Methods of HIV Disclosure by Men Who Have Sex with Men to Casual Sexual Partners

Abstract

The purpose of this paper is to report results of a qualitative investigation into the methods that HIV-positive men who have sex with men (MSM) use to disclose their serostatus to casual sexual partners. In-depth, qualitative interviews were conducted with 57 HIV-positive adult MSM from a large midwestern city. Using an inductive approach to data analysis, our participants revealed a typology of disclosure consisting of strategies that can be placed into five primary categorizations of disclosure. These include: point-blank disclosure, indirect disclosure, stage setting, buffering, and seeking similars. This information can be especially beneficial to those working with men to develop better disclosure skills.

INTRODUCTION

Men who have sex with men (MSM) remain disproportionately represented in national HIV/AIDS statistics. Currently, 73% of all adolescent/adult AIDS cases are men and 48% of these cases can be traced exclusively to MSM.¹ Despite widespread educational campaigns and interventions, MSM continue to engage in risky sexual behaviors. Little progress has been made in understanding nuances of MSM sexual behavior or communication that may be perpetuating the spread of HIV. Not disclosing one’s HIV-positive status may be a key factor in male-to-male HIV transmission because it may leave partners with a false sense of security when engaging in risk-related behaviors. That is, failing to discuss HIV may be construed as an indication that one is HIV-negative. Thus, individuals may be placing themselves at undue risk because of poor communication.

Since the beginning of the HIV/AIDS pandemic, researchers and prevention workers have been investigating to whom HIV-positive persons disclose their serostatus. Investigators have focused on disclosure to family and friends,^2–5 employers and coworkers,^6–8 and medical personnel.⁹ Most pronounced, however, has been the emphasis on understanding rates of disclosure to current and past sexual partners.^10–16

Rates of reported disclosure to sexual partners vary considerably. Hays and colleagues¹⁷ reported 98% of their sample disclosed to lovers/partners, whereas other researchers have reported disclosure rates to sexual partners of 89%¹⁸; 76.3%¹³; 66%¹⁹; 65%²⁰; and 48%.¹⁴ More recently, Niccolai, et al.¹⁵ reported that 75.7% of their sample disclosed to their last sexual partner, while Stein et al.²¹ reported a disclosure rate of 60% to all sexual partners. Hence, overall rates of disclosure to sexual partners are quite low.

From a public health perspective, it is important to understand not only to whom MSM disclose their serostatus, but how this is accomplished successfully. What has yet to be documented are the means by which men disclose their HIV status, particularly to casual sexual partners. Knowing how men accomplish this task can substantially benefit professionals as they strive to help men develop requisite disclosure skills. The identification of successful strategies can inform HIV prevention efforts so that important interventions can be developed and tailored to the needs of this high risk population. The purpose of this paper is to report results of a qualitative investigation into the methods that HIV-positive MSM use to disclose their serostatus to casual sexual partners.

MATERIALS AND METHODS

Recruitment and participants

Participants were recruited in two ways. The first method was through advertising at local AIDS service organizations (ASOs). Case workers were informed of the study and provided information about the project that they could distribute via flyers or through newsletters. Second, recruitment materials were made available at various HIV-related venues and forums (e.g., AIDS Walk and Gay Pride festivities) held in the community. Recruitment efforts resulted in 57 HIV-positive, adult MSM from a large Midwestern city who were eligible to participate in the study. Eligible participants were those 18 years or older and who had, within the past 3 years, engaged in sexual behaviors that resulted in a decision about whether to disclose their serostatus. For this study, men who exclusively had sex with women, could not speak and understand English, and those under the age of 18 were excluded.

Participants were primarily unemployed (64%), African American (51%) men between the ages of 21 and 57 (M = 38 years, standard deviation [SD] = 8.5). At entry into the study, participants had been diagnosed with HIV ranging from one month to 21 years (M = 56 months, SD = 61). These men were well educated, with 47% having had some college education and 21% holding a bachelor’s degree.

