Risks worth taking: safety agreements among discordant gay couples

Conceptions of sexual health by gay men living with HIV in serodifferent couples in Montreal, Canada: results from a qualitative analysis

BACKGROUND

Gay, bisexual, and other men (GBM) who have sex with men living with HIV in serodifferent couples (one partner living with HIV, the other HIV-negative) may encounter unique sexual health challenges. This study aimed to explore their definition of sexual health that could improve service provision.

METHODS

We interviewed 10 gay-identified men living with HIV from 2017 to 2019 as part of CTNPT013, a study on the sexual health of HIV serodifferent GBM couples conducted at two HIV-specialised clinics in Montreal, Canada. Participants partook in semi-structured interviews on the meaning of sexual health. We performed a content analysis of interview transcripts, coding them according to the 10 dimensions of Robinson's Sexual Health Model.

RESULTS

Mean age of interviewees was 35.4years (s.d.,10.2; range, 20-53). Every dimension of Robinson's model was spontaneously evoked, except for body image and spirituality. All men indicated intimacy/relationships (e.g. sexual agreements) and sexual health care/safer sex (e.g. HIV management, risk behaviours) as relevant aspects of sexual health. Other dimensions included: positive sexuality (n =7), such as pleasure and enjoyment during sex; talking about sex (n =5), which mainly concerned HIV disclosure; sexual functioning (n =4); challenges to sexual health (n =3), including substance abuse; and culture/sexual identity (n =3). Two participants (n =2) cited masturbation/fantasy.

CONCLUSIONS

This study emphasises the multi-faceted nature of sexual health for gay men with HIV in serodifferent couples and the pivotal roles of relationships, HIV, risk management (e.g. via health care, knowledge), and positive sexual experiences. These dimensions could be considered in sexual health promotion interventions targeting this population.

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.

Condom-Related Stigma Scale among Men Who Have Sex with Men in China: Development and Psychometric Tests

Condom-related stigma is a frequently mentioned barrier to consistent condom use among men who have sex with men (MSM). Based on the concept and operational definition of condom-related stigma recently defined by our team, we developed the 20-item condom-related stigma scale (CRSS) and examined its psychometric properties among 433 MSM in China, following DeVellis's scale development guidelines. The content validity, convergent validity, empirical validity, factorial validity, scale score reliability, split-half reliability, and test-retest reliability for the CRSS were all assessed. The scale consists of four domains: perceived distrust, perceived potential HIV/STI risk, perceived embarrassment, and perceived violation of the traditional understanding of sexual intercourse. The CRSS has good validity (the scale-level content validity index was 0.99; the empirical validity was greater than 0.70) and high reliability (the Cronbach's alpha coefficient overall was 0.926; the split-half reliability overall was 0.795; the test-retest reliability overall was 0.950). This scale is recommended for assessing the level of condom-related stigma among Chinese MSM, which can serve as an evaluating indicator for safer-sex interventions to prevent HIV infection among the MSM population in a Chinese cultural context.

Condom stigma among men who have sex with men population: Concept synthesis

OBJECTIVES

The epidemic of acquired immune deficiency syndrome (AIDS) among men who have sex with men (MSM) is severe in China. And MSM has now become a key population for the infection and transmission of AIDS. At present, the bottleneck of AIDS prevention and control among MSM population is low rate of continuous condom use and high incidence of unsafe sexual behavior. Inductive summarization of the literature revealed that the most critical reason for low rate of continuous condom use among the MSM population was condom-related stigma. Although many studies mentioned condom-related stigma among MSM populations, there has been no any definition of MSM-related condom stigma and no measurement for it. Therefore, the paper aims to explore barriers to condom use among MSM, then construct the conceptual and operational definition of "MSM-related condom stigma" through Meta synthesis and concept synthesis, and provide a new perspective for AIDS prevention and control among MSM.

