mental health AIDS

Winter 2005 Newsletter / Volume 6, Issue 2

HIV Prevention News

About Men Who Have Sex with Men

In asking 97 men who have sex with men (MSM) in New York City about their continuing HIV-negative status, Halkitis, Zade, Shrem, and Marmor (2004) found an association between three nonseroconversion beliefs – "beliefs about a strong immune system preventing seroconversion, beliefs about treatment advances reducing the possibility of seroconversion, and beliefs that becoming infected with HIV is a low probability occurrence" (p. 455) – and an increased likelihood of receptive unprotected anal intercourse (UAI) with casual partners who were HIV-negative or of unknown status. Because UAI with partners of unknown status represents an unacknowledged risk among some HIV-negative MSM, Halkitis and colleagues encourage clinicians to "address ... false resistance related cognitions, including the perception ... that treatment advances in and of themselves can protect against HIV infection" (p. 457) when they explore antecedents of risky sexual behavior.

What about risky sexual behavior in gay couples? Theodore, Durán, Antoni, and Fernandez (2004) examined the relationship between emotional intimacy and UAI with a primary partner in a sample of 78 MSM living with HIV. They found that, while seroconcordant partners were more likely to engage in UAI than serodiscordant partners, emotional intimacy (i.e., trust, closeness, open communication) between primary partners was associated with decreases in sexual risk within seroconcordant relationships as well as increases in sexual risk within serodiscordant relationships. "Symbolically, men in serodiscordant relationships may try to prove their love by trusting each other with their lives. [UAI] between serodiscordant partners can represent the most intimate expression of love" (p. 329), particularly when the HIV-positive partner is also the insertive partner.

Importantly, "while intimacy may motivate risky sex among serodiscordant partners and protect against risky sex among seroconcordant positive partners, it will only do so under conditions of minimal drug use prior to sex" (p. 330). Although a minority of study participants (41%) reported drug use (with ecstasy, amyl nitrate [poppers], and gamma-hydroxybutyrate [GHB] being the drugs of choice) prior to intercourse, the authors observed that drug use appears to weaken the impact of emotional intimacy on sexual decisions made by both seroconcordant and serodiscordant couples. Thus,

[a]mong seroconcordant positive partners, the ability of emotional intimacy to raise health concerns and strengthen stamina against the physical temptation not to use condoms may be weakened by the intense physical euphoria engendered by ingestion of such drugs. Among serodiscordant positive partners, the greater need to receive and sustain heightened intimacy through [UAI] may also be offset by the physical euphoria and cognitive disinhibition that accompanies such drug use. Regardless of couple serostatus or level of intimacy, drug use has a powerful influence that weakens the influence of emotional intimacy on sexual decision-making. (p. 330)

Even as the authors note that "factors beyond intimacy, drug use, and couple serostatus influence sexual decision-making among HIV-positive MSM in primary relationships" (p. 330), they contend that clinicians should incorporate relationship factors into interventions and "work ... to create a new paradigm equating intimacy with a desire to preserve and protect one's partner's health" (p. 330).

Kalichman, Gore-Felton, Benotsch, Cage, and Rompa (2004) surveyed a convenience sample of 647 MSM attending a major gay pride event. They found that men who reported a history of childhood sexual abuse, in comparison with those who did not, were more likely to engage in receptive UAI; trade sex for drugs or money; use tobacco products, crack cocaine, and/or methamphetamine; experience relationship violence in adulthood; and self-identify as HIV-positive. These men also experienced more borderline personality symptoms. Kalichman and colleagues observe that

[o]ne important residual effect of childhood sexual abuse ... may be difficulties ... in interpersonal relationships as suggested by borderline personality symptoms. ... [B]orderline ... symptoms may result in these men experiencing difficulty with interpersonal boundaries, impulsivity, and distorted social perceptions. ... [Importantly, a]lthough borderline personality symptoms were related to child sexual abuse history [in this study, the authors] did not find that borderline symptoms were associated with high-risk sexual behavior after controlling for substance use and childhood sexual abuse. (p. 12)

With regard to HIV risk reduction interventions for MSM who report a history of childhood sexual abuse, the authors recommend that interventions should "address the long-term effects of ... abuse on social perceptions, sexual decisions, and sexual relationships. ... [I]nterventions delivered at the individual level through counseling and small group workshops offer opportunities for addressing issues of mental health and emotional adjustment that can impede individual choices for self-protective actions" (pp. 12-13).

Utilizing audio computer-assisted self-interviewing (ACASI) questionnaires with 387 drug-using MSM who were largely African-American, Newman, Rhodes, and Weiss (2004) found that sex trading was associated with use of crack cocaine, use of injection drugs, childhood maltreatment, not self-identifying as gay, and homelessness. In considering these risk factors, the authors observe that

the majority of HIV prevention programs, which rely on social-cognitive, individual, or small-group models, may be inadequate for addressing high-risk behaviors among MSM who trade sex. Interventions for MSM who trade sex may need to target drug dependence and economic hardship to prevent HIV infection risk behaviors. In addition, programs that are overtly identified as gay (e.g., housed in gay service organizations) may be unlikely to reach the high proportion of MSM who trade sex but do not self-identify as gay. Our largely African American sample of MSM also suggests that we may need to overcome the frequent stereotypification of high-risk, drug-using MSM as European American methamphetamine users to facilitate innovations in targeting HIV prevention interventions for men who engage in sex trading. (p. 2002)

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