Building intimacy, managing risk: gay men’s relationships and HIV

HIV Australia | Vol. 12 No. 1 | March 2014

By Ian Down

Ian Down discusses HIV risk within gay and bisexual men’s relationships, drawing on findings from the Seroconversion Study.

According to Gay Community Periodic Survey data, about 60% of Australian gay men are in regular relationships.¹

Since the beginning of the HIV epidemic, gay men have often found intimacy through their relationships while also managing risk of HIV transmission within those relationships, especially through ‘negotiated safety’ whereby HIV-negative men in committed relationships agree to forego condoms with each other while continuing to practise safe sex with all other partners.²

Negotiated safety, applied consistently, can substantially protect men from acquiring HIV.³

The first Australian study of recently HIV-diagnosed gay men, which collected data from 1993–2001, found that 42% had become HIV-positive as a result of sex with a regular partner.⁴

Of the men interviewed during the PHAEDRA study from 2003–2004, 29% reported having acquired HIV through sex with their regular partner.⁵

It is possible that this apparent reduction in proportion of infections between regular partners could be attributed to the success of promoting negotiated safety agreements through the ‘Talk, Test, Test, Trust’ campaign, initiated by ACON in 1996.

However, while currently about three quarters of regular relationships are between men who are seroconcordant (where both partners are of the same HIV status), the proportion of HIV-negative men with a negotiated safety agreement has been falling over the years, from about 70% in 2007 to just below in 30% in 2012.⁶

Negotiated safety has remained a component of many peer education workshops, and there has been an increased, and much needed, focus on men in committed serodiscordant relationships (where partners have mixed HIV status).

However, over the past decade there has been less attention paid to reminding men of the necessary components required to implement relationship agreements successfully, including on how men can manage HIV risk within the broad range of relationship styles found among gay men.7

The HIV Seroconversion Study

The Seroconversion Study collects data from people in Australia recently diagnosed with HIV, to help understand the factors associated with recent HIV infection, and learn about the experiences of being recently diagnosed with HIV.

The current version of the study began in 2007. Since then, 506 gay and bisexual men have completed the online survey, 95 of whom were also interviewed.

Participants are asked about their relationships at the time of the high-risk event they believe led to their seroconversion, and about their relationship with the person from whom they believe they acquired their infection. More recently, we have begun asking about the nature of the participant’s relationships since their diagnosis.

Men’s relationships at time of the high-risk event

Less than a third (30%) of the gay and bisexual men in the current Seroconversion Study reported that they had a regular male partner at the time of their high-risk event. While more than half these relationships were of more than two years duration, a significant proportion, one in five, were of less than six months duration.

Most (84%) of the men in regular relationships knew the HIV status of their partner at the time of the high-risk event; 70% believed that partner to be HIV-negative, while 14% believed them to be HIV-positive. Still, one in six did not know their partner’s status at that time.

About half the gay and bisexual men with regular partners engaged in receptive unprotected anal during the six months prior to their diagnosis, regardless of that partner’s HIV status, while one in three engaged in insertive UAI with those partners.

Of the gay and bisexual men in a regular relationship at the time of the high-risk event, more than half reported having more than one regular partner, such as a ‘fuckbuddy’, in the six months prior to testing HIV-positive; the average number of other regular partners was four.

About a quarter of men with regular male partners also engaged in receptive UAI with casual partners, while one in five engaged in insertive UAI with casual partners.

Relationship to source person

In the current version of the study, gay and bisexual men are asked to distinguish between regular male partners they considered to be their primary partner, or ‘boyfriend’, and regular male sex partners they considered to be ‘fuckbuddies’ or ‘friends with benefits’.

Just 11% of men reported sex with their boyfriend on the occasion they believe they acquired HIV, 23% indicated it was through sex with a fuckbuddy, while for the majority (61%) this was through sex with a casual male partner.

When compared with those men who acquired HIV from their boyfriend, men who believed that they had contracted HIV from a fuckbuddy were less likely to describe that person as someone they knew well (34% versus 79%), and were more likely not to know the HIV status of that partner (40% versus 9%).

Only 6% reported that the source person was a boyfriend of more than three months standing. Among the men in the sample who reported that the source person was a casual partner, almost a third (31%) reported some prior acquaintance with that partner, and one in five (21%) reported having had sex with them on a previous occasion – almost three quarters of whom had had sex with them on more than one previous occasion.

In interviews, men described a desire for intimacy and connection in situations where there was an ongoing acquaintance with the partner considered to be the source person.

This was usually expressed as a connection with someone they felt they knew or could trust and with whom they wanted to share a close sense of intimacy.

Building capacity to reduce HIV transmission in relationships

Few gay men appear to acquire HIV from long-term committed regular partners. Tools to assist gay men in negotiating agreements in short-term and non-committed relationships may assist in HIV prevention.

Health promotion initiatives that portray gay men’s relationships, particularly relatively short-term sexual relationships – whether they are with an acknowledged regular partner or a relatively new friendship or other acquaintance that includes a sexual component – may help reduce HIV transmissions within these kinds of partnerships.

Additionally, it would be useful to consider the implications of issues of trust, and what resources might be provided to enable individuals to make decisions about risk behaviour that might assist men to distinguish when and under what circumstances this trust can be considered reliable.

Skills to help men negotiate agreements with multiple regular sex partners, and to communicate when agreements break down could further help. Pre-exposure prophylaxis (PrEP) may also offer an appropriate alternative option for some men in these situations.

The Seroconversion Study continues to recruit people in Australia recently diagnosed with HIV. Anyone who has been diagnosed as HIV-positive in the past two years can join the study at www.hivss.net. The 2013 study report is now available to download from the study website.

For further information, please contact Ian Down on (02) 9385 9954 or at idown@kirby.unsw.edu.au.

References

1 de Wit, J., Mao, L., Holt, M., Treloar, C. (Eds.) (2013). HIV/AIDS, hepatitis and sexually transmissible infections in Australia: Annual report of trends in behaviour 2013 (Monograph 6/2013).Centre for Social Research in Health, The University of New South Wales, Sydney.

2 Kippax, S., Crawford, J., Davis, M., Rodden, P., Dowsett, G. (2013). Sustaining safe sex: a longitudinal study of a sample of homosexual men. AIDS, 7, 257–263.

3 Jin, F., Crawford, J., Prestage, G., Zablotska, I., Imrie, J., Kippax, S., et al. (2009). Unprotected anal intercourse, risk reduction behaviours, and subsequent HIV infection in a cohort of homosexual men. AIDS, 23(2), 243–252.

4 Kippax, S., Slavin, S., Ellard, J., Hendry, O., Richters, J., Grulich, A., et al. (2003). Seroconversion in context. AIDS Care, 15(6), 839–852.

5 Volk, J., Prestage, G., Jin, F., Kaldor, J., Ellard, J., Kippax, S. (2006). Risk factors for HIV seroconversion in homosexual men in Australia. Sexual Health, 3(1), 45–51.

6 Prestage, G., Jin, F., Zablotska, I., Grulich, A., Imrie, J., Kaldor, J., et al. (2008). Trends in agreements between regular partners among gay men in Sydney, Melbourne and Brisbane, Australia. AIDS Behav, 12(3), 513–520.

Ian Down is Associate Lecturer for the HIV Epidemiology and Prevention Program at The Kirby Institute, University of New South Wales and the Australian Research Centre in Sex, Health and Society, La Trobe University.