Whenever I see news reports about anything related to HIV, I have to brace myself for the parts with numbers. Not because I'm afraid of numbers – I'm geeky enough to have participated in math contests when I was in high school, and even won prizes at them (math books). No, I brace myself for what people will do with numbers to try to validate their points of view. 

Most of the uses of numbers that leave me shaking my head involve a lack of context. A classic is the use of percentages to describe trends in HIV infections. First of all, one should be clear that in our society without compulsory and regular testing of the entire population, we are usually talking about statistics regarding diagnoses, and only sometimes about estimates of actual HIV infections. Second, one can't compare on pure percentage changes in these diagnoses without suggesting that an increase of diagnoses in a particular group from 2 to 4 (100%) is somehow more significant than an increase in another group from 300 to 303 (1%). If you see the percentages, you need to also look for the numbers. 

When you don't see the absolute numbers, you might not understand other aspects of the meaning of what you are seeing. It is all well and good to say that gay men are an increasing portion of the new diagnoses, but are they a bigger slice of a shrinking or stable pie? Could those absolute numbers also be decreasing, while the percentage goes up? The percentages won't tell you that on their own. 

There are other times when the absolute numbers on their own don't tell the whole story. I remember my own reaction in the context of a national meeting once when someone from a more rural area talked about a "huge" increase in people being seen in the local AIDS organization. The number was 4 or 5 in the past year. The organization I worked for at the time regularly welcomed between 40 and 60 new HIV positive people every year, and it was only one of almost twenty organizations in the city. In the context of the population of the region being served, however, those 4 or 5 people were probably very significant. 

Another little statistical game occurs in the classifying of the data. It is a very difficult task to classify people when we are talking about those numbers of new diagnoses. People don't stay in their own boxes, so might just fit into several different categories or might even justify a new category that epidemiologists and those responsible for surveillance are not ready to create (it's difficult to follow trends when you keep splitting the lines into their sub-categories). There's more than a little interpretation involved in the classifying, so it's worth asking questions about the results. 

One of the things that has most annoyed me recently is the interpretation of how prevalent condom use is among gay men. We all know the community started at zero – or almost zero – condom use at the beginning of the 1980s, adopted the condom strategy extremely successfully, and that use seems to have declined lately. When the proof of that decline is shrouded in odd definitions, however, I get suspicious. I recently saw one definition that classified people into two groups: those who have consistently used condoms in the last six months, and those who had at least one incident of not using a condom in the last six months. Now suddenly the portrait is of condom-users and condom-eschewers and the person who had sex sixty times in the last six months, only once without a condom, finds himself in the latter group. That's how you get to a rate of consistent condom use somewhere south of 30%, but it doesn't seem to be a very accurate portrait, does it? 

Although I have not entered any math contests lately, I reiterate my geeky childhood love of numbers. I just have to add to that love a cheeky appreciation of context and a freaky suspicion that will always drive me to see what else my little number friends might be telling me. Or hiding from me.

When I first was diagnosed as HIV+, I remember being thankful for all the infrastructure in place to help me ensure that I wasn’t going to die of AIDS.  Whether it was through Philadelphia’s AIDS Activities Coordination Office or my initial visits to Philadelphia FIGHT, I received a care and attention that, just a decade or two ago, would be considered remarkable.  And, thanks to scientific advancements by pharmaceutical companies like Gilead, in part because of the United States government’s tardy, but right, confrontation of HIV/AIDS, my life expectancy is around 70, and I experience mild, if any, side effects.  Even more gratifying is the fact that these side effects have seemingly subsided now that I’ve been on medication for several months and am, happily, undetectable.  This means that, so long as I keep taking my once-a-day single pill Complera, there exists no measurable amount of HIV in my bloodstream, that I am, effectively, neutered from passing on HIV to anyone else, even if I have bareback sex, and that HIV cannot hurt me, generally. 

At the time of my diagnosis, though, I remember thinking, “Now, how am I supposed to have sex?” 

