A third of HIV-positive IDU men reported unprotected sex with HIV-negative and unknown serostatus main and casual partners, and over 50% of men engaged in unprotected sex with HIV-positive partners. Clearly there are many opportunities for the sexual transmission of HIV and other STDs from male IDUs to their female sexual partners and for the acquisition of STDs or superinfection by HIV-positive men. Consistent with prior research,11
the variation in condom use by partner serostatus indicates that men's knowledge of their female partner's serostatus is important and that women's disclosures of their HIV-negative serostatus to HIV-positive men is associated with increased condom use for both main and casual partners. Thus, programs that focus on serostatus disclosure could be beneficial for reducing risk between HIV-positive and HIV-negative persons, particularly in contexts where disclosure is safe (e.g., absence of interpersonal violence). This also indicates, however, the significant risk HIV-positive men have for contracting other diseases that can accelerate HIV disease or make it easier to transmit HIV to uninfected partners.
Interestingly, when examining the patterns of findings, the models are relatively similar for three of the four types of partners. The outlier is the model for unprotected sex with HIV-negative and unknown status casual partners. The unprotected sexual liaisons between HIV-positive men and their uninfected or unknown serostatus casual female partners may particularly fuel the HIV epidemic. IDU men engaging in these relationships have a high number of partners, and if the men come in contact with the public health system (for example, through STD surveillance), they may be less likely to be able to identify their female partners so that they can take advantage of public health resources. In addition, the fact that engaging in sex exchange and lower education were related to sexual risk with HIV-negative or unknown status casual partners speaks to the challenges of promoting protection in the context of the drug–sex economy, where less educated, less skilled members of society are more likely to find themselves.10
HIV-positive IDU men may assume that their exchange partners are HIV positive32
or not care about protecting them because they devalue them.10
Similarly, those men who are exchanging drugs or money for sex may not be asked to use protection in these encounters or may have power that puts them in the position to not use condoms. The drug–sex economy is a challenge to address with traditional HIV prevention interventions—it calls for broader structural solutions that address poverty, power differentials, and education in addition to trying to invoke self-protection and altruism/partner protection.
Despite the challenges in addressing unprotected sex with uninfected casual partners, it is important to note that 65% of the men with these types of partners reported protected sex. This should encourage interventionists despite some of the structural challenges. In addition, across all four models, greater self-efficacy was significantly related to protected sex. While this finding is not new, it extends the importance of self-efficacy to HIV-positive men with female partners. This finding indicates that a cornerstone of programs for HIV-positive IDU men with any type of female partner should be to increase self-efficacy through activities such as modeling, hands on practice, role plays, and discussions. Because self-efficacy is conceptually specific by partner type or situation,33
the context of men's lives should be explored, either individually or in group, to help improve self-efficacy for safer sex in those specific situations where it is individually most challenging.
We also saw that in three of the models, men's unprotected sex was associated with partner norms supporting condom use. Partner norms are made up of 1) beliefs that the partner want to use condoms and 2) how important it is for the man to comply with his partner's beliefs. In interventions for men, it would be feasible and desirable to focus on both of these components, particularly on the second component. Assuming that the woman has that desire to use a condom, increasing the concern a man might have for complying with his partner's desires about condom use is important. Interventions with at-risk women could focus on getting them to be more supportive of having their male partner use a condom and getting them to communicate this preference to their male partners so that men are clear that their female partners do want to use condoms. These two components of partner norms appear to tap into the power dynamics that are often present among male and female IDUs.10
To the extent the women are fearful or feel unable to assert their desires for protection and to the extent that men feel empowered to ignore these desires, unprotected encounters are more likely. To fully understand this dynamic for any particular couple, it might be important to intervene at the level of the couple. Finally, negative condom beliefs were related to unprotected sex in two and of the models, and two mental health variables (frequency of drinking alcohol or using drugs before or during sex and depression) were each significant one model with HIV-positive partners, indicating the importance of evaluating condom attitudes, substance use, and depression in HIV-positive IDU men for their potential relationship to unprotected sex.
The pattern of findings across the four models indicates that an intervention for HIV-positive men should have a number of core components (those relevant regardless of partner type) and additional components that might be used if relevant to the participant(s). This suggests the need to have the flexibility to tailor the intervention, which can be accomplished in an individual setting or in a group setting where subgroups are possible. It also is important to acknowledge that perfect tailoring should not be the goal. A client who does not have a casual partner today may have one in the future, so he could benefit from modules that our data indicate may be less relevant for him. In other words, our data should not be construed as offering a specific list of ingredients for men with specific types of partners. Instead, it should be used to sensitize interventionists to the different factors that may make risk reduction more challenging for some men based on the characteristics of their partners.
Several study limitations should be noted. First, these data are from a convenience sample of primarily poor, African American, IDU men recruited from four urban areas who all had exclusively female sex partners. Thus, generalizations to other IDUs should be made cautiously. However, using a multi-site sample with multiple recruitment venues strengthens potential generalizability. Second, these data are all self-reported, potentially leading to stigmatized behaviors such as sexual risk being underreported. To diminish this concern, we used computerized data collection methods, which have been shown to enhance reporting of sensitive risk behaviors among IDU samples,34
particularly for sexual risk behaviors.35
In any case, we had a significant minority of men reporting unprotected sex. Third, because these data were collected in the context of an intervention trial, we had only limited measures available. Finally the analysis was cross-sectional so causation could not be established. Strengths of this study were the use of psychometric scales that performed well with the present sample and the ability to focus on sexual encounters by partner type and serostatus.
As HIV medications continue to enhance the quality of HIV-positive men's lives, the need intensifies to identify effective and realistic prevention strategies. General interventions that also include targeted strategies based on the relationship pattern of men's lives may improve our current prevention strategies. Constructs such as self-efficacy for safer sex, partner norms, and condom beliefs should be part of most intervention strategies for HIV-positive men. In a group setting, different types of partnerships can be explored, and men can learn about all pairings, whether or not they are currently relevant for them, as well as learning about treating mental health and substance abuse. Relationship factors are also important, and working with couples or separately with the female partners is another intervention strategy. For men with more anonymous couplings (casual partners of unknown serostatus), social factors such as sex trade must be addressed. In sum, prevention efforts with HIV-positive IDU men need to consider personal, partner, and social factors in order to reduce sexual risk behavior with female partners.