a focus on safe sex practices and HIV risk mitigation, specifically highlighting negotiations around fluid exchange or fluid bonding. Changes in sexual desire arose for many couples, often due to hormonal changes during gender-affirming measures. Most couples navigated these shifts successfully, by changing their relationship agreement or sexual practices. Changing sexual behavior included addressing motivations for sex that were unrelated to one's own sexual pleasure; this motivation is called "maintenance sex." Alarmingly, nearly half of the couples interviewed reported discrepant agreements, which is associated with higher sexual risk. With an apparent ambiguity in defining agreements, it is imperative to trans communities' sexual health that relationship agreements are explicitly communicated to partners and healthcare providers.

Substance Use, Sexual Agreements, and Sexual Risk Behaviors Among Adolescent Sexual Minority Males (Aged 13-17) in the United States

PURPOSE

Despite the fact that adolescence represents a distinct developmental period wherein dating and sexual relationships are emergent, much of what is known about substance use, sexual agreements, and sexual risk behaviors among adolescent sexual minority males (ASMM) is extrapolated from research on adults. This study tested associations between substance use and sexual risk behaviors among ASMM and examined whether relationship status and sexual agreements moderated these associations.

METHODS

Cross-sectional online survey data were collected from 2,892 HIV negative ASMM aged 13-17 years between November 2017 and March 2020. All were sexually active with male partners and not on pre-exposure prophylaxis. A multigroup hurdle model predicted the occurrence and frequency of condomless anal sex (CAS) with casual partners.

RESULTS

Non-monogamous ASMM were more likely to use illicit drugs and more likely to have CAS with casual partners compared with single ASMM and those in monogamous relationships. Among ASMM who had CAS at least once, those in relationships (both monogamous and nonmonogamous) had CAS more frequently than single ASMM. Binge drinking (odds ratio (OR) = 1.47, p < .001), cannabis (OR = 1.30, p < .001), and illicit drug use (including prescription drug misuse) (OR = 1.77, p < .001) were associated with the occurrence of CAS with casual partners but only binge drinking (rate ratio (RR) = 1.23, p = .027) and illicit drugs (RR = 1.75, p < .001) were associated with its frequency.

DISCUSSION

While results aligned with adult studies in many respects, unlike adult sexual minority males, these findings suggest partnered ASMM-particularly those in nonmonogamous relationships-were at highest risk of substance use and associated sexual HIV transmission risk.

Biomedical and behavioral outcomes of 2GETHER: A randomized controlled trial of a telehealth HIV prevention program for young male couples

OBJECTIVE

This study evaluated the efficacy of the 2GETHER relationship education and HIV prevention program for young male couples in reducing risk for HIV.

METHOD

We conducted a comparative effectiveness randomized controlled trial of 2GETHER, a five-session hybrid group- and couple-based intervention delivered via videoconference, relative to a single-session HIV testing and risk reduction counseling protocol delivered to couples. We randomized 200 young male couples (N = 400) to 2GETHER or control from 2018 to 2020. Primary biomedical (i.e., rectal Chlamydia and Gonorrhea infection) and behavioral outcomes (i.e., condomless anal sex [CAS]) were measured at 12-months postintervention. Secondary outcomes were other HIV prevention and risk behaviors, relationship quality, and substance use. Multilevel regression was used to model intervention outcomes to account for clustering within couples. Postintervention change over time was modeled as a latent linear growth curve at the within-persons level.

RESULTS

We observed significant intervention effects on primary biomedical and behavioral HIV risk outcomes. Participants in 2GETHER had significantly lower odds of rectal STIs at 12-months relative to control. We also observed significantly steeper declines in the number of CAS partners and acts from baseline to 12-month follow-up in 2GETHER relative to control. Few differences were observed for secondary relationship and HIV-related outcomes.

CONCLUSIONS

2GETHER is an efficacious intervention that has a significant impact on both biomedical and behavioral HIV prevention outcomes among male couples. Couple-based HIV prevention programs enhanced with evidence-based relationship education may effectively reduce the most proximal predictors of HIV infection. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Use of "Strengthening Our Vows" Video Intervention to Encourage Negotiated Explicit Sexual Agreements in Zambian Heterosexual HIV Seroconcordant-Negative Couples

Negotiating sexual agreements in combination with couples' voluntary HIV counseling and testing (CVCT) may help further reduce HIV transmission in Zambian concordant HIV-negative couples (CNC). Though CVCT has been shown to reduce HIV transmission in CNC by 47%, approximately half of residual infections occur in this group. We developed a "Strengthening Our Vows" video session to foster communication and negotiation of explicit sexual agreements to reduce concurrent sexual exposures and prevent HIV transmission to the spouse due to unprotected, extramarital sex. CNC were recruited through CVCT services at five clinics in Lusaka and Ndola in 2016. Enrolled CNC attending the facilitated group video sessions were encouraged to discuss sexual agreements at home and return 1-2 weeks later for follow-up assessment. One-fourth of the 580 CNC returning reported a history of extramarital partners and/or a sexually transmitted infection (STI) prior to enrollment. More than 95% reported a friendly, supportive 15-60 min negotiation culminating in an agreement to remain monogamous or disclose sexual contacts and use condoms together until a repeat HIV test 30 days after an outside sexual exposure. Two-thirds of participants identified at least one threat to adherence of their agreements including alcohol use, financial pressures, travel, discord in the home, and post-partum or menstrual abstinence. CNC negotiated explicit sexual agreements to avoid exposure to HIV through concurrent partnerships and protect the spouse in the event of an outside sexual contact. Open communication was a consistent theme to facilitate mutual protective efforts. Long-term follow-up of HIV/STI incidence is ongoing to assess the impact of these agreements.Trial registration This sub-study is part of a trial retrospectively registered on ClinicalTrials.gov (Identifier: NCT02744586) on April 20, 2016.

