Sexual Agreements and HIV Risk: The Gay Couples Study

1. Sexual Agreements and HIV Risk: The Gay Couples Study April 21, 2006 5th CAPS HIV Prevention Conference

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

3. 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?

4. 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.

5. 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.

6. 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

7. Clip

8. 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

9. Agreement Types • Discrepancies • Some couples described having different understandings of their agreements. • Partner A: “There’s an assumed agreement that we are in a committed relationship… Yeah, a committed and monogamous relationship. And it’s interesting that he didn’t ask me exactly what I thought about it. I didn’t 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: “It’s easy [to keep my agreement].” (2002, HIV-, White)

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

11. Clip

12. 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.

13. 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

14. 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.

15. 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.

16. 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.

17. 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

18. Motivations for Having Agreements • Partner A: “And your level of trust with this person is so strong. And you’re putting so much on the line: You’re putting your health, your life on the line that there’s 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 we’re 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)

19. 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

20. Motivations for Having Agreements • “I feel whole and I just, it’s just a sense of belonging. And knowing that someone besides that’s not your family loves you back unconditionally and its just I never had that feeling before never had that feeling before. That’s what I feel I got out of this relationship arrangement is just a wholeness and being loved, being loved.” (5902, HIV+, Black)

21. 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

22. Motivations for Having Agreements • Partner A: “Well, the agreement that we’ve had ever since I moved in with [my partner] back … in the Fall of ’81 was that we would have an open relationship. [H]e 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 wouldn’t 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 we’ve got that agreement.” (1302, HIV-, White)

23. 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

24. 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.

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

26. 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

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

28. 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)

29. 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.

30. Clip

31. 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.

32. 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 didn’t 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 didn’t have to worry about transmitting HIV to my primary partner.”

33. Clip

34. 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

35. 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.

36. Clip

37. 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

38. 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.

39. 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.

40. 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.

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

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

43. 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

44. 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?

45. 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.

46. Clip

47. 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

48. Sexual Agreements and HIV Risk: The Gay Couples Study Questions & Discussion