Archives of Sexual Behavior

, Volume 35, Issue 4, pp 461–471

Sexual Risk Behavior of HIV-Positive Methamphetamine-Using Men Who Have Sex with Men: The Role of Partner Serostatus and Partner Type

Authors

  • Shirley J. Semple
    • Department of PsychiatryUniversity of California
  • Jim Zians
    • Department of PsychiatryUniversity of California
  • Igor Grant
    • Department of PsychiatryUniversity of California
    • Department of Veterans Affairs Medical Center
    • Department of PsychiatryUniversity of California
    • Department of Veterans Affairs Medical Center
Original Paper

DOI: 10.1007/s10508-006-9045-3

Cite this article as:
Semple, S.J., Zians, J., Grant, I. et al. Arch Sex Behav (2006) 35: 461. doi:10.1007/s10508-006-9045-3

Abstract

This study examined the role of partner serostatus and partner type in relation to the sexual risk behaviors and disclosure practices of HIV-positive methamphetamine (meth)-using men who have sex with men (MSM). The sample consisted of 132 HIV-positive meth-using MSM who reported having both serodiscordant (i.e., HIV-negative and unknown serostatus) and seroconcordant (i.e., HIV-positive) partners. HIV-positive meth-using MSM engaged in significantly fewer acts of anal sex with serodiscordant partners as compared to seroconcordant partners. However, mean levels of unprotected anal and oral sex were high, and mean levels of protected sex were low for both seroconcordant and serodiscordant partners. Oral sex was practiced twice as often as anal sex; however, both types of sex were primarily unprotected. This pattern of risky sexual behavior was reported for steady, casual, and anonymous partners, regardless of partner serostatus. Despite high rates of unprotected sex, rates of HIV serostatus disclosure were consistently high for HIV-positive and HIV-negative steady, casual, and anonymous partners. However, rates of disclosure to unknown serostatus partners were low, particularly in relation to anonymous partners. Future research should address the reasons why HIV-positive meth-using MSM engage in risky sexual activity with serodiscordant partners, and HIV prevention programs for this population should emphasize the risks associated with unprotected sex with seroconcordant partners.

Keywords

MenHomosexualityMethamphetamineSexual behaviorRisk

Introduction

High rates of methamphetamine (meth) use have been documented among gay and bisexual men in California and other western states (e.g., Stall et al., 2001). Within this population, meth has been characterized as a “sex drug” that enhances sexual pleasure and reinforces the sexual identity of the user (Reback, 1997). Studies of gay and bisexual male meth users have also identified a strong link between use of this drug and high risk sexual behavior (Frosch, Shoptaw, Huber, Rawson, & Ling, 1996; Gorman, Morgan, & Lambert, 1995; Molitor, Truax, Ruiz, & Sun, 1998; Reback, 1997; Shoptaw, Peck, Reback, & Rotheram-Fuller, 2003; Shoptaw, Reback, & Freese, 2002). High rates of sexually transmitted diseases have been found across all categories of meth users; however, rates of HIV infection were highest among gay and bisexual meth users as compared to their heterosexual male and female counterparts (Molitor et al., 1998). In one study of HIV-positive meth-using men who have sex with men (MSM), Semple, Patterson, and Grant (2002) reported high rates of unprotected sex with HIV-negative and unknown serostatus partners. Other recent studies have reported similar patterns of risky behavior among HIV-positive gay and bisexual meth users (e.g., Shoptaw et al., 2002).

To date, however, no studies have examined whether factors such as partner serostatus and partner type influence the sexual risk practices and disclosure behaviors of HIV-positive meth-using MSM. Indeed, studies of HIV-positive non-drug using MSM have shown that condom use and disclosure are influenced by factors such as partner type, serostatus of the partner, use of highly active antiretroviral therapy (HAART), and viral load (Marks & Crepaz, 2001; Suarez et al., 2001). The few studies that have focused on HIV-positive, non-drug-using MSM have produced inconsistent findings regarding the role of partner type and partner serostatus in relation to sexual risk behaviors. In a study of the risky behavior of 42 HIV-positive non-drug-using MSM, Fisher, Kimble Willcutts, Misovich, and Weinstein (1998) reported that among those who had engaged in risky behavior, 53 and 82 percent, respectively, had unprotected anal or oral sex to ejaculation with an HIV-negative or unknown serostatus partner during the past two months. A significantly smaller percentage of men (19%) reported unprotected anal or oral sex with an HIV-positive partner during the same time period. The larger percentage of unprotected sex with HIV-negative and unknown serostatus partners may be explained, to some extent, by characteristics of the sample or fewer cases of HIV seropositivity at the time of data collection in 1995. Relationship status appeared to play a motivating role in the safer sex activity of participants in Fisher's study. HIV-positive men in monogamous relationships with HIV-negative partners were more likely to consistently use condoms as compared to men in comparable relationships with HIV-positive partners.

