Continuing this focus on feelings of responsibility, Wolitski, Flores, O'Leary, Bimbi, and Gómez (2007) assessed beliefs about responsibility for preventing the transmission of HIV to others among a convenience sample of 1,163 MSM living with HIV in New York City and San Francisco. Fifty-five percent of those participating in the study were men of color. The study tested
[a] two-dimensional model that represents four orientations toward responsibility ...: (1) self – high personal and low partner responsibility, (2) other – low personal and high partner responsibility, (3) shared – high personal and high partner responsibility, and (4) diminished – low personal and low partner responsibility. As predicted, the self-responsibility group demonstrated the lowest risk of HIV transmission; the other responsibility group had the highest risk. Intermediate risk was observed in the shared and diminished responsibility groups. (p. 676)
Wolitski and colleagues found that
mean personal responsibility scores were generally high, indicating that most HIV-seropositive MSM in this sample believed that they have a special responsibility to protect their partners from HIV infection. ... [Conversely, s]cores on the partner responsibility scale were significantly lower than personal responsibility scores, indicating less support for the idea that HIV-seronegative partners bear primary responsibility for preventing HIV transmission. ...
… Personal and partner responsibility appeared to interact with each other such that partner responsibility exerted little influence when personal responsibility was high …, but was associated with transmission risk when personal responsibility was low … . This pattern of findings suggests that personal responsibility would be an especially important target for prevention programs for MSM living with HIV.
... People living with HIV who would be classified in the other responsibility group may be especially important targets for HIV prevention efforts. Given that some HIV-seronegative MSM assume that HIV-seropositive MSM would act to protect their partners and would disclose their HIV status if they knew they were infected ..., helping HIV-seropositive MSM develop greater understanding [of] and empathy for the perspective of uninfected men may be a useful strategy to explore. (pp. 683-684)
Wolitski and colleagues emphasize that these findings
do not support the perspective that responsibility should be treated as equally shared between HIV-seropositive and HIV-seronegative persons. Persons in the shared responsibility group were significantly more likely to report URAI [unprotected receptive anal intercourse] than were men in the self-responsibility group. This same pattern was observed for UIAI [unprotected insertive anal intercourse] and UIOI [unprotected insertive oral intercourse], but the differences were not statistically significant. These results suggest that prevention programs should encourage HIV-seropositive persons to always view themselves as personally responsible for protecting their partners from HIV. A norm of universally caring for and protecting partners (regardless of whether they are primary or casual partners or are perceived as being aware of the consequences of their actions) should be promoted.
Such a perspective does not negate the responsibility of HIV-seronegative persons for protecting themselves. ... The promotion of a self-orientation toward responsibility among HIV-seropositive and HIV-seronegative persons may be the optimal approach for preventing the further spread of HIV. (p. 684)
Of course, it remains to be determined "whether attributions about responsibility can be changed by behavioral interventions and how norms supporting personal responsibility can best be promoted among HIV-seropositive and HIV-seronegative persons ... . Ultimately, the success of HIV prevention efforts will likely depend upon the ability of prevention programs to empower HIV-seropositive and HIV-seronegative people to take action to protect themselves and others from HIV" (p. 685).
