Actor-partner effects of demographic and relationship factors associated with HIV risk within gay male couples

Main Partner Relationships and the HIV Care Cascade: Examining the Predictive Utility of Sexual Agreements, Partner Concordance, and Drug Use Among Sexual Minority Men Living With HIV in the USA

BACKGROUND

The past 15 years have seen increasing attention to relationship factors among sexual minority male (SMM) couples at high risk for HIV infection. Research has largely focused on HIV prevention outcomes. Outcomes relevant to SMM living with HIV have received relatively less attention.

PURPOSE

This study evaluated associations between relational covariates (relationship status, sexual agreements, and seroconcordance) and HIV care cascade outcomes (having a current antiretroviral therapy [ART] prescription, ART adherence, viral load (VL) testing, and VL detectability) above and beyond cannabis and stimulant drug use.

METHODS

Adult SMM (n = 36,874) living with HIV in the USA were recruited between November 1, 2017 and March 15, 2020 through social networking applications. They completed a cross-sectional survey online.

RESULTS

Nonmonogamous SMM with serodiscordant partners were most likely to have an ART prescription. Those with seroconcordant partners (regardless of sexual agreements) were least likely to be adherent. While relational covariates were not associated with VL testing, SMM in nonmonogamous relationships with serodiscordant partners were significantly more likely to have an undetectable VL. Those in monogamous relationships with seroconcordant partners were significantly less likely to have an undetectable VL.

CONCLUSIONS

SMM with seroconcordant partners and monogamous sexual agreements may experience diminished interpersonal motivation for HIV care engagement. HIV care cascade retention messages that emphasize the prevention of onward transmission may have limited relevance for these SMM. Novel intervention strategies are needed to enhance HIV care outcomes in this population, ideally ones that incorporate attention to drug use.

Day-level associations between drug use and sexual behavior in male couples: Actor partner interdependence modeling of timeline follow-back data

BACKGROUND

Both marijuana and other illicit drugs (e.g., cocaine/crack, methamphetamines, ecstasy, gamma-hydroxybuterate, and ketamine) have been linked to the occurrence of condomless anal sex (CAS) with casual partners among sexual minority men (SMM) and these associations largely generalize to partnered SMM. Software advances now permit testing the day-level correspondence between participants' sexual behavior and their own drug use (actor effects) as well as their partners' (partner-effects).

METHODS

Participants comprised 50 couples (100 individuals) recruited in the New York City metro area. All were 18 or older and identified as cis male. In each couple, at least one partner was 18-29 years old, HIV-negative, reported recent (past 30 day) drug use and recent (past 30 day) CAS with a casual partner or CAS with a non-monogamous or sero-discordant main partner at screening.

RESULTS

Marijuana was associated with CAS between main partners on days both partners reported its use. A similar pattern was observed for other illicit drugs. Respondents were more likely to report CAS with casual partners on days CAS between main partners occurred. Both marijuana and other illicit drugs were associated with increased likelihood of CAS with casual partners on days a main partner did not use drugs. These associations were attenuated on days where partners reported the use of different drugs.

CONCLUSIONS

The co-occurrence of CAS with main and casual partners maximizes shared sexual risk. Results support the continued emphasis on dyadic HIV prevention interventions and the development of theoretically-based interventions that may address drug use by both partners in the relationship.

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.

The effects of intimate relationship characteristics on unprotected anal intercourse among same-sex male couples in China: a dyadic analysis using the actor-partner interdependence model

BACKGROUND

Unprotected anal intercourse (UAI) within the context of concurrent sexual relationship are prevalent among men who have sex with men (MSM) who have regular male sex partners and it aggravates the risk of HIV infection among this community. The aim of this study was to assess the effect of intimate relationship characteristics on UAI among MSM couples at the dyadic level.

METHODS

Two hundred four MSM couples were recruited from a HIV testing clinic from April 2017 to April 2018 in Guangzhou, China. The actor-partner interdependence model (APIM) was applied for dyadic analysis. Each MSM couple was divided into the insertive role and the receptive role according to their regular anal sex role. In this context, actor effect is the impact of an MSM's intimate relationship characteristics on his own UAI, and partner effect is the impact of his partner's intimate relationship characteristics on his UAI.