METHODS

Based on evidence-based method, "PICoS" framework and Meta-synthesis was used to include the literatures. Then, we used synthesized qualitative evidence from included studies to construct the concept and operational definition of MSM-related condom stigma by the means of thematic analysis and concept synthesis.

RESULTS

According to the results of the concept synthesis, MSM-related condom stigma refers to any taboos or misbeliefs about condom use or feeling ashamed or embarrassed to talk about using condoms which perceived by individuals at the individual, interpersonal, and social levels.It was demonstrated through 4 sub-themes at operational level: a symbol of distrust, a symbol of HIV/sexual transmitted infections (STIs) prevention, a symbol of an embarrassing topic, and a symbol of violating the traditional cognition of sexual intercourse. According to the Social-ecological Model (SEM), a symbol of distrust refers to that the MSM population believes that not using condoms represents mutual trust between sexual partners, while using condoms is difficult to express intimacy, trust and loyalty between sexual partners. A symbol of HIV/STIs prevention at the interpersonal level refers to that the MSM population believes that condom use is a "symbol" for the prevention or infection of AIDS; on the one hand, if someone proposes to use condoms, he may be considered infected with HIV or have unsafe sex experiences, thus, making it difficult to propose condom use; on the other hand, if they believe that sexual partners are "AIDS free" (often a wrong perception, such as sexual partners may have the risk of AIDS infection although they do not have AIDS), it is considered that condom use is completely unnecessary. The environmental level includes a symbol of an embarrassing topic and a symbol of violating the traditional cognition of sexual intercourse. A symbol of an embarrassing topic refers to the MSM population feels shame about topics related to sexual behavior and is embarrassed to carry/buy/propose condom use or be ashamed to engage in conversations about whether to use condoms during sexual behavior. And a symbol of violating the traditional cognition of sexual intercourse: The MSM population have limitations in their perception of "sex" or "sexual behavior" and believe that real sex (behavior) is unobstructed contact between the bodies and exchange between all body fluids.

CONCLUSIONS

The concept of MSM-related condom stigma is proposed for the first time, and its operational definition is given. The concept includes 3 levels and 4 dimensions. It is helpful to understand MSM people's attitude and cognition towards condoms, and adds indicators with cultural sensitivity and behavioral sensitivity to the behavioral intervention for AIDS in the future.

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.

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.

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.

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.

"Am I gonna get in trouble for acknowledging my will to be safe?": Identifying the experiences of young sexual minority men and substance use in the context of an opioid overdose crisis

BACKGROUND

North America and other parts of the globe are in the midst of a public health emergency related to opioid overdoses and a highly contaminated illicit drug supply. Unfortunately, there is a substantial gap in our understandings about how this crisis affects key populations not conventionally identified within overdose-related surveillance data. This gap is particularly pronounced for gay, bisexual, and other men who have sex with men (sexual minority men)-a population that experiences substance use-related inequities across adolescence and young adulthood.

METHODS

We draw on in-depth semi-structured interviews conducted in 2018 with a diverse sample (N = 50) of sexual minority men ages 15-30 who use substances and live in Vancouver, Canada, to identify how patterns and contexts of substance use are occurring in the context of the opioid overdose crisis.

RESULTS

Our analysis revealed three themes: awareness, perceptions, and experiences of risk; strategies to mitigate risk; and barriers to safer substance use. First, participants described how they are deeply impacted by the contaminated illicit drug supply, and how there is growing apprehension that fatal and non-fatal overdose risk is high and rising. Second, participants described how procuring substances from "trustworthy" drug suppliers and other harm reduction strategies (e.g., drug checking technologies, Naloxone kits, not using alone) could reduce overdose risk. Third, participants described how interpersonal, service-related, and socio-structural barriers (e.g., drug criminalization and the lack of a regulated drug supply) limit opportunities for safer substance use.

