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AIDS Care
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HIV risk and communication between regular partners in a cohort of HIVnegative gay men G. Prestagea; L. Maoa; D. McGuiganb; J. Crawforda; S. Kippaxa; J. Kaldora; A. E. Grulicha a University of New South Wales, Sydney, Australia b AIDS Council of New South Wales, Sydney, Australia
To cite this Article Prestage, G. , Mao, L. , McGuigan, D. , Crawford, J. , Kippax, S. , Kaldor, J. and Grulich, A. E.(2006)
'HIV risk and communication between regular partners in a cohort of HIV-negative gay men', AIDS Care, 18: 2, 166 — 172 To link to this Article: DOI: 10.1080/09540120500358951 URL: http://dx.doi.org/10.1080/09540120500358951
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AIDS Care, February 2006; 18(2): 166 /172
HIV risk and communication between regular partners in a cohort of HIV-negative gay men
G. PRESTAGE1, L. MAO1, D. MCGUIGAN2, J. CRAWFORD1, S. KIPPAX1, J. KALDOR1, & A. E. GRULICH1 University of New South Wales, Sydney, Australia, and 2AIDS Council of New South Wales, Sydney, Australia
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Abstract This paper reports on the breaking of agreements between regular partners among HIV-negative gay men in Sydney. Data were from the 1333 men completing face-to-face interviews through December 2003 for the Health in Men (HIM) open cohort of HIV-negative gay men in Sydney. 822 men had a primary regular partner during the six month period before their 2003 interview. Most of these men had entered into agreements with their partners about sex either with each other or with other partners (87.2%). They most commonly agreed not to use condoms with each other (50.6%). Regarding casual sex, they most commonly agreed to always use condoms (34.2%) or to have no sex with men outside their relationships (28.6%). 48.8% reported some discomfort discussing with their partner their sex outside the relationship. Among those with agreements with their partners, 27.7% reported ever breaking those agreements. Those who found it more difficult to discuss issues of HIV serostatus and sexuality were more likely to report having broken their agreements (p B/.001; p /.021 at one-year follow-up) and were more likely to have engaged in unprotected anal intercourse with casual partners (p B/.001). A third of those men who broke their agreements did not inform their partner. A substantial proportion of gay men with agreements with their regular partners report some discomfort discussing sexuality and HIV serostatus with their partners. Difficulty discussing these issues may place these men at increased risk of breaking their agreements and may place both themselves and their partners at increased risk of infection.
Introduction Rates of unprotected anal intercourse (UAI) among gay men have increased significantly in recent years in Sydney (Van de Ven et al., 1998; 2000a; 2002a) and internationally (Dodds et al., 2000; Dukers et al., 2001; Chen et al., 2002). Such increases do not always mean increases in HIV risk behaviour (Van de Ven et al., 2002b). Many gay men have adopted various strategies to reduce the risk of HIV transmission, some of which rely on having some familiarity with their sex partners and assumed knowledge of HIV serostatus (Van de Ven et al., 2002b; Prestage et al., 2001). Any evidence of changes in UAI between regular partners needs to be considered in the context of the concept of ‘negotiated safety’ (Van de Ven et al., 1999; Davidovich et al., 2000; Crawford et al., 2001; Kippax et al., 1993; Kippax et al., 1997). While the appropriate definition for negotiated safety agreements has not always been agreed upon (Kippax et al., 1997; Ekstrand et al., 1993; Crawford et al., 2001), it is generally accepted that UAI between regular partners conforms to negotiated safety if both partners have tested HIV-negative
(with some guidelines about appropriate time frames for testing) and they are either both monogamous or have agreed to have only safe sex outside their relationship. In this paper we examine how negotiations around agreements between regular partners are managed. We explore how well those agreements were maintained, what were the consequences when agreements were broken; and what factors were associated with breaking those agreements during the same six month period prior to interview, and during the six month period prior to their subsequent interview one year later. Methods Participants and procedure Health in Men (HIM) is an open cohort of HIVnegative gay men in Sydney (Prestage et al., 2005). The non-random convenience sample of men was recruited into the study from diverse gay community based sources, such as (in descending order of frequency): gay community events (53.7%); word-
Correspondence: G. Prestage, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney NSW 2052, Australia. Tel: /61 2 9385 0900. Fax: /61 2 9385 0920. E-mail:
[email protected] ISSN 0954-0121 print/ISSN 1360-0451 online # 2006 Taylor & Francis DOI: 10.1080/09540120500358951
