Sexual Agreements and HIV Risk: The Gay Couples Study

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Sexual Agreements and HIV Risk The Gay Couples
Study

• April 21, 2006
• 5th CAPS HIV Prevention Conference

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Objectives

• Identify relationship factors associated with
  sexual risk-taking among gay male couples.
• Explore how couple sero-status impacts risk and
  relationship quality.

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Background

• Why conduct this study?
• High rates of sero-conversion among gay male
  couples.
• 50 of gay male couples have open relationships.
• Most prevention efforts focus on individuals.
• Transformation of Motivation Theory suggests
  partners may not always act in their own best
  interests.
• Negotiated Safety good or bad?

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Design

• Phase 1 Qualitative
• 38 couples interviewed. From the rich data,
  various themes emerged and were integrated into a
  unique questionnaire or survey.
• Phase 2 Pilot
• 200 couples interviewed using this survey.
  Reasoning Pilot the survey to test its
  validity and reliability.

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Design

• Phase 3 Cross-Sectional
• 450 couples interviewed using the validated and
  reliable survey. Reasoning Explore various
  issues and questions with a greater number of gay
  male couples.
• Phase 4 Longitudinal
• Interview an additional 200 couples to monitor
  how their relationships and agreements grow and
  change over time.

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Design

• Couples surveyed represent the diversity of Bay
  Area gay communities
• 1/2 men of color and 1/2 White men
• 1/3 sero-concordant negative, 1/3 sero-concordant
  positive, and 1/3 sero-discordant couples
• Couples in monogamous, polyamorous, and open
  relationships

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Agreement Types

• Agreements are commonly dichotomized into either
  open (polyamorous) or closed (monogamous).
• Our data show these terms anchor a spectrum of
  various types of gay male relationship
  agreements
• Classic monogamy
• Open for three-ways only
• Open with restrictions on who, when, where,
  and/or under what circumstances
• Outside sex is OK if it is safe
• Totally open

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Agreement Types

• Discrepancies
• Some couples described having different
  understandings of their agreements.
• Partner A Theres an assumed agreement that we
  are in a committed relationship Yeah, a
  committed and monogamous relationship. And its
  interesting that he didnt ask me exactly what I
  thought about it. I didnt have a way to express
  my own feelings about it. (2001, HIV-, Hispanic)
• Partner B Our agreement is monogamy. (2002,
  HIV-, White)
• Partner A I find it difficult to remain
  monogamous, especially when our sexual
  connection is not strong. When our sexual
  connection is not strong I tend to want to have
  another partner or even a one-night stand. Just
  having sex with someone, even if very brief I
  tend to want it or to desire it. (2001, HIV-,
  Hispanic)
• Partner B Its easy to keep my agreement.
  (2002, HIV-, White)

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Agreement Types

• Discrepancies
• Implications for prevention remain unclear,
  however, discrepancies may pose serious risks to
  emotional and physical health.

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Agreement Negotiation

• Agreement negotiation is a highly varied process
  Negotiation occurs at different times, for
  different reasons, for different people.
• Agreement negotiation may occur at anytime or
  anyplace Negotiation may be spontaneous.
• Agreement negotiation is a process Some may
  discuss it once while for others it is an
  on-going process.

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Agreement Negotiation

• Couple-based needs in agreement negotiation
• When a relationship begins
• When an agreement changes
• When an agreement breaks
• Individual-based needs in agreement negotiation
  may emerge and drive the negotiation process
• Sexual needs
• Emotional needs
• Health needs
• Practical needs

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Agreement Negotiation

• Explicit Implicit Agreements
• Explicit A verbal agreement about the ground
  rules or boundaries around outside sex.
• Implicit An understanding or assumption about
  the ground rules or boundaries around outside
  sex. Importantly, the rules may not be
  specifically defined and/or may have not been
  discussed at all.
• Couples may have different motivations for
  implicit and explicit agreements
• Explicit Individuals may want to protect their
  own emotional or physical well-being, that of
  their partner, or of their relationship.
• Implicit Talking about agreements may be
  difficult or threatening.

