The Influence of Relationship Dynamics and Sexual Agreements on Perceived Partner Support and Benefit of PrEP Use Among Same-Sex Male Couples in the U.S.


Use of Pre-exposure prophylaxis (PrEP) for HIV prevention by men who have sex with men (MSM) may be impacted by relationship dynamics. We assessed perceived partner support of PrEP use and benefit of PrEP by relationship characteristics among male couples. Baseline data from a randomized control trial of video-based HIV counseling and testing among male couples in the U.S. were used in adjusted multilevel regression models to assess individual and dyadic characteristics. Among 659 participants, 73.3% thought their partner would be supportive of their PrEP use; 26.7% reported their partner would not support PrEP use, which was significantly associated with intimate partner violence (IPV) (p = 0.008). Most (57.7%) did not believe PrEP would be beneficial to them or their partner. Couples with a sexual agreement allowing outside partners were significantly associated with higher perceived support of partners for PrEP (p < 0.001) and benefit of PrEP use (p < 0.001). Perceived partner support of PrEP was high but perceived benefit of PrEP was low, both shaped by relationship dynamics that highlight the need for tailored dyadic interventions. The association between perceived PrEP support and IPV points to the need to integrate relationship contexts in HIV prevention programs.

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  1. 1.

    Jenness SM, Goodreau SM, Rosenberg E, Beylerian EN, Hoover KW, Smith DK, et al. Impact of the centers for disease control's HIV preexposure prophylaxis guidelines for men who have sex with men in the United States. J Infect Dis. 2016;214(12):1800–7.

  2. 2.

    Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587–99.

  3. 3.

    Baeten JM, Donnell D, Ndase P, Mugo NR, Campbell JD, Wangisi J, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367(5):399–410.

  4. 4.

    Thigpen MC, Kebaabetswe PM, Paxton LA, Smith DK, Rose CE, Segolodi TM, et al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med. 2012;367(5):423–34.

  5. 5.

    Kamitani E, Wichser ME, Adegbite AH, Mullins MM, Johnson WD, Crouch PC, et al. Increasing prevalence of self-reported HIV preexposure prophylaxis use in published surveys: a systematic review and meta-analysis. AIDS. 2018;32(17):2633–5.

  6. 6.

    Finlayson T. Changes in HIV PrEP awareness and use among men who have sex with men, 2014 vs. 2017 Conference on Retroviruses and Opportunistic Infection; 2019 March 7, 2019 Seattle WA, 2017.

  7. 7.

    Coy KC, Hazen RJ, Kirkham HS, Delpino A, Siegler AJ. Persistence on HIV preexposure prophylaxis medication over a 2-year period among a national sample of 7148 PrEP users, United States, 2015 to 2017. J Int AIDS Soc. 2019;22(2):e25252.

  8. 8.

    Rao DW, Carr J, Naismith K, Hood JE, Hughes JP, Morris M, et al. Monitoring HIV preexposure prophylaxis use among men who have sex with men in Washington state: findings from an internet-based survey. Sex Trans Dis. 2019;46(4):221–8.

  9. 9.

    Chan PA, Mena L, Patel R, Oldenburg CE, Beauchamps L, Perez-Brumer AG, et al. Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three US cities. J Int AIDS Soc. 2016;19(1):20903.

  10. 10.

    Biello KB, Edeza A, Montgomery MC, Almonte A, Chan PA. Risk Perception and Interest in HIV Pre-exposure Prophylaxis Among Men Who Have Sex with Men with Rectal Gonorrhea and Chlamydia Infection. Arch Sex Behav. 2018;48(4):1185–90.

  11. 11.

    Rana J, Wilton J, Fowler S, Hart TA, Bayoumi AM, Tan DHS. Trends in the awareness, acceptability, and usage of HIV pre-exposure prophylaxis among at-risk men who have sex with men in Toronto. Can J Public Health. 2018;109(3):342–52.

  12. 12.