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Communication and agreements of-mouth (13.4%); other studies (7.0%); gay venues (6.3%); gay and AIDS organizations (5.2%); the internet (4.1%); general practice clinics (3.7%); and gay press (2.9%). The remaining 3.7% were recruited from miscellaneous sources. A total of 1333 men were interviewed by the end of 2003. Interview data from the 1179 men interviewed during 2003 and the 948 men re-interviewed during 2004 were included in this analysis. The men who were lost to follow-up were slightly younger than those who completed a follow up interview (mean ages 34 years old vs 37 years old, respectively, p /.001); less likely to have completed a university degree (42.2% vs 54.4%, respectively, p /.006) and less likely to have a managerial/professional occupation (50.0% vs 59.7%, respectively, p /.026). There was little else to distinguish between them. Also, other than a smaller proportion of men interviewed for the first time in 2003 having completed a university degree (50.0% in 2003 recruits vs 52.2% in 2002 recruits vs 59.3% in 2001 recruits, p /.045), there was little difference between the men interviewed for the first time in 2003 and those returning for a follow-up interview. The Human Research Ethics Committee of the University of New South Wales approved the research and each participant gave written consent. Questionnaire The interview schedule was based largely on items used successfully in earlier studies of Australian homosexual men. Questions about demographics, sexuality and identity, involvement in the gay community, sexual relationships and sex practices with men (‘in the previous six months’), and detailed questions about negotiation and maintenance of sexual agreements within regular partnerships were included. Measures Outcome variables. Men were asked questions about verbal agreements with their primary regular partners about sex and condom use inside and outside the relationship, and what happened if they had broken those agreements. Men were first categorized into any breach of agreements, by either partner, and no breach of agreements (to the best of the participants’ knowledge), and secondly into whether or not those who had broken their agreements had subsequently discussed these breaches with their partner. Measure of perceived efficacy in communication with primary regular partner. Participants were asked about their perceived comfort and confidence in communicating with their primary regular partners
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about sex and HIV status: a) comfort discussing sex with each other; b) comfort discussing with each other the sex they had with other men; c) confidence in knowing their regular partner’s HIV serostatus; and d) confidence that their partner would inform them if he broke their agreements. Responses for each item ranged from ‘completely’ (4) to ‘not at all’ (0). These four items formed a single scale: ‘Perceived Efficacy in Communication with the Primary Regular Partner’ (PEC) (Alpha /0.69). A summary score was calculated (Mean /12.2; SD /3.11) with higher scores indicating higher perceived efficacy. Other markers of the relationship. We also asked about: Disclosure of HIV status between regular partners; length of relationship; age differences between partners; whether they were living together at the time of interview; and whether they had a monogamous or open relationship. Other independent variables. Three key demographic variables / age, education and occupation / were included. Year of recruitment (i.e., those recruited in 2001 or 2002 and followed up in 2003 or those recruited and interviewed in 2003) was controlled for. Gay community attachment (GCA) was identified as a key factor regarding sexual risk behaviour among gay men and was regarded as contributing to a ‘safe sex culture’ in Sydney in the early 1990s (Connell et al., 1990). Here, we used an established surrogate scale to measure GCA in general (Van de Ven et al., 1997b; 2000b), which we have called the ‘Gay Social Engagement’ scale. It included two items: proportion of gay friends and proportion of free time spent with gay men (Alpha /0.67). A summary score was calculated (Mean /5.19; SD / 1.15) with higher scores indicating stronger attachment. To assess participants’ awareness of and proximity to the HIV epidemic, self-rated likelihood of HIV infection and a summary scale measuring their personal contact with people living with HIV/AIDS were included. A summary scale measuring ‘Attitudes toward Condom Use’ and the six-item ‘NonSpecific Distress Battery’ scale (Dickey & Blumberg, 2002) were also included. Alcohol consumption was assessed according to measures developed by the National Heart Foundation of Australia (Risk Factor Prevalence Study Management Committee, 1990). A ‘General Drug Use’ scale was calculated on the basis of the eleven most commonly used illicit drugs. Frequency of drug use was coded from ‘never’(0) to ‘everyday’ (5). A mean score was calculated (mean /0.54, SD /0.45) with higher scores indicating more frequent drug use.