Notwithstanding all the tools, helpful professionals, and worthy mission-driven organizations here in Philadelphia, I was still at a loss as to how, exactly, I was supposed to navigate the gay sex and dating world in modern, iPhone hook up app based society.  In fact, I effectively tabled this personal discussion I was having with myself in favor of overtly sexual, overtly bareback, and thus only HIV+ majority population, sexual situations.  For example, there was a solid year where I would only go to bathhouses and sex parties for sexual gratification; after all, in an environment where everyone is barebacking, where everyone is specifically there to have sex, and where everyone, like it or not, has implicitly offered their informed consent to engage in these behaviors by their very participation in these behaviors, there is no need to say, “Excuse me, sir, but before you put your condomless penis into my anus, I’d like to show you my most recent results from Labcorp in Raritan, NJ, which detail that my CD4 count is a little low but that my HIV viral load is undetectable.”

Frankly, personal health matters are of little relevance or concern in overtly sexual, and bareback, environments, and anyone who claims anything to the contrary either doesn’t participate in these activities, and as such has no stakeholdership in the discussion, or they are complete and utter hypocrites (reformed pigs who hilariously take a “Do as I say, not as I have done” attitude in relation to HIV prevention, and who often make a living offering bad advice that won’t be used by anyone, I’m looking at you.  Many of you are HIV+ for a reason, and it isn’t because you had conservative sexual tastes.)

Even so, the longer I’ve been HIV+, the more traditional and, admittedly, boring I have become in relation to my sex and dating.  After all, at the end of the day, you can have all the piggish fun you want in a sling, but nobody who happens by your room at the bathhouse is going to want to cuddle or make dinner for you.  That isn’t to say these behaviors are bad; in fact, I routinely affirm that these exploits in bathhouses and sex parties are natural, fun, and, if done for the right reasons, perfectly healthy.  Yet, I still grapple with the best way to figure out how to easily normalize my relations with monogamy, dating, and more traditional concepts of coupling with my HIV status.  This tightrope walk of being honest with potential sex partners and boyfriends while still casting a net wide enough to actually engage in sex and dating is one that, I think, a great many of us who are HIV+ table, like I did, in favour of situations where we don’t even have to address it (like bathhouses.)  And, when we do try to be open, honest, and informative with our sex and dating partners, the results are, quite often, disheartening.

For instance, recently, I got a man’s number in a local gay bar.  We flirted relentlessly, and we both were obviously sexually attracted to each other.  So, just as our later text conversation started delving into matters that were the standard precursor to engaging in naked time together, I disclosed my HIV status.  His reaction was, at least in my insecure HIV focused insecurity based mind, predictable.  Feigning ambivalence, he, nonetheless, tellingly grew rather cool in the previously hot rapid fire text messaging conversation.  Then, he stopped messaging me altogether.  And, finally, in an attempt to salvage his politeness, said that he was tired.

Now, as I stated, I could entirely be infusing my own preconceived insecurities onto this man who very may well have been tired and entirely fine with my HIV status.  Or, as is the case with a large enough number of potential partners for me to write about it today, situations of which I have literally scores of conversation screenshots that I could chronicle in annoying detail here, he got spooked at the my mentioning of HIV and, in order to play the part of accepting, open-minded progressive, he feigned ambivalence, ran for the hills, and blamed being tired for our 180 away from having sex.  This approach, if that’s the case, while well-meaning, is annoying and compounds the difficulty those of us living with HIV already face in relation to sex and dating.  Frankly, I would much rather someone say, “Ick, gay plague,” and dismiss me summarily rather than “Oh that’s fine *oh god please no*, I’m okay with it *oh god can you get it from kissing?*”  After all, time is a premium for those of us facing death if we don’t continue to have wide, and free, access to antiretroviral medication.

This type of experience, of trying to do the right thing in disclosing and receiving little, if any, benefit to disclosing reinforces my, unfortunately relationship limiting and hostile-to-cuddling, default attraction to overtly sexual, overtly bareback outlets through which to meet men and have sex.

