A little thing called love: Condom use among high-risk primary heterosexual couples

Abstract

Introduction

Research shows that condoms are least likely to be used in primary relationships. A deeper understanding of the expectations women and men hold when entering into these relationships, as well as how decisions related to condom use and other prevention behaviors are made, is essential if we are to curb the spread of HIV.

Methodology

Qualitative in-depth interviews were conducted with 25 high-risk heterosexual couples, including HIV sero-discordant couples, in Hartford, CT. Qualitative data were coded and analyzed in an iterative inductive and deductive process using Atlas.ti.

Results

Participants employed non-use of condoms as a strategy to find and maintain a primary relationship, establish trust and increase intimacy. Many did so while recognizing their risk of HIV/STI illustrating the importance of love and the other emotional needs primary relationships satisfy. Second, several couples described practicing negotiated safety or similar strategies as a way to minimize their HIV/STI risk. These strategies varied in potential effectiveness and included sharing sexual and/or drug use history, disclosure of prior HIV test results, and using condoms until it was decided that this was a monogamous relationship, among others.

Discussion

Findings suggest that men and women may choose not to use condoms as they pursue and attempt to maintain a primary relationship. HIV prevention approaches must recognize the importance of love and the needs primary relationships satisfy if they are to be considered relevant by those at greatest risk. Negotiated safety may be an important risk reduction tool for heterosexuals, particularly those in HIV-affected relationships.

INTRODUCTION

Rates of HIV infection are rapidly increasing among women in the U.S. and worldwide.[1,2] The majority of these new infections are among women infected by their primary male sexual partners.[3] This is mainly due to less condom use in primary versus casual or paying relationships. A variety of factors have been shown to influence whether condoms are used including gender inequity and differential power relations,[4–6] exposure to intimate partner violence,[7,8] level of perceived risk,[9,10] and self-efficacy.[11,12] Beliefs that condoms feel unnatural, reduce sexual pleasure, and are a hindrance to intimacy may also limit their use.[13,14] Other explanations focus more specifically on women’s reluctance to use condoms in primary relationships and include reproductive intentions;[6,15] and the use of hormonal and other forms of contraception.[9] Other research has focused on the emotional and social needs that are fulfilled in committed relationships. Condom use made be inconsistent with relationship ideals of intimacy, trust and fidelity.[6,16] These explanations may be particularly relevant for inconsistent condom use in sero-discordant couples who know their status.[3,17] Further, most research on the relationship between emotional needs, romantic attachment and condom use has studied the importance of primary relationships from the woman’s perspective while the man’s is often overlooked.

In the current language of public health policy-makers and practitioners, sex is conceptualized and verbalized as risk of disease and unwanted pregnancy, and not sex as an expression of love, intimacy, and trust. This is particularly the case with regard to substance users; “while other groups in society have spouses and lovers, drug users are described as only having sex partners.”[18] Regardless of the population, HIV prevention has focused primarily on the individual as the target of intervention, emphasizing risk reduction through safer sex, often neglecting the context in which risky behavior occurs. Safer sex in the age of HIV/AIDS entails talking about condoms and acknowledging the possibility of disease. Such discussion may not be conducive to a romantic, spontaneous passion-filled encounter that could possibly lead to love and a long-term relationship. In contrast, research suggests that some people may actually use casual and/or unprotected sex as a strategy to “catch love”.[19] Research among heterosexuals has demonstrated that, particularly among young women, trust and love are central in defining the meaning of sexual involvements. In relation to safe sex, young women and sometimes men, often “trust to love,” in that they see condom use as unnecessary with a regular partner or within a relationship.[13,20] Furthermore, these women articulate love and trust as prophylactic, and sex is constructed as safe through its relationship with love.[19]

In the search for love and a meaningful relationship, people may not always act rationally. For example, they may make decisions around sex and condom use based on implicit personality or characteristics-based risk theories e.g. he looks clean, she’s not from the streets, etc.[21,22] Also, once a relationship is established, men and women may ascribe to one of several inaccurate AIDS prevention heuristics that support non-condom use e.g. “Known partners are safe partners,” or “It’s too late (to start using protection now).”[21] Condoms and their use within a primary relationship, particularly in an established relationship in which they may not have been used previously, can raise issues of distrust and accusations of infidelity.[5,23] Condomless sex helps maintain the fantasy that one’s partner is faithful.[24]

