Most cases of HIV infection in the United States are among men who have sex with men (MSM), a group in which the epidemic is fairly mature.1 Since the introduction of more effective HIV treatments in the mid-1990s, the frequency of unprotected sex among MSM has increased,2-12 a trend that could enhance the potential spread of the virus within this group. Between 29%-39% of HIV-infected MSM in community samples, including men in known HIV-serodiscordant relationships,13 say that they have engaged in unprotected sex in the past 3 months-1 year.14,15
Focus groups with MSM have identified themes to explain this rise in unprotected sexual behavior.16 Predominant in the participants' explanations was a sense that effective therapies have made HIV less threatening, that MSM communicate less about HIV and that social support for being safe has decreased, and that community norms have shifted to make unsafe sex more acceptable.
People with HIV are now living longer, more sexually active lives. Therefore, in response to continuing risk trends among MSM and other groups, the Centers for Disease Control and Prevention has placed a new focus on “prevention with positives.”17 Until recently, prevention planning shied away from interventions directed toward people living with HIV because of concerns about stigmatization.18 However, considering that the virus is transmitted from one person to another, failing to include HIV-infected individuals in prevention efforts is a missed opportunity to avert new infections.19-21
As part of the efforts to respond to the emerging needs of “prevention with positives,” the National Institute of Mental Health (NIMH) sponsored the Healthy Living Project (HLP), a multisite, randomized controlled trial designed to test the efficacy of a 15-session, individual-level intervention with people, including MSM, who are HIV infected. The intervention is focused on helping people cope with the challenges of living with HIV, including not transmitting the virus to others.22
The intervention is based on social action theory,23 which explains health protection behaviors as an interaction among 3 major domains: the self-regulation capabilities of the individual, including the ability to cope with stress; responses to internal affective states-eg, depression and anxiety-that also influence the self-regulation process; and the larger environmental context, eg, primary vs. casual partner, whether HIV status had been disclosed, and use of substances. Each of these domains has been shown to associate with risk behavior. For example, less effective behavioral coping strategies (self-regulation) correlate with higher levels of risk taking among people living with HIV.24-26 Depression (affective state) has, in some studies, been linked with HIV risk behaviors.27 Previous research has demonstrated that safer sex precautions are less likely to be adopted in affectionate, ongoing relationships than in casual partnerships24,28-32 and that these relationships likely account for a significant proportion of HIV transmission33 (contextual factors). Furthermore, unprotected sex is more likely to occur when people use alcohol34 or drugs.35
Because a significant proportion of new HIV infections would be expected to occur among the sex partners of MSM,36 it is important to understand the context of risk taking among HIV-infected MSM. The goal of this analysis is to examine, from a social action theory framework, the predictors of HIV transmission risk among MSM participants in the NIMH HLP baseline sample.
Participants and Recruitment
A total of 3818 HIV-positive individuals in 4 cities (San Francisco, Los Angeles, New York City, and Milwaukee) were screened for recruitment into the HLP. Recruitment and screening of potential respondents were undertaken primarily in community agencies in San Francisco and New York and medical clinics serving HIV-positive clients in Milwaukee and Los Angeles. Brochures, posters, and project descriptions, as well as direct contact by study staff in clinical and social service agencies were used to recruit respondents. In addition, advertisements were placed in newspapers and magazines serving HIV-positive and gay/bisexual populations, and potential respondents learning of the study by word of mouth were eligible to be screened. Interested persons who provided verbal consent were briefly screened by project personnel to determine their self-reported HIV status as well as basic demographic and contact information, and then, if they wished to participate, they were scheduled for a baseline interview.
Respondents were required to be at least 18 years of age, to provide written informed consent and medical documentation of their HIV infection, to be free of severe neuropsychological impairment or psychosis, and not to be currently involved in another behavioral intervention study related to HIV. Severe neuropsychological impairment and psychosis were assessed on a case-by-case basis by senior project personnel in collaboration with the clinical supervisor at the involved institution. The data reported in this paper are from baseline interviews of the HLP. Assessment interviews lasting 2-4 hours were conducted in private settings in research offices, community-based organizations, and clinics in each of the 4 cities.
Men were categorized as MSM if they reported any sexual contact with other men in the previous 3 months regardless of self-identified sexual orientation or additional sexual contact with women. Men who did not report recent sexual activity were also considered MSM if they self-identified as gay or bisexual. Men who identified as bisexual but reported only sex with women were not included in this analysis. In addition, transgender participants were excluded from analyses.