CONCLUSIONS

Equity-oriented policies and programming that can facilitate opportunities for safer substance use among young sexual minority men are critically needed, including community- and peer-led initiatives, access to low-barrier harm reduction services within commonly frequented social spaces (e.g., Pride, night clubs, bathhouses), nonjudgmental and inclusive substance use-related health services, the decriminalization of drug use, and the provision of a safe drug supply.

"Condoms are … like public transit. It's something you want everyone else to take": Perceptions and use of condoms among HIV negative gay men in Vancouver, Canada in the era of biomedical and seroadaptive prevention

BACKGROUND

The emergence of biomedical and seroadaptive HIV prevention strategies has coincided with a decline in condom use among gay men.

METHODS

We undertook a social ecological analysis of condom use and perceptions using nineteen semi-structured interviews with HIV negative gay men in Vancouver, Canada who used HAART-based prevention strategies.

RESULTS

Contributors to inconsistent condom use were found at various levels of the social ecological model. Ongoing concern regarding HIV transmission and belief in the proven efficacy of condoms motivated contextual use. When condoms were not used, participants utilized seroadaptive and biomedical prevention strategies to mitigate risk.

CONCLUSIONS

These findings indicate that notions of "safety" and "risk" based on consistent condom use are eroding as other modes of prevention gain visibility. Community-based and public health interventions will need to shift prevention messaging from advocacy for universal condom use toward combination prevention in order to meet gay men's current prevention needs. Interventions should advance gay men's communication and self-advocacy skills in order to optimize these strategies.

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.

How Do Gay Serodiscordant Couples in Sydney, Australia Negotiate Undetectable Viral Load for HIV Prevention?

Many gay Australian serodiscordant couples are currently relying on an HIV-positive partner's undetectable viral load (UVL) to practice condomless sex. For these couples, preventing HIV is often considered a mutual responsibility, yet they lack a formally endorsed strategy that helps them navigate 'UVL for prevention' (UfP) as a couple. Drawing on interviews with 21 Australian gay men representing 15 serodiscordant couples, we explored 'the couple' within serodiscordant HIV prevention. In learning to rely on UfP, couples were initially apprehensive as they navigated unfamiliar territory, but their concerns faded over time. Confidence in UfP was facilitated by repeated condomless sex without transmission, consistent test results, and being in a couple framed by trust, commitment, and familiarity. Gay male serodiscordant couples should be encouraged to negotiate clear, spoken 'viral load agreements' (VLAs) if they choose to rely on UfP.

Differences in knowledge, attitudes and behaviors of Israeli HIV-uninfected gay men in HIV-discordant vs. concordant steady relationships

HIV-discordant gay male couples may play an important role in HIV-transmissions. This cross-sectional study compared the knowledge, attitudes and sexual behaviors of HIV-uninfected gay men, between those in HIV-discordant and those in HIV-concordant steady relationships. Anonymous questionnaires were distributed electronically in designated gay-related internet sites and in AIDS-clinics in 2015. The dependent variable was defined as a steady relationship of an HIV-uninfected man with an HIV-infected partner. Risky sexual behavior was defined as unprotected anal intercourse (UAI) with a sex partner whose HIV-status was either positive or unknown. Of 2,319 responders, 460 (20%) were HIV-uninfected gay men in steady relationships, of whom 72 were in HIV-discordant relationships and 388 were in HIV-concordant relationships. Those in HIV-discordant relationships presented better established knowledge regarding HIV-transmission, more lenient attitudes regarding UAI, and reported being involved in riskier sexual behavior, both within and outside their steady relationship compared to men in HIV-concordant relationships. UAI was performed by 48% of the HIV-discordant couples and was associated with the use of sero-positioning strategy and with achieving undetectable viral-load. These findings reflect the complexity of constant use of condoms during long-term sero-discordant relationships. Targeted interventions for HIV-prevention in HIV-discordant couples should be employed for balancing the partners' desire for intimacy and sexual pleasure in the relationship, while reducing the risk for acquiring HIV.