Risky Sexual Behaviors as a Transaction of Individual Differences and Situational Context

Risky sexual behaviors (RSBs) incur large societal and personal costs. Despite widespread prevention efforts, RSBs and associated consequences (e.g., sexually transmitted infections) continue to rise. A proliferation of research has emerged on situational (e.g., alcohol use) and individual difference (e.g., impulsivity) factors to explain this rise, but these approaches assume an unrealistically static mechanism underlying RSB. Because this prior research has resulted in few compelling effects, we sought to innovate by examining the interaction of situation and individual differences in explaining RSBs. A large sample (N = 105) completed baseline reports of psychopathology and 30 daily diary reports of RSBs and associated contexts. These data were submitted to multilevel models including cross-level interactions to test a person-by-situation conceptualization of RSBs. Results suggested that RSBs are most strongly predicted from interactions of person- and situation-level factors in both protective and facilitative directions. These interactions outnumbered main effects and commonly included partner commitment as a central mechanism. These results point to theoretical and clinical gaps in preventing RSB and urge a departure from prior ways of conceptualizing sexual risk as a static outcome.

Correlates of condomless anal intercourse with different types of sexual partners among men who have sex with men and transgender women in Lima, Peru

CLINICAL TRIAL REGISTRATION

The Sabes study was registered in March 2013 with the National Institutes of Health at ClinicalTrials.gov (identifier: NCT01815580).

Agreements, Behaviour, and Change: Sex Outside the Relationship in Male HIV-negative Partners in HIV Serodiscordant Relationships in Australia, Brazil, and Thailand

Male HIV serodiscordant couples have diverse relationship agreements regarding sex outside the relationship. We examined the relationship agreements as described by 343 male HIV-negative partners in HIV serodiscordant relationships in Australia, Brazil and Thailand participating in a multi-year cohort study. At baseline, 125 (34.1%) HIV-negative partners reported no agreement, 115 (33.5%) had a monogamous agreement, and 103 (37.9%) had an open agreement allowing sex outside the relationship. Relationship agreements were largely stable over time, with 76% of HIV-negative men reporting the same agreement across follow up, while changes were predominantly towards having an open agreement. Behaviour largely matched relationship agreements, and the predictors of breaking an agreement by having condomless anal intercourse (CLAI) with an outside partner were CLAI within the relationship (OR = 3.17, 95%CI: 1.64-6.14, p < 0.001) and PrEP use in the last three months (OR = 3.42, 95%CI: 1.48-7.92, p = 0.004). When considering HIV transmission risk for HIV-negative men in serodiscordant relationships, greater focus needs to be placed on sex that is occurring outside the relationship and the agreements that facilitate this.

Collective Sex and Committed Relationships: A Qualitative Exploration of Relationship Desires Among Gay Men Who Attend Sex Clubs

Studies have documented gay men's engagement in collective sex (e.g., group sex in public or commercial environments) but little attention has been paid to these men's relationship desires or agreements. We report on qualitative interviews with 20 gay men who attended private sex clubs in New York City, asking how participants navigated sometimes conflicting desires for collective sex and committed relationships. Participants felt that collective sex was either a) incompatible with relationships, which should be monogamous; b) complementary to a primary non-monogamous relationship; or c) at least as important as relationships. Gay men attending sex clubs attribute different value to collective sex and to committed relationships, and experience different challenges in satisfying their desires for intimacy. Resources could help gay men navigating these apparently conflicting desires and making suitable choices regarding their relationships and/or sexual agreements.

Identifying Patterns of Discontinuing and Recommencing Pre-exposure Prophylaxis in the Context of Sexual Behavior Among Gay and Bisexual Men in Australia

We mapped gay and bisexual men's (GBM) patterns of using pre-exposure prophylaxis (PrEP) over time and explored sexual behavior as PrEP use changed. We conducted semi-structured interviews between June 2020 and February 2021 with 40 GBM living in Australia who had changed their PrEP use since initiating. There was considerable diversity in patterns of discontinuation, suspension, and recommencement of PrEP. Reasons for changing PrEP use mostly centered on accurate perceived changes to HIV risk. Twelve participants reported condomless anal intercourse with casual or fuckbuddy partners after discontinuing PrEP. These sex events were unanticipated, condoms were not a preferred option, and other risk reduction strategies were applied inconsistently. Service delivery and health promotion can support safer sex among GBM when PrEP use fluctuates by promoting event-driven PrEP and/or non-condom-based risk reduction methods during periods off daily PrEP, and guiding GBM to better recognize changing circumstances of risk and when to recommence PrEP.

Explicit Relationship Agreements and HIV Pre-exposure Prophylaxis Use by Gay and Bisexual Men in Relationships

Relationship agreements are important for HIV prevention among gay and bisexual men (GBM) in relationships, with research earlier in the HIV epidemic often finding that agreements specified monogamy or condom use with casual partners. There is evidence that HIV pre-exposure prophylaxis (PrEP) has shifted sexual practices among some men in relationships, such as allowing condomless sex with casual partners, but there has been little attention paid to relationship agreements among GBM who use PrEP. In this paper, we analyzed national, Australian, cross-sectional data from an online survey completed by non-HIV-positive GBM in 2021 (N = 1,185). Using logistic regression, we identified demographic characteristics, sexual practices and the types of relationship agreement that were associated with PrEP use among GBM in relationships. Using Pearson's chi-squared tests, we explored whether PrEP users in relationships reported similar sexual practices to PrEP users not in relationships. PrEP use among GBM in relationships was independently associated with older age, identifying as gay, being in a non-monogamous relationship, having a spoken (explicit) relationship agreement, having a primary HIV-negative partner taking PrEP or a primary partner living with HIV, reporting recent condomless casual sex, reporting an STI diagnosis in the past year, and knowing at least one other PrEP user. We found that PrEP users in relationships had similar sexual practices to PrEP users not in relationships. GBM in relationships who have casual sex and who meet PrEP suitability criteria may be good candidates for PrEP. Our findings suggest that explicit relationship agreements remain important for HIV prevention, and they support PrEP use among GBM in relationships.