In recent years, negotiated safety has been a focus of research particularly among Australian and British scientists.[25] Negotiated safety refers to an explicit agreement between partners about sexual practices which takes into account the HIV status of both partners. After mutual HIV testing, the partners then decide to discontinue condom use within the primary relationship and commit to monogamy or establish rules for condom use with outside partners. While studies have shown it to be a common strategy among homosexual men,[25] less research has examined negotiated safety among heterosexual couples, and there is some disagreement among scientists regarding whether heterosexuals are likely to use such strategies effectively.[19,26]

This paper will examine condom use within the context of high-risk urban couples, including HIV sero-concordant positive, sero-concordant negative, and sero-discordant couples. Specifically we explore reasons cited for condom use or non-use and the strategies employed to reduce HIV/STI risk within these primary partnerships.

METHODOLOGY

The data presented were collected as part of a 4-year qualitative and quantitative study exploring factors affecting initial and sustained use of the female condom (FC) for HIV/STI prevention among women and men at high risk (defined as drug users, partners of injection drug users, commercial sex workers, homeless, and/or urban poor) in Hartford, Connecticut after having reduced the initial barriers of awareness and accessibility. In addition to longitudinal surveys conducted with a cohort of 400+ women, the study included a couples’ component of qualitative and quantitative longitudinal interviews and a 2-week trial of the FC. This paper will present findings from the baseline in-depth narrative interviews conducted with 25 couples.

Heterosexual couples were recruited into the study in one of two ways. Initially, every third woman participating in the larger cohort component of the study was screened for eligibility and asked if she was interested, willing, and able to bring in her male sexual partner to participate. Because it proved difficult to recruit couples using this approach, we later changed to direct recruitment of couples using targeted outreach. Study staff approached men and women found together in parks and on the street outside of social service organizations and asked them if they were a couple. If they responded positively, staff told them about the study, screened them for eligibility, and gave them an appointment card to come to the study offices for enrollment. Eligibility criteria for participation included being 18 years or older, living in the Hartford area, and having had vaginal sex with this partner during the last 30 days.

Participants in the couples study were screened for Chlamydia and gonorrhea using a urine sample. If one or both partners reported current STI symptoms during the survey or tested positive with the urine screen, they were excluded from participation in the couples’ component of the study and referred into treatment at the local health department. It was felt that participating in the couples component of the study, which included a two-week trial of the female condom and filling out sexual diaries, might encourage participants to have more sex (albeit protected sex) than they would if they did not participate in the trial. Women were still eligible to participate in the larger study if excluded from the couples study for current STI. In-depth narrative interviews were conducted at baseline and 10 months and explored current and past relationships, relationship ideals, sexual behavior, sexual and contraceptive decision-making, HIV/STI risk and preventive practices, violence, and FC knowledge, attitudes, and experiences. Men and women were always interviewed separately and were compensated $25 for each in-depth interview. Written informed consent was obtained from each participant prior to STI screening and enrollment in the study. All study protocols were reviewed and approved by [name of authors’ institution] Institutional Review Board prior to initiation of any research activities.

All qualitative interviews were transcribed verbatim and text data coded and analyzed through an iterative inductive and deductive process using Atlas.ti software. Interviews were first coded for demographic variables. Data were then coded for content using a project-developed coding scheme which included broad categories such as first sexual experience with current partner, male condom use, general attitudes towards condoms, reproductive intentions, sexual negotiation, sexual practices, sexuality and pleasure, violence, and substance use. A third level of analysis involved members of the research team working jointly to identify key themes and patterns of response and relationships among the various variables of interest. For example, the importance of love was found to be a recurrent theme in interviews and was related to many other codes such as first sexual experience with partner, sexual negotiation, and sexual practices. Negotiating safety was another theme that emerged in several interviews. For the purposes of this paper, we define negotiated safety as any conscience attempt couples make to assess their risk for HIV/STI as they decide whether or not to use condoms; this assessment may or may not include mutual HIV testing.