 Make no mistake, I am not complaining about this reality, nor am I demanding that the world do something.  Instead, I’m simply politely suggesting that we should be a little more candid with each other; I truly would never want to put anyone in a position where they were tolerating having sex with me under the ridiculous notion that they had to prove their compassionate bona fides.  Conversely, I would hope that others wouldn’t want to put me in a position where I see little benefit to disclosing my HIV status or where others blatantly lie about their status in order to have sex.  This latter group is rampant, based only my anecdotal and admittedly unscientific, personal knowledge, and while I agree with these men in that there is no statistically significant or scientifically probable chance of their transmitting HIV to sexual partners, and thus the idea of HIV status is, essentially, moot, I still cannot very well reconcile my own demands of candor and honesty along with finding sex partners and dates under false, and disrespectful, premises.

Then again, the guys who don’t talk about HIV whatsoever are also the ones who are, seemingly, having a lot more sex than I am.  So, what do I know?

This article originally appeared on Josh’s own blog here. 

“I’m a young African American male, and I have AIDS,” so quoted my priest who is really a middle-aged white guy, straight, and married with grown children.

The script, which my priest read from, was all part of a service recognizing World AIDS Day last December 1^st. The prepared program, held every year, included a handful of well-intentioned faith leaders in the community all playing the roles of someone with AIDS. Following my priest, an older lady, who reminded me of one of those sensible shoe-wearing substitutes we used to get in junior high school, spoke about contracting AIDS through unprotected sex with multiple partners. This was an image that I found quite disturbing. Maybe it’s because I just couldn’t get past my priest telling us all he was really a black man in disguise, but the whole scene was lacking in any kind of credibility for it to be taken too seriously. The only meaningful testimony was when a mother of a young man who died of AIDS came to the podium.

“What did he do wrong?” she asked. “All he did was go looking for love. He just found it in all the wrong places.”

Of course, I have heard this woman speak for the last several years, and every time I hear her talk about her son, I am touched by her honesty and confusion as to why her son died so young. Her talk was brief though, and she said the same thing that she has been saying every year. It seems like she would have gained some insights. Although she was moving, it felt a little like the auntie who repeats the same stories over and over again during reunions just to get some attention.

What was missing in this whole service was someone with AIDS. I live in a metropolitan area with an HIV/AIDS support center. Why wasn’t someone with AIDS speaking at an AIDS event?  Now, I know it takes a good amount of courage to bare your soul in public, and I understand why those with the AIDS virus want to stay in the closet. They have been stigmatized and hurt, especially by the LGBT community. Friends, jobs, and families can be lost. However, had it not been for all those brave souls with ACT-UP, many of whom had AIDS, we never would have made the progress in treating those with HIV/AIDS. All those people put their jobs, relationships and personal health on the line to fight for the common good so that other’s lives could be saved.

Come forward. We are with you. Don’t be afraid. Without people living with HIV participating in all levels of HIV/AIDS awareness, education, research and support programs, there is no passion and therefore no motivation to move forward. Even if you work behind the scenes, it makes a difference. I really don’t want to go to another World AIDS Day event, and have an old lady tell me she has been promiscuous with strangers. I want people living with HIV to come out of the closet.

Last week I celebrated 5 years of LIVING with HIV and while I’m fully aware of just how different my life is since being told I was HIV-positive, it wasn’t until today that I really stopped to pay full attention to just how incredibly blessed my life is and how thankful I am for everything that has transpired in my life.

The first year of being diagnosed was a complete nightmare because I was homeless, sick and everything in my life was temporary. I even switched doctors four times and three clinics before finding a doctor and clinic I trust completely. Part of the reason I’m living where I’ve lived for almost four years now is a direct result of my current doctor and clinic.

I remember my Ma once telling “from the time you came into this world you’ve been a fighter and always striving to live against all odds”.  She was talking about the fact that I was born with Sickle Cell. Nothing has changed since my birth; LIVING has always been my plan. Even through my battles with cancer, through homelessness and now LIFE with HIV. The only option has been to LIVE. In fact I recall my Pops once saying to me “if you have a plan ‘B’, then your plan ‘A’ aint worth a damn” So for me LIVING has been my ONLY plan, my ONLY option.