Do Couple-Based Interventions Show Larger Effects in Promoting HIV Preventive Behaviors than Individualized Interventions in Couples? A Systematic Review and Meta-analysis of 11 Randomized Controlled Trials

This systematic review and meta-analysis aims to compare the effects of couple-based prevention interventions against individual-level interventions on HIV prevention in randomized controlled trials (RCTs), identify potential moderators, and assess study quality. Eleven RCTs were included, comprising 3933 couples in the intervention group and 7125 individuals in the individual control group, predominantly in heterosexual couples from the USA and Africa. Couple-based interventions had a more significant effect in promoting condom use and HIV testing. Education levels of high school or above, residence in low- and middle-income countries, and intervention design incorporating HIV counseling and testing were associated with higher odds of condom use. The quality assessment analysis identified methodological and theoretical heterogeneity factors. Evidence of couple-based HIV prevention RCTs among men who have sex with men, injecting drug users, sex workers, and transgender women warrant further investigation. Recommendations are made to improve the quality and replicability of future intervention studies.

Online Sexual Health Information Seeking Patterns Differentiated by Social Location and Physical Location among Gay and Bisexual Men in Ontario, Canada

Objective

This research aimed to understand the varying needs of diverse gay and bisexual men (GBM) in relation to online sexual health information-seeking dependent upon differing social sociodemographic variables and geographic location.

Methods

A total of 1802 GBM in Ontario participated in this study. Multivariable regressions were conducted to analyze differences in information-seeking based on ethnicity group, HIV status, recent sexual behavior and regionality (urban and rural location).

Results

There were significant differences in online sexual health information-seeking content based on these demographic variables.

Conclusions

Implications for sexual health outreach and service provision for diverse GBM are discussed as well.

Perspectives on a Couples-Based, e-Health HIV Prevention Toolkit Intervention: A Qualitative Dyadic Study with Black, Heterosexual Couples in New York State

Web-based technology provides an unparalleled opportunity to increase access and uptake of couples-based HIV prevention interventions. e-Health HIV prevention interventions for US Black heterosexual couples have largely been understudied. To address this gap, we applied the Assessment Phase of the ADAPT-ITT Framework to investigate Black heterosexual couples' perspectives on an existing e-Health, couples-based HIV prevention intervention. Applying a qualitative descriptive approach, joint dyadic interviews were conducted with 28 Black heterosexual couples from three jurisdictions in New York State. Content dyadic analysis revealed three descriptive categories: perspectives of the toolkit intervention (sub-codes: perceived relevance, reactions to core components), recommendations to enhance intervention relevancy (sub-codes: tailoring to relationship type, adding new content), and lasting intervention considerations (sub-codes: toolkit usability and language use). Overall, couples found the toolkit intervention content and usability acceptable and reflected on its potential to build sexual and relationship health. Couples recommended to enhance toolkit adaptability for varied couple's motivation and types re-consider terms like sexual agreements, and include content to facilitate communication regarding sensitive topics (e.g., childhood sexual trauma, co-parenting, family planning) and other issues that may have more relevance to the experience of US Black persons (i.e., wealth building).

Partner Support and Communication for Pre-exposure Prophylaxis (PrEP) Use Among Male Couples

Between one to two-thirds of HIV infections among gay, bisexual, and other men who have sex with men are from primary partners, and there has been increased research attention focused on strategies to increase PrEP adoption among male couples. While there is evidence that partner support is a strong correlate of pre-exposure prophylaxis (PrEP) adoption, there has been a lack of attention on PrEP communication dynamics among male couples. In this paper, we build upon this literature through analysis of dyadic data from a large cross-sectional survey of 543 concordant sero-negative and serodiscordant male couples to examine individual and relationship factors associated with reports of partner communication around PrEP, comfort in discussing PrEP, and perceived partner-level support for PrEP use. PrEP use was relatively low (16.2%), and although 87.5% of men reported their partners would support their PrEP use, only 26.3% had talked to their partner recently about PrEP. PrEP communication and perceived support for PrEP were significantly negatively associated with PrEP stigma and stigma based on sexuality (i.e., internalized homophobia and enacted external stigma based on sexuality), while men with sexual agreements were more comfortable talking about PrEP with their partner. There is a need to adapt current interventions, or develop new dyadic interventions, that provide opportunities for male couples to talk and learn about PrEP together, as a potential pathway to engage them toward PrEP use.

Protocol for an attention-matched randomized controlled trial of 2GETHER: a relationship education and HIV prevention program for young male couples

BACKGROUND

Young men who have sex with men (YMSM) are disproportionately impacted by the HIV epidemic in the USA, and a large number of new infections among YMSM occur in the context of main or primary partnerships. At the same time, healthy romantic relationships promote health and wellbeing by improving social support and encouraging healthy behaviors. Thus, we created 2GETHER: a relationship education and HIV prevention program for young male couples. 2GETHER is delivered face-to-face in a university setting and is composed of two group sessions and two individualized skills coaching sessions. We observed strong support of the feasibility, acceptability, and preliminary efficacy of 2GETHER in a pilot trial.