Eligible participants were grouped according to their disclosure habits. These categories included “told none/few,” “told some,” and “told most/all.” Categorizing participants in this fashion ensured that the total spectrum of disclosure was investigated. If the level of disclosiveness was not accounted for, it was plausible that only men who were highly disclosive would be interviewed, thereby skewing the sample and results. Participants who had “told most/all” of their sexual partners were defined as those who self-reported disclosing to roughly 80% or more of their sexual partners over the past three years. Participants who had “told some” of their sexual partners were defined as those who self-reported disclosing to roughly 20%–80% of their partners over the past 3 years. Those who had “told none/few” sexual partners were defined as those who self-reported disclosing to roughly less than 20% of their partners over the past 3 years. Interviews were conducted with 23 MSM who qualified as “told none/few,” 14 who had “told some,” and 20 who had “told most/all.”

Procedures

Data collection methods reflected our inductive approach to studying disclosure practices.²² Therefore, extensive, semistructured interviews were used to understand the experience and composition of disclosure from the participant perspective.^23,24 Graduate students experienced with qualitative inquiry conducted the interviews. All interviewers received training during two, 2-hour sessions. Training sessions included instruction on issues related to sex and HIV research (e.g., confidentiality, data safety, and protection issues), clinical and ethical issues involved with interviewing, and expectations of the interview. Interviewers practiced their training during a series of interviews in which more experienced interviewers would offer suggestions for improvement, particularly around questioning techniques.

Both male and female interviewers were trained and available. The decision to include both male and female interviewers was based on the desire to have participants feel comfortable given the sensitive nature of the information elicited as well as to provide a safe environment in which to discuss issues related to sexual behavior. Upon arriving for their interview, participants were asked their preference and then interviewers where assigned based upon the participant’s gender preference. Two thirds (n = 38) of the interviews were conducted by men.

Interviews lasted between 1 and 2 hours. Interviewers were provided an interview protocol that contained both questions to ask the participant and areas where extra probing was appropriate. Interviewers first addressed wider issues of disclosure with the participant, inquiring about their general opinions about disclosure. The interviewer then guided the participant through their three most recent sexual encounters where they had to make a disclosure decision. For each encounter, the participant was asked about their disclosure decision and how they specifically came to that decision. If disclosure occurred, the interviewer asked probing questions to capture the fine-grained details of the strategy the participant used. Participants were compensated $40 for their time. Each interview was audiotaped and transcribed by project personnel. The original interviewer then reviewed the transcript for accuracy. After reviewing the transcript, the data were then analyzed and organized into increasingly specific codes. When analysis revealed that codes began to repeat and new information was not being revealed, we determined data saturation had occurred and ceased recruiting participants.

Data analysis

Data analysis for this study was conducted in five steps. First, at least two members of the research team thoroughly read each transcript. During this initial reading, our goal was to identify disclosive episodes in the data. The focus was to isolate sections of the transcript that captured the specific details of a disclosure event. These sections served as reference data that would later be utilized for inquiry audits²⁵ and referenced for illustrative quotes and examples. Second, each disclosive episode was reread by at least three research team members and distilled into several key sentences (e.g., “direct disclosure to casual partner” or “used hints to indirectly disclose”). The team then met to conduct a collaborative inquiry audit. Over three meetings, the team discussed each transcript and each disclosive episode to ensure that each disclosive episode was captured correctly and interpreted similarly. If the team disagreed over the nature and/or type of the disclosive episode, one member of the team would go back and reread the transcript to clarify. Building upon steps one and two, in step three a qualitative analyst began the process of initial axial coding. Berg²⁶ defines axial coding as the refinement and organization of codes into a relational structure. Here, the research analyst took the coded episodes and subcategorized them so as to most accurately portray the different methods of disclosure. Once the analyst completed axial coding, the team reconvened again to reflect on the coding structure and coding definitions. Thus, at this point each episode could easily be explained by one code that was unique and descriptive. In the final step, two members of the team reread the reference data produced in step one and cross-checked the data. This final step was used to ensure that the data were accurately interpreted and that the methods still fit into the coding categories.