RESULTS

The majority of participants were non-white, poor, with low levels of educational attainment. Nearly half were current drug users (crack or injection drug use), and the majority had used drugs in the past. Eight of the couples were homeless at the time of their first interview. Six women and seven men reported they were HIV positive at their first interview resulting in 3 sero-concordant positive and 7 sero-discordant partnerships. The length of time couples were involved in their current relationships varied widely with a range of 1–240 months. The overwhelming majority of couples reported not using condoms at all; including six of the 10 HIV affected couples.

Analysis of in-depth interviews revealed that condom use was often seen as inconsistent with establishing and maintaining a romantic relationship and that the love and intimacy needs fulfilled in these relationships often superseded health concerns. However, in-depth interviews also revealed that many couples reduced their HIV/STI risk through negotiated safety and other similar strategies.

Love and intimacy: Balancing emotional needs with health risks

As they described the beginning of their current relationships and first sexual encounters, both women and men talked about “taking a chance on love.” Non-use of condoms was a strategy used to help establish a potentially serious as opposed to casual relationship. Amanda⁺ had known Juan for 2 weeks before they had sex for the first time. They met while in an in-patient detoxification program and she described both an immediate physical attraction and a deeper emotional bond stemming from hours of conversation about their life experiences. At the time of their baseline interviews, they had been together about 3 months. Explaining why they chose not to use condoms during their first sexual experience, Amanda states:

Amanda (White Female, 41 (HIV−): …I knew I was just going to be with him. He wasn't just going to be this one person I was just going to mess around with and then…not see him, I was at least hoping that I was going to be with him [for a long time].

For Amanda, her desire to be in a long-term relationship and her belief that Juan could be the one made it easier not to use condoms during their first sexual encounter. In turn, their non-use of condoms supported the hope that this was not just a fling with a relative stranger but rather with someone who was equally invested in fostering a meaningful primary relationship.

In describing their ideal romantic partner, several women and men talked about having searched years for their soul mates and finding them in their current partners. Carmen had spent several years in an abusive relationship by the time she met Manuel who was also already involved in a committed relationship. While they were physically attracted to each other, they spent the next year as friends during which time their feelings deepened. Carmen’s realization that Manuel might be her soul mate was somewhat complicated by the fact that he was HIV positive. The importance of finding a life partner, however, outweighed her fears about health risks in starting a sexual relationship with him. Carmen and Manuel had been together about 8 years by the time they enrolled in this study and used condoms inconsistently.

Carmen (Hispanic Female, 44, HIV−): … I'll be honest; I was a little bit scared because I didn't know much about AIDS or anything like that. I said I know you have to use protection… I was scared…because I didn't know much; if I kissed him or if I this or that, I would have it [AIDS]… [But] The chemistry…more than any other man I've been with…. It's like a love or something. We're supposed to be together, a soul mate. It's like something that you have together; that's how it was with me and him. And it's nothing, like I can't be burdened with it, being sick or whatever can’t stop that from happening, you understand what I mean?

For many participants, the first sexual encounter with their current partner was not just about sex but establishing trust. In these situations, having sex without a condom was used as evidence that a partner had been honest about his or her sexual past and disease status, and/or that he or she was not currently involved in another sexual relationship. Veronica met Wilfredo while in methadone maintenance treatment. They became friends and after 2 years, started dating. They had been together about 2 months by the time they enrolled in the study.

Veronica (Hispanic Female, 38, HIV−): I didn't want to have sex right away. I mean, we're friends and now we are more than friends and now the next step is sex. So, it's something that you have to be whoa, wait a minute. So, I say, "You know what, you're going to have to wait 2 more weeks,”… So, the date comes and I'm all nervous and I felt like I was a freaking 15-year-old girl. I'm like all shaking and nervous. I'm scared but, I'm taking off my clothes and I'm like, "What the hell am I doing?" …The first time was fun… It was so great I could not believe it. No, we didn't [use a condom]. And we didn't even talk about it; but, the day after I ask him, "How come you didn't use any protection with me?" You know, because he had a girl before me and he was using protection [with her]. He says, "Because I trust you, and I know you've been honest to me so far and I can trust you.” … He's the type of guy that when he's in love with a woman, he don't like to use protection; but, if he's just dating someone like he was dating this girl just for sex, he was using protection. So, that makes me, you know, I was so proud of him that at least he was using rubbers with them and the reason he didn't with me because he trusted me.