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Data analysis
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Data were first analysed using descriptive statistics. The focus was contents and contexts of any agreement made with primary regular partners regarding sex within and outside of the relationship. Chisquare and t-tests were conducted to examine the univariate association between factors and any breach of agreements. Multiple logistic regressions were conducted to examine independent associations with any breach of agreements, and with disclosure of such breaches, both during the six months prior to interview and longitudinally, to examine whether the same associations found in 2003 could also be found prospectively for 2004. Results The following analyses were based on the 822 men (69.7%) who reported having a primary regular partner in the six months prior to their 2003 interview. Their age ranged from 19 to 69 years old with a mean of 37 years old. They were mostly born in Australia (573, 69.7%) and predominantly of AngloAustralian background (618, 75.2%). A majority had at least attended university (457, 55.6%) and were in professional/managerial occupations (515, 62.7%). Consistent with the recruitment strategies, a large proportion had extensive gay community social networks: 554 men (67.4%) indicated that ‘most’ or ‘all’ of their friends were gay men and 586 (71.3%) spent ‘a lot’ of their free time with gay men. The men’s relationships ranged from less than six months’ duration (25.7%) to over five years (19.7%). Among these 822 men, 195 (23.7%) reported no sex with casual male partners in the same six months period, although 266 (32.4%) described their relationship as being currently monogamous. The majority of these relationships described as being monogamous were of at least six months duration (192, 72.2%).
About two thirds of the 822 men (556, 67.6%) did not always use condoms for anal intercourse with their primary regular partner, with a third (184, 33.1%) abandoning condoms within the first month of the relationship. 717 men (87.2%) reported clear verbal agreements with their primary regular partners about the sex within and/or outside their relationships. 64.6% made agreements for sex both inside and outside the relationship; 8.0% made agreements only for sex inside the relationship, and 14.6% only for sex outside the relationship; 12.8% made no agreements. The most common agreement about sex within the relationship permitted unprotected anal intercourse (UAI), whereas the most common agreements about sex outside their relationships required either no sex with other men at all or that any anal intercourse with other partners must be with a condom (Table I). Permitting UAI within the relationship was closely correlated with not permitting UAI, or indeed any sex at all, with casual partners. Among the 717 men who had any agreement with their partner, Table II indicates participants’ perceived efficacy in communication with their primary regular partner (PEC) about sex and HIV status. In terms of knowledge of regular partners’ HIV status, most men were ‘very’ or ‘completely’ confident. Regarding the actual rate of HIV status disclosure within regular relationships, 623 men (86.9%) had both told and been told by their primary regular partners about HIV status. Similarly, most felt ‘very’ or ‘completely’ at ease discussing sex within their relationships or were ‘very’ or ‘completely’ confident that their partners would inform if there of any breach of agreements. Close to half, however, were uneasy discussing with their regular partners the sex they had with other men. Being ‘completely’ or ‘very’ confident in knowing the partner’s HIV status, and being ‘completely’ or
Table I. Types of agreements with the primary regular partner (n /822). For sex within relationship
For sex outside of relationship No agreement No sex No anal intercourse All anal intercourse must be with condoms Anal intercourse can be without condoms Other Subtotal
No agreement 105 36 10 19 0
(12.8%) (4.4%) (1.2%) (2.3%)
No sex
All anal No anal intercourse must intercourse be with condoms
1 (0.1%) 12 (1.5%) 0 5 (0.6%) 0 2 (0.2%) 0 4 (0.5%) 0
0
1 (0.1%) 1 (0.1%) 2 (0.2%) 171 (20.8%) 2 (0.2%) 25 (3.0%)
66 49 6 74
(8.0%) (6.0%) (0.7%) (9.0%)
0 6 (0.7%) 201 (24.4%)
Anal intercourse can be without condoms 39 142 36 182
(4.7%) (17.3%) (4.4%) (22.1%)
5 (0.6%) 12 (1.4%) 416 (50.6%)
Note: Includes only those 822 men with a current regular partner. Cell percentages are of total sample.