RESULTS

Using an inductive approach to data analysis, our participants revealed a typology of disclosure resulting in five primary disclosure strategies. In this section, we discuss this typology in reference to these main strategies: point-blank, indirect disclosure, stage-setting, buffering, and seeking similars.

Point blank disclosure

Point-blank disclosure is the most unequivocal strategy that participants utilized. Point-blank methods refer to direct disclosures where there is an overt expression of one’s seropositivity. Overt events are instances of communication whereby an HIV-positive person states, either in written or verbal form, “I am HIV-positive.” This communication can occur through different mediums, including the phone, the internet, or letter. Among our participants, however, the most common form of point blank disclosures were those that occurred in-person (57%). Participants indicated that in-person disclosures were the most effective method because it eliminated confusion. One participant captured this, poignantly:

I tell people up front. I don’t wait around for the spirit to move me. I just tell people. If we’re sitting in a bar having a drink and they say … “Do you want to come to my house?” [or] “Do you want to go get a hotel room?”. … I go, “Look, I’m HIV positive. I have been for over 20 years, that’s the way it is. Deal with it, don’t deal with it, I really don’t care.” [46 years old, Caucasian]

As the in-person disclosers revealed, there is often a level of bluntness that suggests both their relative lack of concern for the costs of disclosure (e.g., rejection, loss of sex, violence) and a comfort with their serostatus. In describing his up-front style of disclosure to a causal sexual partner, a participant reported,

I just flat out told him. I said, “I just want to let you know I’m HIV positive. I hope that’s not a problem. But if it is, now’s your out. So let me know now before we take it any further.” [28 years old, Caucasian]

In-person disclosure, however, did not always present as invariably blunt. That is, participants revealed many nuances to their practice of in-person disclosure with environmental considerations figuring prominently. For instance, many men revealed a preference for disclosing in public places (e.g., bars, clubs, and restaurants) or among trusted friends. Disclosing in a public place can work to minimize the risk of violence or other negative reactions. Furthermore, disclosing to casual sexual partners in a public place may be advantageous for those who fear being rejected sexually. If disclosure makes a potential partner uninterested, the participant can move onto other potential partners. As one participant stated:

… in a way this helps me weed out assholes. Because I figure, if they’re going to act like that even before they start talking to me, if I tell them or if they know that I’m positive, if they’re going to act like that I don’t want nothing to do with them anyway. There’s nine men behind that one waiting in line honey. I don’t need to put up with that kind of nonsense from nobody. [46 years old, Caucasian]

One participant pointed out that point-blank disclosure was easier in public places, particularly restaurants, because he could use the pleasant environment to offset the potentially upsetting news of his serostatus. He described a recent time when he employed this method.

I took him out to dinner because I figured if he got upset and left, at least I had a dinner (laughs). We went to a nice restaurant because I felt like when you have to give bad news … add a little sugar to it. … So generally whenever I have something that I know is unpleasant news for somebody, I’ll cook them dinner or I’ll take them to an amusement park or something. You know, I’m not going to take [them] into a dark room, you know, with crosses hanging up and a light [and then] give [them] bad news (laughs). [50 years old, African American]

Emotional pain from direct rejection is often a cost to disclosure that limits the use of point-blank methods. In many cases, these and other costs (e.g., violence) are so high that some chose to not disclose. One participant spoke about how his choice of a public disclosure ended up backfiring. Believing he could manage an unpleasant reaction, he chose to disclose over dinner at a restaurant.