    Starks TJ, Doyle KM, Shalhav O, John SA, Parsons JT. An examination of gay couples' motivations to use (or Forego) pre-exposure prophylaxis expressed during couples HIV testing and counseling (CHTC) sessions. Prev Sci. 2019;20(1):157–67.

  13. 13.

    Stephenson R, White D, Darbes L, Hoff C, Sullivan P. HIV testing behaviors and perceptions of risk of HIV infection among MSM with main partners. AIDS Behav. 2015;19(3):553–60.

  14. 14.

    Sullivan PS, Salazar L, Buchbinder S, Sanchez TH. Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities. AIDS. 2009;23(9):1153–62.

  15. 15.

    Cuervo M, Whyte J. The effect of relationship characteristics on HIV risk behaviors and prevention strategies in young gay and bisexual men. J Assoc Nurses AIDS Care. 2015;26(4):399–410.

  16. 16.

    Hoff CC, Beougher SC, Chakravarty D, Darbes LA, Neilands TB. Relationship characteristics and motivations behind agreements among gay male couples: differences by agreement type and couple serostatus. AIDS Care. 2010;22(7):827–35.

  17. 17.

    Saberi P, Gamarel KE, Neilands TB, Comfort M, Sheon N, Darbes LA, et al. Ambiguity, ambivalence, and apprehensions of taking HIV-1 pre-exposure prophylaxis among male couples in San Francisco: a mixed methods study. PLoS ONE. 2012;7(11):e50061.

  18. 18.

    Bavinton BR, Prestage GP, Jin F, Phanuphak N, Grinsztejn B, Fairley CK, et al. Strategies used by gay male HIV serodiscordant couples to reduce the risk of HIV transmission from anal intercourse in three countries. J Int AIDS Soc. 2019;22(4):e25277.

  19. 19.

    Wall KM, Canary L, Workowski K, Lockard A, Jones J, Sullivan P, et al. Acceptability of couples' voluntary HIV testing among HIV-infected patients in care and their HIV-negative partners in the United States. Open AIDS J. 2016;10:1–13.

  20. 20.

    Mitchell JW, Lee JY, Woodyatt C, Bauermeister J, Sullivan P, Stephenson R. HIV-negative male couples' attitudes about pre-exposure prophylaxis (PrEP) and using PrEP with a sexual agreement. AIDS Care. 2016;28(8):994–9.

  21. 21.

    Bratcher AKE, Sullivan P, Hidalgo M, Mimiago M, Garofalo R, Pardee D, Hoehnle S, Thai J, Dana R, Stephenson R. Concordance in reported love, trust, and relationship quality among same-sex male relationships. J Relatsh Res. 2018;9:e20.

  22. 22.

    Marsack JKE, Suarez NA, Mimiaga MJ, Garofalo R, Brown E, Bratcher AM, Wimbly T, Hidalgo MA, Hoehnle S, Thai J, Sullivan P, Stephenson R. Relationship characteristics and dyadic approaches to HIV health-enhancing behaviors among a sample of same-sex male couples from three US cities. J Relatsh Res. 2018;9:e10.

  23. 23.

    Willie TC, Stockman JK, Overstreet NM, Kershaw TS. Examining the impact of intimate partner violence type and timing on pre-exposure prophylaxis awareness, interest, and coercion. AIDS Behav. 2018;22(4):1190–200.

  24. 24.

    Stephenson R, Freeland R, Sullivan SP, Riley E, Johnson BA, Mitchell J, et al. Home-based HIV testing and counseling for male couples (Project Nexus): a protocol for a randomized controlled trial. JMIR Res Protoc. 2017;6(5):e101.

  25. 25.

    CDC. Preexposure prophylaxis for the prevention of HIV infection in the United States - 2017 update: a clinical practice guideline. Atlanta, GA: Centers for Disease Control and Prevention; 2017.

  26. 26.

