Gay men, risk and relationships
Elford, Jonathana; Bolding, Grahama; Maguire, Markb; Sherr, Lorrainea
From the aDepartment of Primary Care and Population Sciences and Royal Free Centre for HIV Medicine, Royal Free and University College Medical School, University College London, London, UK; and bHealth Promotion Services, Camden and Islington Community Health Services NHS Trust, London, UK.
Correspondence to: Dr Jonathan Elford, Department of Primary Care and Population Sciences, Royal Free and University College Medical School, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK. Tel: +44 020 7794 0500 (ext 4382); fax: +44 020 7794 1224; e-mail: email@example.com
Received: 30 October 2000; accepted: 22 February 2001.
Relationships are good for you. People in a relationship tend to enjoy better health, suffer less depression and live longer than single people . However, among gay men, an intimate relationship may also present a risk of HIV infection. Numerous studies have shown that gay men are less likely to use condoms with their regular partner than with a casual partner [1–3]. For many men, not using a condom with their regular partner is an expression of intimacy and trust [4–6]. Paradoxically, these two vital aspects of a loving relationship may act as a counterpoise with respect to HIV.
Not all unprotected anal intercourse (UAI) presents an HIV transmission risk, however, particularly in a relationship. The risk can be eliminated if both partners test HIV negative, and agree only to have UAI with one another. This risk reduction strategy, known as negotiated safety, was first reported among gay men in Sydney . Negotiated safety requires both men to be confident they are HIV negative (i.e. seroconcordant), and to comply with their agreement only to have UAI with each other. Seroconcordant UAI between two HIV-positive men also presents no risk of HIV transmission to an uninfected person, but raises the possibility of cross-infection for the positive men themselves.
Any examination of sexual risk behaviour among gay men must therefore make the distinction between seroconcordant UAI, which presents little if any risk of HIV transmission, and UAI with a partner of unknown or discordant status, which presents a substantially higher risk. Surprisingly, not all researchers make this important distinction [8–10]. This crucial differentiation has been made in a study of Swiss gay men published in the current issue of AIDS . In Switzerland, five out of six gay men (84%) with a steady partner reported the safe management of HIV risk within their relationship. Consistent use of condoms was the most common means of managing risk (reported by 43% of men), followed by negotiated safety (25%) and not practising anal sex (16%). The remaining men (16%) reported what the authors called ‘inadequate management of HIV risk’ with their steady partner. Most of these men (10%) chose to have UAI with a partner of unknown HIV status based on a personal assessment of past risks or because they were faithful.
Overall, slightly more than one-third (36%) of Swiss gay men in a relationship reported UAI with their steady partner. However, the majority (25%) were HIV-negative men reporting UAI only with another HIV-negative man (negotiated safety), whereas a few (1%) were HIV-positive men also with seroconcordant UAI partners. It was the remaining 10% who reported high-risk UAI with their steady partner, i.e. with a person of unknown or (potentially) discordant status. Had the investigators used any UAI with a steady partner as a measure of risk they would have substantially overestimated the degree of sexual risk within a relationship. This highlights the importance of distinguishing seroconcordant UAI from UAI with a person of unknown or discordant status.
How does the level of risk reported between steady partners in Switzerland compare with recent surveys among gay men in other countries? Despite some differences in survey design and methodology, two important findings emerge. First, in most countries [12–15] (P. Adam, personal communication) between one half and two-thirds of gay men had a steady partner at the time of the survey, highlighting the importance of the relationship as a context for high-risk behaviour. Second, the percentage of men in a relationship who reported high-risk sexual behaviour with their steady partner varied dramatically between countries. In Amsterdam, nearly 30% of gay men in a relationship reported high-risk sexual behaviour with their steady partner, i.e. UAI with a person of unknown or discordant HIV status . In Germany, the corresponding figure was 23%; in California and Oregon 21%; in France 13% (P. Adam, personal communication); and in London and Sydney 12%[14,17].