This particular excerpt also illustrates the associations many people have about condoms. For many, the use of condoms signifies a level of distrust. In addition, many participants believed that condoms are appropriate for casual and “sex-only” encounters but don’t necessarily have a place within the context of primary, serious relationships.

Again, the need for physical and emotional intimacy outweighed real health concerns. Veronica knew that Wilfredo had been having sex with another woman as they started to get to know each other and had no way of confirming whether he had used condoms with his former partner. However, she chose to believe his assertion and that non-condom use with her was evidence of the seriousness of their relationship. Many women in the project while expressing some doubt about their partners’ monogamy, chose to believe that they were faithful and continued to have sex without condoms.

Jennifer (White Female, 38, HIV−): We honestly believed that we wouldn't ever have sex with anybody else again which is still true this day…That is one thing I do believe. And I do know that he's not messing around. I mean, well, in my heart I believe. I guess nobody can honestly say 100% that they believe their mate is messing around or not. I mean, but he, we both had had HIV tests. He said his was negative. Mine was negative. So, we just felt that in using [a condom] it would be more of a blocker of our love.

This doubt of partner’s fidelity did not lead typically to confrontation or insistence that a condom be used. Rather this more often resulted in continued condomless sex which supported the belief that this was a monogamous and safe relationship founded on true love. This in turn reinforced belief in one or more inaccurate AIDS heuristics, e.g. “known partners are safe partners,”[21] and helped to maintain the fantasy of the ideal, i.e. that her partner was faithful.[24]

In addition to reduced physical pleasure, several participants associated using condoms with reduced intimacy, both physical and emotional, and by not using condoms, they were able to achieve a greater level of intimacy.

Martha (African-American Female, 44, HIV−): What's the use [of using condoms], I mean why? I think your body fluids or whatever is intimacy… And the feeling, you know? His meat against my meat… I think a condom means that you really don't want contact … I mean if I love you, put on a condom, that's just like a rubber band, that's plastic…I think it's only for hookers or somebody that you don't, you want to satisfy them or if they get off but you don't want them touching you totally, you don't want to feel their immediate skin against yours.

Balancing the desire and need for physical intimacy and protecting oneself or partner was particularly difficult for sero-discordant couples as illustrated by Manuel and Carmen. Manuel explains their reasons for not always using condoms.

Manuel (Hispanic Male, 33, HIV+): Well, sometimes she don't want to use a condom, sometimes I get really tired of using condoms. I've been using condoms for so long, for so many years that sometimes I don't want to wear a condom. I want to feel, you know, flesh and flesh, and I don't want to feel rubber…One time I said “ma, we've been using condoms, I just want some type, I hope, I would like to feel…”, and she said “Yeah, me too” and that's how it started, you know? So sometimes we have sex without a condom…It's like something that we want to share, you know…

Manuel’s narrative raises another issue, that of “condom fatigue”, frequently discussed in research on sexual behavior among men who have sex with men[27] but which may also operate in heterosexual and particularly sero-discordant partnerships. Condom fatigue or frustration with the prospect of having less pleasurable safe sex at every sexual encounter[28] combined with the desire and need for physical intimacy may prove overwhelming at times and, as illustrated by Manuel, result in inconsistent condom use despite the very real risk of transmission.

The stories related by the next two participants, both in HIV-affected relationships, clearly illustrate the power of love and that personal health is not always the highest priority for someone involved in a primary relationship. For many people, the emotional and other needs that are fulfilled by intimate relationships may supersede concerns for personal health and safety leaving one unwilling to risk losing what they have. In extreme cases, they may be willing to die for love. Ana, with Lazaro for 20 years, was diagnosed with HIV in 1992.

Ethnographer: You found out that he was positive from his sister. How did she tell you?