He came by my apartment and picked me up for dinner. I had told him before we went out that I had something that I wanted to share with him, but nothing was disclosed as to what it was. [At the restaurant] I said, “You know, I foresee that we are probably going to be intimate, if not tonight, then very soon in the future,” and he agreed with me. I said, “With that in mind, there is something you should know about me,” and I told him about my status. After we finished dinner, he excused himself from the table [and] never returned. The maitre d’ came to my table … and said, “Your dinner date had to leave unexpectedly, however he’s left an open tab for you.” [So] I ordered two bottles of wine (laughing)! [41 years old, Caucasian]

Costs associated with disclosure, whether real or perceived, sometimes force HIV-positive MSM to become creative, modifying point-blank disclosure by using other means to deliver the message. While face-to-face can be thought of as the most point-blank strategy, participants offered examples of disclosure that were still point-blank, but not face-to-face. Among the more popular means of point-blank disclosure that avoided face-to-face interactions were those that occurred through written communication. Participants revealed many such methods (e.g., through letters). One of the more common methods was over the Internet, especially in sex-oriented chat rooms. A participant used chat rooms frequently to find casual sexual partners.

If I’m online, it’s like, “Here’s the next big question.” You know? “Are you positive or are you negative?” And then they’ll come with whatever they are and I’ll come back with what I am. I mostly meet [partners] online. All the questions are [like] “Who are you? What do you look like? Are you positive or are you negative?” [34 years old, Caucasian]

The spatial distance inherent to written point-blank disclosures may be both emotionally and physically self-protective, yet such disclosures were just as clear and upfront as face-to-face point-blank disclosures.

Stage-setting

While point-blank disclosure can be viewed as an unequivocal method of revealing one’s serostatus, it is also one of the more anxiety-producing methods. That is, point-blank disclosure involves the greatest amount of risk, such as loss of sex, immediate ending of a relationship, and violence. These potential costs are often weighed before deciding if and how to disclose their status. An alternative, but also effective, method of disclosure is one that uses a variety of hints and symbols that work to prime a disclosive event. This was labeled stage-setting disclosure, a method of disclosure that begins with providing cues that one is HIV positive. These cues eventually result in an overt event in which the participant’s HIV status is disclosed. We uncovered five different stage-setting strategies used by these men including verbal hinting, symbolic hinting, listing one’s HIV status on an online profile, asking a partner about his HIV status first and insisting on condom usage. Each of these is followed by inquiries, sometimes numerous, which eventually eases into a disclosure.

Verbal hinting

The most obvious method for setting the stage is by dropping verbal hints that one may be HIV positive or opening a general conversation about HIV. This strategy serves to provoke comments from a sexual partner that might better inform the discloser about his attitudes towards HIV. Such “testing of the waters” can either ease fears about disclosure or stop a risky disclosure from occurring. A 34-year-old Caucasian participant illustrated his use of humorous verbal hints to set the stage for his disclosure.

I said, “You know before, if we do ever get together to have sex, I have to tell you something.” And he said, “What? Are you sick?” And I said, “Yeah, and not with a cold.” (laughs) [And then] I told him I was HIV positive.

Another participant spoke about how he crafted his words in order to feel out his partner’s attitudes about HIV-positive persons, but had also spoken to mutual acquaintances who also intimated that this person might also be positive.

We were flirting and talking and he [was] making flirtatious remarks and stuff. And I said, “Well you might not want to have sex with me because I carry a little baggage.” And he said, “Well a lot of us carry baggage.” And I said, “Well you might not accept me for mine.” And he said, “Well you never know, we might be dealing with the same thing.” So then at that point I said, “I’m HIV-positive and on meds.” And he said, “So am I.” I had talked to his friends [who] had somewhat hinted that maybe we were in the same situation [although they] did not disclose my status to him or his status to me. So I felt more confident bringing it up. [44 years old, Caucasian]

Symbolic hinting

Participants also found it helpful to leave HIV-related materials in conspicuous places (passenger car seat, coffee table, etc.) so as to provoke questions about HIV. Materials included HIV-related magazines, medications, posters, or brochures. A 45-year-old African American participant spoke about how he used a variety of HIV-related materials to elicit a disclosure event.