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Agreement Negotiation

• Assumptions about the agreement
• Safety
• Agreement type
• Details or definitions
• Assumptions can act as road blocks to agreement
  negotiation.
• Assumptions can pose emotional and physical risks.

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Assumptions

• Assumption Couples would be motivated by the
  need and desire to prevent HIV/STIs.
• Assumption Motivators will vary based on the
  sero-status of the couple.

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Motivations for Having Agreements

• Sero-concordant negative couples
• Relationship Factors
• Trust
• Emotional intimacy
• Prevention Factors
• Unprotected sex with each other
• safety with outside partners
• monogamy

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Motivations for Having Agreements

• Partner A And your level of trust with this
  person is so strong. And youre putting so much
  on the line Youre putting your health, your
  life on the line that theres a real sense of
  strength that comes to the relationship for doing
  it. When you do something like that. (1801,
  HIV-, White)
• Partner B So, like I say, it elevated it to a
  new level of trust because obviously we had to
  trust one another. If were going to be sexually
  active outside of the relationship we have to
  trust each other not to be bringing STIs into the
  relationship, or HIV, or endangering one another
  in any way. (1802, HIV-, White)

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Motivations for Having Agreements

• Sero-concordant positive couples
• Relationship Factors
• Makes the relationship stronger
• Know where they stand
• Prevention Factors
• To prevent illness
• Uncertainty about HIV re-infection
• Outside partner safety not a major concern

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Motivations for Having Agreements

• I feel whole and I just, its just a sense of
  belonging. And knowing that someone besides
  thats not your family loves you back
  unconditionally and its just I never had that
  feeling before never had that feeling before.
  Thats what I feel I got out of this relationship
  arrangement is just a wholeness and being loved,
  being loved. (5902, HIV, Black)

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Motivations for Having Agreements

• Sero-discordant couples
• Relationship Factors
• Safety with each other was one way to show how
  much they valued their relationship
• Prevention Factors
• Safety with each other was important to prevent
  HIV and other illnesses for the HIV-positive
  partner
• When engaged in behaviors that did not feel safe,
  most couples communicated and modified their
  agreements
• Focused on each other, not outside partners

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Motivations for Having Agreements

• Partner A Well, the agreement that weve had
  ever since I moved in with my partner back in
  the Fall of 81 was that we would have an open
  relationship. He said he wanted to have an open
  relationship so I honored it. (1301, HIV,
  White)
• Partner B After he found out he was positive,
  we talked about it and he expressed that he
  really wouldnt want to do anything that would
  put me at risk. And I think we both have
  different levels of what we consider risky
  behavior, mine being more conservative than his,
  but he was agreeable to go along with my feelings
  on what was safe and what was not safe. So we
  talked about it and weve got that agreement.
  (1302, HIV-, White)

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Motivations for Having Agreements

• General Motivators
• Agreements supported a non-hetero relationship
• Agreements encouraged sexual exploration and
  experimentation while staving off boredom and
  disinterest
• Agreements created an opportunity to trust
  partner in a deep and meaningful way

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Motivations for Having Agreements

• Main focus for most couples is to have a loving
  relationship.
• Agreements are deeply embedded in relationships.
• Disentangling prevention and relationship issues
  may be difficult but necessary.

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Agreement Change

• Agreements are not static.
• Relationships and needs change over time.
• Important to look at motivation for change.

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Reasons for Change

• Approximately 15 reported a change in the past
  12 months.
• Top reasons for changing the agreement
• Wanted to improve the relationship
• Changes in the relationship
• Differences in sex drive
• Sexual stagnation inside the relationship
• Broken agreements

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Process for Change

• Motivations for change can come from factors that
  are either internal or external to the
  relationship.
• Broken agreements

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Internal Factors

• Evolved naturally
• Take relationship to the next level (note used
  for becoming both monogamous and non-monogamous)
• Aging
• Psychological Issues (e.g., depression)

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External Factors

• Contracting an STI
• Sero-converting
• Busted
• Broken Agreements
• There is some evidence that motivations (e.g.,
  internal vs. external) can have an influence on
  the likelihood of breaking agreements.

