Limitations to Participation in Family of Origin Among Same Sex Couples: A Couple-Level Minority Stressor

Emerging studies focus on minority stressors emanating from society's stigmatization of particular relationship forms (i.e., couple-level minority stressors). The present study examines how same-sex couples experience one such couple-level minority stressor: limitations to participation in families of origin. Qualitative data are drawn from a sub-sample of same-sex couples (N = 18) who participated in a large-scale study of minority stress among 120 same-sex couples distributed equally across two study sites (Atlanta and San Francisco) in 2012 and 2013. Instances of limitations to participation in families of origin ranged in severity, falling into three distinct areas: 1) partial acceptance, where some family members were accepting and others were not, 2) mixed messages where some family members said they were accepting but behaved as though they were not and, 3) rejection, where some family members were blatantly unwelcoming or hostile. These types of exclusion were also evidenced in dyadic minority stress processes of stress proliferation (e.g., stress discrepancies and stress contagion) causing additional stress for both partners. These narratives portray struggles associated with experiences of couple-level minority stress faced by people in same-sex relationships.

Experiences of discrimination and support among trans men and women partnered with cis men

Trans individuals routinely experience discrimination. In this study, thirty-nine couples consisting of a trans partner and a cis male partner from the San Francisco Bay Area were interviewed about their relationship. The interviews were digitally recorded, transcribed and reviewed for accuracy. Guided by grounded theory, coders began thematic analysis until inter-coder reliability was achieved. Further qualitative coding produced several codes, two of which are focused upon here: namely, discrimination and support. This study highlights discrimination at the institutional level, such as being denied housing and employment, and at the interpersonal level, such as experiencing harassment from strangers and exclusion from queer community spaces. Trans individuals reported becoming desensitised to discrimination, moving to safer geographic locations, and acknowledged cis or straight passing as a privilege and a prevention tactic against discrimination, although this sometime left participants feeling their gender had been invalidated. Although most trans individuals sought support from their cis partners, some cis partners reacted with violence to discrimination, provoking the situation's severity and upsetting their trans partner. Transphobic discrimination is widespread, and it is crucial for frontline health and other service providers to understand the impact it has on both trans individuals and trans/cis couples, and for agencies to offer resources to support these relationships.

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

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

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.

Measuring a New Stress Domain: Validation of the Couple-Level Minority Stress Scale

Existing social stress frameworks largely conceive of stress as emanating from individual experience. Recent theory and research concerning minority stress have focused on same-sex couples' experiences of both eventful and chronic stressors associated with being in a stigmatized relationship, including having ongoing or episodic fears of discrimination, and experiencing actual acts of discrimination. Such couple-level minority stressors represent a novel domain of social stress affecting minority populations that is only beginning to become a focus in empirical investigations testing minority stress theory. This article presents the results of psychometric analyses of dyadic data from 106 same-sex couples from across the U.S., introducing the Couple-Level Minority Stress (CLMS) scale featuring eight new couple-level minority stress factors: (1) Couple-Level Stigma; (2) Couple-Level Discrimination; (3) Seeking Safety as a Couple; (4) Perceived Unequal Relationship Recognition; (5) Couple-Level Visibility; (6) Managing Stereotypes about Same-Sex Couples; (7) Lack of Integration with Families of Origin; and (8) Lack of Social Support for Couples. The CLMS demonstrated a clear factor structure with satisfactory model-data fit and subscale reliabilities. The CLMS also exhibited validity as a correlate of one indicator of relationship quality (relationship satisfaction) and three indicators of mental health (nonspecific psychological distress, depressive symptomatology, and problematic drinking) when controlling for individual-level minority stressors and has great potential to extend and enrich minority stress research, particularly studies that deepen understandings of longstanding health inequities based on sexual orientation.