METHODS

We are conducting an attention-matched randomized controlled trial (RCT) to test the efficacy of 2GETHER relative to a control condition based on a well-validated positive affect enhancement program. Enrollment occurred between August 2017 and March 2021 in Chicago and surrounding areas, and we enrolled and randomized 128 dyads (N = 256 individuals). Follow-up is ongoing and we will examine primary and secondary behavioral outcomes at 12 months post-intervention, with interim follow-up at 3, 6, and 9 months post-intervention. The primary biomedical outcome is sexually transmitted infection incidence at a 12-month follow-up.

DISCUSSION

2GETHER is innovative in that it places an equal emphasis on relationship skill building and HIV prevention. Thus, the program has the potential to impact numerous health-related outcomes. Despite challenges related to the recruitment of couples and the COVID-19 pandemic, we were able to enroll a robust sample of young male couples with sufficient power to detect effects on study outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03186534 .

Negotiating Use of a Blood-Based, Dual HIV and Syphilis Test with Potential Sexual Partners Among a Sample of Cisgender Men and Transgender Women Who Have Sex with Men in New York City

Cisgender men who have sex with men (cMSM) and transgender women (TGW) are disproportionally burdened by HIV. Among these populations, HIV partner-testing is a highly acceptable harm reduction tool. Particularly, cMSM and TGW report a stronger preference for blood-based tests that include assays for multiple STIs. However, no existing research has explored how these populations negotiate blood-based testing with sexual partners. In the SMARTtest study, 48 sexually active cMSM and TGW took home dual, blood-based HIV/Syphilis kits for self- and partner-testing. After 3 months, they completed a follow-up assessment and in-depth interviews about their experiences initiating testing. Of the 42 responding participants, 27 (64%) reported that it had been "fairly" or "very easy" to raise the idea of testing with partners. Participants predominantly employed partner-conscious communication strategies, including framing the testing proposal as a mandatory, non-personal component of their participation in a research study, gradually incorporating testing mentions into discussions about sexual health, and using the kits to facilitate joint testing. Yet, 21 (44%) participants reported having sex with at least one partner they did not ask to test. Concern regarding partner reactions emerged as a significant barrier to discussing test use; similarly, many partners were averse to taking a blood-based test in the context of a casual sexual encounter. Nonetheless, these findings suggest that dual, blood-based HIV/STI rapid tests may represent acceptable harm reduction tools among similar populations of cMSM and TGW, particularly if future partner-testing research is broadened to consider key couples' dynamics that may impact test usage.

A national recruitment strategy for HIV-serodiscordant partners living in Canada for the Positive Plus One study: a mixed-methods study

Background

With the recent shift in focus to addressing HIV risk within relationships and couple-based interventions to prevent HIV transmission, successful recruitment of individuals involved in HIV-serodiscordant relationships is crucial. This paper evaluates methods used by the Positive Plus One (PP1) study to recruit and collect data on a diverse national sample of dyads and individuals involved in current or past HIV-serodiscordant relationships, discusses the strengths and limitations of the recruitment approach, and makes recommendations to inform the interpretation of study results and the design of future studies.

Methods

PP1 used a multi-pronged approach to recruit adults involved in a current or past HIV-serodiscordant relationship in Canada from 2016 to 2018 to complete a survey and an interview. Upon survey completion, index (first recruited) partners were invited to recruit their primary current HIV-serodiscordant partner. We investigated participant enrollment by recruitment source, participant-, relationship-, and dyad-level sociodemographic characteristics, missing data, and correlates of participation for individuals recruited by their partners.

Results

We recruited 613 participants (355 HIV-positive; 258 HIV-negative) across 10 Canadian provinces, including 153 complete dyads and 307 individuals who participated alone, and representing 460 HIV-serodiscordant relationships. Among those in current relationships, HIV-positive participants were more likely than HIV-negative participants to learn of the study through an ASO staff member (36% v. 20%, p < 0.001), ASO listserv/newsletter (12% v. 5%, p = 0.007), or physician/staff at a clinic (20% v. 11%, p = 0.006). HIV-negative participants involved in current relationships were more likely than HIV-positive participants to learn of the study through their partner (46% v. 8%, p < 0.001). Seventy-eight percent of index participants invited their primary HIV-serodiscordant partner to participate, and 40% were successful. Successful recruitment of primary partners was associated with longer relationship duration, higher relationship satisfaction, and a virally suppressed HIV-positive partner.

Conclusions

Our findings provide important new information on and support the use of a multi-pronged approach to recruit HIV-positive and HIV-negative individuals involved in HIV-serodiscordant relationships in Canada. More creative strategies are needed to help index partners recruit their partner in relationships with lower satisfaction and shorter duration and further minimize the risk of “happy couple” bias.

Recruiting Black Men Who Have Sex With Men (MSM) Couples via Dating Apps: Pilot Study on Challenges and Successes

Background

HIV disproportionately impacts Black men who have sex with men (MSM), and targeting the primary relationship (ie, couples) using mobile technology for health holds promise for HIV prevention. Web-based recruitment of MSM is commonly employed in HIV prevention and intervention research. However, little known about recruiting Black MSM couples on the internet in the United States.

Objective

This study describes the process of recruiting Black MSM couples over social networking and dating apps frequented by MSM. We describe the activities for recruiting, screening, and enrolling participants as part of a randomized trial employing a multipronged recruitment approach.

Methods

Black MSM in couples were recruited via three apps (ie, Jack’d, Adam4Adam, and Growlr) between May 2020 and March 2021 during the COVID-19 pandemic in the United States. Black MSM couples were eligible if one or both partners are Black, MSM, and living with HIV, and if both partners were 18 years or older, and have been together for at least 2 months in what they both consider a primary relationship (ie, one in which both partners reported feeling most committed to over any other partner or relationship).