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Broken Agreements Disclosure

• Broken agreements can occur within the
  relationship or outside of it.
• Following an agreement break, partners can choose
  to either disclose or not disclose it.
• Broken agreements can be difficult to disclose
• Lack of disclosure can lead to possible risk for
  the partner.
• Lack of disclosure can provide possible window
  for HIV infection.
• Broken agreements may be related to forbidden
  sexual behavior.

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Reasons for Breaking Agreements

• Most common reasons
• 93 I was horny.
• 89 The guy was really hot.
• 89 Someone wanted to have sex with me.
• 74 I didnt have to worry about becoming
  infected with HIV by my partner.
• 72 Most men who find themselves in the same
  situation would have broken their agreement
  too.
• 66 I felt emotionally distant from my
  partner.
• 65 I didnt have to worry about transmitting
  HIV to my primary partner.

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Broken Agreements Disclosure

• Approximately 30 broke agreements.
• 15 disclosed a broken agreement at least once.
• By agreement type
• 43 of monogamous couples
• 45 of non-monogamous couples
• 12 of ambiguous couples

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Broken Agreements Disclosure

• No differences between sero-status groups or
  agreement groups in number of times couples
  broken their agreements.
• No differences between sero-status groups or
  agreement groups in number of times partners
  disclosed broken agreements.

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Agreements Sexual Risk

• Agreement type and risk
• Negotiated safety literature says those who have
  an agreement report less risk than those who did
  not.
• More explicit agreements means less opportunity
  for risk.
• Monogamous couples had more explicit agreements.
• Discrepant agreements means potential for risk.
• Motivations for agreements are often the
  prevention of HIV/STI.
• Better compliance Less risk

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Agreements Sexual Risk

• Sero-status and risk behavior
• Sero-concordant negative couples reported less
  unprotected anal intercourse (UAI) with outside
  partners than sero-discordant or sero-concordant
  positive partners.

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How to Define Risk

• Most HIV prevention literature defines risk
  behavior for gay men as UAI.
• However, it is important to take sero-status and
  relationship status into account.

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Definitions Impact Outcome

• We constructed several outcome variables and
  examined our sample as 191 couples and 382
  individuals.
• When examining UAI with any sero-discordant
  partner (primary or outside), we found that 24
  of the entire sample reported this. By
  sero-status 8 of sero-concordant negatives, 19
  of sero-concordant positives, and 60 of
  sero-discordant couples reported this behavior.

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Dyadic Data Potential

• Dyadic analysis allows comparisons both between
  and within couples.
• Actor-partner analysis allows us to identify
  particular partner-dependent dynamics.

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Data Analysis Questions

• Is the relationship satisfaction of the
  HIV-positive partner responsible for the couples
  level of risk?
• Does it matter if one partner values their
  agreement more?
• Is one partners risk behavior influenced by
  their partners relationship satisfaction?
• Do couples who value their agreements report less
  risk than other couples?

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Conclusions

• Agreements are an important aspect of gay male
  relationships
• Foster trust
• Sexual exploration
• Validate relationships
• It remains unclear whether having an agreement is
  a reliable prevention strategy
• Some agreements are vague
• Safety assumed, yet not clear
• Discussed once and never again
• Some break agreements and do not disclose

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Conclusions

• Unanswered Questions
• Do agreements offer a false sense of security?
• What aspects of agreements are helpful for
  prevention?
• How are relationship factors are associated with
  risk?
• How do these issues change over time?
• What tools do couples need to maintain their
  agreements?

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Conclusions

• Having a good relationship is a priority for most
  gay male couples.
• Future HIV prevention efforts must support
  couples to continue to have honest, loving, and
  fulfilling relationships.

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The Gay Couples Study
Staff Colleen Hoff Principal
Investigator Lynae Darbes Co-Investigator Tor
Neilands Co-Investigator Edwin
Ramos-Soto Project Director Lei Han Senior
Statistician Sean Christian Beougher Research
Assistant Chris Boyd Research Assistant Brad
Vanderbilt Recruitment Coordinator Hernan
Ludueña Segre Recruiter Rand
Dadasovich Recruiter Craig Wingate Recruiter
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Sexual Agreements and HIV Risk The Gay Couples
Study

• Questions Discussion