Other studies also indicate that partner serostatus and relationship type influence the safer sex practices of HIV-positive men. Kalichman, Rompa, Luke, and Austin (2002) reported that HIV-positive individuals (mostly gay and bisexual men) had more protected and unprotected sex with their serodiscordant regular partners as compared to their serodiscordant non-regular partners. In another study of HIV-positive gay and bisexual men, Kalichman, Kelly, and Rompa (1997) reported that the majority of men indicated that their most recent partner was HIV-negative or of unknown serostatus. Unprotected sex was common in both serodiscordant and seroconcordant relationships. In another large-scale study of HIV-positive gay and bisexual men who had HIV-negative or unknown serostatus partners, Semple, Patterson, and Grant (2003) found that men with steady partners only had higher levels of unprotected anal and oral intercourse as compared to men with casual partners only. The serostatus of the sexual partner has also been shown to affect disclosure behavior. In at least one study, HIV-positive men were significantly more likely to disclose their HIV serostatus to sexual partners who were also seropositive (Marks et al., 1994).

The purpose of this study was to examine the sexual risk practices and disclosure behaviors of HIV-positive meth-using MSM as a function of the serostatus of their partner and the nature of the sexual relationship (i.e., partner type). Data were gathered from a sample of HIV-positive meth-using MSM who had both serodiscordant (HIV-negative or unknown serostatus) and seroconcordant (HIV-positive) partners during a two-month period. Two major research questions were addressed: Do HIV-positive meth-using MSM engage in different patterns of sexual risk practices based on the serostatus of their sexual partners? Does partner type influence risk behavior with serodiscordant and seroconcordant sexual partners? An enhanced understanding of the role of partner type and partner serostatus in relation to the sexual risk behavior of HIV-positive meth-using MSM should help to inform the development of effective behavior change interventions for this target population.

Method

Participants

These analyses used baseline data from a subsample of 132 men who were enrolled in the EDGE research project at the University of California, San Diego. The EDGE was named by focus group participants who considered their lifestyles as “living on the edge.” The EDGE is a theory-based, eight-session, one-on-one safer sex counseling intervention that was designed specifically for HIV-positive meth-using MSM. Eligibility criteria for the intervention and the current study were the same. Eligible participants were HIV-positive, at least 18 years of age, used meth at least twice in the past two months, and had unprotected anal or oral sex with at least one HIV-negative or unknown serostatus male partner during the same time period. Exclusion criteria involved the following behaviors and characteristics assessed over the previous two months: consistent (100 percent) use of condoms with all HIV-negative or unknown serostatus partners or HIV-positive partners only (i.e., no HIV transmission potential), active psychotic or suicidal symptoms, and HIV-positive for less than two months. The subsample whose data were used in the present analyses was made up of participants who reported having both serodiscordant (HIV-negative or unknown serostatus) and seroconcordant (HIV-positive) sexual partners during the previous two months. Because the EDGE project was focused on reducing HIV transmission potential, the investigators adopted a conservative approach whereby unknown serostatus partners were considered serodiscordant partners. Source of recruitment and background characteristics of the participants in the subsample did not differ significantly from those in the parent sample of 237 participants.

The majority of participants self-identified as homosexual/gay (80.3%). Other categories of sexual orientation included bisexual (19.2%) and “not sure” (1.5%). Participants were primarily Caucasian (60.6%) with other categories of ethnicity as follows: African American (19.7%), Hispanic (10.6%), Native American (4.5%), Asian (1.5%), and “other” (3.1%). The majority of participants were never married (86.4%), had some college or a college degree (58.3%), and were unemployed (70.0%). Participants were most likely to be living alone or with other adults in a non-sexual relationship (37.1% and 28.8%, respectively). Other living arrangements included living with a same sex steady partner (15.9%), homeless (15.9%), and “other” (2.3%). The mean age of participants was 36.2 years (SD=7.2; range, 21–61). Participants had been HIV-positive for an average of 7.4 years, and 34.7 percent had an AIDS diagnosis. Viral load, as reported by 70% of the sample, ranged from 0 to 775,000 copies per milliliter (mL) of blood (M=54,814). Fifty percent of the sample reported having a psychiatric diagnosis, most often depression. Beck Depression Inventory (BDI) scores ranged from 0 to 44 (M=14.0; SD=9.1) (Beck, Steer, & Garbin, 1988).

Based on the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA-II), 91 percent of the sample met criteria for meth dependence; five percent met criteria for meth abuse, and 4 percent were classified as not dependent (Bucholz et al., 1994). On average, participants had been using meth for 12 years (SD=7.8; range, <l year to 41 years). Primary method of meth consumption was (in rank order): smoking (36.4%), snorting (30.3%), injecting (30.3%), and other (3.1%). Participants used meth an average of 10.5 days during the past 30 days (SD=8.9; range, 0–30). Participants used meth an average of 6 times per day (SD=7.1; range, 1–50). Over a 30-day period, participants used an average of 5.7 grams of meth (SD=9.6; range, .05–60).

Participants were recruited into the EDGE project through a variety of community outreach strategies. For example, recruitment staff organized large-scale poster/media campaigns and conducted street outreach in social environments that were known to have high concentrations of meth users and MSM. Recruitment sources included gay organizations and groups, HIV-specialty health clinics, gay-identified venues and events, referrals from care providers, and referrals from active participants. The EDGE was advertised as a university-based program for HIV-positive meth users who wanted to learn more about safer sex practices. Forty-four percent of the present sample was referred from community-based service providers, 30% were recruited through the poster/media campaign, 23% were referrals from friends and active participants, and 3% were recruited through face-to-face contact with community outreach workers.