I had to basically figure out the ins and outs of HIV all on my own the first year. There was no such thing as “community” support in my life and ya’ll already know how I feel about the word “community”.  I was my own support system.

I made the choice to LIVE, even in the midst of an entire world being upside down, inside out and totally flipped. I was not going to be a victim, nor was I going to hide in shame and I certainly was not going to believe that I was damaged or no longer worthy of being loved. I refused to run from support group to support group and not truly move forward with my life. I know support groups work well for some people, but for me that represented a full and complete surrender; for me they represented guilt, shame, silence and the closet of HIV. Closets are for clothes and where you hide things you don’t want company to see. They’re not a place for people who want to LIVE.

I’ve surrounded myself with people who are creative, out of the box self-thinkers.  People who don’t give a rat’s ass about my HIV status, but are willing to listen and learn about HIV when I talk or want to share some information with them. People who do not subscribe to groupthink mentality of any form . In doing so I have some pretty amazing people in my life.

A major part of my choice to LIVE is tied to me being completely honest about my HIV status and not being afraid or ashamed to talk about it with anyone at any time.  In being as open and honest as I’ve been this has meant that some people will choose not be get to know me, not want to work with me or even stand or sit near me, but those are their own issues and demons that they must deal with. I refuse to take the low pulpit in order to make someone else feel comfortable about my HIV status.

LIVING also requires that I am fully and totally honest, without any reservation about disclosing my HIV status to someone I may fuck or begin to develop a relationship with. This has not been hard for me because I don’t fuck or suck any Tom’s dick that’s hairy. Full disclosure speaks to who I am and exposes the depth and strength of my character which is turns speaks volumes about who I am as a human being. Full disclosure means I’m FULLY in charge, on board with and accepting of the fact that I’m HIV positive and with this comes responsibility. However this does not mean that some knucklehead may choose to look past me because of my status. But if this is the case, then they are someone I wouldn’t want in my life to begin with.

So as I look back over the past five years I see so much growth, but I also see where my foundation remains solid and unbreakable. I am so very thankful for everything that has happened in my life….even the bad things and things that caused me so much hurt, pain and tears.

My friends say to me all the time “When I look at you I don’t see someone with HIV. I see someone who is living and enjoying their life”

If I were to die today, I know none of my friends would mention HIV at my home going service, because they know HIV is irrelevant in my LIFE.

Writing my last blog post was very difficult for me. It was a very emotional topic and I found it a mental battle to keep my thoughts and feelings in check.  Like many women, the events made me incredibly angry that, even today, we have to argue that women have the right not to be raped. It is so preposterous that we even need to discuss these issues anymore. It is disheartening.  And yet, when I finished that post, I knew my next blog post would be about hope.

You may recall an earlier post on International Women’s Day where I pondered the absence of men in events to do with women’s rights and women’s health. My musings turned out to foreshadow what would be dismal participation by men in our otherwise successful International Women’s Day events. No men showed up to a film screening on the history of Canadian feminism at the public library. No men showed up to the lecture on HIV campaigns and their (mis)representation of women by a professor of Sociology on campus.  Two men (ACG’s Executive Director and a member of our Board of Directors) showed up at our HIV & Pregnancy forum for medical & social service workers - two men, that is, out of 65 participants. And at our Women on the Bridge event, the small number of men in attendance seemed to have an organizational or political affiliation. It reinforced my feelings that somehow we are in this alone.

And so it was with some spark of hope that I began to see men respond to the issues around violence against women and rape culture as news of Steubenville infiltrated the media. There was word from Patrick Stewart. And George Takei. And Henry Rollins.