RESULTS

Of the 408 participants, 58.82% had UAI with regular male sex partner (UAI-RP) and 8.09% had concurrent UAI. Intimate relationship characteristics were associated with concurrent UAI, but not associated with UAI-RP. For the receptive role, his relationship investment exerted significant actor and partner effects on concurrent UAI (AOR actor = 1.31, P < 0.001; AOR partner = 1.17, P < 0.001). Meanwhile, receptive role's violence experience within relationship exerted significant actor effects on his own concurrent UAI (AOR actor = 6.43, P = 0.044).

CONCLUSIONS

Relationship investment and violence experience influenced concurrent UAI among MSM couples and it varied in different sex roles. Additional assistance on empowerment, relationship therapy and sexual agreement is urgently needed to reduce their high possibility on engagement of HIV-related risk behaviors.

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.

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.

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.

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.

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.

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.

Associations Between Relationship Power and Pre-Exposure Prophylaxis (PrEP) Use Among Men Who Have Sex With Men

Few studies have attempted to understand relationship-level factors impacting PrEP utilization among men who have sex with men (MSM). This study examined associations between relationship power and PrEP use among 826 MSM participating in a cross-sectional, Internet-based survey. The results of our analysis indicate that decision-making dominance was positively associated with PrEP use among MSM, but the association between relationship control/overall relationship power and PrEP use was inconclusive. Furthermore, when examining specific types of decision-making dominance, equal and greater dominance compared to one's partner regarding types of sexual activity engaged in, as well as dominance more generally, were positively associated with PrEP use. However, the relationships between decision-making dominance related to condom use/sexual initiation and PrEP use were inconclusive. This study suggests that the promotion of egalitarian relationships-as well as other relationship-level determinants-should be an essential component of biobehavioral interventions targeting this population.

Feasibility and Acceptability of an Electronic Health HIV Prevention Toolkit Intervention With Concordant HIV-Negative, Same-Sex Male Couples on Sexual Agreement Outcomes: Pilot Randomized Controlled Trial

BACKGROUND

There is a need to develop innovative and accessible dyadic interventions that provide male couples with the behavioral skills to manage the risk of HIV transmission within their relationship.

OBJECTIVE

We conducted a pilot randomized controlled trial (RCT) to assess the feasibility and acceptability of the electronic health (eHealth) HIV prevention toolkit intervention to encourage seroconcordant negative male couples in the United States to establish and adhere to a sexual agreement (SA).

METHODS

Eligible, consented couples were randomly assigned to the intervention or education control and followed up for 6 months, with assessments occurring every 3 months after baseline. Acceptability items were assessed at both follow-up assessments. Descriptive and comparative statistics summarized cohort characteristics, relationship dynamics, and SA outcomes for the entire cohort and by trial arm. To examine the association between couples' relationship dynamics and their establishment of an SA over time and by trial arm, multilevel logistic regression analyses were performed with a random intercept to account for correlations of repeated measurements of relationship dynamics at months 3 and 6; the odds ratio (OR) of establishment of an SA and the corresponding 95% confidence interval were then reported.

RESULTS

Overall, 7959 individuals initiated screening. Reasons for individual ineligibility varied. An electronic algorithm was used to assess couple-level eligibility, which identified 1080 ineligible and 266 eligible dyads. Eligible couples (n=149) were enrolled in the pilot RCT: 68 received the intervention and 81 received the education control. Retention was 71.5% (213/298 partnered men) over the 6 months. Participants reported high acceptability of the intervention along with some areas for improvement. A significantly higher proportion of couples who received the intervention established an SA at 6 months compared with those who received the education control (32/43, 74% vs 27/50, 54%; P=.05). The OR of establishing an SA for couples in the intervention versus those in the control condition was greater than 2 when controlling for a number of different relationship dynamics. In addition, the odds of establishing an SA increased by 88% to 322% for each unit increase in a variety of averaged relationship dynamic scores; the opposite result was found for dynamics of stigma. Differences between trial arms for SA type and adherence were nonsignificant at each assessment. However, changes in these 2 SA aspects were noted over time. The average number of items couples included in their SA was 18, and about one-fourth to one-third of couples included HIV prevention items.