Procedure

Participants in the EDGE project attended a 60-minute baseline interview. The face-to-face interview covered a range of topics, including participants' use of meth, alcohol and other substances, sexual risk practices with HIV-positive and HIV-negative/unknown serostatus partners, HIV-related attitudes, sexual communication skills, disclosure behaviors, social cognitive factors, and background characteristics of the individual. Participants were paid a total of $30 for completing their baseline assessment and first counseling session. Data for the present analyses were collected between November 2000 and October 2003.

Measures

Sexual risk behavior

Sexual risk behavior was defined as unprotected anal, oral, or vaginal sex with serodiscordant (i.e., HIV-negative/unknown serostatus) and seroconcordant (HIV-positive) partners. Three categories of partner type were assessed. Steady partner(s) were defined as person(s) with whom the participant had sex with on a regular basis (e.g., spouse, primary partner, or boyfriend). Casual partner(s) were defined as a person(s) with whom the participant was acquainted, and had a one-night stand or had sex with only once or twice. Anonymous partner(s) were defined as person(s) whom the participant did not know (e.g., hustler, someone encountered at a bathhouse or park). For each category of partner type, participants were asked two questions regarding five types of sex acts: receptive anal sex (i.e., “your partner inserted his penis into your anus”); insertive anal sex (i.e., “you inserted your penis into the anus of your partner”); receptive oral sex (i.e., “your partner licked or sucked your genitals”); gave oral sex (i.e., “you licked or sucked your partner's genitals”); and insertive vaginal sex (i.e., “you inserted your penis into the vagina of your partner”). The first question quantified the number of times that the type of sex act was engaged in during the past two months. The second question quantified the number of times that a condom or other barrier method was used in relation to the type of sex act. Summary variables were created to represent total number of protected and unprotected anal, oral, and vaginal sex acts during the past two months broken down by partner type. The serostatus of sexual partners was determined by participants' reports. For each of the three partner types, participants were asked: How many did you have? How many were (HIV-negative/unknown serostatus/HIV-positive)? To ascertain partners' use of meth, participants were asked the following question in relation to each partner type for both serodiscordant and seroconcordant partners: “How many of your (HIV-negative steady partners) were meth users?” Interviewers were instructed to probe for actual rather than perceived use of meth by sexual partners.
Table 1

Mean number of serodiscordant and seroconcordant partners broken down by partner type

 

Serodisconcordant partners

Seroconcordant partners

   
 

M

SD

Range

N

M

SD

Range

N

t

df

p

All partner types

8.8

11.9

1–71

132

4.6

7.4

1–53

132

4.0

53

<.001

Steady partners

1.5

0.8

1–4

39

1.9

1.6

1–8

39

1.5

67

ns

Casual partners

2.5

2.3

1–30

37

4.6

8.1

1–48

37

1.6

115

ns

Anonymous partners

10.2

14.5

1–70

37

4.6

6.1

1–35

37

2.6

84

<.01

Note. Sample size reflects number of subjects who had both serodiscordant and seroconcordant partner type.

Disclosure behavior

For each partner type (i.e., steady, casual, anonymous), participants were asked three questions regarding their disclosure behavior with HIV-negative partners, unknown serostatus partners, and HIV-positive partners. The wording of the question was modified to reflect the different combinations of partner type and partner serostatus. For example, when asked in relation to HIV-negative steady partners, the question was worded as follows: “How many of your HIV-negative steady partner(s) did you tell that you were HIV-positive before having sex?” Nine summary variables were computed. Each variable represented the mean number of disclosures for the partner type by partner serostatus variable (i.e., 3 partner types × 3 serostatus). A follow-up question regarding the use of meth in the disclosure process was asked in relation to each partner type by partner serostatus variable. When asked in relation to HIV-negative steady partners, the question was worded as follows: “When you disclosed your HIV serostatus to your (HIV-negative steady partner), were you high on meth?” Response categories were 1 = Yes and 0 = No. Nine dichotomously-scored summary variables were calculated.

Results

Number and type of serodiscordant and seroconcordant sexual partners

Table 1 presents data on the mean number of serodiscordant and seroconcordant partners for steady, casual, and anonymous partners, and all partner types. Anonymous partners were the most frequently occurring category of serodiscordant partners, and steady partners were the most frequently occurring category of seroconcordant partners. Overall, participants reported significantly more HIV-negative or unknown serostatus partners as compared to HIV-positive partners. In terms of partner types, 38 percent of the sample reported having a serodiscordant steady partner, and 69 percent reported having a seroconcordant steady partner (χ2 = 18.9, df = 1, p < .001). Among participants who reported having both a serodiscordant and seroconcordant steady partner during the past two months, there were no significant differences in the mean number of HIV-negative or unknown serostatus steady partners versus HIV-positive steady partners. Approximately 58% of the sample reported having at least one serodiscordant casual partner, and 45% reported having at least one seroconcordant casual partner (χ2 = 1.5, df = 1, ns). Among participants who had both serodiscordant and seroconcordant casual partners during the past two months, the mean number of HIV-negative or unknown serostatus casual partners, and the mean number of HIV-positive casual partners was not significantly different. Approximately 70 percent of the sample had at least one HIV-negative or unknown serostatus anonymous partner. A significantly smaller percentage of participants (32%) reported having at least one HIV-positive anonymous partner (χ2=20.4, df = 1, p < .001). Among those who had both serodiscordant and seroconcordant anonymous partners during the previous two months, the mean number of HIV-negative or unknown serostatus anonymous sex partners was significantly greater than the mean number of HIV-positive anonymous partners.