And then, of course, there were the women. The social media response to the rape culture problem has been amazing. Finally, we are seeing healthy, powerful messages broadcast through media (especially social media). For instance, the message that no woman – regardless of what she wears, what she drinks, or what she says, deserves to be raped. The message that victim blaming is not an appropriate response to rape. The message that we need to, finally, teach boys not to rape. These messages have been loud and clear – in countless campaigns, public service announcements, blog posts, you-tube videos, protests, memes and graphics. It truly gives me hope to see so much concerted effort towards this issue, and much of it youth-oriented, powerful, fresh - even fun.

But nothing has given me as much hope as the open letter by Melissa Harris-Perry.

It immediately re-shifted my focus. As a global community we have been discussing the problems with rape culture - as we should be.  But as much as we need to discuss these problems, there is something that is very good here. The young woman who was raped (and I say “young woman” because I suspect any identity of “girlhood” is gone now) had the bravery to come forward and the tenacity to persist through the god-awful trial. What she has endured will no doubt complicate her life with trauma. It will undoubtedly complicate her relationship with the world, with her body, with her relationships. But I hope she can someday see herself as someone who stood up for the rights of women worldwide. 

When women push towards their rights, they are often punished – socially, if not legally, physically, financially.  The social media smearing and shaming and the CNN coverage were evidence of this. But by going through with the trial and enduring all of it, this young woman helped to address some very serious issues and bring these issues to light.

The boys’ sentence, however mild, was still enforced, and this is a very good thing. I believe it was Emile Durkheim who theorized that the law is not a tool to enforce justice, but a tool used to solidify and reaffirm the existing moral code of a society. Using this theoretical framework, we can imagine that the boys’ sentence helps to reinforce a moral code which says women do not deserve to be raped - no matter what.

Because this young woman persevered, these issues became the catalyst to get a lot of people raising concerns about rape culture and finding new, interesting, colourful ways to change these cultural attitudes. Because of her, many new people are speaking about these issues and discussing them in different ways. It is not because of the rape itself that these positive things are happening, for rapes happen all the time. It is because she made the choice to proceed with the trial and use her voice, if only by being honest, to make a stand for women’s rights over their bodies and their lives.

Sometimes women activists don’t even realize that what they are doing is powerful and perhaps this is the case for this young woman. I hope then, that someday she can reshape her identity. Not as “slut” as so many have called her and not as “victim” either. I hope she can reshape her identity to acknowledge her strength, and her power.

From Rosa Parks, “Quiet Strength:”

I did not get on the bus to get arrested; I got on the bus to go home...  I had no idea that history was being made. I was just tired of giving in. Somehow I felt that what I did was right by standing up to that bus driver. I did not think about the consequences. I knew that I could have been lynched, manhandled, or beaten when the police came. I chose not to move. When I made that decision, I knew that I had the strength of my ancestors with me.

This article by Roger Pebody  first appeared on aidsmap.com here.  

The majority of American gay men in relationships say they establish a ‘sexual agreement’ with their partner, both to minimise HIV risks and to maintain the quality of their relationship, according to research published online ahead of print by the Journal of Sex Research last month.

However, partners do not always agree on whether they have an agreement, on whether it was explicitly discussed, or on what sex is allowed with other people. And the agreement had been broken by one or both partners in just under half the couples studied.

The study has also found that around a quarter of the HIV-negative men who have casual sex attempt to 'serosort' or use 'strategic positioning' when doing so. However, regular HIV testing was far from universal in this group, making such practices potentially unreliable.

“From a public health perspective, we need to encourage gay couples to have more honest and explicit discussions when establishing and honouring sexual agreements,” commented Dr Jason Mitchell of the University of Michigan, who conducted the research. “Sexual agreements are not only advantageous from a prevention standpoint for couples, but the agreement can also help strengthen their relationship.”

A sexual agreement is made between two individuals, and concerns what sexual behaviour may occur within and outside their relationship. Some agreements may simply clarify that sex is not permitted with other people. Other agreements may concern the relationship being ‘open’ to a lesser or greater extent. Many couples use agreements, in part, to limit their risk of HIV infection.

