Many factors influence individuals' choice to engage in risky sexual practices, for example, self-efficacy and substance use.1,2 Beliefs about who is responsible for preventing HIV transmission may also influence sexual practices. In sexual partnerships, including serodiscordant partnerships, these beliefs may differ between partners.
Studies of HIV-positive men who have sex with men (MSM) found varying beliefs about their responsibility to protect others from infection or their partners' responsibility to protect themselves.3,4 Data on prevention responsibility beliefs from the perspective of HIV-negative individuals are limited.5
We conducted a secondary analysis using data from an HIV seroadaption study among MSM in San Francisco to assess prevention responsibility beliefs of HIV-negative and HIV-positive MSM.6 We examined associations between these beliefs, and HIV status discussion and serodiscordant condomless anal intercourse (CAI). Men who have sex with men 18 years or older and San Francisco area residents were recruited by time-location sampling between December 2007 and October 2008. Demographic characteristics and behavioral data were collected using a computer-based, self-administered survey. Recruitment and survey administration procedures are detailed in a previous publication.6 The study received approval from the institutional review board at the University of California, San Francisco.
HIV prevention responsibility beliefs were assessed via 5 statements. Two statements indicated that HIV-positive persons were primarily responsible for preventing transmission; 2 indicated that HIV-negative persons were primarily responsible; 1 indicated mutual responsibility. Responses consisted of a 5-point scale, ranging from 1 (strongly disagree) to 5 (strongly agree), and were considered as continuous variables in multivariable regression models. Respondents were asked about their 5 most recent male sexual partnerships (i.e., sexual dyad) in the previous 6 months, including partnership type, sexual behaviors, and whether they discussed HIV status. Serodiscordant CAI was defined as CAI with a partner of discordant/unknown serostatus. Partnerships were grouped as main, casual, and anonymous/exchange.
Respondents reporting any sex in the previous 6 months were included in these analyses. Mean and SDs for belief statements were calculated overall and by respondent HIV status. Differences were assessed using the Mann-Whitney U or χ2 tests. To determine correlates of responsibility beliefs, statements were dichotomized (strongly/somewhat agree vs. neutral-somewhat/strongly disagree). Multivariable generalized estimating equations with the binomial model, logistic link, and robust SEs examined associations between responsibility beliefs and outcomes of interest (discussed HIV status and had serodiscordant CAI) within sexual dyads, adjusting for multiple observations per respondent. Separate models were conducted for each belief and by serostatus. Demographic characteristics associated with any beliefs in bivariate analyses at P < 0.10 and partnership type were included in multivariable models.
Data from 912 men (752 HIV-negative and 160 HIV-positive) and 3364 sexual dyads were included. Respondents were 18 to 77 years old (median, 35 years); 7% were black, 11% were Asian, 69% were white, 13% were other race, and 19% were Hispanic; and 57% graduated college, 31% attended some college, and 10% were high school graduates or the equivalent. Respondents reported a median of 5 (interquartile range, 2–5) sexual dyads, consisting of 47% casual, 14% main, and 38% anonymous/exchange.
HIV prevention responsibility beliefs by HIV status are presented in Table 1. Beliefs were grouped as HIV-positive individuals' responsibility, HIV-negative individuals' responsibility, or mutual responsibility. HIV-negative men agreed more with statements for both HIV-positive and HIV-negative responsibility compared with HIV-positive men. HIV-negative and HIV-positive men had similar agreement on mutual responsibility (P = 0.27).
Bivariate associations with beliefs by HIV status are shown in Table 2. Older HIV-positive men and non-Hispanic HIV-negative men were more likely to agree with HIV-positive responsibility beliefs. Older and non-Hispanic HIV-negative men were more likely to agree with HIV-negative and mutual responsibility beliefs.
Multivariable models are presented in Table 3. Higher agreement was associated with increased odds of discussing HIV status for the statements: “A man who is HIV-positive should discuss his status before having anal sex with new partners” among HIV-negative (P = 0.04) and HIV-positive men (P < 0.01), and “It is the responsibility of HIV-positive men to make sure that they don't infect their partners” among HIV-positive men (P < 0.01). HIV status discussion was not associated with HIV-negative or mutual responsibility beliefs among HIV-negative or HIV-positive men.
HIV-negative and HIV-positive men with higher levels of agreement that “It is the responsibility of HIV-positive men to make sure that they don't infect their partners” were less likely to report discordant CAI (P < 0.01). Among HIV-negative men, higher levels of agreement were associated with decreased odds of serodiscordant CAI for the statements: “Men who are HIV-negative should always make sure they are safe with positive or unknown HIV status partners” (P < 0.01), “It is the responsibility of HIV-negative men to make sure that they don't get infected” (P < 0.01), and “HIV-positive and HIV-negative men have an equal responsibility to stop more men from becoming infected” (P < 0.01). In contrast, agreeing that HIV-negative MSM hold responsibility or that the responsibility is mutual was not associated with decreased serodiscordant CAI among HIV-positive MSM (P = 0.06 and 0.15, respectively).