Studying the Motivations Behind Sexual Agreements: A First Look at the Motivations Behind Agreement (MBA) Scale for Male Couples

Sexual agreements are ubiquitous among male couples, yet little is known about motivations behind agreements and their association with sexual risk for human immunodeficiency virus (HIV). Qualitative interviews with 39 couples informed the development of the items in the Motivations Behind Agreement (MBA) scale. The scale was validated via exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) using quantitative data from two (790 and 882 men) independent samples of couples. The EFA yielded two factors: relationship quality enhancement motive (RQEM) and sex life enhancement motive (SLEM). The CFA indicated satisfactory global model data fit. Finally, in predicting sexual risk, RQEM and SLEM showed significant interactions with agreement type. For men with monogamous agreements, higher RQEM was associated with less condomless anal sex (CAS) with an outside partner of discordant or unknown serostatus (aOR = 0.15; 95% CI = 0.05, 0.46). For men with nonmonogamous agreements, higher RQEM was associated with less CAS (aOR = 0.76; 95% CI = 0.60, 0.97) while higher SLEM was associated with greater odds of CAS (aOR = 1.57; 95% CI = 1.18, 2.08). Men whose agreements were highly motivated by relationship enhancement were less likely to engage in sexual risk with outside partners regardless of agreement type. HIV-prevention interventions targeting male couples will benefit from incorporating an understanding of couples' agreement motivations.

Development and Validation of the Power Imbalance in Couples Scale

Few researchers have quantitatively explored the relationship power-HIV risk nexus in same-sex male couples. We developed and validated the Power Imbalance in Couples Scale (PICS) to measure relationship power among men in same-sex, committed relationships and its association with sexual risk behaviors. We recruited three independent and diverse samples of male couples in the greater San Francisco and New York City metropolitan areas and conducted qualitative interviews (N1 = 96) to inform item development, followed by two quantitative surveys (N2 = 341; N3 = 434) to assess the construct, predictive, convergent, and discriminant validity of the PICS. Exploratory factor analysis of the first survey's data yielded four factors-overtly controlling partner, supportive partner, conflict avoidant actor, and overtly controlling actor-that accounted for more than 50% of the shared variance among the PICS items. Confirmatory factor analysis (CFA) of the second survey's data supported these four factors: χ²(1823) = 2493.40, p < .001; CFI = .96, RMSEA = .03 and WRMR = 1.33. Strong interfactor correlations suggested the presence of a higher-order general perception of power imbalance factor; a higher-order factor CFA model was comparable in fit to the correlated lower-order factors' CFA: χ²(2) = 2.00, p = .37. Internal reliability of the PICS scale was strong: α = .94. Men perceiving greater power imbalances in their relationships had higher odds of engaging in condomless anal intercourse with outside partners of discordant or unknown HIV status (OR 1.27; 95% CI 1.01-1.60; p = .04). The PICS is an important contribution to measuring relationship power imbalance and its sequelae among male couples; it is applicable to research on relationships, sexuality, couples, and HIV prevention.

Composite Risk for HIV: A New Approach Towards Integrating Biomedical and Behavioral Strategies in Couples-Based HIV Prevention Research

A substantial number of new HIV infections among gay, bisexual, and other men who have sex with men and transgender women occurs in the context of primary partnerships. Given the diversity of risk reduction needs and various approaches available for reducing risk within couples, condomless sex is no longer the gold standard HIV outcome. We present a novel, comprehensive, and flexible Composite Risk for HIV (CR-HIV) approach for integrating evolving biomedical and behavioral HIV prevention strategies into couples-based HIV prevention intervention and survey research. We provide illustrative examples of the utility of the CR-HIV approach based on couples' HIV status.

The complex contribution of sociodemographics to decision-making power in gay male couples

Relationship power is an important dyadic construct in close relationships that is associated with relationship health and partner's individual health. Understanding what predicts power in heterosexual couples has proven difficult, and even less is known about gay couples. Resource models of power posit that demographic characteristics associated with social status (e.g., age, income) confer power within the relationship, which in turn shapes relationship outcomes. We tested this model in a sample of gay male couples (N = 566 couples) and extended it by examining race and HIV status. Multilevel modeling was used to test associations between demographic bases of power and decision-making power. We also examined relative associations among demographic bases and decision-making power with relationship satisfaction given the literature on power imbalances and overall relationship functioning. Results showed that individual income was positively associated with decision-making power, as was participant's HIV status, with HIV-positive men reporting greater power. Age differences within the relationship interacted with relationship length to predict decision-making power, but not satisfaction. HIV-concordant positive couples were less satisfied than concordant negative couples. Higher power partners were less satisfied than lower power partners. Demographic factors contributing to decision-making power among same-sex male couples appear to share some similarities with heterosexual couples (e.g., income is associated with power) and have unique features (e.g., HIV status influences power). However, these same demographics did not reliably predict relationship satisfaction in the manner that existing power theories suggest. Findings indicate important considerations for theories of power among same-sex male couples. (PsycINFO Database Record

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.