Other
Subtotal
2 (0.2%) 225 (27.4%) 3 (0.4%) 235 (28.6%) 0 54 (6.6%) 2 (0.2%) 281 (34.2%) 0
5 (0.6%)
0 22 (2.6%) 7 (0.9%) 822 (100%)
Communication and agreements
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Table II. The scale of perceived efficacy in communication with the primary regular partner.
My partner and I find it easy to talk about sex we have with each other My partner and I find it easy to talk about sex we have/do not have with other men I am confident that I know my regular partner’s HIV status I am confident that my regular partner will tell me if he breaks our agreement
Not very
Not at all
Unsure/ No response
TOTAL
97 (13.5%) 47 (6.6%)
8 (1.1%)
2 (0.3%)
717 (100.0%)
10 (1.4%)
717 (100.0%)
28 (3.9%)
3 (0.4%)
717 (100.0%)
24 (3.3%)
40 (5.6%)
717 (100.0%)
Completely
Very
Somewhat
335 (46.7%)
228 (31.8%)
190 (26.5%)
168 (23.4%)
427 (59.6%)
189 (26.4%)
58 (8.1%)
12 (1.7%)
341 (47.6%)
209 (29.1%)
86 (12.0%) 17 (2.4%)
161 (22.5%) 75 (10.5%) 113 (15.8%)
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Note: Items are not mutually exclusive. Includes only those men with an agreement with their primary regular partner.
‘very’ confident that the partner would disclose any breach of agreements were both significantly associated with a being in a relationship of longer duration. Among the 717 men who had agreements about sex (either inside or outside the relationship) with their primary regular partner, 697 men reported whether these agreements had been broken. Over a quarter (193, 27.7%) reported any breach of agreements, by either partner, although the specific nature of this breach was not identified. Among these 193 men who reported at least one breach, by either partner, 115 men (59.6%) had broken their agreements themselves, 59 men (30.6%) reported that both partners had broken their agreements, and 19 men (9.8%) reported that only their partner had broken their agreements. These breaches in their agreements may have included, but were not restricted to, condom use. These 193 men who reported a breach in their agreements were compared with the other 504 men who had not breached their agreements. Participants who reported any breach of agreements also reported a higher percentage of having any casual partners in the six months prior to interview (84.5% versus 65.3%, p B/.001), and a higher percentage of UAI with casual partners (41.5% versus 14.9%, p B/ .001), both of which may have been the reported breach in agreements. Based on both the univariate and the multivariate analyses, any breach of agreements by either partner
was associated with the participants: being better educated (p /.015), having a longer relationship (p B/.001), sensing a greater likelihood of HIV infection (p /.001), reporting lower PEC (p B/.001), and using more drugs (p /.001) in the six months prior to interview (Table III). Holding unfavourable attitudes toward condom use was associated with any breach of agreements only at the univariate level (p /.017). Age, occupation, social engagement with gay community, contact with people living with HIV/AIDS, reported level of distress in the four weeks prior to interview, estimated alcohol risk, use of sex-on-premises venues, self-description as ‘sexually adventurous’ and year of recruitment, along with age differences between the participants and their primary regular partner, cohabitation or not, and mutual disclosure of HIV status within the relationship, were not significant in either the univariate or multivariate analyses. After controlling for other factors, we tested for interactions between the PEC scale and participants’ age as well as between the PEC scale and length of the regular relationship. Neither of these was significant in the logistic model. Of the 193 men who reported any known breach of agreements by either partner, over a third (71, 36.8%) had never informed each other of such breach. Fewer than half (88, 45.6%) reported any impact on the relationship (e.g. negotiation of a new
Table III. Final multivariate logistic model: factors significantly associated with any breach (193 men) versus no breach (504 men) of agreements by either partner within regular relationships among men who reported having such agreements (n /697). Adjusted Odds Ratio 95% Confidence Interval p -value Participant completed a university degree (versus others) Longer relationship with the primary regular partner Participant self-rated more likely to get HIV infection Perceived higher efficacy in communication with the primary regular partner Participant used more drugs in the six months prior to survey
1.58 1.48 1.61 0.82 2.02
1.09 /2.29 1.30 /1.68 1.26 /2.06 0.77 /0.87 1.35 /3.01
.015 B/.001 B/.001 B/.001 .001
