Impact of Relationship Dynamics and Gender Roles in the Protection of HIV Discordant Heterosexual Couples: an Exploratory Study in the Puerto Rican Context

Abstract

Background

Most of the HIV/AIDS prevention efforts have not taken into consideration the context of the relationship and the gender constructs that influence relationship dynamics. These efforts have failed to view HIV prevention as a collaborative process between partners. Therefore, it is important to explore how relationship dynamics and gender constructs influence how men and women involved in an HIV discordant heterosexual relationship, visualize their role in the protection of their partners in order to design more effective prevention interventions.

Methods

Five Puerto Rican HIV discordant heterosexual couples were interviewed via a qualitative semi-structured interview. The taped interviews were transcribed and analyzed using content analysis according to a set of defined categories.

Results

Women visualized their role as one of convincing their partners to use protection as well as being strong and firm in the demand of its use. Men viewed their role as one of being more supportive and willing to use protection, but recognized their resistance towards the use of condoms. Relationship dynamics such as communication and support promoted protection.

Conclusions

Traditional and non-traditional gender roles were assumed by both men and women. Traditional gender roles inhibited protection but were also used in positive ways to promote it. Men showed a greater initiative to break with traditional gender norms. A positive relationship, marked by communication and support could serve as a facilitator in the protection and in the transformation of traditional gender norms. This points out to the need of viewing HIV/AIDS prevention as a collaborative rather than individualistic process.

There is no doubt that HIV/AIDS has left its mark in the history of humanity. It is estimated that around 2.5 million new infections occurred during the year 2007, for a total of approximately 33.2 million people infected worldwide (1). In the Caribbean, around 17,000 people were newly infected in 2007, amounting to a total of 230,000 people living with HIV in this region. This has led the Caribbean to become the second most affected region worldwide, as well as making HIV/AIDS one of the leading causes of death for people between the ages of 25 and 44 (2). Unfortunately, Puerto Rico’s statistics reflect this reality. Currently, there have been approximately 32,415 confirmed cases of AIDS and around 20,197 lives have been claimed. Approximately, 25% (8,087 cases) of the infections have occurred through heterosexual contact (3).

It is estimated that over 70% of the HIV infections worldwide occur through heterosexual contact (4). Consequently, this has become the predominant mode of transmission in the Caribbean and the second in Puerto Rico (2). Therefore, the modification of high-risk sexual practices between HIV positive people is of utmost importance in order to change the course of this epidemic (5).

However, most of the interventions aimed at the prevention of HIV/AIDS with heterosexual couples have focused almost exclusively on the provision of basic information about the disease and the modes of protection to the individual, failing to take into consideration the context of the relationship in which these high-risk sexual practices take place (6–8). By ignoring the dynamics that take place in those intimate relationships, the attitudes that both the female and male partner have regarding sexuality, the difficulties that men and women encounter regarding protection, and the socio-cultural context in which these people are immersed in have also been left aside.

Specifically, this socio-cultural context has shown to promote certain gender roles, as well as power relationships, which affect the sexual dynamics within the relationship (6). Moreover, the main target of these interventions has been the woman, based on the premise that she will have the power to negotiate safer sexual practices with her partner (9). These initiatives, directed towards the reduction of HIV/AIDS by using women as the main and/or only partner that can or should play a part in the prevention, have not had a notable impact. Clearly, they have failed to consider the central role of the dynamics that take place within the relationships and the role played by socio-cultural constructions of the feminine and masculine (4).

In all societies, there are a set of predominant ideologies that have assigned particular roles to men and women known as gender roles. These dictate what types of conducts are considered appropriate for both men and women, as well as which are considered inappropriate. At the same time, they have been used to indicate the access that men and women will have to certain resources, including the authority to make decisions. Even more concerning, studies have found that these ideologies and social constructions of gender frequently lead to high-risk sexual practices and, consequently, the vulnerability of becoming infected with HIV (10).

Several authors have pointed out that the interaction between the gender sexual norms with cultural sexual norms become explicit in the Latino population (11–12). This can be explained from a historical perspective if we take into account that the Latino culture has been characterized for the strong presence of machismo values such as: an exaltation of power, strength, virility, authority, independence and hyper-sexuality (11). At the same time, marianismo values among women have intertwined values such as chastity, abnegation, submission, obedience, purity and inferiority with the appropriate behavior of women (13).