He went to the bathroom and I had some reading material in the bathroom that was AIDS-related … and he picked it up and said “You, you positive?” I said, “Yep” from the other room. It got quiet and I said, “You alright with that?” … And he said, “Well were you going to tell me?” I said, “I left that in there in the hopes that you would go in there.”

Online

For those who met sex partners online, listing their HIV-positive status in their profile set the stage for a more explicit discussion of HIV and expected safer sex practices. An online profile can contain a variety of personal information, including body dimensions, preferred sexual activities, and sexual health status. If contacted by another member of the website, participants who choose to indicate their HIV-positive status in their profile begin their disclosure with, “Have you read my profile?” In theory, such profiles would help weed out potential partners that would react negatively to the participant’s HIV-positive status, thus making disclosure less risky. A participant explained how he used online profiles to begin a wider disclosure discussion.

This guy was asking about meeting me and possibly going to dinner or something like that, and I asked him, “Well, did you look at my profile?” And he was like, “Yeah.” I said, “Well did you really look at my profile?” And he said, “Yeah.” And he knew what I was talking about and I was like, “So you’re okay with that?” He said, “Yes,” and we starting talking about that more and came to find out he was positive too. [28 years old, Caucasian]

A 36-year-old Caucasian participant provided another illustration for using the internet to simplify disclosure.

I’ve had several encounters with one guy online. He [lists his status] in his profile and we talked because both of us were [positive]. He would come over and we didn’t have to worry about the whole disclosure crap. It was all out and done. That’s why we use the chat rooms that let you announce your status in your profile. Most of us put it in.

Other men related only visiting chatrooms designated for HIV-positive persons. As one man noted, however:

Just being in that chat room gives you sort of a ball park. I think you probably are HIV positive. You’re in this chat room, looking for a friend, so you sort of figure. Just to get the confirmation you have to ask the question. [34 years old, Caucasian]

Asking a partner first

Some participants felt that asking their sex partner about his status before disclosing their own helped them ease into disclosure. This tactic can minimize the sense of vulnerability. For example, a 43-year-old African American man related:

It just so happens that I looked that he had the same kind of lunches that I get, because I am HIV positive and I found out and I said, “You are HIV positive ain’t you?” and he said, “How do you know?” I said, “I saw those lunches up there” and then he said, “Yeah.” I said, “I am too” and that’s when I disclosed it. (laughing)

Insisting on condom usage

Talking about safer sex and condoms is another way to begin the disclosure conversation. Once the issue of condoms was raised, the discussion about why such barriers are important seems to progress more naturally. A 42-year-old African American participant described how the use of a condom can often lead to an overt disclosure of one’s serostatus.

He wanted to give me oral and I asked, “Do you want to use a condom?” And he said, “No.” And, just in the heat of the moment, he started giving me oral sex, and I pulled away. And he asked me why I pulled away. And I just told him, “You have to have a condom to give me oral sex.” And he asked me what the difference was in him using a condom on me and why I didn’t use a condom on him. So I had to explain to him, you know, “Basically, I’m HIV positive.” He said, “Yeah, I know.” And I said, “So basically, it’s quicker for you to catch it through me if you’re, you know, if,” I said, “If there’s premature ejaculation, and you know, in the heat of the moment, you may forget to pull out, or pull back.” I said, “So there’s a lot of risks.”

Indirect

The key for stage-setting strategies is following up with inquiries that force an overt disclosure. At times, however, participants believed that overt disclosures were not always necessary for two reasons. First, many thought that partners understood the hints well enough that an overt disclosure was unnecessary. Second, some participants believed that hinting alone was an adequate form of disclosure. The assumption was that if the partner did not understand it, then it was not the participants’ responsibility to ensure comprehension.