ABBREVIATIONS

ART: Antiretroviral therapy; PEP: Post exposure prophylaxis; PrEP: Pre exposure prophylaxis; STI: Sexually transmitted infections; UAI: Unprotected anal intercourse.

Relationship Power Among Same-Sex Male Couples in New York and San Francisco: Laying the Groundwork for Sexual Risk Reduction Interventions Focused on Interpersonal Power

Research is clear that power differentials between women and men shape women's human immunodeficiency virus (HIV) risks; however, little research has attempted to examine power differentials within same-sex male (SSM) couples and whether these influence sexual risk outcomes. To produce the first quantitative scale that measures power in SSM relationships, the current work was a Phase 1 qualitative study that sought to understand domains of relationship power and how power operated in the relationship among 48 Black, White, and interracial (Black-White) SSM couples recruited from San Francisco and New York. Interview domains were focused on definitions of power and perceptions of how power operated in the relationship. Findings revealed that couples described power in three key ways: as power exerted over a partner through decision-making dominance and relationship control; as power to accomplish goals through personal agency; and as couple-level power. In addition, men described ways that decision-making dominance and relationship control could be enacted in the relationship-through structural resources, emotional and sexual influence, and gender norm expectations. We discuss the implications of these findings for sexual risks and HIV care and treatment with SSM couples that are focused on closing gaps in power.

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

AIM

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

BACKGROUND

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

DESIGN

Integrative review of empirical and theoretical literature.

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

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.

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.

Partner Disclosure of PrEP Use and Undetectable Viral Load on Geosocial Networking Apps: Frequency of Disclosure and Decisions About Condomless Sex

BACKGROUND

Recent advances in biomedical prevention strategies, including pre-exposure prophylaxis (PrEP) and achieving an undetectable viral load (UVL) among HIV-infected persons, show promise in curbing the rising incidence of HIV among men who have sex with men (MSM) in the United States. This mixed-methods study aimed to investigate the frequency with which MSM encounter potential sex partners on geosocial networking apps who disclose biomedical prevention use, and how MSM make decisions about condom use after these disclosures.

METHOD

Participants were recruited through advertisements placed on a large geosocial networking app for MSM. A total of 668 and 727 participants, respectively, responded to questionnaires assessing partner disclosure of PrEP use and UVL. Each questionnaire included an open-ended item assessing reasons for condomless anal sex (CAS) with partners using biomedical prevention.

RESULTS

Across both surveys, most respondents encountered potential sex partners who disclosed PrEP use or UVL, and the majority of those who met up with these partners engaged in CAS at least once. Qualitative analyses found that most participants who reported CAS did so after making a calculated risk about HIV transmission. We also describe a novel risk reduction strategy, "biomed-matching," or having CAS only when both individuals use PrEP or have UVL. We report serostatus differences in both quantitative and qualitative findings.

CONCLUSIONS

Disclosure of PrEP use and UVL is not uncommon among MSM. Many MSM make accurate appraisals of the risks of CAS with biomedical prevention, and mobile apps may aid with disclosing biomedical prevention use.

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

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

Homophobia and communal coping for HIV risk management among gay men in relationships

Men who have sex with men (MSM) remain disproportionately affected by the HIV epidemic in the US and estimates suggest that one to two-thirds of new infections occur among main partners. Previous research has focused on individual MSM and their risk for HIV, yet couples' ability to manage risk has been largely understudied. In particular, the role that homophobia plays in shaping the ability of gay male couples to cope with HIV risk is currently understudied. A sample of 447 gay/bisexual men with main partners was taken from a 2011 survey of gay and bisexual men in Atlanta. Linear regression models were fitted for three couples' coping outcome scales (outcome efficacy, couple efficacy, communal coping) and included indicators of homophobia (internalized homophobia and homophobic discrimination). Findings indicate that reporting of increased levels of internalized homophobia were consistently associated with decreased outcome measures of couples' coping ability regarding risk management. The results highlight the role that homophobia plays in gay male couples' relationships and HIV risk, extending the existing literature in the field of same-sex relationships as influenced by homophobia.