In the mists of the HIV/AIDS epidemic, these concepts of what it means to be a man or a woman play a fundamental role in the vulnerability of an individual to become infected with the virus, his or her capacity to access medical care, help and/or treatments, and his or her ability to deal with the situation (14). These gender constructions at the same time have promoted: a) the exaltation of the act of penetration as the one true sexual act, b) the ignorance of women and men regarding their body and sexuality, c) the expectancy of men to have multiple sexual partners in order to prove their sexuality, d) the view of condoms as stumbling blocks in terms of sexual spontaneity, and e) the lack of communication between partners regarding sexual practices (14–15).

One study conducted with women found that gender roles and unequal power relationships are main barriers for the prevention of HIV (16). Women in this study argued that the partner’s stubbornness and denial for the use of condoms made protection impossible. They expressed feelings of despair, low self-esteem, lack of voice in the relationship and frustration when faced with little or no power to make decisions regarding their protection.

Another study showed that even when a group of women were provided correct information about HIV and protection, this did not translate into the adoption of safer sex practices (17). Nearly half of all the participants indicated that they felt as if they had no right to insist in the use of condoms or abstain from having sexual intercourse because the man was the one who could make these decisions. On the other hand, the fear of obtaining a negative response from ones partner, as well as the emotional involvement that one might have, inhibits safer sexual practices such as condom use and mutual masturbation (18). Another factor that can contribute to high-risk sexual practices as well is that a woman that demands the use of condoms can be accused of infidelity and thus become a victim of abuse.

Now, in terms of what has been identified as the main barriers that men face regarding safer sexual practices, a study conducted with heterosexual males found that there was a resistance to becoming engaged in such practices for different reasons (19). These included: a) thinking that birth control pills protected them from the virus, b) perception of the condom as an inhibitor of sensation and sexual pleasure, c) attributing condom use to the ruining of sexual spontaneity, and d) saying that in a relationship based on trust there is no need to use a condom given that there is no risk of becoming infected.

In another study with Latino men, it was found that men who engaged in risky sexual practices did so because they felt that they needed to prove their masculinity in numerous forms such as: a) having multiple sexual partners, b) allowing themselves to be led by their sexual drives, c) considering it unmanly to ask for information about safer sexual practices and/or about sexually transmitted diseases such as HIV/AIDS, and d) thinking that a real man can handle a situation by his own means and resources (20).

Other studies have also found that certain values prescribed to the roles of men and women can serve as facilitators regarding protection from HIV/AIDS. For example, the role traditionally assigned to men as provider and protector can contribute to assuming this role in his sexual relationship and, thus, motivate him to protect his partner (20). Others found that effective communication skills between partners as well as characteristics of assertiveness and confidence in men and women are positively correlated with condom use and safer sexual practices (21). Moreover, some have argued that over the last several decades, gender roles have begun shifting from the ‘traditional’ roles, which attribute passivity to women and dominance to men, to ‘non-traditional roles’ displayed in both females and males which were not present thirty years ago (22).

Unfortunately, most studies that discuss HIV prevention and its relationship with gender have focused mainly in the individual barriers that both men and women face when practicing safer sex and on the negative impact that gender roles have in the protection process. Prevention efforts with HIV discordant heterosexual couples have been minimal, when it is actually imperative to work with this population given that these barriers or facilitators take place in the context of a relationship (23). Moreover, most studies have focused on examining how men and women perceive they can protect themselves as individuals and in providing basic information about the modes of protection. Therefore, this approach has not explored how couples perceive they can work together and help protect each other from HIV and how gender roles can have a negative or positive impact in these processes. Any model concerning the risk factors involved in acquiring HIV that proposes gender roles as fundamental in understanding high-risk behaviors, must also take into account the role that men have in the sexual high-risk behavior of women and vice-versa (24).

Given these findings, we conducted a study to examine how men and women involved in an HIV discordant heterosexual relationship visualize and interpret their role in the protection of their partners. We also wanted to explore the barriers that they face, examining how their relationship functions as a barrier or a facilitator in the protection, if gender discourses are present in their narratives, and how these act as barriers and/or facilitators in the protection.