Why are there such striking differences between countries in the level of sexual risk within a relationship? One, but not the only factor is the extent to which couples are aware of their own and their partner's HIV status. In Switzerland, just over half the couples said they knew each other's HIV status. In Amsterdam , the figure was substantially lower, whereas in Australia  it was considerably higher. This may reflect differences between countries in both the availability of HIV testing, as well as incentives for seeking an HIV test such as access to highly active antiretroviral therapy. Other factors include agreements between partners concerning unprotected sex , the disclosure of HIV status , and the extent to which health promotion programmes have focused on sex in relationships.
The paper from Switzerland serves to remind us that mapping patterns of sexual risk behaviour is complex and requires a degree of sophistication. In behavioural research, investigators should distinguish men who are in a relationship from those who are not; seek information on UAI insertive and receptive, with both steady and casual partners; and ascertain the HIV status of the respondent as well as his sexual partners, in order to differentiate seroconcordant UAI from UAI with a person of unknown or discordant status. This distinction is particularly important when interpreting time trends in sexual risk behaviour. An increase over time in the percentage of men reporting UAI  does not, in itself, signify an increase in the level of sexual risk taking. It is the increase in the percentage of men reporting UAI with a partner of unknown or discordant HIV status that provides a marker of increasing high-risk behaviour . This needs to be differentiated from any parallel increase in the proportion of men reporting seroconcordant UAI. Concerning couples, because sexual risk occurs between steady partners, any investigation of risk behaviour should preferably include rather than exclude  these men.
A relationship may be a crucible of both security and risk. Behavioural research conducted over the past decade has consistently shown that a substantial minority of gay men report high-risk sexual behaviour with their steady partner [11–16,22–26] (P. Adam, personal communication). Interventions to reduce the risk of HIV transmission among gay men should therefore target couples as well as individuals , focusing on the quality of communication within the relationship and the degree of support partners provide one another . A number of health promotion strategies have been developed, including mass media campaigns plus community and clinic-based interventions. Posters, cards and booklets focusing on risk within relationships were central to health promotion initiatives targeting couples in London (`Thinking it through') and Sydney (`Talk, test, test, trust'). A project in London currently allows couples, working in groups with a facilitator, to explore the potential for behaviour change and the maintenance of low risk within the relationship. A genitourinary medicine clinic provides sessions in which couples can be screened for sexually transmitted diseases/HIV together, and then discuss the test results with a counsellor as well as a physician. The effectiveness of these interventions requires further examination as does their transferability from one setting to another; or indeed, from one relationship to another. Not all relationships last for ever; in the Swiss study the median length was 3 years. Consequently, gay men need to be equipped with the skills to negotiate risk reduction not only with a current but also with a future steady partner. In this way, with the further development of couple-focused interventions, we may be able to anticipate a time when an intimate relationship protects against, rather than presents a risk for, HIV.
1. Misovich SJ, Fisher JD, Fisher WA. Close relationships and elevated HIV risk behavior: evidence and possible underlying psychological processes. Rev Gen Psychol 1997, 1: 72 –107.
2. Hospers HJ, Kok G. Determinants of safe and risk-taking sexual behaviour among gay men: a review. AIDS Educ Preven 1995, 7: 74 –94.
3. Hunt AJ, Weatherburn P, Hickson FC, Davies PM, McManus TJ, Coxon AP. Changes in condom use by gay men. AIDS Care 1993, 5: 439 –448.
4. McLean J, Boulton M, Brookes M. et al
. Regular partners and risky behaviour: why do gay men have unprotected intercourse. AIDS Care 1994, 6: 331 –341.
5. Boulton M, McLean J, Fitzpatrick R, Hart G. Gay men's accounts of unsafe sex. AIDS Care 1995, 7: 619 –630.
6. Remien RH, Carballo-Dieguez A, Wagner G. Intimacy and sexual risk behaviour in serodiscordant male couples. AIDS Care 1995, 7: 429 –438.
7. Kippax S, Crawford JM, Davis M, Rodden P, Dowsett G. Sustaining safe sex: a longitudinal study of a sample of homosexual men. AIDS 1993, 7: 257 –263.
8. Koblin BA, Torian LV, Guilin V, Ren L, MacKellar DA, Valleroy LA. High prevalence of HIV infection among young men who have sex with men in New York City. AIDS 2000, 14: 1793 –1800.
