A key component in human immunodeficiency virus (HIV) prevention strategies is serostatus disclosure between sexual partners. Some individuals may use serostatus information to select partners of the same serostatus, e.g., serosorting, whereas others may use it to negotiate sexual behaviors to reduce risk, e.g., strategic positioning.1–3 Implementation of these HIV prevention strategies, however, depends upon serostatus disclosure between partners. HIV disclosure may be influenced by individual-level attributes such as age, sexual identity, and HIV serostatus; partnership-level attributes such as partnership type; choice of sexual behaviors such as anal intercourse with or without a condom; and environmental-level attributes such as where the sexual partner was met.1,4–8
International travel provides an opportunity for some gay and bisexual men to meet sexual partners while in the destination countries. Previous studies have described HIV and sexually transmitted infections acquired during the course of international travel.9–12 Although Internet access has made it easier to develop sexual partnerships while traveling, travelers still face multiple challenges, such as unfamiliarity with the local surroundings and lack of fluency with the local language.13 The ability to communicate in a common language is pivotal for HIV serodisclosure and sexual negotiations, and difficulties with communication could create situations that result in increased transmission risk.
We evaluated risk and preventive behaviors that gay and bisexual men engaged in during international travel. We specifically assessed respondents' knowledge of sexual partners' HIV status, disclosure of their own serostatus, and ability to communicate in a common language with partners.
A probability-based sample of gay and bisexual men was recruited between 2009 and 2011 using an adapted sampling. A detailed description of the recruitment procedures has been previously reported.14 Men were eligible if they were ≥18 years, San Francisco Bay Area residents, and traveled internationally in the previous 12 months.
Respondents completed an interviewer-administered, computer-assisted survey. Demographic characteristics collected included age, race/ethnicity, and sexual orientation. Respondents' HIV status was based on self-report of perceived HIV status at the interview.
Respondents were asked about sexual partners in the previous 12 months while traveling internationally. Detailed partnership-level data were collected for up to 3 sexual partnerships per country visited, for up to 2 countries. A partnership refers to a unique individual in each country. Partnership-level data collected included partners' sex, age, race and HIV status, HIV status disclosure to partner, partner type and sexual behaviors with the partner. This analysis focused on respondents' casual partners, that is, individuals with whom respondents did not have a commitment or did not know well; and anonymous partners, that is, individuals with whom respondents had 1-time sex and did not know how to contact again. Partnerships were classified as HIV seroconcordant when partners were known to be of the same serostatus as the respondent.
Respondents reported how well they could communicate with each partner: “poorly, difficult to communicate”; “sufficiently, communication was difficult but possible”; “well, able to have a conversation easily”; or “fluently, both spoke the same language fluently.” We created 2 communication categories: poor versus sufficient or better.
Medians, interquartile ranges, and percentages were calculated for various individual-level demographic, behavioral, and trip variables. Individual-level survey weights were derived using RDSAT 7.1 to account for the sampling design. Age group was used to derive weights because age is a relatively visible trait, likely to influence recruitment. Individual-level weights were used as approximations for partnership-level weights. Using survey correction, that is, weighting by aforementioned weights and clustering by respondent, we estimated the number and percentage of partnerships in partnership-level groups of interest, supplemented with survey-corrected χ2 tests. We fit survey-corrected bivariate logistic regression models to examine associations between various partnership characteristics and partnership-level behavioral outcomes, stratified by partnership type. These models generated odds ratios for the outcomes of condomless anal intercourse (CAI), insertive CAI (CIAI), receptive CAI (CRAI), disclosure of the respondent's serostatus and knowing the partner's serostatus. With the exception of derivation of weights, all analyses were conducted in R using a significance level of 0.05 and a 95% confidence interval.
Of the 501 total respondents, 303 men reported having casual and anonymous partners while traveling internationally. The demographic characteristics and self-reported HIV status for these 303 respondents are presented in Table 1. The median age was 40 years (interquartile range, 31–47 years), and 26% of respondents were HIV-positive.
Detailed behavioral data were collected for 373 casual and 427 anonymous partnerships. Table 2 presents the partnership characteristics, weight adjusted. Nearly all the anonymous partners were met in the country being visited while some casual partners were met in the United States or elsewhere. Anonymous partners were more commonly met at a bathhouse or sex club, whereas casual partners were met through the Internet.