    Larzelere RE, Huston TL. The dyadic trust scale - toward understanding interpersonal-trust in close relationships. J Marriage Fam. 1980;42(3):595–604.

  27. 27.

    Gabbay NLM, Bourque L. Factor structure and reliability assessment of the dyadic trust scale with individuals in same-sex romantic relationships. J GLBT Fam Stud. 2012;8(3):258–69.

  28. 28.

    Salazar LF, Stephenson RB, Sullivan PS, Tarver R. Development and validation of HIV-related dyadic measures for men who have sex with men. J Sex Res. 2013;50(2):164–77.

  29. 29.

    Stephenson R, Finneran C. The IPV-GBM scale: a new scale to measure intimate partner violence among gay and bisexual men. PLoS ONE. 2013;8(6):e62592.

  30. 30.

    Liu H, Feng T, Rhodes AG, Liu H. Assessment of the Chinese version of HIV and homosexuality related stigma scales. Sex Transm Infect. 2009;85(1):65–9.

  31. 31.

    Szymanski DM. Does internalized heterosexism moderate the link between heterosexist events and lesbians' psyschological distress? Sex Roles. 2006;54(3–4):227–34.

  32. 32.

    Hoff CC, Campbell CK, Chakravarty D, Darbes LA. Relationship-based predictors of sexual risk for HIV among MSM couples: a systematic review of the literature. AIDS Behav. 2016;20(12):2873–92.

  33. 33.

    Hoff CC, Chakravarty D, Beougher SC, Neilands TB, Darbes LA. Relationship characteristics associated with sexual risk behavior among MSM in committed relationships. AIDS Patient Care STDS. 2012;26(12):738–45.

  34. 34.

    Stephenson R, Sullivan PS, Salazar LF, Gratzer B, Allen S, Seelbach E. Attitudes towards couples-based HIV testing among MSM in three US cities. AIDS Behav. 2011;15(Suppl 1):S80–S8787.

  35. 35.

    Mimiaga MJ, Closson EF, Kothary V, Mitty JA. Sexual partnerships and considerations for HIV antiretroviral pre-exposure prophylaxis utilization among high-risk substance using men who have sex with men. Arch Sex Behav. 2014;43(1):99–106.

  36. 36.

    Hannaford A, Lipshie-Williams M, Starrels JL, Arnsten JH, Rizzuto J, Cohen P, et al. The use of online posts to identify barriers to and facilitators of HIV pre-exposure prophylaxis (PrEP) among men who have sex with men: a comparison to a systematic review of the peer-reviewed literature. AIDS Behav. 2018;22(4):1080–95.

  37. 37.

    Stephenson R, White D, Mitchell JW. Sexual agreements and perception of HIV prevalence among an online sample of partnered men who have sex with men. Arch Sex Behav. 2015;44(7):1813–9.

  38. 38.

    Gamarel KE, Golub SA. Intimacy motivations and pre-exposure prophylaxis (PrEP) adoption intentions among HIV-negative men who have sex with men (MSM) in romantic relationships. Ann Behav Med. 2015;49(2):177–86.

  39. 39.

    Rios-Spicer R, Darbes L, Hoff C, Sullivan PS, Stephenson R. Sexual agreements: a scoping review of measurement, prevalence and links to health outcomes. AIDS Behav. 2019;23(1):259–71.

  40. 40.

    Safren SA, Blashill AJ, Lee JS, O'Cleirigh C, Tomassili J, Biello KB, et al. Condom-use self-efficacy as a mediator between syndemics and condomless sex in men who have sex with men (MSM). Health Psychol. 2018;37(9):820–7.

  41. 41.

    Stephenson R, Finneran C. Receipt and perpetration of intimate partner violence and condomless anal intercourse among gay and bisexual men in Atlanta. AIDS Behav. 2017;21(8):2253–60.

  42. 42.

    Stephenson R, Freeland R, Finneran C. Intimate partner violence and condom negotiation efficacy among gay and bisexual men in Atlanta. Sex Health. 2016;13(4):366–72.