Results

A total of 10 Black MSM couples (n=20) were enrolled via social networking apps. App recruitment activities were a combination of passive (eg, in-app advertisements) and active (eg, direct messaging of users) engagement. Recruitment approaches varied by the social networking app owing to differences in app features. A full-time recruiter experienced challenges such as bugs (ie, technical errors in computer program or system), navigating technical requirements specific to each app, and web-based harassment.

Conclusions

Despite challenges, it was possible to recruit Black MSM couples virtually into research as part of a multipronged recruitment strategy. We identify tips for using web-based dating and other social networking apps as part of a recruitment strategy in future research with Black MSM couples.

Characteristics of Agreements to have Condomless Anal Intercourse in the Presence of an Undetectable Viral Load Among HIV Serodiscordant Male Couples in Australia, Brazil and Thailand

The use of undetectable viral load (VL) to negotiate condomless anal intercourse (CLAI) in HIV serodiscordant male relationships has become more common as more data regarding the effectiveness of antiretroviral treatments for the prevention of HIV transmission has been described. We examined viral load agreements (VLAs) for condomless sex in the presence of an undetectable VL in 343 HIV serodiscordant male couples in Australia, Brazil and Thailand. Factors associated with having a VLA included having agreements for the HIV-positive partner to report his VL result (p < 0.001), agreeing that VL affects agreements about sexual practice (p < 0.001), the HIV-negative partner's perception of his partner's undetectable VL (p < 0.001), the couple's belief in the efficacy of undetectable VL in preventing HIV transmission (p < 0.001), and the couple engaging in CLAI with each other (p < 0.001). Over time, these agreements became more common although 49.3% of couples in the sample never had a viral load agreement. As these agreements become more common, further education is required to support male couples in using them safely.

A Behavioral Cascade of HIV Seroadaptation Among US Men Who Have Sex with Men in the Era of PrEP and U = U

Seroadaptive behaviors help reduce HIV risk for some men who have sex with men (MSM), and have been well documented across MSM populations. Advancements in biomedical prevention have changed the contexts in which seroadaptive behaviors occur. We thus sought to estimate and compare the prevalence of four stages of the "seroadaptive cascade" by PrEP use in the recent era: knowledge of own serostatus, knowledge of partner serostatus; serosorting (matching by status), and condomless anal intercourse. Serosorting overall appeared to remain common, especially with casual and one-time partners. Although PrEP use did not impact status discussion, it did impact serosorting and the likelihood of having condomless anal intercourse. For respondents not diagnosed with HIV and not on PrEP, condomless anal intercourse occurred in just over half of relationships with HIV-positive partners who were not on treatment. Biomedical prevention has intertwined with rather than supplanted seroadaptive behaviors, while contexts involving neither persist.

Pre-Exposure Prophylaxis Stigma and Beliefs in the Efficacy of Pre-Exposure Prophylaxis: An Analysis of a Cross-Sectional Survey of Male Couples in the United States

ABSTRACT

Increasing the use of pre-exposure prophylaxis (PrEP) among male couples is critical to the success of the United States' Ending the HIV Epidemic campaign. By leveraging dyadic data from a larger cross-sectional study of male couples, the present analysis examined individual, partner, and relationship characteristics associated with PrEP stigma and perceived efficacy of PrEP. Actor-Partner Independence Models were fit separately for both outcomes. Individual and partner risk behaviors, including substance use, binge drinking, and higher number of condomless casual sex partners, were associated with lower levels of both PrEP stigma and belief in the efficacy of PrEP. Networks that supported PrEP use were associated with decreased PrEP stigma and increased belief in PrEP efficacy. Stigma-informed PrEP interventions for couples should be considered foundational to the success of the United States' Ending the HIV Epidemic campaign.

Assessing Self-Efficacy and Communication Regarding Sexual Agreements among Men Who Have Sex with Men in the USA: Development and Validation of Two Novel Scales

HIV disproportionately impacts men who have sex with men (MSM) in the USA. Building upon research on relationship constructs unique to MSM couples’ HIV-prevention needs, we developed two new scales measuring sexual agreement self-efficacy (SASE) and importance of sexual agreement communication (ISAC). Following qualitative item development, we used two large independent samples of MSM couples (N1 = 441, N2 = 388) to conduct scale validation. Exploratory factor analyses indicated both SASE and ISAC to be unidimensional with 7 and 5 items (eigenvalues = 5.68 and 3.50), respectively, with strong factor loadings. Confirmatory factor analyses yielded satisfactory model fit for SASE (CFI = 0.99; SRMR = 0.03) and ISAC (CFI = 0.99; SRMR = 0.05). Reliability was high for SASE (ω = 0.92) and ISAC (ω = 0.84). Predictive validity analysis revealed a protective association between higher scores on both scales and the outcomes of sexual risk behavior and agreement breaks. Convergent and discriminant validity analyses demonstrated associations in the expected directions between these scales and multiple measures of relationship quality. Therefore, SASE and ISAC are two brief, valid, and reliable scales that can facilitate more in-depth explorations of sexual agreements in MSM and thereby contribute greatly to improving our understanding of and ability to intervene on sexual agreements to improve health and relationship outcomes.

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.

Analysis of Male Couples' Sexual Agreements After Using an eHealth, Couples-Based HIV Prevention Intervention in Lima, Peru

Few studies have investigated the composition of male couples' sexual agreements and whether their agreement composition differs by dyad HIV serostatus. To help assess the utility that agreements could have for sexual health and prevention, the present study analyzed dyadic paradata collected from an acceptability project of an eHealth HIV prevention toolkit intervention with 42 male couples in Lima, Peru (16 serodiscordant, 12 seroconcordant positive, 14 seroconcordant negative). Couples used the toolkit as designed, which included an agreement builder activity to encourage formation of a tailored agreement by selecting items from five categories (wellness, sex with partner, sex with others, social etiquette, substance use). The number of items couples included in their agreement varied (range: 7-59), and did not differ by dyad serostatus. For agreement composition, couples included the highest number of items about wellness, followed by sexual behaviors with the partner, and social etiquette. Between one- and two-thirds of couples included regular HIV/STI testing. However, far fewer specified guidelines about condom use and no couples included biomedical HIV prevention strategies. Findings suggest additional intervention mechanism(s) (e.g., prompts, algorithms) may be needed to encourage couples to include HIV/STI prevention strategies in their agreements while also balancing their sexual health preferences.