Meth use by sexual partners

Participants were asked about their sexual partners' use of meth. Among those who had steady partners, 53% of those partners were also meth users. A similar rate of meth use (52.8%) was also reported among HIV-negative and unknown serostatus casual partners. In contrast, only 37% of HIV-negative and unknown serostatus anonymous sex partners were known to be meth users. With respect to HIV-positive partners, the majority were meth users. Among participants with HIV-positive steady partners, 74% indicated that their steady partner(s) was also a meth user. Among those with HIV-positive casual partners, 67% were known to be meth users. The percentage of HIV-positive anonymous partners who used meth was approximately 76%. A chi-square test indicated that significantly more HIV-positive anonymous partners used meth as compared to HIV-negative and unknown serostatus anonymous partners (χ2 = 8.2, df = 1, p < .05). There were no significant differences in the percentage of participants who reported meth use by their seroconcordant versus serodiscordant steady and casual partners.

Serostatus disclosure to sexual partners

Rates of serostatus disclosure were examined for both serodiscordant and seroconcordant partners using chi-square and t-test for paired samples. Eighty-six percent of the sample reported disclosing their seropositive status to at least one HIV-negative partner during the past two months. In contrast, only 50% of participants reported disclosing to an unknown serostatus partner during this time period. Rates of disclosure to seroconcordant partners were similar to rates reported in relation to HIV-negative partners. Specifically, 79% of the sample reported disclosing their serostatus to at least one HIV-positive partner during the previous two months. Information on the serostatus of HIV-positive partners was usually obtained through partner self-disclosure. The mean number of disclosures to HIV-negative, unknown serostatus, and HIV-positive partners during the two-month period was 2.5 (SD = 4.1; range, 0–24), 2.4 (SD = 4.7; range, 0–30), and 3.3 (SD = 6.9; range, 0–52), respectively (p > .05).

Rates of disclosure by partner type

Rates of disclosure across partner types were similar. The highest rates of HIV serostatus disclosure were to HIV-negative and HIV-positive steady partners. Specifically, 81% of the sample disclosed to all of their HIV-negative steady partners, and 89% disclosed their serostatus to all of their HIV-positive steady partners. In contrast, only 36% of those who had unknown serostatus steady partners disclosed to all of their partners. Among those with HIV-negative casual partners, 76% disclosed to all partners. Similarly, among those who had HIV-positive casual partners, 80% disclosed to all of their partners. In contrast, the rate of disclosure to all unknown serostatus casual partners was 43%. In terms of anonymous sex partners, the rates of serostatus disclosure to HIV-positive and HIV-negative anonymous partners were 79 and 80%, respectively. In contrast, the disclosure rate to unknown serostatus anonymous partner was only 16%. Chi-square analyses revealed that rates of disclosure across partner types did not differ significantly by serostatus of the partner.

Meth use and serostatus disclosure

Thirty-eight percent of those who disclosed to an unknown serostatus steady partner indicated that they were high on meth at the time of disclosing. In contrast, 24% reported that they were high on meth when they disclosed to an HIV-negative steady partner, and 51% were high on meth while disclosing to an HIV-positive partner. Among those who disclosed their serostatus to casual partners, 79% were high on meth when they disclosed to their unknown serostatus casual partner; 76 and 75% were high when they disclosed to their HIV-negative and HIV-positive casual partners, respectively. With respect to anonymous partners, 92 and 94% of participants, respectively, were high on meth when they made their disclosure to unknown serostatus and HIV-negative anonymous partners. Seventy-four percent were high on meth while making their disclosure to an HIV-positive partner. Chi-square analysis revealed that the percentage of participants who were high on meth when they disclosed their seropositivity did not vary by partner type or partner serostatus.

Sexual risk behavior

As shown in Table 2, participants reported engaging in approximately the same total number of sex acts with serodiscordant and seroconcordant partners over a two-month period; however, participants reported significantly fewer unprotected sex acts with their HIV-negative and unknown serostatus partners as compared to their HIV-positive partners.
Table 2

Sexual risk behavior

 

Serodisconcordant partners

Seroconcordant partners

   
 

M

SD

Range

N

M

SD

Range

N

t

df

p

Total number of sex acts

29.6

35.0

1–207

130

36.3

46.9

0–244

130

1.5

129

ns

Number of unprotected sex acts

25.7

32.4

1–189

129

34.6

46.6

0–244

129

2.0

128

<.05

Number of protected sex acts

4.0

11.2

0–93

129

2.1

5.7

0–42

129

2.1

128

<.05

Total number of anal sex acts

9.3

14.0

0–71

129

12.7

20.0

0–125

129

1.9

128

<.05

Number of unprotected anal sex acts

8.9

13.7

0–63

94

12.6

18.7

0–125

94

1.8

93

ns

Number of protected anal sex acts

3.3

8.1

0–68

94

1.9

5.4

0–42

94

1.5

93

ns

Total number of oral sex acts

19.8

23.2

1–150

130

23.5

29.1

0–160

130

1.3

129

ns

Number of unprotected oral sex acts

18.9

22.9

1–150

129

23.3

29.3

0–160

129

1.5

128

ns

Number of protected oral sex acts

1.0

4.5

0–35

129

0.4

1.8

0–18

129

2.2

128

<.05

Note. Sample size reflects number of subjects who engaged in sex act with both serodiscordant and seroconcordant partner(s).