Method

The impact of relationship dynamics and gender roles in the protection of HIV discordant heterosexual couples was investigated as part of a larger study called Project Encuentro III. This study was targeted at adapting and implementing a group-based intervention aimed at promoting safer sex and preventing HIV transmission in HIV discordant heterosexual couples. The specific goals of this intervention were to: a) promote positive attitudes toward male condom use and the practice of mutual masturbation, and b) increase male condom use and the practice of mutual masturbation as a safer sex method. The intervention was based on the Information-Motivation-Behavioral Skills Model (IMB) of behavior change (25). This model proposes that having accurate information about HIV transmission and prevention, being motivated to engage in HIV preventive behavior, along with promoting the acquisition of the necessary behavioral skills will produce an AIDS preventive behavior. The adapted intervention consisted of four three-hour sessions which were held once a week.

The following four topics were discussed: a) basic information about HIV/AIDS, b) condom use and negotiation, c) mutual masturbation (MM), and d) the experience of living with HIV/AIDS and disclosure of status. These sessions had the following objectives respectively: a) provide basic information about some medical terms such as viral load, CD4 cells, HIV transmission and prevention and emphasize advantages of using a male condom and practicing mutual masturbation as safer sex practices, b) Promote a sense of self-efficacy for the negotiation and use of condoms, develop conflict management skills when the partner refuses to use a condom, discuss barriers and facilitators related to the use of condoms and identify and reflect upon the factors in their relationship and in their social context that can facilitate or impede the use of condoms, c) Demystify wrong ideas about the MM, promote positive attitudes toward MM as a safer sex method, promote the acquisition of skills to practice MM and identify and reflect upon the factors in their relationship and in their social context that can facilitate or impede the practice of MM, and d) Discuss how stressful it may be to disclose or not their HIV/AIDS status to family and friends, reflect upon the advantages and disadvantages of disclosing their HIV/AIDS status and develop skills in order to disclose their HIV/AIDS status to family and friends, if they so decide.

Participants

The participants of this study included five HIV discordant heterosexual couples. To be eligible for the study, participants had to: a) be involved in an HIV discordant heterosexual relationship for the last six months, b) be 21 years of age or older, c) not have used any type of illegal drug during the last 30 days, d) know how to read and write, e) express a commitment to attend to all four sessions of the intervention along with their partner, and f) not being participating simultaneously in any other prevention activity.

From these participants, two were HIV positive men and three HIV positive women. The mean age was 45 years old (range of 32–57). Two couples were legally married, and the other three couples were living together, but were not legally married. However, all five couples were involved in a serious and stable relationship with their partner. The modal joint monthly income was $500–1,000 and the mean education level was a high school diploma. Sixty percent (60%) professed to be protestant, but all indicated to have religious beliefs of some sort. Two of the HIV positive participants were infected through needle-sharing and three were infected trough sexual relations.

Instruments

For the purposes of this exploratory study, the same interview used to assess the intervention’s impact was used to examine our categories of interest. This was a qualitative semi-structured interview with the following five sections: a) recruitment and retention (6 questions), process and content of the activities (10 questions), impact of the intervention (9 questions), d) logistics (i.e. place, food, telephone follow-up) (3 questions), and e) general evaluation (1 questions). The pertinent themes to this study were brought by participants in a spontaneous manner during the interview.

Procedure

A qualitative individual in-depth interview was conducted with all participants one month after the intervention. The interviews were conducted by trained research assistants. Before initiating the interview, the interviewer read out loud a consent form and provided the participant a copy of this document. Participants had the opportunity to ask questions or clarify any concerns. All procedures were previously approved by the Institutional Review Board of the University of Puerto Rico, Rio Piedras Campus.

Data analysis

For the specific purposes of this study, a coding sheet with the following categories was developed: a) Ways of Protecting Ones Partner, b) Men's Role as Facilitator in the Protection, c) Women’s Role as Facilitator in the Protection, d) Men’s Role as Barrier in the Protection, e) Women’s Role as Barrier in the Protection, f) Couples Relationships as Facilitator, g) Couples Relationships as Barrier, h) Perceived Importance of Women’s Role in the Protection, and i) Perceived Importance of Men’s Role in the Protection. The complete contents of the interviews were coded using these specific categories with a focus on the themes that emerged from the participants while they responded to the questions asked.