Dyadic dynamics of HIV risk among transgender women and their primary male sexual partners: the role of sexual agreement types and motivations

Transgender women - individuals assigned a male sex at birth who identify as women, female, or on the male-to-female trans feminine spectrum - are at high-risk of HIV worldwide. Prior research has suggested that transgender women more frequently engage in condomless sex with primary cisgender (i.e., non-transgender) male partners compared with casual or paying partners, and that condomless sex in this context might be motivated by relationship dynamics such as trust and intimacy. The current study examined sexual agreement types and motivations as factors that shape HIV risk behaviors in a community sample of 191 transgender women and their cisgender primary male partners who completed a cross-sectional survey. Overall, 40% of couples had monogamous, 15% open, and 45% discrepant sexual agreements (i.e., partners disagreed on their type of agreement). Actor-partner interdependence models were fit to examine the influence of sexual agreement type and motivations on extra-dyadic HIV risk (i.e., condomless sex with outside partners) and intra-dyadic HIV serodiscordant risk (i.e., condomless sex with serodiscordant primary partners). For male partners, extra-dyadic risk was associated with their own and their partners' sexual agreement motives, and male partners who engaged in extra-dyadic HIV risk had an increased odds of engaging in HIV serodiscordant intra-dyadic risk. Study findings support inclusion of the male partners of transgender women into HIV prevention efforts. Future research is warranted to explore the interpersonal and social contexts of sexual agreement types and motivations in relationships between transgender women and their male partners to develop interventions that meet their unique HIV prevention needs.

Attitudes Towards PrEP and Anticipated Condom Use Among Concordant HIV-Negative and HIV-Discordant Male Couples

Since the July 2012 approval by the FDA of emtricitabine/ tenofovir disoproxil fumarate (Truvada) for use as pre-exposure prophylaxis (PrEP) against HIV, its feasibility and acceptability has been under study. HIV-discordant couples are likely targets for PrEP but little is known about how this new prevention tool impacts relationships. We examined, among gay male couples, the acceptability of individual and partner use of PrEP and intentions to use condoms with primary and outside partners in the context of PrEP use. Data are from two independent samples of couples recruited in the San Francisco bay area and New York City-a qualitative one (N=48 couples) between March and November, 2011, and a quantitative one (N=171 couples) between June, 2012 and May, 2013. Data were categorized by couple HIV status and general linear models; chi-square tests of independence were used to examine condom-use intentions with primary and outside partners, by sexual risk profile, and race. Almost half of the HIV-negative couples felt PrEP was a good HIV prevention strategy for themselves and their partner. Over half reported that they would not change their current condom use if they or their partner were taking PrEP. However, approximately 30% of HIV-negative couples reported that they would stop using condoms or use them less with primary and outside partners if they were on PrEP or if their partner was on PrEP. A large percentage of couples view PrEP positively. However, to ensure safety for both partners, future programing must consider those who intend not to use condoms while on PrEP.

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.

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.

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.

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.

Rates of testing for HIV in the presence of serodiscordant UAI among HIV-negative gay men in committed relationships

We examined testing rates for HIV-negative men (N = 752) from a sample of gay male couples. Approximately half (52 %) tested in the past year. Among men who had engaged in sexual risk behavior in the past 3 months, 27 % tested within that period and 65 % within the past year. For men in concordant relationships these rates were 25 and 60 %, for men in serodiscordant relationships they were 34 and 72 %. MSM in primary relationships are testing at lower rates than the general MSM population, even after potential exposure to HIV. Testing and prevention messages for MSM should factor in relationship status.

Relationship dynamics as predictors of broken agreements about outside sexual partners: implications for HIV prevention among gay couples

Agreements about sex with outside partners are common among gay couples, and breaks in these agreements can be indicative of HIV risk. Using longitudinal survey data from both partners in 263 HIV-negative and -discordant gay couples, we investigate whether relationship dynamics are associated with broken agreements. Twenty-three percent of respondents reported broken agreements. Partners with higher levels of trust, communication, commitment, and social support were significantly less likely to report breaking their agreement. Promoting positive relationship dynamics as part of HIV prevention interventions for gay couples provides the opportunity to minimize the occurrence of broken agreements and, ultimately, reduce HIV risk.

