Nearly every couple had safety agreements and negotiating them involved establishing a level of acceptable risk, determining condom use, and employing other risk-reduction techniques. Safety agreements were remarkably stable over the course of data collection. Half of couples reported using condoms inconsistently or not at all. Their motivations reveal a preference for other risk-reduction techniques. No seroconversions were reported.
There are limitations to this study. Though couples were randomly selected for the qualitative arm, they were part of a larger quantitative study whose sample was recruited via a convenience strategy. Similarly, all couples were residents of the San Francisco Bay Area. Therefore, generalizations should be made cautiously. Finally, the HIV status of participants was self-reported – no actual testing occurred. We forwent testing because we are interested in how one’s perception of serostatus guides sexual behavior.
This study significantly expands what is known about the HIV risk and safer sex efforts of discordant couples. While previous research verified the existence of agreements about sex and charted their typography, it focused on whether couples allow sex with outside partners. Data from this study demonstrates that discordant couples also make agreements about safety, which, with epidemiological support, could expand negotiated safety to include discordant couples by adding rules such as periodic STD testing for both partners and regular viral load testing and ART adherence for the HIV-positive partner. Lacking other strategies to model, this study shows discordant couples striking out on their own, sometimes against their own doctors’ recommendations and oftentimes against conventional HIV prevention messages, negotiating agreements that balance their sexual and relational needs with their concerns about HIV.
Important issues remain where long-term HIV prevention is concerned. The decision to forgo condoms demands scrupulous adherence to ART, close monitoring of viral load, and regular testing for STDs and prompt treatment if they occur (Hallett, Smit, Garnett, & de Wolf, 2011
; Vernazza, Hirschel, Bernasconi, & Flepp, 2008
; Whittington, et al., 2002
). Adroit, forthright communication between partners is also important to maintain both partners’ health (Darbes, Chakravarty, Beougher, Neilands, & Hoff, in press
; Remien, et al., 2003
). Furthermore, it is imperative that discordant couples have accurate and complete information about the relative risk and safety of the other risk-reduction techniques they employ (Cohen & Gay, 2010
; Jin, et al., 2009
; Persson, 2011
; Vernazza, et al., 2008
). For example, couples spoke of limiting the frequency, duration, and intensity of anal sex to avoid HIV transmission, however, no data is available on these methods and their efficacy is dubious at best. Couples must separate fact from fiction to make knowledgeable decisions about their level of acceptable risk.
Safety agreements offer unique opportunities to reduce risk among discordant couples. Interventions could target the negotiation process to help them make the safest agreements possible. Ideally, this would occur at the beginning of the relationship as safety agreements, and the decision to forgo condoms, gel quickly (Davidovich, et al., 2004
; C. C. Hoff, et al., 2006
; Remien, et al., 1995
). That most couples adhered to their safety agreements over time suggests partners are committed to each other’s health and wellbeing. Interventions could latch onto this to sustain safer sex efforts over time. That condom use was conspicuously absent from most safety agreements exposes a critical disconnect between many of those who dispense HIV prevention messages and many of those for whom those messages are targeted. Typically, sexual behaviors are presented as increasing one’s HIV risk. The participants, however, framed them as decreasing HIV risk. There is truth to both perspectives.
On the one hand, some gay men overestimate how safe and underestimate how risky their sexual behaviors are, especially when they make assessments retrospectively. Additionally, some lose sight of their cumulative risk over time by focusing on individual risky episodes. On the other hand, some counselors and health practitioners, who offer absolutes as prevention strategy and eschew the relative protection afforded by certain behaviors, preclude a more honest discussion of risk. Unfortunately, this dynamic frames condom use as a choice between having a sexually and interpersonally satisfying relationship and one’s long-term health. Certainly, condoms work for some discordant couples. However, for the majority of couples who do not use them, prevention messages promoting condoms may be ignored. Prevention efforts should work with, rather than fight against, the couple’s decision to use condoms (Mao, et al., 2011
; Persson, 2011
). Rather than ask discordant couples to use condoms every time they have sex, future interventions could implement a situational approach by asking them to use condoms when the HIV-positive partner is insertive or when either partner has anal sex with outside partners. Research suggests that condom use may increase if couples use them in a targeted fashion (Hallett, et al., 2011
). Future interventions should endeavor to complement and accentuate discordant couples’ other safer sex efforts.