  43. 43.

    Cabral A, J MB, Ngure K, Velloza J, Odoyo J, J EH, et al. Intimate partner violence and self-reported pre-exposure prophylaxis interruptions among HIV-negative partners in HIV serodiscordant couples in Kenya and Uganda. J Acquir Immune Defic Syndr. 2018; 77(2):154–9.

  44. 44.

    Braksmajer A, Leblanc NM, El-Bassel N, Urban MA, McMahon JM. Feasibility and acceptability of pre-exposure prophylaxis use among women in violent relationships. AIDS Care. 2019;31(4):475–80.

  45. 45.

    Roberts ST, Haberer J, Celum C, Mugo N, Ware NC, Cohen CR, et al. Intimate partner violence and adherence to HIV pre-exposure prophylaxis (PrEP) in African women in HIV serodiscordant relationships: a prospective cohort study. J Acquir Immune Defic Syndr. 2016;73(3):313–22.

  46. 46.

    Garfinkel DB, Alexander KA, McDonald-Mosley R, Willie TC, Decker MR. Predictors of HIV-related risk perception and PrEP acceptability among young adult female family planning patients. AIDS Care. 2017;29(6):751–8.

  47. 47.

    Crepaz N, Tungol-Ashmon MV, Vosburgh HW, Baack BN, Mullins MM. Are couple-based interventions more effective than interventions delivered to individuals in promoting HIV protective behaviors? A meta-analysis. AIDS Care. 2015;27(11):1361–6.

  48. 48.

    El-Bassel N, Gilbert L, Witte S, Wu E, Hunt T, Remien RH. Couple-based HIV prevention in the United States: advantages, gaps, and future directions. J Acquir Immune Defic Syndr. 2010;55(Suppl 2):S98–101.

  49. 49.

    Leblanc NM, Mitchell J. Providers' perceptions of couples' HIV testing and counseling (CHTC): perspectives from a US HIV epicenter. Couple Fam Psychol. 2018;7(1):22–33.

  50. 50.

    Purcell DW, Mizuno Y, Smith DK, Grabbe K, Courtenay-Quick C, Tomlinson H, et al. Incorporating couples-based approaches into HIV prevention for gay and bisexual men: opportunities and challenges. Arch Sex Behav. 2014;43(1):35–46.

  51. 51.

    Li J, Berg CJ, Kramer MR, Haardorfer R, Zlotorzynska M, Sanchez TH. An integrated examination of county- and individual-level factors in relation to HIV pre-exposure prophylaxis awareness, willingness to use, and uptake among men who have sex with men in the US. AIDS Behav. 2018;23(7):1721–36.

  52. 52.

    Eaton LA, Driffin DD, Bauermeister J, Smith H, Conway-Washington C. Minimal awareness and stalled uptake of pre-exposure prophylaxis (PrEP) among at risk, HIV-negative, Black men who have sex with men. AIDS Patient Care STDS. 2015;29(8):423–9.

  53. 53.

    Lelutiu-Weinberger C, Golub SA. Enhancing PrEP access for Black and Latino Men who have sex with men. J Acquir Immune Defic Syndr. 2016;73(5):547–55.

  54. 54.

    Philpot SP, Prestage G, Ellard J, Grulich AE, Bavinton BR. Opposites attract study g: how do gay serodiscordant couples in Sydney, Australia negotiate undetectable viral load for HIV prevention? AIDS Behav. 2018;22(12):3981–90.

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Correspondence to Erin M. Kahle.

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Kahle, E.M., Sharma, A., Sullivan, S. et al. The Influence of Relationship Dynamics and Sexual Agreements on Perceived Partner Support and Benefit of PrEP Use Among Same-Sex Male Couples in the U.S.. AIDS Behav (2020) doi:10.1007/s10461-020-02782-9

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  • HIV
  • Pre-exposure prophylaxis
  • Male couples
  • Relationship dynamics