Ana (Hispanic Female, 37, HIV+): I went to her house one day and she was like, "You know my brother's sick, right? You know my brother got AIDS?" I said, "No." I didn't want to hear it from her. I was very betrayed, I was very hurt because it came from her and it could have come from him. It wouldn't have changed nothing just that I knew it and I would have been more protective. That's it, but I wouldn't have left him because he had AIDS. Because the love was already there, you know. So I think maybe he was afraid. [Once I found out] I didn't do nothing for a while with him. I didn't want the sex or nothing for a while, because I was hurt. I was very betrayed. I was using [drugs] more because I was in pain. So I just lost the sex thing with him for a while. Then we started back again and we didn't use condoms. Never used condoms because I said, "Damn, I love him and everything. If I love him, I shouldn't even use condoms with him" but I didn't know [about re-infection] at the time, you know? Like I said, that's my man, I love him and so what. We'll die together. That's how I felt.

Additional themes are suggested by Ana’s story. Feelings of betrayal at not only his dishonesty regarding his HIV status but his disregard for her health are clearly evident. Ana also displays a certain level of fatalism, in other words a general outlook on life founded on the belief that life events are inevitable and that one’s destiny is not in one’s own hands.[29] Finally, once Ana had reconciled the fact that the man she loved was HIV positive, she then had to make a decision; leave him, stay with him and use condoms, or stay with him and not use condoms. While it is obvious that her final decision was to stay with Lazaro and not use condoms, it isn’t entirely clear if this was due more to the unbearable thought of him eventually dying and her being left alone, an assumption that she had already been infected by him and acceptance of the “it’s too late to start using condoms now” heuristic,[21] a conscious expression of her love for him which has been suggested has a major reason for non-condom use in sero-discordant relationships [17] or a combination of the above.

Javier and Karla had been together 3 years when they enrolled in the study. She was diagnosed with HIV in 2005 while Javier was negative at his first interview. When asked what prevents him from taking greater precautions against infection with Karla, he responded:

Javier (Hispanic Male, 29, HIV−): That's a good question. I don't know. I go with the flow like I always do…Well, because I feel so comfortable and I feel great and I'm living this life, you know, and whatever happens, it happens, you know? Right now I'm enjoying it. Whatever time God wants [to give me and then] he'll take me. I'm having the best time right now. I don't want to change this for nothing.

Ethnographer: So for you…you're in a good place in your life and you're willing to risk your life, put yourself at risk…

Javier: For being happy, yeah.

Not using condoms with an HIV positive partner as an expression of love is also demonstrated by Javier’s narrative. Furthermore, it is clear from Javier’s words that the love and happiness he feels in his relationship with Karla are worth the risk of infection.

All participants to a greater or lesser extent either minimized or denied their risk of contracting HIV or, in the case of HIV sero-discordant couples, chose to have unsafe sex even when aware of the risks. The reasons participants express for not using condoms in spite of very real risk of HIV infection suggest that the emotional needs filled by these primary relationships is even greater for this population of participants than among heterosexual populations at lower risk for HIV infection. Participants were all low-income, many were drug using and either were currently homeless or had been at some point in their pasts. All these conditions are highly stigmatizing and reduce the desirability of participants as sexual and romantic partners for many in mainstream society. In addition participants described lifetimes filled with violence and marginalization (such as low educational attainment, school failure, spotty or non-existent employment records). Finding a “soul mate” or a partner to share and help them navigate their difficult lives, therefore, helped participants feel worthy of love and more a part of mainstream society. As Steven said,

You are not going to be in love with someone and want to use a condom. For what? You’re preventing something…But being in love with someone, I mean to a point in your relationship where you want to spend the rest of your life with them. You want to build a life. You want to have a house, car, children, dog, everything.

It is striking that many of the things mentioned by Steven, e.g. a car and house, were things that the participants largely had not been able to obtain in their lives. Achieving these goals was tied in his mind with his relationship. The importance given to relationships, however, not only affects condom use but could also undermine negotiated safety as seen below.

Assessing and minimizing risk

Several couples described using a negotiated safety approach in their decisions to use or not use condoms, although their thoroughness in assessing their risk varied considerably, and some couples reported never explicitly discussed their risk or condom use at any point in their relationships. Jose and Linda, together for four and a half years, decided to use protection at the beginning of their relationship because of their drug use histories. After assessing their risks and intentions for the relationship, they then were tested for HIV, committed to monogamy, and proceeded to engage in “unprotected,” condomless sex.