In terms of specific types of sex, 82% of the sample reported having anal sex with an HIV-negative or unknown serostatus partner, and 86% had anal sex with at least one HIV-positive partner. The mean number of anal sex acts with HIV-negative and unknown serostatus partners was significantly lower than the number of anal sex acts with HIV-positive partners; however, the mean number of unprotected and protected anal sex acts was not significantly different for serodiscordant versus seroconcordant partners. Anal sex with both serostatus partner types was primarily unprotected.

With respect to oral sex, 100% of the sample engaged in this activity with their serodiscordant and seroconcordant partners. Oral sex was primarily unprotected. One hundred percent of the sample reported unprotected oral sex with their HIV-negative and unknown serostatus partners, and 95% of the sample reported at least one incident of unprotected oral sex with their HIV-positive partner(s). The mean number of oral sex acts with serodiscordant and seroconcordant partners was not significantly different. Similarly, the mean number of unprotected oral sex acts was not different for HIV-negative and unknown serostatus partners versus HIV-positive partners; however, the mean number of protected oral sex acts with serodiscordant partners was significantly greater than the number reported for seroconcordant partners.
Table 3

Unprotected receptive versus insertive sex with serodiscordant and seroconcordant partners

 

Serodisconcordant partners

Seroconcordant partners

   
 

M

SD

Range

N

M

SD

Range

N

t

df

p

Unprotected insertive anal sex

5.3

10.3

0–51

54

10.6

14.7

0–68

54

2.4

53

<.05

Unprotected receptive anal sex

7.6

11.5

0–50

68

7.8

12.4

0–80

68

.08

67

ns

Give oral sex

10.3

12.5

0–75

116

11.6

14.7

0–80

116

.76

115

ns

Receptive oral sex

11.5

12.5

0–75

85

14.8

19.1

0–110

85

1.5

84

ns

Note. Sample size reflects number of subjects who engaged in sex act with both serodiscordant and seroconcordant partner(s).

Receptive versus insertive sex with serodiscordant and seroconcordant partners

An analysis was conducted to assess differences in the mean levels of unprotected receptive versus insertive sex with serodiscordant versus seroconcordant partners. As shown in Table 3, no significant differences in mean levels of unprotected receptive anal sex were found for serodiscordant versus seroconcordant partners; however, participants were significantly more likely to engage in unprotected insertive anal sex with their HIV-positive partners as compared to their HIV-negative and unknown serostatus partners. Mean levels of giving unprotected oral sex with serodiscordant and seroconcordant partners were not significantly different. Similarly, there were no significant differences in the mean number of unprotected receptive oral sex acts with serodiscordant as compared to seroconcordant partners.

Sexual risk behavior associated with partner types

Additional analyses were conducted to examine differences in sexual risk behaviors according to partner type. For both serodiscordant and seroconcordant partners, mean levels of oral and anal sex were examined in relation to steady, casual, and anonymous partners. The findings are presented in Table 4.
Table 4

Sexual risk behavior by partner type

 

Serodisconcordant partners

Seroconcordant partners

   
 

M

SD

Range

N

M

SD

Range

N

t

df

p

Steady partners

           

Number of anal sex acts

4.3

8.2

0–60

38

7.3

10.0

0–120

38

1.5

37

ns

Number of unprotected anal sex acts

3.1

2.7

0–60

22

6.5

7.7

0–120

22

2.3

21

.03

Number of oral sex acts

11.8

17.4

0–100

38

16.0

16.0

2–150

38

1.3

37

ns

Number of unprotected oral sex acts

11.9

17.6

0–100

37

15.5

16.1

0–150

37

1.1

36

ns

Casual partners

           

Number of anal sex acts

3.3

4.3

0–35

36

5.9

9.7

0–49

36

1.5

35

ns

Number of unprotected anal sex acts

2.7

4.4

0–35

24

5.1

7.0

0–32

24

1.5

23

ns

Number of oral sex acts

6.5

6.9

0–70

36

11.1

15.2

1–88

36

1.7

36

ns

Number of unprotected oral sex acts

6.1

6.9

0–70

35

10.6

15.5

0–88

35

1.6

34

ns

Anonymous partners

           

Number of anal sex acts

7.6

13.6

0–65

37

5.4

9.9

0–60

37

1.5

36

ns

Number of unprotected anal sex acts

4.5

6.5

0–47

22

4.2

3.9

0–60

22

.17

21

ns

Number of oral sex acts

16.6

20.9

0–90

37

10.4

14.3

0–70

37

1.8

36

ns

Number of unprotected oral sex acts

15.7

19.8

0–90

36

10.4

14.1

0–70

36

1.4

35

ns

Note. Sample size reflects number of subjects who engaged in sex act with both serodiscordant and seroconcordant partner(s).