I didn’t outright say, “By the way, I’m HIV-positive,” but I made sure that he knew. … One time I went over to his place and I had had lab work done that day, so I still had the cotton ball and the Band-Aid, but he didn’t say anything. One of the last times I was at his house, I made sure that I had the meds that I was taking in my pocket. So then we got ready to go to bed, I reached into my pocket and pulled out these pills and asked him if I could have a glass of water. I said, “I take these medications twice a day.” And he looked at them. He was like (laughing), “I recognize that blue one. Viracept!” [41 years old, Caucasian]

Unlike stage-setting strategies, there is no attempt here to link these hints to an overt disclosure. In fact, as the next example further illustrates, indirect methods are used to entirely circumvent an overt disclosure. A 47-year-old Latino participant described how he avoided an overt disclosure, while providing his partner a chance to suspect it:

I kept dropping [hints], you know what I’m saying? Like, you know, “This isn’t safe.” And he’s like, “Well fuck it.” So I told, but I didn’t tell. It was one of those things where I dropped enough [hints]. There’s enough information around. And you know, the people that I deal with, it’s like well understood that [HIV] is something that’s there. You know? But it’s not spoken of. [47 years old, Hispanic/Latino]

We came to understood these episodes as disclosures, albeit indirectly delivered. Indirect disclosure can be thought of as beginning with clues that one is HIV positive; however, the interaction does not result in an overt event in which one’s HIV status is disclosed. Rather, it is assumed or acknowledged that the partner understood the meaning of the clue or the partner is left to figure it out on his own.

Buffering

At times, anticipated costs of disclosure may be so great that a third party (person, thing or event) is utilized to facilitate HIV disclosure. Strategies that utilize a third party to disclose were labeled “buffering” because something serves as a cushion between the discloser and his sexual partner. The most common buffers employed for disclosure are supportive friends. A 46-year-old Caucasian participant explained a strategy of using public environments and friends to disclose for him, often to avoid unwanted sexual advances.

[My friend’s] will say, “So-and-so thinks you’re cute.” And [I say,] “Did you tell them I’m positive?” “Well no [name], we wouldn’t say that. That’s up to you.” I go, “Go ahead and tell them. Watch how they react.” And so I have this friend. He’ll go, “Well you know [name] been on meds for years. [He’s] been positive for years.” (Snaps fingers) Right then they leave me alone. They don’t come near me, they don’t buy me drinks, they leave me alone, which is the way I’d rather have it. Just let me alone. I’m fine. I like my life just the way it is.

Buffers can also be AIDS-related events. At events such as AIDS walks or rallies, one can use the activities of the day to gauge a potential partner’s reaction to disclosure. A 42-year-old Caucasian participant spoke about using such methods at an AIDS vigil.

He asked me to go to an AIDS vigil. A few of his friends has passed away and they do this candle light vigil once a year. … Prior to that I had asked him out for a drink or something and on our second date, you know, we’re at this vigil and running into all these people that I know, and it was just, kind of intense and I disclosed to him that day.

Seeking similars

Participants commonly reported positioning themselves where they could easily meet other HIV-positive persons or where other positive persons or those sympathetic or compassionate towards those with HIV could be found. Participants readily mentioned meeting sexual partners at AIDS walks or HIV support groups. We labeled this strategy seeking similars because under these circumstances disclosure pressure is eased. This process is different from serosorting in that the intention is not to seek sexual partners for unsafe encounters, to only have sex with other positive people, or to protect others from HIV, but rather it is to alleviate or reduce disclosure anxiety by surrounding oneself with people who more likely to be accepting. Given this definition, disclosure must occur before serosorting. One 28-year-old African American participant related:

It was like a network meeting for a black organization … and they actually do a lot of stuff with HIV/AIDS, so as far as marketing was concerned it was for everyone, but they kind of marketed to a lot of the gay clubs and stuff like that. So they talked about HIV prevention and hosted parties. So the particular two people that I met they pulled me to the side and asked, “Are you HIV positive?” And I was like, “Well are you?”

DISCUSSION

Results of this study suggest that HIV-positive men have developed numerous strategies to disclose to casual sexual partners. These can range from blunt face-to-face tactics to approaches that are more distant or strategic and calculating in nature. Although more research is needed, the data presented suggests that a variety of factors seem to impact the selection of a particular strategy, including individual personality, the environment, and the nature of the sexual relationship.