A couples study

Jason Mitchell’s study recruited both partners in couples and compared their responses, rather than relying on just one partner’s perspective. Men were recruited to this cross-sectional online survey via adverts on Facebook in 2011 – the advertising was targeted to reach individuals whose profile information indicated that they might be a man in a relationship with a man. The first participants provided the email address of their partners, who were then contacted and asked to complete the survey.

The study recruited 722 men (361 couples). This was a predominantly white (77%) and relatively well-educated sample, with a mean age of 33, all living in the United States. Couples had been together for an average of an average of five years; three-quarters were living together.

One in eight men had been diagnosed with HIV. Half of them were in a relationship with another man with HIV, and half with an HIV-negative man (i.e. in a 'serodifferent' or ‘serodiscordant’ relationship).

Most men reported that they were HIV negative. (Just 3% of the sample reported that they did not know their HIV status.) However, one in five of the ‘HIV-negative’ men had not tested since the beginning of their relationship, and on average, HIV-negative men had last taken an HIV test two years ago. There was considerable diversity in the men’s HIV testing practices, with a minority testing much more frequently than others.

On average, men said that they had discussed their HIV status 12 days into the relationship, and this occurred before the couple started having unprotected sex (a mean of 81 days into the relationship). However, when the couple made a sexual agreement, this typically occurred much later – 174 days into the relationship. 

Agreements

Although seven in ten men reported having a sexual agreement, this perspective was not always shared by the man’s partner. In 57% of couples both men agreed that they had a sexual agreement, but in 25% of couples, one man thought there was an agreement, while his partner said that there wasn’t.

Amongst those couples who agreed that they had agreed, 58% said that there had been an explicit discussion, while 11% reported that their understanding was more implied or assumed. In a further 31% of cases, one partner had thought they had had an explicit discussion, while his partner thought that it was implicit.

For 56% of men who thought they had an agreement, it was that the relationship was monogamous.

For a further 41%, the agreement was to permit sex with casual partners, but with some rules or guidelines. For the last 3%, there was an open relationship, without any conditions.

Responses detailing what was permitted for those with open relationship guidelines showed that around a quarter actually permitted unprotected anal sex with casual partners. While the data shows that some couples had different rules for receptive and insertive sex, and for withdrawal before ejaculation, respondents were not asked whether there were conditions based on the partner’s HIV status and seroadaptive behaviours.

Far more couples allowed oral sex and masturbation.

Open relationship guidelines were not just about the risk of infections, but also about intimacy and context. Having sex with a casual partner on more than one occasion, physically sleeping together and dating were all permitted by half or less of couples, whereas threesomes or group sex were allowed by 81%.

Men’s motivations for making agreements were not just about minimising the risk of HIV or sexually transmitted infections, although this was the most common primary reason, cited by 23%. Other important reasons included wanting monogamy or exclusivity; fulfilling sexual desires; establishing guidelines so as to manage expectations; and building and maintaining trust.

Jason Mitchell did not analyse motivations by type of agreement, but in a separate study, another group of researchers previously found that the themes of trust, honesty and strengthening the relationship were predominant in the motivations both of men with open agreements and men with monogamy agreements.

Breaking agreements

Looking at couples, including those with an agreement to monogamy, in 46% of cases, either one or both partners had broken the rules at some point during the relationship.

But in the previous three months, 80% of couples had stuck to their rules. In 15% of the couples, one partner had broken the agreement, and in 5% both partners had.

The main reasons for breaking agreements were sexual frustration and the ‘heat of the moment’. Only a minority of men (30%) told their partner that they had broken the agreement. Reasons given for not disclosing included not giving the partner a reason not to trust the respondent and fearing that this could lead to the relationship ending.

Risk reduction strategies

In a separate article, published in AIDS & Behavior in December, Jason Mitchell has also reported on the risk-reduction strategies employed by this group of men, both inside and outside of their primary relationships.

He was interested in strategies such as serosorting, strategic positioning, 100% condom use and taking undetectable viral load into account.