Individual private assessment interviews of each participant were conducted using a combination of audio computer-assisted self-interviewing (ACASI) and computer-assisted personal interviewing (CAPI) procedures based on the Questionnaire Development System version 2.0 by Nova Research Co. (Bethesda, MD). ACASI allows respondents to listen to an item via headphones while reading the text of that item on the computer monitor. The respondent then enters a response directly into the computer. This approach decreases social desirability bias and thereby enhances the self-reports of sensitive behaviors and attitudes.37,38 CAPI involves an interviewer reading items from a computer and allowing the respondent to make verbal responses that are entered directly into the computer by the interviewer. Both ACASI and CAPI obviate a separate data entry process and may therefore reduce data errors. Participants were compensated $50 for completing the baseline interview and were also eligible for $10 to defray child care costs.
Demographic Characteristics and Health Status Indicators
Demographic characteristics and health status indicators were assessed using CAPI. Detailed background and demographic data included items such as participant age, race/ethnicity, gender, self-identified sexual orientation, relationship status, educational level, employment status, and income. In addition, health status indicators, including self-reported most recent CD4 count, HIV viral load, and current use of antiretroviral medication were assessed.
Sexual Behavior: Partner-by-Partner and Global Assessment
A detailed ACASI interview was developed to assess sexual behavior. The interview had a 3-month recall period and included separate but equivalent versions of questions for heterosexual men, MSM, and women, each with language tailored to be consistent with the participant's gender and sexual orientation. The interview began with an introduction and definition of sexual terms to minimize ambiguity. All participants were then asked if they had engaged in any sexual activity during the previous 3 months with men, women, or both and the number of partners of each gender. Based on responses to these items and the gender of the participant, the computer-based interview asked pertinent questions about sexual behavior.
Beginning with the most recent sex partner and working backward, the participants provided initials or nicknames to identify up to 5 sexual partners of each gender in the previous 3 months. For each partner, the participant was asked to describe the person's HIV serostatus, to indicate whether they disclosed their own HIV infection to the individual or if the individual had uncovered this information independently (eg, met participant at an HIV-seropositive support group), and to define the nature of their relationship with the person. For the latter question, a participant was permitted to describe a person as a steady, main partner; as someone with whom they had sex for love or fun but not as a main partner; as someone with whom they had had sex once but not again; as someone with whom they had sex for drugs, money, or a place to stay; or as someone who forced them to have sex.
To assess sexual behavior with these partners, the participants were asked a sequence of questions about the number of times vaginal, anal, and oral sex took place and, if appropriate, whether anal sex was insertive or receptive. For anal and vaginal sex, participants were asked about the number of times they had used condoms from the beginning to the end of penetration (using separate questions for male and female condoms, when appropriate), about the number of times that condoms were used but had slipped or broken, and about the number of times internal ejaculation occurred with no protection.
Finally, a set of global measures was used to assess sexual behavior with any additional partners not already captured in the assessment. For both male and female partners, participants were queried about the number of times they had engaged in protected and unprotected sexual activities with all partners beyond the 5 most recent.
Use of legal and illegal substances in the past 3 months was assessed using ACASI. Items included alcohol, cocaine/“crack,” sedatives, tranquilizers, stimulants (such as crystal methamphetamine), analgesics, inhalants, marijuana, hallucinogens, and heroin. Because alcohol and stimulants were specifically associated with risk in previous studies,34,35,39 we examined them separately. We aggregated the assessments of the remaining drugs into 1 variable labeled “other drug use.” Because data for the stimulant and other drug use variables were skewed (ie, most participants indicated no or little use), we dichotomized the responses into 2 indicator variables (0 = no use of substance; 1 = use of substance). Alcohol use was more prevalent and so we created dummy variables to code for 3 categories of usage: none, some, and daily.
Past-week depression was assessed using the Beck Depression Inventory (α = 0.85),40-42 a 21-item self-report measure with ratings from 0 (absent) to 3 (severe). Anxiety was assessed with the State Form of the State-Trait Anxiety Inventory,43 a 20-item measure with high internal reliability (α = 0.90). Burnout was assessed with a 16-item scale adapted from the anger and fatigue subscales (eg, “worn out,” “resentful”) of the Profile of Mood States.44 An overall burnout score was created by summing the ratings using a 5-point Likert-type response format (α = 0.93).45 Perceived stress was assessed by summing ratings on the 10-item form of the Perceived Stress Scale (α = 0.83).46 The Social Provisions Scale47,48 was used to assess level, type, and perceived satisfaction with social supports from the person's social network. Coping self-efficacy was assessed with a truncated (15-item) version of the 26-item scale developed for a coping skills training study.49 For this study, an overall coping self-efficacy score was created by averaging the item responses (α = 0.92).
