Colleen C. Hoff

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.

Disclosing Hiv seropositivity to significant others

ObjectivesTo examine gay mens patterns of self-disclosure of HIV seropositivity to friends, lovers, relatives and colleagues; to assess the effects of disclosure; and to identify reasons for not disclosing to particular individuals. DesignLongitudinal questionnaire survey of gay men. MethodsA total of 163 HIV-positive men participating in the AIDS Behavioral Research Project, a longitudinal study of San Francisco gay men, completed questionnaires about their self-disclosure patterns, health status, and psychological well-being. ResultsHIV-positive men were most likely to disclose their status to lovers and closest gay friends. Asymptomatic men were less likely to disclose to relatives and colleagues than symptomatic men. Friends and lovers were rated as responding more helpfully than relatives and colleagues. Men who perceived their significant others as responding more helpfully were less depressed and anxious currently and 1 year later. A variety of reasons were given for not disclosing, including not wanting to worry others, fear of discrimination, fear of disrupting relationships, and emotional self-protection. ConclusionWhile disclosure can have advantages for both HIV-positive individuals and their significant others, HIV-positive individuals must be assured that the benefits of doing so will outweigh the potential costs.

Longitudinal predictors of reductions in unprotected anal intercourse among gay men in San Francisco: the AIDS Behavioral Research Project.

Predictors of unprotected anal intercourse were examined among 508 gay men in San Francisco. The cohort was recruited in 1983-84 at which time 49.8 percent of non-monogamous men (N = 435) and 71.2 percent of monogamous men (N = 73) reported practicing unprotected anal intercourse. Only 12 percent of non-monogamous and 27.4 percent of monogamous men reported these practices in 1988. The non-monogamous men who practiced unprotected anal intercourse in 1984 were more likely to be younger, to report that unprotected anal intercourse was their favorite sexual activity, to be low in perceived efficacy to change sexual behavior, to report that friends were more likely to engage in high-risk behaviors, to have less knowledge of health guidelines, and to be less depressed at that time. Non-monogamous individuals who in 1984 reported that unprotected anal intercourse was their favorite sexual activity were more likely to practice that behavior in 1988. Those who knew their serostatus as positive were less likely to report unprotected anal intercourse in 1988. These data infer that in order to modify AIDS-related high-risk behaviors, community risk-reduction programs be differentially aimed at young persons so as to increase personal efficacy about risk reduction, challenge peer norms, promote antibody testing, and eroticize safer sexual activities.

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.

Decisions to get HIV tested and to accept antiretroviral therapies among gay/bisexual men : implications for secondary prevention efforts

The objective of this study was to report prevalence rates of adherence by HIV-seropositive individuals to medical recommendations for the treatment of HIV infection, a behavioral pattern referred to as AIDS secondary prevention. We report cross-sectional data (n = 2,593) from two household-based and two bar-based samples of gay/bisexual men, gathered in 1992 in Tucson, Arizona, and Portland, Oregon. The main outcome variables were prevalence of HIV antibody testing and adherence to recommended secondary prevention behaviors to prevent onset of AIDS symptoms. Approximately one-third of the gay/bisexual men in these samples do not know their current HIV status. Of the gay/bisexual men who do know that they are HIV-seropositive, approximately three-fourths adhere to each of the secondary prevention recommendations, as appropriate to their stage of disease progression. In a multivariate logistic model, three variables distinguished between HIV-seropositive men who did and did not adhere: perceived antiviral treatment norms (OR = 1.4, CI = 1.1-1.7), perceived efficacy of secondary prevention treatments (OR = 1.4, CI = 1.1-1.7), and quality of the relationship with ones health-care provider (OR = 2.5, CI = 1.6-4.0). These findings indicate that efforts to support AIDS secondary prevention behaviors can occur not only through health education to change the perceptions of at-risk communities about the options available to delay the onset of opportunistic infections among HIV-seropositive individuals but also by enhancing effective doctor/patient communication.

Childhood Sexual Abuse and HIV Risk-Taking Behavior Among Gay and Bisexual Men

We explored the prevalence of childhood sexual abuse among adult gay and bisexual men and measured the association between childhood sexual abuse and high-risk sexual behavior in adulthood. Two separate population-based samples of gay and bisexual men (n = 1,941) residing in Portland and Tucson were surveyed. Over one quarter reported a history of childhood sexual abuse (sexual behavior with someone at least 5 years older prior to age 13, or with someone at least 10 years older when between ages 13 and 15). Men who were abused were more likely to engage in sexual risk behavior than men who were not abused (e.g., unprotected anal intercourse with non-primary partners in the previous 12 months: 21.4% vs. 15.0%, p < .001). Perception of having been coerced was associated with greater sexual risk. Furthermore, childhood sexual abuse and level of coercion were associated with reported levels of HIV infection among gay and bisexual men. It is recommended that existing programs for those at risk for HIV be modified to deal with these issues, and that efforts to bring about behavior change will require approaches that go beyond simply increasing knowledge and awareness.

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

Abstract 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.

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 partners HIV status (n = 785). Comparisons were made between three groups: (a) HIV + respondents/HIV + partners; (b) HIV- respondents/HIV- partners; and (c) respondents whose partners 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 ones own and ones partners HIV status.

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.

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.