Population-Specific Correlates of Sexual Arrangements and Communication in a National Sample of Latinx Sexual Minority Men

While the literature on sexual arrangements has expanded considerably, less is known about sexual arrangements among ethnically diverse populations, particularly Latinx sexual minority men (LSMM). Relationship research may overlook culturally salient correlates (e.g., ideals of masculinity or immigration-related factors) of sexual arrangements. The current study explored relationship-related factors (i.e., sexual arrangements, sexual communication, and relationship functioning) as well as Latino-specific factors, including dominant cultural views of masculinity (machismo/caballerismo) and immigration among partnered LSMM. Participants were recruited nationwide through social media and geo-location dating apps. All participants were aged 18 or older, cisgender male, lived in the U.S., including Puerto Rico, were able to read in either English or Spanish, and indicated they were currently in a relationship with a cismale partner. Multinomial regression was used to calculate the odds of being in an open or monogamish arrangement relative to a monogamous arrangement. Multivariable linear regression analysis was conducted to examine factors related to sexual communication. Language spoken with partner, adherence to more general heteronormative beliefs (genderism), and substance use were associated with specific sexual arrangement groups. The findings also suggested that birthplace, language spoken with partner variables, and machismo were associated with specific sexual arrangements and with sexual communication. This study highlights that factors associated with sexual arrangements and sexual communication may be population specific. The current study points to a complex interplay between culturally relevant ideals of masculinity and sexual arrangements as well as sexual communication among partnered Latinx sexual minority men.

Consensual Non-Monogamy Relationship Rules Among Young Gay and Bisexual Men: A Dyadic Qualitative Analysis

Consensual non-monogamous (CNM) relationship rules, the boundaries and understandings partners have about acceptable behaviors related to their CNM relationship, are associated with relationship functioning and sexual health risk among gay and bisexual men. Partnered young gay and bisexual men (YGBM) experience unique relational challenges and sexual health disparities. Thus, understanding the nuances of relationship rules among YGBM in CNM relationships is of particular importance. However, few studies have examined relationship rules specifically among YGBM. The current study sought to explore relationship rules among YGBM in CNM relationships, including both those explicitly discussed and those implicitly assumed. We also assessed concordance and discrepancies in partners' reports of their relationship rules, as well as rule violations. Partners from 10 CNM couples (n = 20; M_age = 25.3) completed separate semi-structured interviews that included questions about their relationship rules. Individual- and dyad-level analyses were conducted using a modified version of the consensual qualitative research method. Three main themes of relationship rules emerged from the data: extradyadic partner criteria, conditions regarding extradyadic sex, and conditions regarding maintenance of the primary relationship. While 39% of participants reported rules that were not endorsed by their partner, few clearly contradictory discrepancies in partners' reports were observed. Nine participants reported having at least one implicit rule and 70% of participants (from 8 of 10 couples) reported that they and/or their partner violated at least one rule. Explicit rules and rule concordance may be associated with improved relationship functioning. Common violations of sexual risk reduction rules may contribute to YGBM's increased HIV/STI risk.

Arrangements versus Agreements: Evaluating Two Approaches to Measuring Male Couples' Rules and Understandings Around Sex with Outside Sex Partners

One- to two-thirds of new HIV infections among sexual minority men occur within the context of main partnerships. This has led to increasing attention to the rules and boundaries male couples form around sex with outside partners as a mechanism to manage HIV risk. These rules and boundaries have generally been operationalized either as a sexual agreement-the decisions couples make together about their sexual boundaries with outside partners-or a sexual arrangement-how couples handle sex outside the relationship, which may or may not involve an implicit or explicit consensus between partners. The goal of the current study was to examine the correspondence of these two approaches to the operationalization of rules and boundaries. Additionally, the study tested whether agreements and arrangements were differentially associated with dyadic communication and sexual behavior with casual partners. Results indicated a high level of correspondence between assessment methods. Similarly, patterns of sexual behaviors with casual partners were consistent across both sexual agreements and sexual arrangements. In contrast, patterns of communication varied as a function of assessment type. Specifically, constructive, avoidant, and sexual communication varied across sexual agreement types, whereas sexual arrangement types only differed with respect to constructive communication. These findings suggest that there is substantial overlap between arrangements and agreements. Findings particularly related to associations with sexual behavior may largely generalize across these methods of operationalization. In contrast, survey-reported sexual agreements were a more sensitive correlate of dyadic communication.

Motivations for Engaging in Consensually Non-Monogamous Relationships

Sexual, romantic, and intimate relationships provide opportunities for individual and interpersonal fulfillment and the enhancement of well-being. Though research has identified that consensual non-monogamy (CNM) offers unique relational benefits, little work has examined why individuals pursue CNM relationships. Both self-determination theory and self-expansion theory provide frameworks for understanding the range of intra- and interpersonal motives for choosing or negotiating a multipartnered relationship. We explored the reasons for which people engage in CNM and discuss how motivations for CNM might be linked to well-being and need fulfillment. Our study used a qualitative approach to examine the motivations individuals report for engaging in CNM relationships. As part of a larger online survey, participants completed open-ended questions examining motivations for, and experiences of, CNM relationships. Data from participants who indicated that they were currently in a CNM partnership was selected for the analyses (n = 540). Data were analyzed using thematic analysis, within a critical realist framework. Motivations were organized into six interconnected themes: reasons related to autonomy, beliefs and value systems, relationality, sexuality, growth and expansion, and pragmatism. Individuals reported diverse reasons for engaging in CNM relationships; reasons addressed both individual and relational needs and well-being. Findings contrast with stereotypic views of CNM relationships as unstable/unfulfilling or that individuals engage in CNM because of relationship problems. The findings may facilitate therapeutic interventions for counselors working with individuals who are in the process of negotiating or re-negotiating relationship boundaries.