Steady partners

Among participants with steady partners, oral sex occurred twice as often as anal sex for both serodiscordant and seroconcordant partners. Oral sex with seroconcordant steady partners was almost always unprotected. Anal sex with HIV-positive steady partners was also primarily unprotected, although anal sex occurred less often than oral sex. Sexual activity with HIV-negative and unknown serostatus steady partners yielded a similar pattern to the one observed in relation to HIV-positive steady partners. Oral sex with HIV-negative and unknown status partners occurred almost twice as often as anal sex, and both anal and oral sex were, for the most part, unprotected; however, the mean number of unprotected anal sex acts with serodiscordant steady partners was significantly lower than the mean number reported for seroconcordant steady partners. Moreover, the overall level of sexual activity with HIV-negative and unknown serostatus steady partners was about half the amount reported with HIV-positive steady partners.

Casual partners

As shown in Table 4, the overall level of sexual activity with HIV-positive casual partners was approximately one-third less than the amount reported with HIV-positive steady partners; however, a similar pattern of sexual behaviors emerged. Oral sex with HIV-positive casual partners occurred almost twice as often as anal sex, and both types of sex were primarily unprotected. Sexual activity with HIV-negative and unknown serostatus casual partners also revealed a pattern similar to that observed with HIV-positive casual partners. Oral sex was practiced more frequently than anal sex. Both anal and oral sex with HIV-negative and unknown status casual partners were primarily unprotected.

Anonymous partners

As also shown in Table 4, levels of sexual activity with HIV-positive anonymous partners were similar to those for HIV-positive casual partners; however, fewer participants reported having an HIV-positive anonymous partner. Oral sex occurred almost twice as often as anal sex, and both types of sex with HIV-positive anonymous partners were primarily unprotected. Participants reported having a larger number of HIV-negative or unknown serostatus (mostly unknown) anonymous partners as compared to HIV-positive anonymous partners. Oral sex was the most common type of sexual activity with HIV-negative and unknown serostatus anonymous partners. Both oral and anal sexual activity tended to be unprotected.

Sexual risk behavior with HIV-negative versus unknown serostatus partners

As previously stated, this research treated HIV-negative and unknown serostatus partners as a single category. However, within the total sample, we were able to identify 17 participants who had HIV-negative partners only and 76 participants who had unknown serostatus partners only. This allowed us to conduct an exploratory analysis to examine differences in participants' sexual risk practices with HIV-negative versus unknown serostatus partners. As shown in Table 5, the two groups were similar in terms of their overall frequency of sexual activity. Participants with HIV-negative partners only and those with unknown serostatus partners only reported similar mean numbers of anal and oral sex acts. In terms of mean number of unprotected anal and oral sex acts, there were no statistically significant differences between the two groups.
Table 5

Sexual risk behavior with HIV-Negative partners only versus HIV-serostatus unknown partners only

 

HIV-negative partners only

Serostatus unknown partners only

   
 

M

SD

Range

N

M

SD

Range

N

t

df

p

Mean number of anal sex acts

8.6

13.0

0–34

16

7.7

12.1

0–55

76

.27

90

ns

Mean number of oral sex acts

16.2

17.8

1–64

17

18.3

22.7

1–90

76

.36

91

ns

Mean number of unprotected anal sex acts

7.3

12.0

0–33

9

7.8

12.6

0–55

61

.11

68

ns

Mean number of unprotected oral sex acts

12.1

17.2

1–64

17

18.1

22.7

1–90

76

1.0

91

ns

Discussion

A primary research question in the present study asked whether HIV-positive meth-using MSM engage in different patterns of sexual risk practices and disclosure behaviors on the basis of partner serostatus. Overall, HIV-positive meth-using MSM reported only one difference in their sexual risk behaviors with serodiscordant and seroconcordant partners. Participants had almost twice as many HIV-negative and unknown serostatus partners as compared to HIV-positive partners. This difference is mostly likely explained by the fact that the majority of meth-using MSM in San Diego are either HIV-negative or do not know their HIV serostatus (Zians, Houke, & D'Hont, 2004). Thus, HIV-positive meth users are simply more likely to encounter an HIV-negative or unknown serostatus partner; there is no evidence that HIV-positive men seek out serodiscordant partners. In terms of sexual activity, HIV-positive meth-using MSM engaged in approximately the same mean levels of oral sex with their serodiscordant and seroconcordant partners; however, mean levels of anal sex were significantly lower with serodiscordant partners. Among those who engaged in oral or anal sex, the mean levels of protected and unprotected sex were similar across partners' serostatus. These findings suggest that HIV-positive meth-using MSM modify their sexual risk activity to some degree based on their partner's HIV serostatus.

In terms of serostatus disclosure, a few differences were noted based on the partner's serostatus. Rates of serostatus disclosure to sexual partners who were known to be HIV-positive were consistently high across all partner types. One might assume that disclosure is made easier if the sexual partner is known to be HIV-positive since the likelihood of rejection is probably reduced. Also, since most disclosures to HIV-positive partners took place under the influence of meth, it is possible that using together may enhance communication between HIV-positive partners. Finally, knowing that a partner is HIV-positive may also be a marker of closeness or familiarity with that individual which, in turn, may facilitate disclosure.