Paramount in the successful utilization of these strategies is the fit between an individual’s personality and chosen strategy. That is, men who are more confident or activist by nature would probably gravitate to point-blank methods. In fact, point-blank disclosures were most often utilized by men who disclosed all or most of the time. This suggests that they have come to terms with their serostatus and have developed a more cavalier attitude regarding others’ reactions. It is equally plausible that this bravado has developed over time as a result of numerous rejections from potential sexual partners. For others, however, point-blank disclosure served as an open and honest communication meant to alert others to the potential risks of an unsafe encounter.

Men who tend to be introverted in social settings, fearful of rejection, or prefer a passive role in sexual encounters may chose strategies that are not as confrontational as point-blank disclosure. For these individuals, buffering or setting the stage strategies may be preferable. Hinting as a means of “testing the waters” can provide a transition into disclosure that is more comfortable and may reduce unnecessary side effects of disclosure. That is, if all the signs they are receiving from their hinting are positively received, then disclosure can progress. If individuals encounter pejorative or hostile signals, then the process can be diverted or aborted.

For individuals concerned about legislation mandating HIV disclosure to sexual partners, the degree of disclosure clarity may impact strategy selection. From a legal perspective, point-blank disclosures are the preferable strategy. However, disclosing through e-mail, other electronic means, or in the company of friends might also prove beneficial to those fearful of not fulfilling legal responsibilities. In fact, documentation of HIV disclosure can be accomplished though many of the proposed strategies.

The particular choice of HIV disclosure strategies also varies depending on environmental influences in which disclosure will occur. For example, certain environments (e.g., bathhouses or parks) have unspoken codes that may facilitate stage-setting, or even tacit assumptions about the risk of HIV that increase the odds of indirect disclosure. Similarly, fears of violence or abuse promote the use of more distant strategies such as detailing an online profile or writing an e-mail to disclose. In these circumstances men can protect themselves while still seeking sexual gratification.

The nature of the relationship with the sexual encounter also appears to play a role in method selection. If disclosure was to occur in the more fleeting sexual encounters, it was more likely to be a point-blank disclosure. Alternatively, men who desired intimacy in their sexual encounters, and were willing to delay sex, preferred stage-setting. Dropping hints about one’s serostatus can help investigate the potential partner’s attitudes towards HIV. Nonjudgmental responses to symbolic or verbal hints would be especially significant for men who seek “friends with benefits” or even potentially long-term monogamous relationships.

Although not articulated by men in this study, other possible strategies emerged from the research team as the data were coded and analyzed. For example, there is some evidence that body art has and can be used as symbolic hinting to facilitate disclosure.²⁷ Tattoos, temporary or permanent, such as red ribbons and positive (+) signs, among others, symbolize HIV and may entice potential sex partners to inquire about the tattoo’s meaning, resulting in disclosure. In addition, it was curious that Disease Intervention Specialists associated with partner notification programs never emerged as a buffer; however, they serve as another example of a professional that could be utilized for disclosure purposes.

For many of the men in our study, the successful utility of a particular strategy was the result of the complex interplay between strategy-personality fit, environmental circumstances, and the nature of the sexual relationship. In light of the critical gaze on MSM’s role in the HIV epidemic, it is promising to find such thought and effort put into developing very complex and at times ritualistic strategies to accomplish the monumental task of HIV disclosure. HIV prevention workers, physicians, therapists, and case managers are encouraged to share these strategies with the HIV-positive men with whom they work. If viewed as a continuum, prevention workers can easily assist men move from indirect disclosing to more point-blank strategies as comfort permits. In addition, these strategies can be easily adapted to personal and environmental situations in which sex is likely to occur. Theoretically, men who are aware of the robust variety of disclosure strategies available will be able to find strategies that are comfortable for them and match their environmental and relational circumstances. Thus, a combination of knowledge, creativity, and the ability to minimize risks and costs may be the key to successful HIV disclosure.