The present study showed that the majority of HIV-positive MSM reported engaging in safer sexual behavior either though abstinence or consistent condom use for anal sex. Nonetheless, a high number of men who had had anal sex reported that they had not used condoms consistently with steady and casual sex partners. Results further indicated that HIV-positive MSM were more likely to engage in unprotected anal intercourse in the context of casual sex encounters than in steady sexual relationships (overall 34.1% and 24.7%, respectively). This finding was consistent with patterns of sexual risk behavior observed in other populations of HIV-positive MSM (cf. Crepaz & Marks, 2002
In this study, we tested a model of factors that influence intended condom use for anal sex with steady and casual sex partners. The results showed that, compared with the TPB (Ajzen, 1991
), our proposed model of sexual decision-making led to a significant increase of explained variance from 53% to 62% for steady sex partners and from 52% to 68% for casual sex partners. Furthermore, evidence was obtained for the mediating role of personal norms on intended condom use with both steady and casual sex partners, suggesting that moral issues play an important role. However, the study also showed that sexual motives may undermine the influence of personal norms on intended condom use in the context of casual sex, with the likelihood of unprotected sexual intercourse. Taken together, the results revealed strong support for our model of sexual decision-making.
In this study, the finding that personal norms appeared to exert a strong direct effect on intention to use condoms with both steady and casual partners was consistent with results of earlier studies that suggest that safer sex in HIV-positive MSM is largely determined by moral concerns or feelings of personal responsibility (e.g., Godin et al., 1996
). Moreover, this finding lends further indirect support to the proposition that condom use behavior among HIV-positive MSM is a form of prosocial behavior (e.g., Kok, 1999
; Nimmons, 1998
). For steady partners, personal norms were identified as the most proximal determinant of intended condom use, whereas an indirect effect was found for self-efficacy on intended condom use through personal norms. Furthermore, some evidence that personal norms mediate the tentative effect of subjective norms on intended condom use with steady sex partners was found. Similar results were found for intended condom use with casual sex partners. However, we also found an additional indirect effect of ascription of responsibility on intended condom use through personal norms. These findings are important because they underscore the need to take into account the role of social expectations, self-efficacy expectations, and attributions about responsibility for condom use in promoting feelings of moral obligation-a process that has not been identified in previous research on sexual risk behavior in HIV-positive MSM.
Furthermore, in the case of casual sex partners, condom use intention was not only directly related to personal norms, but was also negatively influenced by sexual motives for unprotected anal sex. Thus, the findings from this study suggest that the need to engage in unprotected anal sex for physical and emotional satisfaction may supercede the prosocial motivation for safer sex. The fact that sexual motives contributed toward explaining intended condom use in casual sex encounters but not in steady relationships does not imply that sexual motives are not important in the context of steady sex. More likely, there are some differences between steady and casual sex that encourage HIV-positive MSM to suppress sexual motives within the context of steady relationships but not within casual sex encounters. As discussed previously, a possible explanation may lie in the so-called affect-heuristic. In the context of casual sex, the benefits of unprotected sex may be more salient, thus resulting in a decreased assessment of risk. It is worth noting that the affect-heuristic is especially likely to color judgments under time pressure, which may play a more important role in the context of casual sex (Finucane et al., 2000
). The “Coolidge effect” may also explain why sexual motives play a role in the casual sexual context, but not in steady sexual relationships. The Coolidge effect refers to enhanced sexual arousal that is felt when sexual stimuli and partners are novel (Gregoire, 1999
A final explanation may be the greater ambivalence that HIV-positive MSM experience in casual sex encounters as opposed to steady relationships. Greater ambivalence is likely to result in a reduction in both behavioral intention and actual behavior. In addition, people who experience ambivalence are more easily persuaded (Conner & Armitage, 2000
). It may be that pointing out the potential for casual sex partners to become steady partners in the future could increase the perceived benefits of safer sex, thus facilitating prosocial motivation to engage in protected sex. Indeed, the study by van Kesteren et al. (2005