Rates of serostatus disclosure to HIV-negative partners were also high across all three partner types. This finding suggests that despite the use of meth, HIV-positive MSM who knew that their partner was HIV-negative informed that person prior to exposure. A different picture emerged in relation to unknown serostatus partners; rates of serostatus disclosure were notably lower. A qualitative study of the sexual risk behaviors of HIV-positive meth-using MSM suggests two primary explanations for lower rates of disclosure to unknown serostatus partners (Semple et al., 2002). First, it is typically assumed that unknown serostatus partners who engage in risky sexual acts are HIV-positive; thus, disclosure is believed to be unnecessary. Second, most sexual contacts with unknown serostatus partners occur in settings or locations, such as the park, where it is often considered inappropriate to discuss one's HIV serostatus.

Another primary research question addressed differences in sexual risk behavior on the basis of partner type, taking into account partner serostatus. Overall, partner type appeared to have very little influence on the practice of safer sex. Across all partner types, sex with serodiscordant and seroconcordant partners was mostly unprotected. However, a type of harm reduction model appears to be practiced by meth-using HIV-positive MSM. Harm reduction is a public health approach that is committed to improving the health of individuals as well as the health of the public. Heller, McCoy and Cunningham (2004) describe harm reduction as a care delivery approach that “promotes safety in behaviors without mandating abstinence or imposing penalties” (p. 36). Harm reduction principles as applied to HIV/AIDS include the practice of sexual behaviors that are known to carry less risk of HIV transmission as compared to other behaviors. In the present study, lower risk activities, such as unprotected oral sex, were practiced more often than unprotected anal sex. Also, HIV-positive meth-using men had lower mean levels of sex with casual and anonymous partners as compared to steady partners. Suarez et al. (2001) argued that non-drug using gay and bisexual men utilize complex risk assessment strategies that take into account the nature of the sexual relationship (e.g., partner type) and the actual or perceived HIV serostatus of the sex partner. The present study of HIV-positive meth-using MSM suggests that these same factors of risk assessment may be operative in a population of HIV-positive meth users.

The reported rates of unprotected anal and oral sex with HIV-negative and unknown serostatus partners raise concerns because of the potential for HIV transmission. The current data did not address participants' reasons or justifications for engaging in behaviors that put their sexual partners at risk for infection; however, in a previous study, we identified three main reasons or explanations for engaging in unprotected anal or vaginal sex with “at risk” partners (Semple et al., 2002). The most common explanation involved the “perceived” serostatus of the sex partner (“If they want to have unsafe sex, I just assume that they are HIV-positive”). HIV-positive meth-using MSM indicated that if a partner did not ask to use a condom and was willing to engage in risky sex, he must be HIV-positive. This assumption, which Suarez et al. (2001) termed “confirmation of status bias,” helps the HIV-positive individual convince himself that he is not causing harm to another individual. A second explanation for engaging in risky sex with HIV-negative and unknown serostatus partners involved the effects of the drug on the individual's choices. Participants indicated that their unsafe sexual behavior was driven by the drug itself (“You're not in your right head when you're on meth. You just don't care. It's all about sex. You do things that you wouldn't do sober”). A third explanation involved the meth user's discharging of responsibility for the well-being of his sex partners (“If they are HIV-negative and want to have unsafe sex, that's up to them. It's on them”). Participants' reasons for engaging in oral sex without condoms were different from those offered in relation to anal sex. The “bad taste” associated with condoms was the most frequently stated reason for engaging in unprotected oral sex with HIV-negative and unknown serostatus partners. Low perceived risk of HIV transmission and erection difficulties were also cited as reasons for not using condoms for oral sex with HIV-negative and unknown serostatus partners.

An important implication of these findings for HIV prevention focuses on meth users' sexual activity with anonymous partners. In this study, anonymous sex partners were significantly more likely to be HIV-negative or unknown serostatus, thereby heightening concerns regarding the risk for new infections and re-infections. By comparing the current findings with those of a previous study on the sexual behaviors of primarily non-drug-using HIV-positive gay and bisexual men, we may conclude, with caution, that meth-using HIV-positive MSM engage in higher levels of sexual risk activity with their anonymous partners as compared to their non-meth-using counterparts (Semple, Patterson, & Grant, 2004). Despite limitations associated with this comparison, it is not unreasonable to suggest the need for HIV prevention programs to focus more attention on the risks associated with anonymous sexual encounters and the development of effective strategies for reducing risk behavior.

Overall, rates of disclosure to serodiscordant and seroconcordant sexual partners were high. Although it is commonly assumed that disclosure of HIV-positive serostatus will increase the likelihood of safer sex occurring, there was no empirical support for this in our data. HIV-positive meth-using MSM typically engaged in unsafe sex despite high rates of disclosure. Drug use may be one factor that contributes to this phenomenon. Marks and Crepaz (2001) reported that “informed exposure” (i.e., HIV-positive men disclosing and then having unsafe sex) was correlated with both the participant's and their sex partner's use of drugs/alcohol before sex. This explanation is most likely relevant in the present study. The majority of participants were high on meth during their sexual encounters as were most of their partners. Thus, it is not unreasonable to suggest that the act of using together and being “high” during sex reduces both partners' concerns about the possibility of HIV infection or reinfection in the case of seroconcordant partners. Rates of disclosure to HIV-negative partners were high across all three partner types, whereas rates of disclosure to unknown status partners varied according to partner type, with the highest rates of disclosure for steady and casual partners and the lowest rates for anonymous partners. In our qualitative interviews, HIV-positive meth-using MSM reported that it was important to disclose to a steady partner because the relationship may turn out to be long-term (“If you have a steady partner and you have feelings for that person, you want a long term commitment, and you don't want them to get sick. You want them to be safe”). Disclosure to casual partners was motivated by both moral code and self-comfort (“I think that it's important to share because it is a life-altering illness”; “I just feel better knowing that they know”). Disclosure to anonymous sex partners was viewed quite differently. With anonymous sex partners, everyone was assumed to be HIV-positive (Semple et al., 2002).