Sexual agreements in the partnerships of internet-using men who have sex with men

Recent studies among men who have sex with men (MSM) have found that the majority of HIV transmission results from sex with a main partner. One factor likely to affect the risk of transmission is the type of agreements the couple has regarding sexual behaviour within and outside the relationship. This study recruited 732 Internet-using MSM through Facebook banner ads. Participants completed an online questionnaire regarding demographic characteristics of the respondent and their main partner, the sexual behaviour of the couple, the existence of a sexual agreement, and the strength of investment in that agreement. The Pearson chi-square test was used to assess the association between sexual agreements (categorized as open, closed, or none) and the predictive variables. Respondents' investment in their sexual agreement was measured using the sexual agreement investment scale (a composite score ranging from 0 to 52). Ninety-one percent of respondents had some form of sexual agreement in place with their main partner. The presence and type of sexual agreement was found to be strongly associated with many characteristics of the individual and couple, including the respondent's HIV status, length of time with the main partner, having unprotected anal intercourse with a man other than their main partner, and happiness in the relationship. Increases in the strength of respondents' investment in their sexual agreement were found to be associated with newness of the relationship, relationship happiness, having a closed relationship, and decreases in risky sexual behaviour. This study offers further evidence of the important role that sexual agreements play in male couples. The overwhelming prevalence of sexual agreements and their association with relationship happiness and risky sexual behaviours has important implications for future HIV prevention and control strategies, including the implementation of couples voluntary counseling and testing.

Risks worth taking: safety agreements among discordant gay couples

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

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.

The couple as context: Latino gay male couples and HIV

HIV-prevention efforts with gay men in relationships frequently omit primary partners. When they are considered, examinations of race/ethnicity are often overlooked despite higher infection rates among gay men of colour. Acknowledging both the need to contextualise the behaviours that may affect HIV risk for gay men of colour and the disproportionate impact of HIV on Latino gay men, the present study utilised semi-structured, qualitative interviews to explore relationship dynamics, sexual agreements and behaviours, safer sex choices and HIV risk among nine Latino gay male couples. All participants were HIV-negative and in concordant negative relationships. Additionally, nearly all reported closed agreements. Analysis revealed participants engaging in four behaviours that may actively reduce their HIV risk: approaching sexual agreements from a practical standpoint, maintaining a high literacy around HIV, having exposure to social support groups for Latino gay men and finding support in their relationship with another Latino gay man. Additional issues are raised where long-term HIV prevention is concerned. Intimate relationships are an important context for understanding both HIV risk and prevention among Latino gay men. Likewise, race/ethnicity provides an indispensable perspective on all research with gay couples. Future prevention efforts with gay men must strive to include both.

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

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

Sexual agreements among gay male couples

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

Development and validation of the sexual agreement investment scale

Sexual agreements are ubiquitous among gay men. Lower levels of investment in these agreements may be associated with breaking them or engaging in risky sexual behavior. A scale was developed to measure agreement investment levels among gay men. Qualitative data from 78 gay men in committed relationships were analyzed to inform item development, followed by quantitative analyses of two larger samples (n = 380, n = 1,001) to assess construct, convergent, and discriminant validity. The Sexual Agreement Investment Scale (SAIS) is a psychometrically sound measure of the level of investment in sexual agreements among gay men in relationships. Men with higher agreement investment were less likely to break agreements and less likely to engage in unprotected anal intercourse with outside partners. The SAIS can be used to measure investment in sexual agreements and its impact on sexual behavior in a wide variety of settings, including research on relationships, sexuality, couples therapy and HIV prevention.

Serostatus differences and agreements about sex with outside partners among gay male couples

This article describes agreements gay male couples make about sex outside the relationship and how the process of making those agreements, and their perceived quality, varies depending on couple serostatus. Data include 191 couples recruited in the San Francisco Bay Area from June to December 2004. Monogamous agreements were reported by 56% of participants in concordant-negative, 47% in concordant-positive, and 36% in discordant relationships. The remaining participants reported agreements allowing sex with outside partners in some form. Agreement quality was lowest among men in discordant relationships. Overall, few (30%) reported breaking their agreements; only half of whom reported disclosing those breaks to their partners. Although differences in agreement type, quality, and satisfaction were found among the three couple serostatus groups, rates of breaks and their disclosure did not vary significantly by group. Future HIV prevention efforts aimed at couples must integrate both couple serostatus and relationship-based issues.