CONCLUSIONS

The findings demonstrate strong evidence for the acceptability and feasibility of the eHealth toolkit as a brief, stand-alone, couples-based HIV prevention intervention. These findings support the need to update the toolkit and evaluate it in a larger clinical trial powered for efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02494817; http://clinicaltrials.gov/ct2/show/NCT02494817.

Trust, Sexual Trust, and Sexual Health: An Interrogative Review

Trust is experienced almost constantly in all forms of social and interpersonal relationships, including sexual relationships, and may contribute both directly and indirectly to sexual health. The purpose of this review is to link three aspects of trust to sexual health: (1) the role of trust in sexual relationships; (2) the role of trust in sexually transmitted infection (STI) prevention, particularly condom use; and (3) the relevance of trust in sexual relationships outside of the traditional model of monogamy. The review ends with consideration of perspectives that could guide new research toward understanding the enigmas of trust in partnered sexual relations in the context of sexual and public health.

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

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

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

The online version of this article (10.1186/s12879-018-3044-6) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Sexual behavior and HIV risk among age-discrepant, same-sex male couples

Research has suggested that men who have sex with men and who have older sexual partners are at increased risk of HIV infection. However, while several studies have explored risk among men in age-discrepant non-primary partnerships, only two have explored age discrepancy and risk in primary same-sex male relationships. We used data from semi-structured in-depth interviews to explore sexual behaviour and HIV risk among 14 Black, white and interracial (Black/white) same-sex male couples with an age difference of 10 or more years. Most couples regularly used condoms, and sexual positioning tended to lead to lower risk for younger partners. Some serodiscordant couples abstained from anal sex, while others used seropositioning to avoid transmission within the relationship. Within some couples, older partners acted as mentors on HIV prevention and broader life lessons. Future studies should further explore the potential risks and benefits of large age differences in same-sex male primary relationships.

Relationship-Based Predictors of Sexual Risk for HIV Among MSM Couples: A Systematic Review of the Literature

Behavioral and epidemiological studies report high risk for HIV among MSM couples. Over the last decade, studies have examined relationship dynamics associated with sexual risk for HIV. It is important to examine the impact this research has had on HIV prevention and what is still needed. We conducted a review of the literature focusing on relationship dynamics associated with sexual risk for HIV among MSM couples. Procedures used for this review were guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses established to provide a framework for collecting, reviewing and reporting studies systematically (Mohler et al. in Ann Intern Med 151(4):264-269, 2009). We found that positive relationship dynamics are associated with less risk with partners outside the relationship, but were associated with greater odds of unprotected anal intercourse with primary partners. We also discuss other factors including sexual agreements about outside partners and make recommendations for next steps in HIV prevention research among MSM couples.

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

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

Relationship Dynamics and Partner Beliefs About Viral Suppression: A Longitudinal Study of Male Couples Living with HIV/AIDS (The Duo Project)

Accurate beliefs about partners' viral suppression are important for HIV prevention and care. We fit multilevel mixed effects logistic regression models to examine associations between partners' viral suppression beliefs and objective HIV RNA viral load tests, and whether relationship dynamics were associated with accurate viral suppression beliefs over time. Male couples (N = 266 couples) with at least one HIV-positive partner on antiretroviral therapy completed five assessments over 2 years. Half of the 407 HIV-positive partners were virally suppressed. Of the 40 % who had inaccurate viral load beliefs, 80 % assumed their partner was suppressed. The odds of having accurate viral load beliefs decreased over time (OR = 0.83; p = 0.042). Within-couple differences in dyadic adjustment (OR = 0.66; p < 0.01) and commitment (OR = 0.82; p = 0.022) were negatively associated with accurate viral load beliefs. Beliefs about a partner's viral load may factor into sexual decision-making and social support. Couple-based approaches are warranted to improve knowledge of partners' viral load.