Jose (Hispanic Male, 32, HIV−): Well at the beginning when we first met it took us a while before we had sexual relations and we used condoms at first ‘cause, you know, we met in a program. Which you know what I'm saying half of them are sick or something. They have some type of disease, so she had taken her [HIV test]. Well she told me to use [condoms]…She wanted to protect herself, you know…She made the decision and I agreed with it ‘cause we just met not too long ago and even though we had got tested, still though.

Ethnographer: And when did you decide not to use any protection?

Jose: Right after awhile I just decided not to, I mean she agreed with it why should we be using protection? “I can't get pregnant you know. We're not fooling around with nobody else so. If you're sick I'm gonna be sick so it's because it's us, it's not because there's more people in it.” But we were tested for everything so we shouldn't be sick…unless one of us went out there and fooled around and got sick.

In comparing Jose and Linda with other couples we can see that negotiated safety may be more appropriately viewed as a continuum in which there are different levels of risk assessment and potential responses to risk. Furthermore, as a continuum, couples may engage in more or less effective or conscientious assessments of their risk. Although not frequently mentioned, a few participants described using characteristics-based theories and other “evidence” in their determination that their partners were safe for unprotected sex. This evidence was not only grounded in “looking healthy” or not looking like “that kind of person” as illustrated by Roberta.

Roberta (African-American Female, 44, HIV−): I really couldn't tell you [how I knew that he didn’t have a disease]. Because I, just looking at him seeing that he ain't had nothing. I asked him, you know, did you ever have any kind of disease or blah, blah, I just look at him and see that he wasn't the type of person… Because he was telling me about he had like condoms and stuff before I met up with him, whoever he been with, he must have been using condoms because he always had condoms on him.

For Roberta, the fact that Lionel carried condoms meant that he used condoms with other partners and as such was safe.

In the case of Amanda and her boyfriend Juan with whom she has never used condoms, she decided to engage in unprotected sex once she knew they both had Hepatitis C and took his word that he was HIV negative based on testing performed prior to their meeting. The decision to not use condoms was similarly made by Jennifer with her boyfriend Alberto upon the realization of their mutual Hepatitis C infection and their HIV negative status based on tests taken some time before they met. In these examples, we can see three distinct approaches to assessing risk with potentially very different levels of success in actually minimizing risk. Roberta’s risk assessment consisted of using characteristics-based theories and Lionel’s claim that he used to carry condoms, and according to her involved very little discussion. Amanda and Jennifer’s consisted of taking into account that both they and their partners had Hepatitis C and were HIV negative based on earlier tests, and was carried out over the course of many hours of conversation during which they discussed their pasts. Finally, Jose and Linda decided to continue to use condoms while they waited to see, first, if they were still HIV negative having acknowledged their engagement in high risk behaviors prior to entering drug treatment; and second, that they were really in a committed and monogamous relationship indicating a relatively high level of discussion and negotiation.

While it is clear that several couples consciously engaged in negotiated safety to a certain degree at the beginning of their relationships, this strategy did not appear to be used consistently throughout the relationship. As demonstrated in the preceding section, this was the case even when considerable risk existed, as when one partner was living with HIV, or infidelity was suspected.

DISCUSSION

While factors such as substance use, intimate partner violence, and self-efficacy most certainly play a role in condom use generally, among these 25 couples, these factors seem to have very little effect on the desire or ability to use or insist on condom use within their current relationships. Our participants, while overwhelmingly marginalized socially and economically and in many cases drug-abusing, tended to be in long term, committed relationships. Due to their marginalized and stigmatized status as inner-city, minority, poor, homeless, and/or drug addicted, their need for security, acceptance, and to love and be loved in return may have been greater, or granted more significance, than what is generally seen among other heterosexual populations at lower risk for HIV infection. Not using condoms then stemmed from their desire for a loving and meaningful relationship and doing whatever necessary, including risking their personal health, to attain and maintain it. Most participants were well aware of the risks they were taking but finding their “soul mates”, and achieving a sense of “normalcy” was a higher priority.