This analysis is especially interesting because Mitchell actually asked respondents whether they had used strategies to reduce their risk of HIV or sexually transmitted infections. In contrast, most other studies on this topic have examined the pattern of men’s sexual practices with partners of different HIV statuses, and attempted to infer whether there was a strategy in place or not.

It therefore hasn’t been clear from previous research whether the conscious and deliberate use of strategies such as strategic positioning is something widely practiced by gay men, or just a minority pursuit.

For this couple-based analysis, those couples in which both partners had diagnosed HIV were excluded. Participants were asked about strategies used in the last previous three months – they could name more than one strategy, either because strategies were combined, or because different strategies were used in different situations.  

Always using condoms for anal sex, or always doing so with an HIV-positive partner, was reported by a minority of men. Within the main relationship, 15% of HIV-negative couples (i.e. in which both partners thought they were negative) always used condoms, rising to 38% of serodifferent couples (i.e. in which one partner had HIV and the other did not).

When having sex outside the relationship, 38% of men always used a condom for anal sex.

Only having oral sex and never anal sex was reported, for the main relationship, by 23% of HIV-negative couples and 31% of serodifferent couples. This strategy was more commonly reported for sex with casual partners – by 51% of men.

'Serosorting' (having unprotected anal intercourse [UAI] with a partner because he was thought to have the same HIV status) was reported by 66% of HIV-negative couples. Moreover, this was also reported for sex with casual partners, by 27% of men.

‘Strategic positioning’ (only having UAI with the HIV-positive partner in the receptive role) was reported, for the main relationship, by 32% of serodifferent couples. During casual sex, it was also reported by 23% of men.

Having unprotected sex because the HIV-positive partner was either taking HIV treatment or had an undetectable viral load was reported by 24% of serodifferent couples.

It was much less commonly employed as a strategy with casual partners – by 1% of men in an HIV-negative couple and 14% of men in a serodifferent couple

Finally, it’s important to note that a significant proportion of men did not have a risk-reduction strategy at all, especially with their main partner. One of the answers men could choose was ‘‘regardless of HIV-status, we never use condoms and ejaculate inside’’.

For their primary relationship, 24% of HIV-negative couples and 22% of serodifferent couples chose this answer. It was also chosen by 9% of men having sex outside the relationship.

Overall, having unprotected sex within the main relationship (in the last three months) was reported by 87% of HIV-negative couples and 69% of serodifferent couples. Moreover, for 16% of couples, there had been unprotected sex both with the main partner and at least one casual partner during the same time frame.

Improving the quality of agreements

Clearly, with a number of couples permitting unprotected anal sex outside of the relationship and with a significant minority of men breaking agreements in one way or another, there are risks that HIV can be brought into relationships.

The research highlights a number of other limitations of some men’s sexual agreements, in terms of the frequency of HIV testing, the discrepancy in partners’ perceptions of whether there is an agreement and what it entails, and the quality of communication following breaks in an agreement.

This suggests that HIV-prevention interventions which support men in strengthening their relationships and in making better agreements would be warranted.

One such approach that is being piloted is couples voluntary counselling and testing, in which couples take an HIV test and receive the results together. The focus of the counselling is not on past sexual history, but on how the couple wish to manage the risk of HIV in the future. Quantitative and qualitative research suggests that this is an intervention that many men in relationships would be interested in.

References

Mitchell JW Characteristics and Allowed Behaviors of Gay Male Couples' Sexual Agreements. Journal of Sex Research, online ahead of print, 2013. (Abstract here)

Mitchell JW, Petroll AE Patterns of HIV and sexually transmitted infection testing among men who have sex with men couples in the United States. Sexually Transmitted Diseases 39: 871-876, 2012. (Abstract here)

Mitchell JW HIV-Negative and HIV-Discordant Gay Male Couples' Use of HIV Risk-Reduction Strategies: Differences by Partner Type and Couples' HIV-Status. AIDS & Behavior, online ahead of print, 2012. (Abstract here)