In Australia, Jin et al. (2007) interviewed 158 gay men recently diagnosed with primary HIV infection and found that "143 (91%) were able to identify the high-risk event that they believed led to their HIV seroconversion, and this involved UAI in 102 [cases] (71%). Among these 102 men, 21 (21%) reported they were certain that the source partner was HIV-negative. Ten men (10%) reported insertive UAI as the[ir] highest risk behavior. Of the 21 men who reported knowing the HIV-positive partner's viral load, 9 reported that the man had an undetectable viral load (43%)" (p. 245). According to Jin and colleagues, these data
demonstrate that UAI in the context of risk reduction strategies2 is implicated in a substantial proportion of HIV infections in homosexual men. Knowledge of the partner's serostatus was central in the occurrence of UAI. Approximately 1 in 5 HIV seroconverters in ... [this] study wrongly perceived that the source person was HIV-negative, despite the high level of HIV testing in this setting. ... It remains possible that some of these behavioral risk reduction strategies [i.e., serosorting, strategic positioning, UAI with a partner whose viral load was believed to be undetectable] might be effective on a population level. That depends on the degree to which these behaviors replace higher risk UAI behaviors, or replace "safe[r] sex" behaviors. ... [These] data demonstrate that, not infrequently, risk reduction strategies seem to fail to prevent HIV infection on an individual level. This finding should be communicated to the populations of gay men who might see these risk reduction strategies as an alternative to the more effective strategy of consistent condom use. (p. 247)
Parsons, Kelly, Bimbi, Muench, and Morenstern (2007) interviewed a diverse sample 180 gay and bisexual men "who self-identified that their sex lives were spinning out of control" (p. 5) for the purpose of examining social triggers of sexually compulsive behavior. "Two types of social triggers emerged from the data: event-centered triggers and contextual triggers. Event-centered triggers arise from sudden, unforeseen events. Two major event-centered triggers were identified: relationship turmoil and catastrophes [ranging from personal calamities to community/national tragedies]. Contextual triggers, on the other hand, have a certain element of predictability, and included such things as location, people, the use of drugs, and pornography" (p. 5).
Parsons and colleagues observe that "[c]linicians can utilize the framework of social triggers in the therapeutic process to provide insight into ways to effectively work through symptoms of sexual compulsivity. Awareness of the contextual aspects of sexual compulsivity may be critical to understanding the behaviors of sexually compulsive clients. Thus, therapeutic assessments should focus upon the social context in addition to the psychological components of the disorder" (pp. 5-6). More specifically, the investigators
suggest working with a "top-down" approach to identify the key social triggers of sexual compulsivity in a client's life. The clinician may decipher the "worst" triggers in the individual's life and work towards identifying the least problematic triggers using techniques such as a functional analysis for each trigger. This process enables the individualization of treatment and tailors efforts to modify interactions. Once a client's triggers are identified, the next step ... is to come up with an effective means to discuss these triggers and identify how to eliminate the elements of them that lead the client to sexually compulsive behavior. The "worst" triggers should be dealt with first so that a foundation may be laid to contend with less severe triggers as the client manages the more severe ones. (p. 14)
Parsons and colleagues recommend different clinical approaches for each category of triggers. For event-centered triggers, the investigators encourage clinicians to focus on issues that inhibit the formation of healthy sexual outlets; these may include depressive symptomatology and poor stress management skills. Additionally,
[c]linicians should encourage clients to seek out treatment when event-centered triggers first arise such that they may be dealt with prior to the occurrence of compulsive sexual behaviors. Because event[-]level triggers are unpredictable, teaching clients to anticipate feelings that arise during time[s] of turmoil or uncertainty and learn to cope with them can be quite helpful. Additionally, ... [promoting the development of] "surfing skills" ... to ride out a craving during these times may be particularly useful because ... [cravings] appear to be primarily a result of an affective reaction to an external situation.
... Since contextual triggers are rooted primarily in social encounters, it can be more difficult for clinicians to intervene directly than with the triggers rooted in stress and depression treatable through traditional clinical approaches. However, in such instances, clinicians may be inclined to use motivational interviewing or [CBTs] to enable the client to deal with such triggers. Clinicians may aid the client in identifying behaviors and uncover[ing] potential ways to work/cope through them. Clients and clinicians should work together on the identification of contextual triggers such as drug and alcohol abuse, visits to places that cater to sexual encounters (backrooms, bars, steam rooms, etc.), former lovers or friends who provoke the behavior, or places that are common to sexual behavior. Upon the identification of these triggers, counter conditioning or stimulus control strategies may be devised as a way of reducing or eliminating contact with these triggers so as to reduce or eliminate the compulsive sexual behavior. (pp. 14-15)
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Winter 2008 Newsletter / Volume 9, Issue 2
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