Sero-discordant and concordant positive partnerships are faced with particular challenges in terms of intimacy and the very real barrier to it that condoms can present. Entangled with the desire and need for physical pleasure are those of physical and emotional intimacy, wanting to express love for one’s partner, fear of loss due to death and being left alone, and wanting to be with that person and share their experiences in the fullest sense. The challenge for researchers and practitioners is to develop interventions that address these concerns, and promote the importance of protection as complementary with the desire for love and intimacy.

Because condoms were seen as inconsistent with establishing and maintaining a committed, primary relationship, couples used other strategies, some more thoroughly than others, to assess their risk. Some couples took conscious steps to assess their risk (e.g. testing) while others have used evidence (e.g. assuming that if she/he hasn’t gotten an STD so far, his/her partner must be clean and she/he is safe.) While several couples described using some form of negotiated safety at the beginning of their relationships, this approach was not used consistently throughout the relationship. In fact, many participants seemed to ignore or minimize their risk, or acknowledged a real risk of contracting HIV, as in sero-discordant couples, but still chose not to use condoms consistently. Given the high importance of establishing and maintaining committed, romantic relationships, negotiated safety must be re-conceptualized and communicated as a way of increasing intimacy and strengthening relationships among high-risk heterosexuals. On-going risk assessment could be presented as ways of increasing trust and intimacy within the relationship through open and honest communication. Similarly, periodic testing could be conceptualized as a way of expressing love and maintaining trust within the relationship. However, the fact that many couples were attempting to assess risk in spite of the fact that negotiated safety has not been widely promoted in the U.S. among heterosexuals, suggests that this may be a more acceptable HIV prevention tool for those in committed relationships.

The fact that so many HIV-affected couples self-selected for participation in a study about female condoms that did not use HIV status in its inclusion/exclusion criteria may indicate that high-risk couples are interested in safer sex and seeking alternatives to the male condom. Two such alternatives may include the already available, although not always accessible, female condom, and microbicides, currently in development. The quantitative and qualitative results from a 2-week FC trial involving these same couples are beyond the scope of this paper and will be reported elsewhere. However, several trial participants reported female condom use at baseline. Also, early analysis of trial data indicate that couples sometimes prefer the female condom over the male condom and female condoms, if more accessible, would be incorporated into the couple’s repertoire of HIV/STI/pregnancy prevention strategies. Additionally, as reported previously,[30] vaginal microbicides hold promise as an acceptable and desirable option for women drawn from the same community as those in this study.

There are several limitations to this study which should be recognized. This was not a representative sample for a variety of reasons. First, participation was limited to those who were willing to enroll in the study with a partner. Second, while all types of partners were eligible (primary, casual, and paying/paid), participation was limited to those with primary partners, likely due to the in-depth and longitudinal nature of the study. As such, findings are not representative of heterosexuals without serious relationships, or who have casual or paying/paid partners. Third, due to difficulties encountered during recruitment, the sample may have limited to those with an intrinsic motivation to participate, hence the abundance of sero-discordant and sero-concordant positive couples. Fourth, the sample was comprised of socially and economically marginalized and often drug-involved persons making the findings less generalizable to those with a higher socio-economic status or without a substance abuse problem. The latter may also be considered a strength of the study as these perspectives are often lost in research and the literature. Finally, self-report bias was an inherent risk of the study; however by interviewing both members of a couple we were able to validate the consistency of participants’ reports.

There is a clear disconnect between public health and lay conceptualizations of sex and the nature of sex between “high-risk” individuals. This is evident both in how research questions are asked and the resulting data are interpreted. The findings of this study clearly support the need to explore the context in which sex is occurring, i.e. relationships, and, in fact, suggest that primary, committed relationships may be even more important for this high risk population than other heterosexual populations at lower risk for contracting HIV. By referring to drug users as only having sex partners rather than lovers we are, as Singer asserts,[31]

“robbing these human relationships of anything but their sexual component, and even robbing that form of human interaction of any meaning except its mechanical ability to transmit infection.”

HIV prevention interventions need to acknowledge the real needs that primary relationships satisfy. Greater attention must be paid to developing HIV prevention interventions that acknowledge these needs and do not contradict people’s beliefs about their relationships to the point where they reject those interventions as irrelevant.