Addressing gaps on risk and resilience factors for alcohol use outcomes in sexual and gender minority populations

ISSUES

In 2011, the Institute of Medicine released a report that constituted the first comprehensive effort by a federal body to understand the current state of science pertinent to the health needs of sexual and gender minority populations. This mini-review summarises recent empirical, methodological and theoretical advances in alcohol-related research among to lesbian, gay, bisexual and transgender (LGBT) populations and highlights progress towards addressing gaps, with a particular interest in those identified by the Institute of Medicine report.

APPROACH

Articles published since 2011 were identified from PsycINFO and PubMed database searches, using various combinations of keyword identifiers (alcohol, alcohol abuse, substance abuse, LGBT, lesbian, gay, bisexual, transgender). Reference sections of included articles were also examined for additional citations.

KEY FINDINGS

Recent empirical work has contributed to a greater understanding of sub-group differences within this diverse population. Evidence has supported theorised influences that can account for alcohol-related disparities, yet important gaps remain. Studies that examine the role of gender identity and its intersection with sexual identity within transgender and gender non-conforming sub-populations are lacking. Methodological advances in this literature have begun to allow for examinations of how minority-specific and general risk factors of alcohol misuse may contribute to patterns of alcohol involvement over time and within social-relational contexts

CONCLUSIONS

The recommendations made in the current mini-review are meant to facilitate future collaborative efforts, scale development, thoughtful methodological design and analysis and theoretically driven nuanced hypotheses to better understand, and ultimately address, alcohol-related disparities among sexual and gender minority populations. [Talley AE, Gilbert PA, Mitchell J, Goldbach J, Marshall BDL, Kaysen D. Addressing gaps on risk and resilience factors for alcohol use outcomes in sexual and gender minority populations. Drug Alcohol Rev 2016;35:484-493].

Relationship Power, Sociodemographics, and Their Relative Influence on Sexual Agreements Among Gay Male Couples

Men who have sex with men (MSM) in primary relationships engage in condomless sex both within and outside their relationships and a majority of HIV transmission risk may actually occur within primary relationships. Sexual agreements regarding non-monogamy are a critical component to understanding HIV prevention in male couples. Relationship factors have been associated with how sexual agreements function and power is one dyadic construct likely to affect couple's maintenance of non-monogamy agreements. Multilevel modeling was used in a cross-sectional study of gay male couples (N = 566 couples) to examine associations between partners' demographic characteristics traditionally used to define relationship power, a scale of decision-making power, and outcomes related to sexual agreements, including investment, agreement breaks, and break disclosure. Results indicated that decision-making power relative to one's partner was not associated with any agreement outcome, contrary to hypotheses. However, controlling for decision-making power, demographic bases of power were variably associated with sexual agreements' functioning. Younger partners were less invested in and more frequently broke their agreements. Lower-earning partners broke their agreements more frequently, but also disclosed breaks more often. White men in white-minority relationships broke their agreement more often than their partners. Concordant HIV-positive couples were less invested in their agreements and HIV-positive men disclosed breaks more frequently. HIV prevention efforts for same-sex couples must attend to the social, developmental, and cultural influences that affect their agreements around non-monogamy.

Sexual agreements and perception of HIV prevalence among an online sample of partnered men who have sex with men