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agreement, or reintroduction of condom use into the relationship) as a result of such a breach. Although a minority, these 71 men who, after any breach of agreements, had not disclosed this breach were compared with the 122 men who reported that either partner had ‘sometimes’ or ‘always’ informed each other after any breach. Participants’ reported PEC was the only significant factor in the final multivariate logistic model (Adjusted Odds Ratio / 0.73 with 95% Confidence Interval /0.65 /0.82, p B/.001), suggesting that participants’ lower efficacy in communication was associated with failing to inform each other after any breach of agreements. Among the 822 men who had a primary regular partner in 2003, 697 (84.8%) men were re-interviewed in 2004, among whom 432 (62.0%) had kept the same relationship throughout that twelve month period. We examined longitudinal data for these 432 men who had the same partner at both interviews. In 2003, 411 of these men (95.1%) had clear spoken agreements, with 290 men (70.6%) reporting that neither partner had breached any agreements in the six months prior to their 2003 interview. These 290 men formed the basis of the following longitudinal analyses. To the best of the respondents’ knowledge, within their ongoing relationships, from the time of their 2003 interview until they were reinterviewed in 2004, 224 men reported no breach of any agreement while 57 men reported some breach by either partner (9 men failed to answer these questions). The same set of variables tested for association with any breach of agreements with the same primary regular partner in 2003 were also applied to predict any breach of agreements in 2004. Participants’ PEC, as reported in 2003, was the only significant predictor of a breach of agreements in 2004 in the final multivariate logistic model (Table IV). Discussion These data support previous findings (Kippax et al., 1997; Davidovich et al., 2000; Crawford et al., 2003) that many gay men with a regular partner have some form of agreement about sex and condom use, both inside and outside, their relationship. Most gay men adhere to these agreements (Crawford et al., 2001). Nonetheless, such agreements are vulnerable to fail-
ure as are any other risk-reduction strategies (Davidovich et al., 2000; Kippax et al., 2003). The majority of respondents in this study adhered to their agreements, including negotiated safety. Nonetheless, some gay men appeared to disregard aspects of the negotiated safety guidelines, such as waiting up to three months after testing HIV-negative and then re-testing before discarding condoms. In Sydney, HIV testing is virtually universal among gay men, with in excess of 90% reporting they have been tested for HIV and about two thirds of those who have not tested HIV-positive having been tested within the previous twelve months (Van de Ven et al., 2000b; Jin et al., 2002). In this context, the assumed knowledge of HIV serostatus may influence some men to disregard aspects of these guidelines. For a minority of men, their agreements were not maintained. For many of these men, their capacity to discuss issues of HIV and sexuality with their partner was a key factor in whether they were able to keep their agreements, both at that time and during the following year, and whether they were able to inform their partners of this. Nonetheless, most men trusted their partners would inform them of any breach of their agreements, despite a third of respondents who had breached their agreements having not informed their partners of this themselves. Those men who found greater difficulty discussing these issues with their partners were also more likely to engage in risk behaviour with other men. Longitudinal analysis found that these difficulties in communication also predicted future likelihood of breaking their agreements. Poorer communication between partners had long-term consequences for these men and their relationships, regardless of the initial reason for the difficulty discussing these issues. Men who reported UAI with casual partners have also been found to be more likely to have disclosed their HIV serostatus to their casual partners (Prestage et al., 2001, 2005), which suggests that some men may be negotiating around HIV status and condom use with casual partners, despite such negotiations falling well outside the context of ‘negotiated safety’ and carrying with them increased risk of HIV infection. In this analysis, difficulty communicating about sex with casual partners, or about HIV serostatus, within a regular partnership, appears to place some men and their regular partners at further risk of infection.