) suggests that such a mechanism exists. Further, the results of this study demonstrated that the use of antiviral therapy was associated with a greater intention to use condoms with casual sex partners. To date, inconclusive evidence exists regarding the association between the use of antiviral therapy and unprotected sex (for a meta-analysis, see Crepaz, Hart, & Marks, 2004
Some study considerations and limitations and implications for practice should be mentioned. First, as Ajzen and Fishbein (1970
) held, it may be argued that the important role of personal norms as a predictor of intention can be attributed to a certain amount of overlap between the measures of personal norms and intention. In this study, high correlations were found between personal norms and intention. On theoretical grounds, however, it seems imperative to distinguish personal norms from intentions. As Manstead (2000
) argued, holding the belief that something is morally “right” or “wrong” is not the same as the perceived likelihood of performing certain behaviors. Consequently, an individual may feel a personal obligation to act in a certain way, but intend to behave in a way that is contradictory to his personal norm because the personal or social advantages of acting inconsistently with his personal norm outweigh the personal or social advantages of acting consistently with the norm. Second, it should be noted that the data were cross-sectional, which hampers conclusions about causality. Due to the cross-sectional design, we did not specifically address the relationship between the psychosocial factors and behavior. It should be noted, however, that tentative support for our model was found in an additional analysis when intention was examined as a mediator of the personal norms-behavior relationship, both for steady and casual sex partners. Yet, longitudinal studies are needed to determine causative relationships between the measured constructs. A third limitation of the present study concerns the use of a single-item approach to measure awareness of consequences, as single-item measures are known to be less reliable. This issue merits attention in future research. Finally, the sample used in this study warrants some concern. More than 70% of those who received questionnaires did not respond. This raises the question as to whether these participants were predominantly more aware of the need to practice safer sex and, as such, are not a representative sample of Dutch HIV-positive MSM. On the other hand, Swanborn (2002
) found that 30% is a common response rate for this type of research in the Netherlands. It is possible that the sensitivity of the subject and the fact that the participants suffer from a chronic disease may create barriers to participation. Moreover, substantial efforts were made to recruit HIV-positive MSM from throughout the Netherlands. Although this approach did not ensure that the sample was representative, it did enhance its diversity and therefore strengthens the external validity of the study results.
The findings reported in this study carry several implications for HIV-prevention efforts to promote safer sexual behavior among HIV-positive MSM. When addressing condom use behavior with steady and casual sex partners, it seems particularly crucial to enhance feelings of moral obligation to use condoms for anal sex. Feelings of moral obligation could be addressed by inducing HIV-positive MSM to reflect on their own personal risk and personal standards for safer sex (Kalichman, 1998
). The findings of this study further suggest that desirable changes in subjective norms and self-efficacy expectations might lead to corresponding changes in personal norms and intentions (e.g., Deci & Ryan, 2000
; van Empelen, Kok, Jansen, & Hoebe, 2001
; van Empelen, Schaalma, Kok, & Jansen, 2001
). Therefore, preventive interventions should focus on helping HIV-positive MSM to cope with an unsupportive social environment and to encourage them to build the skills and confidence required for communicating and negotiating condom use. For the promotion of condom use with casual sex partners, personal norms may be further increased by urging HIV-positive MSM to accept responsibility for safer sexual behavior. Moreover, especially within casual sex encounters, it is imperative to help HIV-positive MSM to deal with feelings that may conflict with the goal of safer sex. Possible methods that can help HIV-positive MSM to identify and control high risk situations are, for example, action planning and coping planning (Sniehotta, Schwarzer, Scholz, & Schüz, 2005
). Action plans and coping plans are detailed plans of what a person needs to do when a specific situation occurs. When such situation arise, it is likely to function as a cue for the execution of those precise plans of implementation. Additionally, stimulating HIV-positive MSM to imagine how they would feel if they were in their sex partners shoes (i.e., perspective taking) may evoke a mixture of egoistic and altruistic motivation and, as such, lead to more protected sex (Batson, Early, & Salvarani, 1997
). That such an approach is feasible has been shown in a study by van Kesteren, Kok, Hospers, Schippers, and De Wildt (2006
), in which the above-mentioned methods have been integrated in an intervention to promote sexual health in HIV-positive MSM.