Data collected as part of the partner-by-partner risk assessment were aggregated to derive the total number of times that participants had anal and vaginal sex, as well as the number of times that condoms were used during those sexual acts. Because we were interested in the partner characteristics associated with HIV risk behaviors, these summations were tallied from sex acts reported in the detailed assessments conducted for each participant's 5 most recent male and female partners. The summations excluded information that was collected in the global measures, which assessed sexual behavior with ≥6 partners of a given gender, because we could not link these behaviors to specific partner attributes. Fifteen percent (n = 294) of the MSM participants reported >5 partners in the global measure.
We then examined the relative proportion of total sex acts and unprotected sex acts that occurred in various participant-partner dyads. We compared 2 characteristics: partner type and partner serostatus. For partner type, we compared steady partners, casual or one-time partners, transactional sex partners (sex for money or drugs), and sexual encounters involving force or coercion. For partner serostatus, we compared partners described as HIV infected with those who were described as either HIV negative or of unknown serostatus.
Finally, we examined the predictors of unprotected sex with any steady and casual male partner whose HIV status was negative or unknown (“transmission-risk events”). Unprotected sex was limited to any act of insertive or receptive anal or vaginal intercourse in which a participant did not use a condom, a definition that excludes risk acts produced by accidental condom slippage or breakage. Because the counts of transmission-risk events were highly skewed, we first collapsed the data into dichotomous indicator variables (0 = no transmission-risk sex; 1 = some transmission-risk sex). These indicators were used as the dependent variables in logistic regression models examining the effect of demographic characteristics (sexual identity, race, education, employment, age, primary relationship, disclosure of HIV status to all partners), health status (CD4 cell count, viral load, current use of antiretroviral therapy), drug use (alcohol, stimulants, other drugs), and psychosocial assessments (coping self-efficacy, perceived stress, depression, anxiety, anger and burnout, positive states of mind, and social support). We first ran univariate analyses examining the relationship between each predictor and the 2 key dependent variables (transmission-risk events with steady partners and transmission-risk events with casual partners). Predictor variables that were significantly associated with sexual behavior in univariate analyses (P < 0.05) were then included in multivariate models.
The overall sample contained 1910 individuals classified as MSM. Of these MSM, 40 reported having had sex with both men and women in the previous 3 months. A majority (98%) identified as gay or bisexual. African Americans were 36% of the sample, Hispanics were 18%, and whites were 38%. Table 1 displays participants' demographic characteristics, health status, and drug use, as well as their mean scores on depression, anxiety, and other psychosocial measures. Men who had sex with both men and women were more likely than men who had sex with only men to be African American (χ2 (3) = 20.6, P < 0.00), to have had only a high school education (χ2 (1) = 7.74, P < 0.01) or less, and to have lower scores on measures of social provisions (guidance: F (1, 1905) = 9.25, P < 0.005; reassurance of worth: F (1, 1894) = 17.44, P < 0.001; social integration: F (1, 1903) = 4.43, P < 0.05; social nurturance: F (1, 1900) = 4.50, P < 0.05; and reliable alliance: F (1, 1904) = 4.31, P < 0.05).
Overall, 1268 of MSM participants (66%) reported at least 1 sexual partner in the previous 3 months. These men reported a total of 18,731 acts among their 5 most recent male partners and 1534 acts among their 5 most recent female partners. A majority of acts (63%) occurred with an HIV-infected partner. Of the 8328 acts reported with negative or unknown status partners, 6805 (82%) were reported as protected. Table 2 displays the distribution of total sex acts, as well as unprotected sex acts, by partner type and partner serostatus.
A small, but not insignificant, portion of the MSM sample (12.7% or 243 men) had at least 1 episode of unprotected sex with a partner whose serostatus was HIV negative or unknown. This involved 1523 acts, which are of particular importance because they represent instances in which HIV transmission could have occurred. Of these acts, 1334 (88%) were with male partners and 189 (12%) were with female partners. Of these potential transmission acts, 57% were with casual partners, 31% with steady partners, and 12% with partners with whom money or drugs were exchanged, while <1% occurred during coercive sexual encounters. Although the total number of potential transmission acts with women was relatively small (189/1534), the proportion of risk acts out of total acts (12%) was higher than with male partners (7%).