Among both HIV-negative and HIV-positive men, discussing HIV status was lower with casual and anonymous/exchange partners compared with main partners (P < 0.01, all models). The odds of discussing HIV status tended to decrease with increasing age for HIV-positive men, although not significantly across all models. Among HIV-negative men, serodiscordant CAI was lower with casual and anonymous/exchange partners compared with main partners, and higher among men who did not graduate college compared with those who graduated. Demographic characteristics and partnership type were not consistently associated with serodiscordant CAI among HIV-positive men in multivariable models.
We found high levels of agreement regarding HIV-positive and HIV-negative men's prevention responsibility beliefs. HIV-negative men felt that it is the responsibility of HIV-positive men to discuss their status and not infect partners, and their own responsibility to not become infected. Accepting mutual responsibility for prevention was similarly high among HIV-negative and HIV-positive men. However, decreased likelihood of serodiscordant CAI among HIV-positive MSM was only evident when they felt that prevention was the responsibility of HIV-positive men. That is, significantly decreased CAI was not reported when HIV-positive men felt that HIV-negative men had or shared responsibility. Taken together, these findings suggest the effectiveness of supporting HIV-positive men's altruism and social responsibility for preventing transmission.7–10
Prevention responsibility beliefs, however, did not always correspond with discussing HIV status with sexual partners or refraining from serodiscordant CAI. Men who agreed more strongly that HIV-positive men should discuss their status before sex with new partners were significantly more likely to report discussing HIV status with their partner, whereas the other 4 beliefs were not consistently associated with serostatus discussion. Further research is needed to examine discrepancies between individuals' HIV prevention responsibility beliefs and their sexual behaviors, particularly in the preexposure prophylaxis (PrEP) era.
The concepts of “others” and “shared” responsibility have been noted in qualitative studies.9,10 One study defining 4 categories of personal responsibility that found men in the “self” category (high personal/low partner responsibility) reported the lowest levels of risk behaviors, whereas men in the “others” category (low personal/high partner responsibility) exhibited the highest levels.4 Men who accept personal responsibility for preventing HIV may be more willing to adopt risk reduction strategies. We acknowledge that thinking on personal responsibility is controversial in the field, particularly in a context of structural factors, inequalities, and disparities among the populations most affected by HIV. We refer the readers to Siconolfi et al.11 for alternate views on the subject.
A major limitation of our study is that it was conducted during a time when antiretrovirals were increasingly seen as a means to prevent onward transmission (“treatment as prevention”) but before the wide use of PrEP. We hypothesize that PrEP will enable HIV-negative persons to assume more responsibility for HIV prevention and may be reflected in prevention beliefs in current and future studies. Our findings may also be limited by social desirability of reporting higher personal responsibility and lower risk behavior. Our findings also may not be generalizable, because there may be greater knowledge about HIV prevention, less HIV stigma, more visible HIV-positive individuals, high levels of treatment, and higher levels of HIV status discussion in San Francisco compared with MSM elsewhere.
Because treatment as prevention and PrEP have been shown to be effective in reducing HIV transmission risk, these biobehavioral interventions are likely to impact individuals' perspectives on prevention responsibility.12–17 Although PrEP may encourage some HIV-negative individuals to accept greater personal responsibility in preventing HIV acquisition, some HIV-positive persons may transfer more responsibility to HIV-negative partners. However, the assumption that a partner is using PrEP may not be accurate. Likewise, increased effectiveness of antiretroviral treatment may lead some HIV-positive persons to accept greater personal responsibility to reduce transmission risk by adhering to their regimen to attain viral suppression. However, some HIV-negative individuals may transfer more responsibility to HIV-positive partners under the assumption that the partner is virally suppressed, which may not be accurate. With wider scale-up of early treatment and PrEP, it is important to evaluate the impact of these recent biobehavioral interventions on HIV prevention responsibility beliefs and subsequent sexual behavior. Our findings of correlations of responsibility with increased odds of preventive behavior indicate that HIV-positive and HIV-negative MSM can be supported in these beliefs to maximize prevention efforts even in the current era. Efforts to stem the HIV epidemic may be greatly advanced if HIV-negative and HIV-positive individuals both assume greater personal prevention responsibility by maximizing HIV combination prevention options such as condoms, PrEP, and treatment.
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