Sexual behaviors varied significantly by partnership type. Mutual masturbation, finger-anal contact, and oral-anal contact were most commonly reported, as shown in Table 2. Men were more likely to engage in finger-anal contact, oral-anal contact, anal fisting, CIAI, receptive anal intercourse, and CRAI in casual partnerships than in anonymous partnerships. Men were less likely to know their partner's HIV status and disclose their own HIV status in anonymous partnerships than in casual partnerships. Men were able to communicate well or fluently in 86% of casual partnerships but had difficulties communicating in 30% of anonymous partnerships.
Fluency in a common language and venue type where respondents met the partners were considered with regard to the outcomes of respondents' HIV status disclosure to partners and knowledge of partners' HIV status, as shown in Table 3. Men were more likely to disclose their HIV status in both casual and anonymous partnerships with sufficient or better communication. They were more likely to know the partner's HIV status in anonymous partnerships with sufficient or better communication compared with partnerships with poor communication. Men were more likely to disclose their HIV status in anonymous partnerships met through the Internet compared with partnerships met at a bar or nightclub. In casual partnerships, men were more likely to know the HIV status of partners met through the Internet, at a sex club or bathhouse or on the street, at a park or at a public venue compared to partnerships met at a bar or nightclub.
HIV seroconcordancy, venue type where partners were met, respondent's HIV status disclosure to partner, and knowledge of partner's HIV status were considered with regard to the outcomes of any CAI, CIAI, and CRAI, as shown in Table 4. In casual partnerships, CRAI was more likely to occur with partners met on the street, at a park or at a public venue, at a sex club or bathhouse, on the Internet, or introduced by friends compared with partners met at a bar or nightclub. Insertive CAI was more likely to occur with partners of unknown HIV status than with partners of known HIV status. In anonymous partnerships, men were less likely to engage in CAI or CRAI with HIV serodiscordant partners and in partnerships where the partner's HIV status was unknown. Overall, men disclosed their HIV status in 55 of 75 (73%) casual partnerships and 23 of 59 (39%) anonymous partnerships where CAI occurred.
Language barriers can complicate HIV prevention communication and behaviors. The men in our study who reported difficulties communicating in a common language with partners were less likely to disclose their own HIV status and to know the partner's HIV status. HIV status disclosure occurred less frequently and communication was more difficult in anonymous partnerships than in casual partnerships. Men were less likely to engage in CAI in partnerships where they did not disclose their own HIV status or did not know their partner's status, with a significant association detected in anonymous partnerships between CAI and knowledge of partner HIV status.
Because HIV serodisclosure and knowledge of partners' serostatus appeared to be hampered by the lack of a common language and CAI was less likely to occur in partnerships where HIV serostatus was not disclosed or known, taken together, these observations suggest that language barriers may affect sexual decision-making. Avoiding CAI with partners with whom communication was difficult may have represented a risk reduction strategy for some men. However, there was still substantial overlap in the lack of HIV disclosure and risk behavior, because HIV status disclosure did not take place in one quarter of casual partnerships and one third of anonymous partnerships in which CAI did occur. This observation suggests poor communication between partners could be contributing to risk dynamics.
One-quarter of anonymous and casual partners were met through the Internet, and HIV disclosure occurred in more than half of those partnerships. The Internet may facilitate HIV disclosure by making it possible to indicate serostatus in online profiles.15,16 However, one study found only one-quarter of HIV-positive gay and bisexual men disclosed their serostatus accurately online and three quarters of men who had never been tested indicated they were HIV-negative.17 Sexual negotiation based on inaccurate serostatus information poses an HIV transmission risk.
Potential limitations of the study include misreporting of high-risk sexual behavior due to social desirability bias and small cell sizes of some response categories. Viral load status may have influenced serostatus disclosure and sexual behavior. Although HIV-positive men reported their most recent viral load date and results, we were unable to align these results with each sexual partnership and thus could not assess associations with viral load. We believe the study recruited a representative sample of the population of gay and bisexual men. We are not aware of any population-based data of gay and bisexual men in the San Francisco Bay Area who travel internationally against which to compare our study sample.
Given the greatly variable nature of worldwide destinations, international travelers may not always possess the behavioral skills essential for negotiating safer sex practices and disclosing HIV serostatus. Factors such as not sharing a common language could inhibit risk reduction negotiations and result in behaviors that increase HIV transmission risk. To the best of our knowledge, this is the first study of gay and bisexual men assessing the impact of language barriers on HIV disclosure with partners met while traveling internationally. More detailed examination of the situational dynamics and individual traits that lead to CAI despite difficulties in communicating could inform the development of targeted interventions for gay and bisexual men during international travel.
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