A majority of participants disclosed their HIV serostatus before unprotected sexual acts. Eighty-eight percent (4951/5656) of unprotected sex acts between men occurred after disclosure. Similarly, 83% (419/502) of unprotected sex acts between a man and a woman were preceded by disclosure. However, disclosure of HIV infection was less common before transmission-risk events with partners of negative or unknown status. Fifty-five percent (734/1334) of the transmission-risk events between a participant and a male partner of seronegative or unknown status, and 59% (112/189) of the transmission-risk events between a participant and a female partner of seronegative or unknown status, occurred after disclosure of the participant's HIV infection. Disclosure also varied significantly by type of partner. Among individuals reporting risk with partners of seronegative or unknown serostatus, disclosure was significantly more likely with steady or primary partners (2919/3222 = 91%) than with casual or one-time partners (2361/4749 = 50%, P < 0.001).
Psychosocial Predictors of Transmission Risk
Table 3 reports the psychosocial predictors of transmission-risk acts (unprotected vaginal or anal intercourse with negative or unknown status partners) for steady and casual partners. Among transmission-risk acts with steady partners, none of the psychosocial measures predicted risk of transmission, although the association between depression and higher risk was marginally significant (P = 0.06). Among casual partners, both greater coping self-efficacy (P < 0.01) and positive states of mind (P < 0.02) were associated with less transmission risk. Depressive symptoms again were of marginal significance in predicting risk (P < 0.07).
Because the psychosocial measures were moderately correlated with one another (range of r: 0.16-0.65), we decided to select 1 measure for multivariate modeling to avoid potential problems with multicolinearity. We selected coping self-efficacy for inclusion in analyses because it is a measure of a person's belief's about his or her ability to cope with stress, which is known to be associated with risk behavior.50 Consistent with social action theory, coping self-efficacy is also known to influence stress-related moods such as perceived stress and burnout.49 In addition, coping self-efficacy displayed the largest univariate odds ratio (OR) associated with any transmission-risk event (for casual partners: OR = 0.79, 95% CI: 0.67 to 9.94, P = 0.006).
Predictors of Risk With Primary Partners
Table 4 presents univariate and multivariate predictors of transmission-risk acts with steady partners. Univariate predictors of transmission risk included younger age (<40 years), identifying oneself as being in a “primary relationship,” the use of stimulants (eg, methamphetamines), the use of other drugs, and not always disclosing one's HIV serostatus to partners. Identifying as being in a primary relationship, partner disclosure, and stimulant use remained significant in the multivariate model.
Predictors of Transmission Risk With Casual Partners
Table 5 presents univariate and multivariate predictors of transmission-risk acts with casual partners. Univariate predictors of transmission-risk acts included having at least some college education, being employed, some alcohol use, stimulant and other drug use, having lower coping self-efficacy, and not always disclosing one's HIV serostatus to partners. Stimulant and other drug use, coping self-efficacy, and partner disclosure retained significance in multivariate modeling.
Our findings point to the importance of developing interventions that respond differently to risk of transmitting in the context of primary relationships and risk occurring in casual partnerships. About two-thirds of transmission-risk events among MSM occurred with casual partners. Deficiencies in coping self-efficacy, a construct that can be modified through education and training, proved to be a significant predictor of this kind of risk. Consistent with previous research,34,35,39 risk of transmission with casual partners was also associated with using stimulants (eg, crystal methamphetamine) and other drugs. Another third of transmission-risk events occurred with steady partners and were more likely to occur if a participant was younger or had used stimulants. Taken together, these findings suggest that stimulant use, particularly crystal methamphetamine, contributes significantly to risk of HIV transmission and that interventions designed to minimize or eliminate its use should be an important component of primary HIV prevention.
Transmission-risk events with casual partners appear to be driven in part by self-regulatory factors, one component of social action theory. Higher coping self-efficacy was associated with less risk in casual partnerships. Coping self-efficacy is a measure of beliefs about one's ability to cope with stress by managing emotional responses and effective problem solving, including making plans to address problems and following them through. It is likely that sexual interactions with casual partners are perceived as more challenging or stressful, given that the casual partner's behavior is less predictable than interactions with a primary partner. Measures of efficacy, in general, are associated with the constructs of self-esteem, emotional stability, and locus of control.51 Thus MSM high in self-efficacy may be more capable of maintaining personal control and managing the stress inherent in sexual interactions with casual partners, which in turn puts them at lower risk.50 Of relevance to prevention, interventions such as coping effectiveness training have been shown to improve coping self-efficacy in HIV-infected MSM and these improvements have been found to be associated with other outcomes, including reductions in perceived stress and burnout.49 Fortunately, cognitive-behavioral and supportive group interventions have both been effective in enhancing coping in men living with HIV.42,47-49
Affective states, a second component of social action theory, did not emerge as predictive in multivariate analysis although such a relationship with depression was suggested in univariate analysis. This may have been due to the correlations among coping self-efficacy and these affective states.