Examining the role of partner status in an HIV prevention trial targeting HIV-positive gay and bisexual men: the seropositive urban men's intervention trial (SUMIT)

The goal of this analysis was to examine whether partner status impacted behavioral outcomes from the Seropositive Urban Men's Intervention Trial (SUMIT). We contrasted sample characteristics of HIV-positive gay and bisexual men with and without main partners and then examined differences in sexual behaviors among men participating in an enhanced HIV prevention intervention compared to those in a standard condition. Logistic regression analyses were performed to differentiate characteristics of men with and without main partners and mixed-model logistic regression analyses were performed to test for intervention effects. Men with main partners showed a greater likelihood of having unprotected anal sex with any partner, although the number of male sexual partners was higher for men without a main partner. SUMIT generally produced few differences in sexual risk behaviors and did not affect several potential mediator variables of the relationship between the intervention and sexual behaviors with main and nonmain partners.

Recruitment source and behavioral risk patterns of HIV-positive men who have sex with men

To effectively target HIV prevention activities, community outreach workers need to know how to locate persons at greatest risk for acquiring or transmitting HIV. This study compared the behavioral characteristics of HIV-positive men who have sex with men recruited from different sources: AIDS service organizations, mainstream gay environments, public/private sex environments, and friend referrals. Men recruited from sex environments exhibited the riskiest behavior: more male partners, more likely to have casual sex, more likely to have had unprotected insertive sex with men of HIV-negative or unknown status, less likely to have disclosed serostatus to primary partners, less comfortable discussing serostatus with others, and less feeling of personal responsibility for disclosure. A distinctive group of men, the referral group, did not identify with the gay community and reported sex with men and women. Future efforts should continue to assess the types of people that are recruited from different sources so that program and research efforts can be appropriately targeted.

Sexual harm reduction practices of HIV-seropositive gay and bisexual men: serosorting, strategic positioning, and withdrawal before ejaculation

OBJECTIVE

This study assessed unprotected anal and oral sex behaviors of HIV-positive gay and bisexual men in New York City and San Francisco with their main and non-main sexual partners. Here we focus on the use of three harm reduction strategies (serosorting, strategic positioning, and withdrawal before ejaculation) in order to decrease transmission risk.

METHOD

The data from a baseline assessment of 1168 HIV-positive gay and bisexual men in the two cities were utilized. Men were recruited from a variety of community-based venues, through advertising and other techniques.

RESULTS

City differences were identified, with more men in San Francisco reporting sexual risk behaviors across all partner types compared with men in New York City. Serosorting was identified, with men reporting significantly more oral and anal sex acts with other HIV-positive partners than with HIV-negative partners. However, men also reported more unprotected sex with partners of unknown status compared with their other partners. Some evidence of strategic positioning was identified, although differences were noted across cities and across different types of partners. Men in both cities reported more acts of oral sex without ejaculation than with ejaculation, but the use of withdrawal as a harm reduction strategy for anal sex was more common among men from San Francisco.

CONCLUSION

Overall, evidence for harm reduction was identified; however, significant differences across the two cities were found. The complicated nature of the sexual practices of gay and bisexual men are discussed, and the findings have important implications for prevention efforts and future research studies.

Barebacking identity among HIV-positive gay and bisexual men: demographic, psychological, and behavioral correlates

OBJECTIVES

To determine the correlates associated with barebacking identity among HIV-positive gay and bisexual men.

DESIGN

An analysis of data from the baseline quantitative assessment of a randomized controlled intervention study of 1168 HIV-positive gay and bisexual men from New York City and San Francisco.

METHODS

Participants were actively and passively recruited from mainstream gay venues, AIDS service organizations, and public and commercial sex environments. Participants completed a computerized quantitative questionnaire assessing their identity as a barebacker, sexual behavior, demographic factors, psychosocial states, perceptions of health risks, and substance use.

RESULTS

Men of color were less likely to identify themselves as barebackers. Men who did identify themselves as barebackers were slightly younger. They were more likely to miss a dose of medication; report drug use (non-injection and injection); exhibit higher levels of sexual compulsivity and lower personal responsibility for safer sex; and report higher rates of unprotected insertive anal intercourse, unprotected receptive anal intercourse, and unprotected insertive oral intercourse with all partners, regardless of their HIV serostatus.