This study contributes information regarding the role of partner serostatus and partner type in terms of understanding the sexual risk behavior of some HIV-positive meth-using MSM. The findings suggest that HIV-positive meth users (specifically, men who met eligibility for a sexual risk reduction intervention because of their risky behavior) engaged in similar patterns of unprotected anal and oral sex with serodiscordant and seroconcordant partners, although mean levels of anal sex with serodiscordant partners was significantly less than noted for seroconcordant partners. The clinical and research implications of these findings are twofold. First, more research should be conducted to enhance our understanding of the reasons why some meth users do not change their sexual risk behaviors with serodiscordant partners–individuals who are at risk for contracting the virus. Second, the reported levels of unprotected sex with seroconcordant partners suggest that the risks associated with reinfection and transmission of other STDs should be emphasized in prevention and intervention programs that target HIV-positive meth users, particularly those who have a history of engaging in risky sexual behavior.

The potential contribution of this work to HIV prevention research should be evaluated in the context of study limitations. Although the present sample was comprised of an understudied population of community-residing, active meth users, participants were volunteers in a sexual risk reduction intervention, and were selected for study participation on the basis of their sexual risk behavior, i.e., HIV-positive meth-using MSM were eligible for the safer sex intervention if they reported having unprotected anal or oral sex with at least one HIV-negative or unknown serostatus male partner in the past two months. Accordingly, this sample cannot be considered representative of the general population of HIV-positive meth-using MSM. In particular, HIV-positive meth-using MSM who used condoms with all of their partners over the previous two months and those who had HIV-positive partners only were excluded from the intervention study. Moreover, participation in the intervention study may have been motivated by individuals' concerns about their high level of sexual risk behavior and/or meth use. Another potential limitation of this study derives from the use of self-report to gather data on sexual risk and drug use behaviors. Because these are socially sensitive behaviors, there is the possibility that participants either underestimated or overestimated their actual risk behaviors.

Concerns regarding the reliability and validity of self-reported sexual behavior data will remain ongoing due to the practical and economic infeasibility of collecting collaborative data from all sexual partners; however, studies that have examined rates of concordance between self-reported behavior and reports of sexual partners have found reasonable rates of concordance (Catania, Chitwood, Gibson, & Coates, 1990). Another reliability and validity issue stems from the possibility that participants, particularly drug users, who are very sexually active provide inaccurate reports of their behavior over a two-month recall period. A shorter period of recall might be more appropriate for a sample of sexually active meth users. Another methodological limitation stems from the organization of our data. Because of the parent study's focus on HIV transmission, sexual risk behaviors with HIV-negative and unknown serostatus partners were combined into a single category to represent sexual partners who are “at risk” for HIV infection. To address the research questions in this paper, it would have been desirable to have data that distinguished participants' sexual behaviors with HIV-negative versus unknown serostatus partners. Also, a dataset that had sufficiently large samples of men with HIV-negative partners only, unknown serostatus partners only, and HIV-positive partners only would offer an alternative approach to addressing these research questions.

Despite the limitations of this study, particularly the selective nature of our sample, the present findings can be placed in a broader context that makes them of wider interest to HIV prevention researchers. From a clinical perspective, these findings should encourage those who work with HIV-positive meth users to routinely ask questions about partner type and partner serostatus in the context of HIV prevention counseling and/or drug treatment. From a research perspective, further investigations to determine whether or not HIV serostatus and partner type play a role in the sexual risk behavior of HIV-positive meth users should be conducted with less selective samples of individuals drawn from the broader target population. It is also important in future studies to consider the interactive nature of sexual behavior by taking into account the role of the partner in determining the risk level associated with the sexual encounter. Finally, researchers should seek to identify factors that may help to explain differences in sexual risk and disclosure behaviors with serodiscordant and seroconcordant partners. A broad range of factors should be considered, including background characteristics, relationship dynamics, personality variables, cognitive factors, social context, and emotional needs of the individual.

Acknowledgments

Support for this work was provided, in part, by the National Institute of Drug Abuse (NIDA) R01 DA12116 (Promoting Safer Sex in HIV+ MSM Methamphetamine Users), The National Institute of Mental Health (NIMH) grant 1 R01 MH61146-01A2 (HIV/STD Risk and Maintenance in “At Risk” People), NIMH Center grant 2 P50 MH45294 (HIV Neurobehavioral Research Center), the Department of Veterans Affairs, and the State of California's University-wide AIDS Research Program (IS02-SD-701).

Copyright information

© Springer Science+Business Media, Inc. 2006