Stemming from recent evidence that between one- and two-thirds of new HIV transmissions among men who have sex with men (MSM) occur within main partnerships, research and programmatic efforts have begun to recognize the role of the male-male dyad in shaping HIV risk. Central to this new focus has been studies detailing the presence of sexual agreements, which provide guidelines governing permissions around sex with partners outside of the relationship. Using a Facebook-recruited sample of US-partnered MSM (n = 454), this study examines the associations between reporting of sexual agreements and perceptions of HIV prevalence among male sex partners, friends, and local and national MSM populations. Men who perceived that 10-20 % (OR 6.18, 95 % CI 1.28-29.77) and >20 % of their male sex partners were HIV positive (OR 2.68, 95 % CI 1.02-7.08) had significantly higher odds of reporting having an open agreement with their current main partner than men who perceived that less than 10 % of their male sex partners were HIV positive. Partnered men with open sexual agreements may have more sexual partners than those who report monogamy, possibly leading to heightened perceptions of HIV risk, which may result in reporting of perceptions of greater local HIV prevalence. Additionally, men who have made agreements with their partners may have done so due to concerns about HIV risks, and may also be more aware of increased risks of HIV infection, or may have greater knowledge of HIV prevalence through discussions of serostatus with sex partners. Attention is needed to develop prevention efforts, such as toolkits and resources that enable men to form sexual agreements that are based on comprehensive knowledge of the potential risks for acquisition of HIV.

HIV testing behaviors and perceptions of risk of HIV infection among MSM with main partners

Male couples represent a high priority group for HIV prevention interventions because primary partners have been identified as the source of one-third to two-thirds of HIV infections among men who have sex with men (MSM). HIV testing is an important component of the U.S. National AIDS Strategy. In previous research rates of HIV testing among partnered MSM have been found to be lower compared to other MSM. In this paper, we use a sample of 906 MSM recruited through internet advertisements to contrast HIV testing behavior, perceived risk of HIV infection and confidence in remaining HIV sero-negative between single MSM and MSM who report having a main partner. We also examine associations between sexual agreements and HIV testing and perceived risk among partnered MSM. Although results were marginally significant, men with a main partner had significantly higher odds of perceiving zero risk of HIV infection, higher odds of being very confident they will remain HIV-negative, and lower odds of testing for HIV in the past 6 months. Partnered men who reported they were in an open relationship had higher odds of recent HIV testing, lower odds of perceiving zero risk, and lower odds of being very confident in remaining HIV-negative, relative to those who reported monogamy. The results point to the need for dyadic interventions to tackle the underestimation of potential risk associated low HIV testing among partnered MSM. Couples HIV Testing and Counseling-CHTC-affords male couples the opportunity to learn their sero-status together and discuss the realities of their agreement and relationship and should be considered a priority intervention for male couples in the U.S.

Systematic review of couple-based HIV intervention and prevention studies: advantages, gaps, and future directions

We conducted a systematic review of couple-based HIV biobehavioral (skills-building, VCT, and adherence) and biomedical (ART, circumcision) prevention and intervention studies designed to reduce sexual- and drug-risk behaviors and HIV transmission and acquisition. Of the 11,162 papers identified in the search, 93 peer-reviewed papers met the inclusion criteria and yielded a total of 33 studies conducted globally. Biobehavioral couple-based prevention and intervention studies have been efficacious in reducing sexual- and drug-risk behaviors, increasing access to HIV testing and care, and improving adherence. Biomedical couple-based studies were found to reduce HIV incidence among HIV-negative sex partners and viral load among HIV-positive partners. Despite much progress, couple-based HIV prevention and intervention studies remain limited; a number of methodological gaps exist and studies focusing on MSM, people who inject drugs, and sex workers are scarce.

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

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

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

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

Actor-partner effects associated with experiencing intimate partner violence or coercion among male couples enrolled in an HIV prevention trial

Background

Intimate partner violence (IPV) and coercion have been associated with negative health outcomes, including increased HIV risk behaviors, among men who have sex with men (MSM). This is the first study to describe the prevalence and factors associated with experiencing IPV or coercion among US MSM dyads using the actor-partner interdependence model (APIM), an analytic framework to describe interdependent outcomes within dyads.

Methods

Among MSM couples enrolled as dyads in an HIV prevention randomized controlled trial (RCT), two outcomes are examined in this cross-sectional analysis: 1) the actor experiencing physical or sexual IPV from the study partner in the past 3-months and 2) the actor feeling coerced to participate in the RCT by the study partner. Two multilevel APIM logistic regression models evaluated the association between each outcome and actor, partner, and dyad-level factors.