CONCLUSION

Barebacking and its corresponding behaviors pose immediate public health risks for HIV-positive gay and bisexual men. Further work is needed to understand this phenomenon more fully in relation to the psychological, sociological, biomedical, and cultural realities.

Prevention with gay and bisexual men living with HIV: rationale and methods of the Seropositive Urban Men's Intervention Trial (SUMIT)

OBJECTIVES

To provide a public health rationale for prevention with HIV-seropositive gay and bisexual men and to describe the methods of the Seropositive Urban Men's Intervention Trial (SUMIT).

DESIGN

A randomized intervention trial.

METHODS

Self-identified HIV-positive gay and bisexual men were recruited from community-based venues in New York City and San Francisco. Eligible participants completed an A-CASI baseline assessment, were asked to provide samples for sexually transmitted infection (STI) testing, and were randomly assigned to either a single-session intervention or a six-session enhanced intervention designed to reduce HIV transmission risk and promote serostatus disclosure. Participants who attended the first intervention session were assessed 3 and 6 months post-intervention. STI testing was offered at the 6-month assessment.

RESULTS

A total of 1168 self-identified HIV-seropositive gay and bisexual men completed the baseline assessment, and 1110 of these (95%) opted for STI testing. A total of 811 attended the first intervention session, of which 85% were assessed at 3 months and 90% were assessed at 6 months. Of those assessed at 6 months, 92% (670/729) provided a blood or urine sample for STI testing.

CONCLUSION

SUMIT demonstrates the feasibility and acceptability of prevention research with HIV-seropositive gay and bisexual men. The study provides new information about the sexual behavior, serostatus disclosure practices, and the efficacy of an intervention to reduce HIV transmission risk.

Seroconcordant sexual partnerings of HIV-seropositive men who have sex with men

OBJECTIVES

To describe the sexual behaviors of HIV-positive men with their seroconcordant partners and to determine the factors associated with unprotected anal intercourse (UAI) in these sexual partnerings.

METHODS

The data were drawn from the baseline assessment of a randomized controlled intervention study of 1168 HIV-positive men who have sex with men recruited from mainstream gay venues, AIDS service organizations, and public/commercial sex environments.

RESULTS

Of the 1168 men, 596 engaged in sexual experiences with other HIV-positive men, and 371 of the 596 (62%) practised UAI with their seroconcordant partners. Those who engaged in UAI expressed less self-evaluation with regard to their unsafe sexual practices, had higher levels of hedonism associated with unsafe sex, and were more likely both to inject recreation drugs and use methamphetamine in particular. Furthermore, these participants expressed less concern with regard to HIV re-infection, infection with other sexually transmitted infections, and the transmission of pathogens causing opportunistic infections.

CONCLUSION

Our findings suggest that at least three sets of factors predispose HIV-positive men to engage in unsafe anal sexual behaviors with their concordant partners: a decreased belief that infection with other pathogens or re-infection with HIV present health problems; less evaluation of sexual activities and behaviors; more hedonistic expectations of sex and higher levels of sexual compulsivity, as well as recreational drug use with and without sex.

Predictors of the use of viagra, testosterone, and antidepressants among HIV-seropositive gay and bisexual men

OBJECTIVE

To examine the use and correlates of the use of prescription drugs that may affect sexual behavior among HIV-positive gay and bisexual men.

METHODS

In a cross-sectional assessment of baseline data from a behavioral intervention, we recruited 1168 HIV-positive gay and bisexual men in 2000-2001 from community venues in New York City and San Francisco, and determined the point prevalence of the use of viagra, testosterone, and antidepressants. We examined bivariate and multivariate associations between the use of each drug and demographics, health status, substance use, psychological symptoms, and sexual risk.

RESULTS

The current use of antidepressants was 21%, testosterone 19%, and viagra 12%. Some viagra users reported using drugs that could interact dangerously with viagra. The use of viagra, testosterone, or antidepressants was related to unprotected receptive anal intercourse and unprotected insertive oral intercourse (UIOI) with both HIV-positive and HIV-negative/unknown-status casual partners. The use of viagra was also associated with unprotected insertive anal intercourse. In multivariate models, viagra use was associated with being older, more educated, using ketamine, and engaging in UIOI with HIV-negative/unknown-status casual partners. Testosterone use was associated with being more educated and using nitrites (poppers). Antidepressant use was associated with race, using poppers, and being more depressed.