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.

The Who and Why of Consensual Nonmonogamy Among African Americans

Prevalence rates of consensual nonmonogamy (CNM) demonstrate little difference across race. Yet, not much is known about CNM among African Americans. Through an online survey study, we examined the correlates of CNM among African Americans as well as the reasons why they engage. A total of 1050 African Americans between the ages of 18-40 years participated in this study. Binomial logistic regression was utilized to determine the correlates of CNM. Sexual orientation was the only significant predictor of CNM. The following variables were nonsignificant predictors of CNM: age, gender, household income, religiosity, and education. Qualitative analysis revealed several reasons for CNM engagement: (1) belief that it is natural; (2) excitement; (3) not meant for each other; (4) scared of losing partner; (5) bisexuality; (6) does not want commitment; and (7) maintain honesty, trust, and integrity. This study adds to the sparse knowledge base of CNM among African Americans.

Sexual Agreements and Intimate Partner Violence Among Male Couples in the U.S.: An Analysis of Dyadic Data

Prior research with male couples has focused on how sexual agreements can influence relationship dynamics, sexual risk taking, and health promoting behaviors. Little is known about the association between sexual agreements and the experience or perpetration of intimate partner violence (IPV) in this population. Our study sought to evaluate these associations using dyadic data from a sample of 386 male couples residing in the U.S. Both partners independently reported on their relationship characteristics, sexual agreements, and specific acts reflecting physical, emotional, controlling, and monitoring IPV in separate surveys. Participants were more likely to have experienced IPV in the past year if they were in a relationship for ≥ 3 years versus < 3 years (aOR = 1.62, 95% CI = 1.03-2.53). Among 278 couples who had formulated sexual agreements, men who concurred with their partners on being in an "open" relationship were less likely to have experienced IPV versus those in a "closed" relationship (aOR = 0.47, 95% CI = 0.25-0.89). However, participants were more likely to have experienced IPV if their partners believed they had previously broken their sexual agreement (aOR = 2.79, 95% CI = 1.03-7.52). The verbal explicitness and duration of sexual agreements were not associated with either experiencing or perpetrating IPV in the past year. However, increasing levels of depressive symptomatology were associated with a greater likelihood of both experiencing and perpetrating IPV. Our findings highlight the need to prioritize dyadic interventions for male couples that focus on skills building around enhancing mutual communication and negotiating sexual agreements to reduce IPV.

Sexual Agreements Among Young Sexual and Gender Minorities Assigned Male at Birth: Associations with Relationship Quality and Break-Up

Previous studies have shown that sexual non-monogamy is not associated with lower relationship satisfaction among adult male same-sex couples and may therefore be a viable alternative to monogamy. However, sexual minority men with non-monogamous agreements have reported lower commitment and trust in their relationships than those with monogamous agreements-potentially raising their risk of break-up. In this study, we investigated whether sexual agreements (monogamous, non-monogamous, or no sexual agreement) were associated with relationship quality and rates of break-up over 1 year in a sample of 338 young sexual and gender minorities assigned male at birth (SGM-AMAB). Participants reported their sexual agreement and indices of relationship quality (satisfaction, trust, and commitment) at baseline, as well as their relationship status (intact or broken up) at 6- and 12-month follow-up. Results showed no significant differences by sexual agreement in concurrent trust, but participants with monogamous agreements reported higher satisfaction and commitment than those with non-monogamous agreements or no sexual agreement. Despite these significant differences in relationship quality, there were no significant differences in rates of break-up at 6- or 12-month follow-up across the sexual agreement types. However, having a monogamous agreement was indirectly associated with lower rates of break-up through relationship commitment. Although results were mixed, findings provide some preliminary support that young SGM-AMAB in relationships with monogamous agreements may have higher satisfaction and commitment at early relationship stages, and that monogamous agreements may be a protective factor against break-up over 1 year through the mechanism of relationship commitment.

PrEP Demonstration Project Showed Superior Adherence with Tenofovir Alafenamide/Emtricitabine Compared to Tenofovir Disoproxil Fumarate/Emtricitabine in a Sample of Partnered Sexual Minority Men

Sexual minority men (SMM) remain at high risk of HIV infection in the United States, and for those in relationships, dyadic functioning may contextualize prevention decisions. Pre-exposure prophylaxis (PrEP) for HIV prevention was previously limited to tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) until the FDA approved tenofovir alafenamide/FTC (TAF/FTC) for PrEP in 2019. Data regarding substance use, sexual behavior, holding an active PrEP prescription, and type of PrEP regimen (TDF/FTC versus TAF/FTC) were analyzed from a sample of 421 partnered SMM. The majority of the sample on PrEP reported a TDF/FTC prescription as opposed to TAF/FTC. However, SMM reported significantly better adherence to TAF/FTC than TDF/FTC in multivariable models. Novelty of TAF/FTC, treatment fatigue with TDF/FTC, and/or a belief in TAF/FTC's superior efficacy and mitigated side effects may be plausible contributing factors. More studies using objective adherence metrics and surveys are needed.