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

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

Health, trust, or "just understood": explicit and implicit condom decision-making processes among black, white, and interracial same-sex male couples

Among gay and bisexual men, primary partners are a leading source of HIV infection. Trust, intimacy, and advancements in HIV treatment may impact same-sex male (SSM) couples' decisions to engage in unprotected anal intercourse (UAI). This qualitative study explored how Black, White and interracial couples discussed, and made decisions regarding condoms. Qualitative interviews were conducted with 48 SSM couples in the New York and San Francisco metropolitan areas. Stratified purposive sampling was used to include Black (n = 16), White (n = 17), and interracial (Black-White) (n = 15) couples. Twenty-six couples were concordant HIV-negative and 22 were HIV-discordant. Interviews were recorded, transcribed, coded, and analyzed using a grounded theory approach. Some couples described explicit processes, which involved active discussion, while others described implicit processes, where condom-use decisions occurred without any explicit discussion. These processes also differed by race and HIV status. Black couples tended to report condom-use as "just understood." White, HIV-discordant couples decided not to use condoms, with some identifying the HIV-positive partner's suppressed viral load and high CD4 count as deciding factors. After an unplanned episode of UAI, White, HIV-negative couples tended to discontinue condom use while Black HIV-negative couples decided to revert to using condoms. HIV prevention efforts focused on same-sex, male couples must consider the explicit/implicit nature of condom decision-making processes. Understanding differences in these processes and considering relationship dynamics, across race and HIV status, can promote the development of innovative couple-level, HIV prevention interventions.

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

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

Incorporating couples-based approaches into HIV prevention for gay and bisexual men: opportunities and challenges

Thirty years after the beginning of the HIV epidemic, gay, bisexual, and other men who have sex with men (collectively called MSM) bear a disproportionate burden of HIV in the United States and continue to acquire a distressingly high number and proportion of new infections. Historically, HIV prevention for MSM has been focused on individual-level behavior change, rarely intervening with MSM as part of a couple. Yet, an estimated 33–67% of HIV infections among MSM are acquired from primary sexual partners, suggesting that work with MSM as couples could be an important contributor to prevention. Given the emergence of high impact combination HIV prevention, it is timely to consider how work with the broad variety of male couples can improve both personal and community health. Couples HIV testing and counseling for MSM is an important advance for identifying men who are unaware that they are HIV-positive, identifying HIV-discordant couples, and supporting men who want to learn their HIV status with their partner. Once men know their HIV status, new advances in biomedical prevention, which can dramatically reduce risk of HIV transmission or acquisition, allow men to make prevention decisions that can protect themselves and their partners. This paper highlights the present-day challenges and benefits of using a couples-based approach with MSM in the era of combination prevention to increase knowledge of HIV status, increase identification of HIV discordant couples to improve targeting prevention services,and support mutual disclosure of HIV status.

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

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

HIV-negative and HIV-discordant gay male couples' use of HIV risk-reduction strategies: differences by partner type and couples' HIV-status

Previous research has found that gay men and other men who have sex with men have adopted a variety of HIV risk-reduction strategies to engage in unprotected anal intercourse (UAI). However, whether gay male couples' use these strategies within and out of their relationships remains unknown. The present national cross-sectional study collected dyadic data from an online sample of 275 HIV-negative and 58 discordant gay male couples to assess their use of these strategies, and whether their use of these strategies had differed by partner type and couples' HIV-status. The sample used a variety of risk-reduction strategies for UAI. Some differences and patterns by partner type and couples' HIV-status were detected about men's use of these strategies. Findings indicate the need to bolster HIV prevention and education with gay male couples about their use of these strategies within and outside of their relationships.

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.

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

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