Finally, contextual issues, the third component of social action theory, emerged as a major factor associated with risk of transmitting HIV. In particular, the study documented the important association between risk behaviors and failure to always disclose HIV serostatus to partners. MSM who failed to disclose to ≥1 partner were significantly more likely to engage in transmission-risk acts. This was true for behavior within steady relationships and, to a greater extent, with casual partners. These findings highlight the need to evaluate interventions that aim to increase disclosure and their impact on unprotected sex with partners of seronegative or unknown serostatus.
Based on the findings from this study, transmission risk with steady partners appears to be less amenable to self-regulatory interventions. Psychosocial constructs had little relationship to sexual behavior in primary partnerships. This is unfortunate because previous research has demonstrated that safer sex precautions are less likely to be adopted in affectionate, ongoing relationships than in casual partnerships.24,28-32 HIV-infected people are motivated to use condoms as a way to protect their partners26,52,53 but condom use impedes intimacy and commitment in primary relationships.32,53-55 Future work needs to clarify how to respond to the prevention challenges faced by serodiscordant couples.
These findings are limited by the cross-sectional nature of the data. Longitudinal designs are needed to prove, definitively, cause-and-effect relationships between psychosocial or contextual factors and the likelihood of transmission-risk sex. Our findings are also limited by the need to restrict our assessment of risk to only the 5 most recent partners. It was not possible to continue a detailed partner-by-partner assessment, indefinitely, and all sex acts with ≥6 partners were assessed in one set of global measures. Thus, the total amount of transmission risk in the sample is higher than what we have reported. A final limitation of the study arises from the need to use different recruitment procedures across sites, which may affect the degree to which the sample is representative of the population.
In the United States and other developed countries, MSM continue to represent a disproportionate share of new HIV infections. We believe that coping effectiveness training, which addresses coping with stress via multiple strategies including substance use, can be effective in responding to this challenge. For the nearly one-third of risk that is occurring in the context of steady serodiscordant couples, additional strategies are needed to respond to the relationship dynamics that are supporting the ongoing risk. Above all, we need to develop and implement these strategies in a way that involves and respects these men, so that they become partners in reducing HIV transmission.
The following individuals comprised the research team-research steering committee (site principal investigators and NIMH staff collaborator): Mary Jane Rotheram-Borus, PhD (University of California, Los Angeles), Jeffrey A. Kelly, PhD (Medical College of Wisconsin, Milwaukee, WI), Anke A. Ehrhardt, PhD (New York State Psychiatric Institute and Columbia University, New York, NY), Margaret A. Chesney, PhD (University of California, San Francisco), Willo Pequegnat, PhD (National Institute of Mental Health, Bethesda, MD); co-principal investigators, investigators, collaborating scientists: Naihua Duan, PhD, Marguerita Lightfoot, PhD, Risë B. Goldstein, PhD, MPH, Fen Rhodes, PhD, Robert Weiss, PhD, Richard Wight, PhD, Tyson Rogers, MA, Philip Batterham, MA (University of California, Los Angeles), Lance S. Weinhardt, PhD, Eric G. Benotsch, PhD, Michael J. Brondino, PhD, Sheryl L. Catz, PhD, Cheryl Gore-Felton, PhD, Steven D. Pinkerton, PhD (Medical College of Wisconsin, Milwaukee, WI), Robert H. Remien, PhD, A. Elizabeth Hirky, PhD, Robert M. Kertzner, MD, Sheri B. Kirshenbaum, PhD, Lauren E. Kittel, PsyD, Robert Klitzman, MD, Bruce Levin, PhD, Susan Tross, PhD (New York State Psychiatric Institute and Columbia University, New York, NY), Stephen F. Morin, PhD, Mallory O. Johnson, PhD (University of California, San Francisco), Don C. Des Jarlais, PhD (Beth Israel Medical Center, New York, NY), Hannah Wolfe, PhD (St. Luke's Roosevelt Medical Center, New York, NY); site project coordinators: Willy Singh, MPH, Daniel Hong, MA (University of California, Los Angeles), Kristin Hackl, MSW, Margaret Peterson, MSW (Medical College of Wisconsin, Milwaukee, WI), Joanne Mickalian, MPH (University of California, San Francisco); NIMH staff support: Ellen Stover, PhD, Christopher M. Gordon, PhD, and Dianne Rausch, PhD (National Institute of Mental Health).
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