A dyadic examination of self-determined sexual motives, need fulfillment, and relational outcomes among consensually non-monogamous partners

Intimate and sexual relationships provide opportunity for emotional and sexual fulfillment. In consensually non-monogamous (CNM) relationships, needs are dispersed among multiple partners. Using Self-Determination Theory (SDT) and dyadic data from 56 CNM partnerships (112 individuals), we tested how sexual motives and need fulfillment were linked to relational outcomes. We drew from models of need fulfillment to explore how sexual motives with a second partner were associated with satisfaction in the primary relationship. In a cross-sectional and daily experience study we demonstrated that self-determined reasons for sex were positively associated with sexual satisfaction and indirectly linked through sexual need fulfillment. Self-determined reasons for sex predicted need fulfillment for both partners at a three-month follow up. The association between sexual motives and need fulfillment was stronger on days when participants engaged in sex with an additional partner, though this was not related to satisfaction in the primary relationship. Implications for need fulfillment are discussed.

Association between relationship characteristics and willingness to use PrEP among same-sex male couples: a cross-sectional actor-partner analysis in Guangzhou, China

The association between relationship characteristics and pre-exposure prophylaxis (PrEP) acceptability among same-sex male couples has been limitedly examined. Dyadic survey data of 139 concordant HIV-negative same-sex male couples in Guangzhou, China were collected. The willingness to use PrEP was measured assuming that the participant's partner was HIV-positive. The actor-partner interdependence model was used to examine how one's relationship characteristics affected the PrEP willingness of the subject and his partner. Most participants (79.5%) were willing to use PrEP. The two individuals of the couple were distinguished by sex role in relationship, namely one usually playing the insertive role and the other usually playing the receptive role in anal intercourse. The former was labeled as "top" and the latter labeled as "bottom". The PrEP willingness of the top partner increased when he would think his partner is having sex with other people if the partner requests condom use in relationship (AOR: 5.74, 95% CI: 1.10-29.87), and decreased when his partner would get violent upon condom use requests in relationship (AOR: 0.19, 95% CI: 0.04-0.88). The PrEP willingness of the bottom partner increased when he trusted his partner (AOR: 1.13, 95% CI: 1.02-1.25) and when he or his partner disclosed the relationship to parents (AOR: 10.57, 95% CI: 1.91-58.61). Considering the sex role and relationship characteristics in couple-based interventions are important to optimize PrEP uptake among HIV-discordant same-sex male couples.

Interpersonal and Intrapersonal Influences on Sexual Satisfaction in Young Male Couples: Analyses of Actor-Partner Interdependence Models

Very little research has examined sexual satisfaction in young gay, bisexual, queer, and other men who have sex with men (YMSM). Sexual satisfaction has important implications for individual wellbeing and is a central component of romantic relationship functioning and satisfaction. In order to fill this gap, this study examined interpersonal and intrapersonal factors associated with sexual satisfaction in a large sample of young male couples. Data for these analyses came from the baseline visits of two ongoing randomized controlled trials of 2GETHER, a relationship education and HIV prevention program for young male couples. Participants for the current analytic sample were 419 couples (individual N = 838) from across the United States who were diverse in terms of race/ethnicity, HIV status, and geographic region. Analyses found that relationship functioning (i.e., relationship satisfaction, communication) was positively associated with sexual satisfaction, while not having a specified relationship agreement (i.e., monogamy/non-monogamy agreement) was associated with less sexual satisfaction. Intrapersonal factors (i.e., depression, substance use) were associated with sexual satisfaction, but most of these effects became non-significant in a full multivariate model. Relationship functioning plays a central role in sexual satisfaction and should be addressed in couple-based programs to optimize relationship functioning and sexual health.

Romantic relationships and sexual minority health: A review and description of the Dyadic Health Model

A large body of literature has documented the health promotive effects of healthy committed relationships on the health and wellbeing of heterosexual people in different-sex relationships, including observational and longitudinal studies, couple-based intervention development and evaluation efforts, and articulation of theoretical frameworks. A much smaller but growing field of research has observed that same-sex relationships have similar effects on health outcomes but that these couples face unique stressors that may impact relationship functioning and health. Further, extant theoretical frameworks do not sufficiently address the multiple pathways by which psychosocial vulnerabilities and stressors impact same-sex relationship functioning, engagement in health-related risk behaviors, and the mental and physical health of sexual minorities in relationships. The purpose of this manuscript is to: a) review the existing literature on relationship functioning and health among sexual minorities, including both observational and intervention studies; and b) present an integrated model of relationship functioning and health for same-sex couples that can be used as a basis for further studies on sexual minority dyads, as well as the development of novel couple-based interventions to optimize the health promoting effects of relationships.

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.

Power relations in sexual agreements among male couples in Southern Africa

Sexual agreements between same-sex practising men facilitate communication about health promotion activities, including HIV prevention. In African contexts, male couples negotiate their sexual agreements in relation to rigid cultural prescriptions about male power and privilege, intense hostility towards same-sex sexualities and persistent heterogendered socio-cultural norms. Yet the impact of such norms on relationship practices and HIV risk among male couples remains inadequately explored. This qualitative study examined the role of gendered power disparities in establishing sexual agreements among male couples in two Southern African contexts. Eighteen male couples completed in-depth interviews focused on relationship practices, including sexual agreements. The research employed critical social theory to analyse power relations and socio-cultural norms shaping male couples' explicit and implicit sexual agreements, with a focus on implications for HIV risk. The findings outline different types of and motivations for sexual agreements among male couples, including qualified non-monogamy with female partners only. The study illustrates how Southern African male-male sexual practices remain embedded in a cultural context favouring the replication of heteronormative sexual behaviours and relationship practices. These heterogendered norms impact negatively on the process of establishing explicit, mutually agreed-upon sexual agreements, and thus place male couples at increased risk for HIV.