Results

Of 190 individuals (95 MSM couples), 14 reported experiencing physical or sexual IPV from their study partner in the past 3 months (7.3%) and 12 reported feeling coerced to participate in the RCT by their study partner (6.3%). Results of multivariate APIM analyses indicated that reporting experienced IPV was associated (p < 0.1) with non-Black/African American actor race, lower actor education, and lower partner education. Reporting experienced coercion was associated (p < 0.1) with younger actor age and lower partner education.

Conclusions

These findings from an HIV prevention RCT for MSM show considerable levels of IPV experienced in the past 3-months and coercion to participate in the research study, indicating the need for screening tools and support services for these behaviors. The identification of factors associated with IPV and coercion demonstrate the importance of considering actor and partner effects, as well as dyadic-level effects, to improve development of screening tools and support services for these outcomes.

Gay male couples' attitudes toward using couples-based voluntary HIV counseling and testing

Many men who have sex with men acquire HIV from their primary male partners while in a relationship. Studies with gay couples have demonstrated that relationship characteristics and testing behaviors are important to examine for HIV prevention. Recently, couples-based voluntary HIV counseling and testing (CVCT) has become available to male couples throughout the U.S. However, HIV-negative couples' attitudes toward using CVCT and how their relationship characteristics may affect their use of CVCT remain largely unknown. This information is particularly relevant for organizations that offer CVCT. To assess couples' attitudes, and associated factors toward using CVCT, a cross-sectional study design was used with a novel Internet-based recruitment method to collect dyadic data from a national sample of 275 HIV-negative gay couples. Multivariate multilevel modeling was used to identify factors associated with differences between and within couples about their attitudes towards using CVCT. Findings revealed that couples were "somewhat" to "very likely" to use CVCT. More positive attitudes toward using CVCT were associated with couples who had higher levels of relationship satisfaction and commitment toward their sexual agreement and among those who had at least one partner having had sex outside of the relationship. Less positive attitude toward using CVCT was associated with couples who had higher levels of trust toward their partners being dependable. Differences within couples, including age between partners, whether sex had occurred outside of the relationship, and value toward a sexual agreement also affected their attitudes toward using CVCT. Providing additional testing methods may help HIV-negative gay couples better manage their HIV risk.

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

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

HIV risk in group sexual encounters: an event-level analysis from a national online survey of MSM in the U.S

INTRODUCTION

Researchers have investigated group sexual encounters (GSEs) as potential sources for HIV/STI transmission among men who have sex with men (MSM); however, much of this work has focused on organized sex parties.

AIM

To compare behavioral and social characteristics of groups of men who engaged in three types of GSEs: threesomes, spontaneous group sex, and organized sex parties.

METHODS

In 2012, 1,815 U.S.-based MSM completed an online survey.

MAIN OUTCOME MEASURE

We compared men based on their most recent type of GSE: threesome (68.2%), spontaneous group sex (19.7%), or organized sex party (12.1%).

RESULTS

Using multinomial logistic regression, with type of GSE as the dependent variable, MSM who were HIV-positive, used stimulants (cocaine, methamphetamine, crack), consumed five or more alcoholic drinks, and reported receptive unprotected anal intercourse (UAI) during the most recent GSE had significantly higher odds of having had spontaneous group sex as compared to a threesome. MSM who were HIV-positive, not in a relationship, and did not report receptive UAI during the most recent GSE had significantly higher odds of having attended an organized sex party as compared to a threesome. MSM who were in a relationship, had consumed five or more alcoholic drinks, had used stimulants, and reported receptive UAI during the most recent GSE had significantly higher odds of having had spontaneous group sex as compared to an organized sex party. Compared to others, those having engaged in a GSE were more likely to report recent UAI (65% vs. 45%).

CONCLUSIONS

Men having engaged in a GSE were at greater risk for behaviors that transmit HIV and STIs. Unique social and behavioral characteristics inherent to threesomes, spontaneous group sex, and sex parties highlight the need to identify prevention strategies to help those who participate in GSEs reduce their risk for HIV and STI transmission.

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

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