9. Mansergh G, Marks G, Miller L, Appleby PR, Murphy S. Is ‘knowing people with HIV/AIDS’ associated with safer sex in men who have sex with men? AIDS 2000, 14: 1845 –1851.
10. Valleroy LA, MacKellar D, Karon JM. et al
. HIV prevalence and associated risks in young men who have sex with men. JAMA 2000, 284: 198 –204.
11. Moreau-Gruet F, Jeannin A, Dubois-Arber F, Spencer B. Management of the risk of HIV infection in male homosexual couples. AIDS 2001, 15: 1027 –1037.
12. Bochow M. The response of gay German men to HIV: the national gay press surveys, 1987–96.
In:Partnership and pragmatism. Germany's response to AIDS prevention and care.
Rosenbrock R, Wright MT (editors). London: Routledge; 2000.
13. Hays RB, Kegeles SM, Coates TJ. Unprotected sex and HIV risk taking among young gay men within boyfriend relationships. AIDS Educ Preven 1997, 94: 314 –329.
14. Elford J, Bolding G, Maguire M, Sherr L. Sexual risk behaviour among gay men in a relationship. AIDS 1999, 13: 1407 –1411.
15. Van de Ven P, French J, Crawford JM, Kippax S. Sydney gay men's agreements about sex.
In:Families and communities responding to AIDS
. Aggleton P, Hart G, Davies P (editors). London: UCL Press; 1999.
16. Davidovich U, de Wit JBF, Stroebe W. Assessing sexual risk behaviour of young gay men in primary relationships: the incorporation of negotiated safety and negotiated safety compliance. AIDS 2000, 14: 701 –706.
17. Kippax S, Noble J, Prestage G. et al
. Sexual negotiation in the AIDS era: negotiated safety revisited. AIDS 1997, 11: 191 –197.
18. Holt R, Court P, Vedhara K, Nott KH, Holmes J, Snow MH. The role of disclosure in coping with HIV infection. AIDS Care 1998, 10: 49 –60.
19. Denning P, Nakashima AK, Wortley P. Increasing rates of unprotected anal intercourse among HIV-infected men who have sex with men in the United States. XIIIth International AIDS Conference
. Durban, 2000 [Abstract ThOrC714].
20. Dodds JP, Nardone A, Mercey DE, Johnson AM. Increase in high risk sexual behaviour among homosexual men, London, 1996–8: cross sectional, questionnaire study. BMJ 2000, 320: 1510 –1511.
21. Kelly JA, Murphy DA, Sikkema KJ. et al
. Randomised, controlled, community-level HIV-prevention intervention for sexual-risk behaviour among homosexual men in US cities. Lancet 1997, 350: 1500 –1505.
22. Valdiserri RO, Lyter D, Leviton LC, Callahan CM, Kingsley LA, Rinaldo CR. Variables influencing condom use in a cohort of gay and bisexual men. Am J Public Health 1988, 78: 801 –805.
23. Fitzpatrick R, McLean J, Boulton M, Hart G, Dawson J. Variation in sexual behaviour in gay men.
In:AIDS: individual, cultural and policy dimensions
. Aggleton P, Davies P, Hart G (editors). London: Falmer Press; 1990.
24. Hays RB, Kegeles SM, Coates TJ. High HIV risk-taking among young gay men. AIDS 1990, 4: 901 –907.
25. Bochow M, Chiartotti F, Davies P. et al
. Sexual behaviour of gay and bisexual men in eight European countries. AIDS Care 1994, 5: 533 –549.
26. Hoff CC, Coates TJ, Barrett DC, Collette L, Ekstrand M. Differences between gay men in primary relationships and single men: implications for prevention. AIDS Educ Preven 1996, 8: 546 –559.
27. Bosga MB, de Wit JBF, de Vroome EMM, Houweling H, Schop W, Sandfort TGM. Differences in perception of risk for HIV infection with steady and non-steady partners among homosexual men. AIDS Educ Preven 1995, 7: 103 –115.
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Gay men; relationships; unprotected anal intercourse
© 2001 Lippincott Williams & Wilkins, Inc.
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