CONCLUSION

Prescription medications used by HIV-positive men can have unintended negative effects such as drug interactions or associations with risky sexual behavior, particularly a drug such as viagra that is fast acting, short lasting, and provides a desirable effect. Physicians should discuss these issues with patients when prescribing, and interventions should address these challenges.

What happened in the SUMIT trial? Mediation and behavior change

OBJECTIVES

We wished to identify which potential mediators of the Seropositive Urban Men's Intervention Trial (SUMIT) intervention were in fact changed by the intervention, and further to identify which among these factors distinguished men who decreased their risk behavior relative to those who increased it, irrespective of the intervention arm.

METHODS

We examined social cognitive theory and other psychosocial variables that the intervention was designed to affect (potential mediators) in both sets of analyses. These were assessed at baseline, 3-month follow-up, and 6-month follow-up. We tested which potential mediators were changed by the intervention relative to the comparison arm, and which of these factors distinguished men discontinuing risk behavior [unprotected insertive anal intercourse (UIAI) or UIAI with HIV-negative or status-unknown partners] compared with those initiating it.

RESULTS

Factors changed by the intervention included partner serostatus assumption making, hedonistic condom outcome expectancies, anxiety and depression. Factors associated with behavioral risk reduction included personal responsibility to protect others from infection and self-evaluative outcome expectancies regarding transmission risk behavior. These constructs are similar and involve the engagement of moral processes and altruism in sexual behavior with others.

DISCUSSION

The present results suggest that, although we designed the intervention to enhance personal responsibility to protect others from HIV, we were not successful in this goal. However, changes in this factor did prove to be an important correlate of behavior change. Possible ways to design and deliver more successful interventions are discussed.

Sexual risk of HIV transmission is missed by traditional methods of data collection

Brief acts of unprotected anal sex (i.e.'dipping') have not been systematically measured in AIDS research. Eleven per cent of HIV-positive men who reported that they had not engaged in any unprotected insertive anal intercourse with an HIV-negative or unknown status partner reported that they did engage in insertive 'dipping'. Men reported 'dipping' an average of 5.1 times, representing 773 acts of insertive intercourse that would have been missed by traditional methods of sexual data behavior.

Differences in sexual behavior among HIV discordant and concordant gay men in primary relationships

We investigated differences in unprotected anal intercourse among gay men in HIV concordant and discordant primary relationships. Individuals were recruited in 1992 from household- and bar-based samples of gay/bisexual men in Portland, Oregon, and Tucson, Arizona. Respondents were men who reported that they were in primary relationships of > or = 1 month and who reported their own and their partner's HIV status (n = 785). Comparisons were made between three groups: (a) HIV + respondents/HIV + partners; (b) HIV- respondents/HIV- partners; and (c) respondents whose partner's HIV status was different from their own (discordant), on sexual behavior, psychosocial, and demographic variables. Men in HIV concordant relationships reported significantly higher rates of unprotected anal intercourse (54% for +2 and 48% for --) than discordant couples (17%). HIV- men in concordant relationships were more likely to be monogamous (58%) and younger (22% < or = 25 years) than the other two groups. There were no significant differences among the groups regarding the kind of sexual behaviors they engaged in with nonprimary partners. The substantially lower rate of unprotected anal intercourse among men in discordant relationships compared to men in concordant relationships suggests that individuals and couples make judgments about sex and behavior based on knowledge of one's own and one's partner's HIV status.

Differences between gay men in primary relationships and single men: implications for prevention

This study describes psychological and behavioral differences between gay men in primary relationships and single men from 1985 through 1989. In addition, differences in sexual behavior, relationship status, and relationship quality between HIV positive and HIV negative men were investigated. Data are from the San Francisco Men's Health Study and included only men who were gay identified and who participated in the longitudinal surveys in 1985, 1987 and 1989 (N = 452). Participants were stratified by relationship status and by HIV status. HIV positive men were less likely than HIV negative men to be in primary relationships (38.9% vs. 52.9%, respectively in 1989). In addition, men in relationships had higher rates of unprotected anal intercourse than single men (32.6% vs. 17.0%, respectively in 1989). Differences in psychosocial and behavioral variables were found and have considerable implications for prevention programs and mental health services trying to meet the needs of the gay men's community.