Table IV. Final multivariate logistic model: factors significantly associated with any breach one year later (57 men) versus no breach (224 men) of agreements by either partner within regular relationships among men who reported having such agreements with same regular partner between 2003 and 2004 (n /281). Adjusted Odds Ratio 95% Confidence Interval p -value Perceived higher efficacy in communication with the primary regular partner
0.87
0.78 /0.98
.021
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Communication and agreements Illicit drug use has been previously associated with risk behaviour among gay men (Colfax et al., 2004; Strathdee et al., 1998; Woody et al., 1999). In this analysis we found an association between breaches in agreements between regular partners and illicit drug use in the previous six months. We cannot, however, determine from the data whether such use occurred on those occasions when the men broke their agreements. We have previously found that while illicit drug use was associated with risk behaviour in general, it was not a factor in the use of condoms during the respondents’ most recent sexual encounters (Prestage et al., 2005). Dowsett et al. (2005) argue that drug use is one aspect of the relationality of aspects of gay community for some gay men. It appears to play a particular role in the lives of sexually adventurous men (Smith et al., 2004), among whom risk behaviour is increased (Kippax et al., 1998; Crawford et al., 2003). The association between illicit drug use and breaches in agreements found here may have as much to do with the characteristics of the men themselves and the cultural contexts in which they enact their sexualities, as with the particular effects of those drugs on the specific occasions concerned. In this study, being in longer-term relationships was a predictor of men breaking their agreements, yet, previously, men in short-term relationships were found to be at greater risk of HIV infection (Kippax et al., 2003). It may be, however, that some of this was due to the sex that occurred, and the failure to adequately determine and disclose HIV serostatus, within the relationship, rather than the breakdown of an agreement regarding sex with other partners. In this analysis, men were only included if they had an agreement with their regular partner, and it may well be that where such agreements have been made, they are likely to be more easily maintained in the short term than the long term, without constant attention. Without revisiting these agreements and reinforcing them over time they may be more vulnerable to being broken, particularly in the context of increasingly complex methods of risk reduction that would presumably require detailed discussion between partners to ensure that their agreements adequately reflect the men’s beliefs about relative risk. Regardless of these beliefs and the complexities of their risk-reduction strategies, the men who broke their agreements were more likely to believe they were at risk of HIV infection. Presumably, then, they understood that their actions carried some risk. These men also felt less able to communicate with their partners about sex and HIV, and it was this capacity alone which predicted their likelihood to disclose to their partner their breach of their agreements. Although gay men in longer-term relationships may be negotiating a complex set of
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arrangements to minimize their risk of infection, the inability to effectively communicate with their partner could eventually place them, and their partners, at increased risk. These findings have direct implications for educational practice when developing HIV prevention programmes for gay men in a relationship or gay men seeking a relationship. The fact that one third of men discarded condoms within one month of their relationship highlights the need to provide information to gay men either before they enter a relationship or as early as possible once the relationship has begun. These data also demonstrate that educational interventions addressing this issue need to also address effective communication skills. Developing communication skills to discuss sex openly and honestly, particularly when discussing sex with other partners, will enable gay men to discuss breaches in the relationship agreement and to renegotiate that agreement over time if one or both partner’s needs change. Negotiated safety and other forms of agreement between regular partners can be maintained within relationships where communication between both partners is well-established and open. These data indicate that the maintenance of ongoing open and honest communication needs stronger reinforcement in the consideration of negotiated safety as a riskreduction strategy.
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