It is important to keep in mind that the participants took part in an intervention designed to help reduce risky sexual behavior and thus, the content of the interview is largely saturated with how their attitudes towards protection may or may not have changed. However, the present study sought to examine how recurring themes regarding the impact of the intervention in their lives as couples remit to gender constructs and relationship dynamics.

In order to attain adequate reliability in the analysis and interpretation of the data, interviews were audio-recorded, transcribed and coded using the double coding technique (26). In this technique, two persons independently observed and coded the data and then met to reach consensus. Only those passages in which the judges agreed on were included for analysis.

Results

The results are presented in sections using the categories used in the analysis. The definitions of each of the categories are presented as well. Each category includes one or two passages of the participant’s narratives that we considered appropriate for illustrating the results. These passages were translated from Spanish to English.

Ways of protecting ones partner

This category sought to explore the activities and/or methods engaged in by the participants in order to protect their partner from HIV or prevent re-infection. The use of condoms, as a means of engaging in safer sexual practices, was the most recurrent theme among participants. It was consistently viewed as their main method of protection, as well as the most efficient. The second method of protection mentioned was practicing mutual masturbation. However, this method was used less frequently and was not favored at all by some participants. Finally, other methods of protection included not engaging in promiscuous behavior and simply being ‘careful’ when having sexual relations. As one participant expressed:

It is a secure means of protection [the condom], it is something safe, and it is something that should never be absent in a relationship in which one partner is positive and the other one is not […] it should be right there in the middle in order to have safer sex. (HIV− woman)

Men’s role as a facilitator in protection

This category sought to explore the responses men gave regarding their role in the protection of their partners from HIV or prevent re-infection, and how they could facilitate this process. Some recurring themes emerged as the major roles men believed they played or should play in protecting their partners. These included: supporting their partners emotionally, helping them ‘feel better’, protecting and ‘guarding’ them, caring for them and taking them into account more often, having a positive and good attitude, adjusting their lifestyle, becoming involved in workshops and orientations about HIV/AIDS and recognizing that using condoms and/or other methods of protection is important. This can be illustrated in the following comments:

…and as her partner, I can contribute by helping her so that she can have a normal life in the midst of the illness and also help so that she can protect herself; I can help in that moment when she feels anguished… (HIV− man)

…take care of her more, value her more and know that you are with a human being, not with an animal, in other words someone who has life… (HIV+ man)

Women’s role as a facilitator in the protection

This category sought to explore the responses women gave regarding their role in the protection of their partners from HIV or prevent re-infection, and how they could facilitate this process. Some of the emergent themes regarding women’s perceived roles in the protection of their partner included the following: ‘worrying’ about the use of protection during intercourse, being ‘insistent’ in partner’s use of condoms, being ‘strong’, ‘firm’ and ‘unyielding’ in the practice of having unprotected sex, ‘convincing’, ‘motivating’ and ‘encouraging’ partners to become engaged in workshops or orientations regarding HIV/AIDS, and finally, break with the ‘hay bendito’ discourse (‘oh poor thing’ discourse) which often leads them to yield to their partners demands for having unprotected sex and, consequently, compromise their health. As one participant expressed:

Yes, I have to be stronger; I can’t be driven by the ‘oh poor him’ idea: “oh poor him he is so good to me, let me do as he wishes” No, no, no, no! No, if you don’t wear it [the condom] we won’t do anything. (HIV+ woman)

Men’s role as barrier in the protection

In this category, we explored the responses men gave or the attitudes they displayed which could make protection a difficult task and in some cases, non existent. Several recurring themes emerged from the participants. These were mainly centered on placing sexual pleasure and sensation before protection. The barriers identified could be divided into three main themes:

Discarding protection methods

Participants expressed that they frequently discarded the use of condoms for several reasons. These included: saying that it made them ‘dysfunctional’ or ‘impotent’, feeling as if the condom was a ‘in the way’, that it felt ‘uncomfortable’ and ‘bothersome’, feeling ‘frustrated’ when they wore it and saying that it reduced sexual sensation and pleasure. A few also expressed a disregard for the practice of mutual masturbation because they felt as if this was not ‘real’ sex. As one participant expressed:

…Its just that I get frustrated, there is frustration and at the same time well, I get impotent by just thinking that I have to wear that thing [the condom] […] I just can’t get around with how to deal with myself. (HIV− man)

Ideas about sexuality

Almost all male participants expressed a general view of sexuality as a subject that should not be discussed openly around women and that it is more acceptable and ‘comfortable’ to do so with other men. Participants also expressed that having ‘real sex’ is equivalent to having sexual intercourse and that if a man ‘has a women’, he should engage in penetration instead of mutual masturbation. This can be illustrated in the following comments:

…you know, when surrounded by women we feel uncomfortable talking about that [sex]. It is better being us men alone because we let loose and let it all out you know, and we say it like it is. (HIV+ man) It’s just that as a ‘macho’ you know, I thought that as a ‘macho’ I always had to reach an orgasm through penetration. (HIV+ man)

Individual characteristics

Participants also expressed certain personal beliefs or attitudes which in turn inhibited protection. These included: a) thinking that the woman was responsible for the protection and not the man; b) not taking the illness seriously and joking about it continuously; c) not wanting to look for help or for orientations about the condition; d) not wanting to get involved in anything that had to do with HIV/AIDS because of the fear that a family member or friend would find out they or their partner had the illness; e) not wanting to communicate with the partner about sexuality or the illness; f) being unfaithful and looking for sex in the ‘streets’ and g) thinking that they had the last word regarding when and how sex with their partners would take place. As one participant expressed:

Well, I hadn’t taken it with the seriousness that this had [HIV/AIDS] […] I just had intercourse with [partner’s name] without a condom and without anything […] I took everything as a joke. (HIV− man)

Women’s role as a barrier in the protection

In this category, we explored the responses women gave or the attitudes they displayed which could make protection a difficult task and in some cases, non existent. Most women expressed barriers in two main areas: view of sexuality as a taboo and personal characteristics that promoted submissiveness and passivity regarding sexual decisions.

Ideas about sexuality

Most of the women participants indicated that women should not talk about sex in public because this is ‘not right’. Talking about sex was regarded as a taboo and as a private matter. If it is going to be discussed, it should be done among women rather than around men. Some women also believed that sexual practices other than sexual intercourse, such as mutual masturbation, are a ‘sin’ as well as ‘immoral’ and therefore, it is ‘not right’ to engage in them. Finally, some women expressed a strong inclination towards the belief that ‘real sex’ is having sexual intercourse and that mutual and/or individual masturbation should not be practiced. These women expressed a feeling of anger when their partners masturbated and did not feel satisfied during the occasions that mutual masturbation had taken place. This can be illustrated in the following comments:

… There are things that you can’t be talking about when men are around and even worse when men you don’t know are around. It is better for us women, even though sometimes we don’t know each other, because we are all women and we understand each other. (HIV+ woman)

I don’t know, I thought that speaking so much about sex, wow, I thought this should be something more personal, you know […] I felt ashamed. (HIV+ woman)

Individual characteristics

Some women expressed a lack of orientation regarding their sexuality such as not knowing about sexual practices other than penetration and having little or incorrect information regarding methods of protection. On the other hand, some women attributed themselves the characteristic of being shy and passive. Some of them believed that condoms should only be used when the partner ‘wanted to’. This can be illustrated in the following comments:

Sex is sex [referring to penetration] but masturbation, this I have come to learn; I didn’t know anything about those kinds of things. (HIV+ woman) Well, if he wants to, we will use them [the condoms] because I have them at home, (HIV+ woman)

Couples relationships as a barrier

In this category, we explored the characteristics of the couple’s relationship which could be viewed as possible barriers in the partner’s mutual protection from HIV. Participants mentioned several of the following characteristics in their relationship which they perceived as barriers in their protection: lack of communication with one’s partner out of fear of being judged or misunderstood, and lack of communication regarding sexuality and methods of protection. Some women also expressed frustration when they tried to communicate with their partners about protection, the illness or their emotions because they felt as if their partners took everything as a ‘joke’. They felt that protection was impossible when their partners were not even willing to discuss it. This can be illustrated in the following comments:

…not all of us want to share an opinion when we are with our partners (laughs). Some of us feel awkward and some simply don’t like talking when our partner is around… (HIV+ man)

…I sit and talk to him [about the condition] and he takes it as a joke… (HIV− woman)

Couples relationships as a facilitator

In this category, we explored the characteristics of the couple’s relationship that facilitated the partner’s mutual protection from HIV. Participants mentioned several characteristics of their relationships which they perceived facilitated the protection. These included: a) being committed to one’s partner, b) having empathy towards the other’s feelings and emotions, c) not ‘hiding’ anything, d) promoting peace and tranquility, e) being more understanding towards one another, f) being communicative and more ‘open’, g) being affectionate towards one’s partner, show support and making decisions together, h) achieving a high level of intimacy and trust, i) communicating openly about sexual matters as well as taking them seriously, j) having interest in learning about, as well as using new methods of protection, and k) viewing the protection as a collaborative process. This can be illustrated in the following comments:

…I believe that he should take better care of me and that way I will take better care of him too because we will be protecting each other mutually. (HIV− woman)

There is something that you feel when you are with a person and you see what she is going through. She [his wife] had the unfortunate event of contracting this disease or virus. But I have been a support for her and she has been a support for me as well… (HIV− man)

Perceived importance of women’s role in protection

In this category we sought to examine opinions that the participants in general had regarding the importance of women’s role in their protection as a couple. The main theme that emerged was the idea that if the woman did not insist or worry about protection, no one would. Therefore, women and men favored the idea that women should ‘insist’, ‘persuade’, ‘convince’ and ‘remind’ the partner to use protection, attend workshops and orientations and remind men of the consequences of having unprotected sex. For example, men consistently pointed out that it was the women who ‘reminded’ them to wear the condom and that if they did not do it, they would usually ‘forget’ and not wear it. Women also pointed the importance of being supportive of their partners and looking out for their best interests. This can be illustrated in the following comments:

…I always tell him to use condoms, because how can I explain it, he is a little bit close minded. (HIV+ woman)

I kept at it until I convinced him [to attend an orientation about HIV/AIDS]. (HIV+ woman)

Perceived importance of men’s role in protection

In this category we examined opinions that the participants in general had regarding the importance of men’s role in their protection as a couple. The main theme that emerged was that men’s attitudes towards safer sex methods had a significant impact on whether the couple would engage in protective methods or not. Both men and women indicated that without a change in attitude from the male’s part, regarding importance of protection, support and responsibility towards the partner, the protection would be more difficult to achieve. Participants also pointed out that usually, it was the man’s attitude that influenced the dynamic in the relationship. Therefore, if the male partner had a negative attitude towards the protection and support of his female partner, not only would protection be less likely to occur, but also, factors such as communication and trust would decrease. Finally, participants indicated that the importance of the man’s role in the protection is centered on changing their views about condoms and mutual masturbation, adapting and modifying previous sexual schemes, showing their partners that they are not ‘irresponsible’ and ‘cooperating’ so that their partners wouldn’t feel ‘bad’. Male participants emphasized that it was the life of their partners they had in their hands and that they couldn’t forget this. This can be illustrated in the following comments:

…you know, I have to protect myself from her and she has to protect herself from me because [partner’s name] could become re-infected. If I get an infection and have sexual relations with [partner’s name], even though I don’t have the virus [referring to HIV], I could re-infect [partner’s name]. [… ] and if she is in a delicate state and I have sexual relations with her I could also do her harm. (HIV− man)

I always use it [condom]. I don’t discard using it because it is my life and my partner’s life that doesn’t have the virus that is at stake. (HIV+ man)

I know that I have to do my part… (HIV− man)

Discussion

In this study, we wanted to examine the presence and/or absence of traditionally enforced gender roles in the men and women that composed the heterosexual HIV discordant romantic dyad, as well as to explore how these gender roles served as possible barriers and/or facilitators in the protection from HIV We also wanted to explore how relationship dynamics between these couples both impeded and/or facilitated the protection of the couple, in order to prevent the HIV negative partner from becoming infected or the HIV positive partner from becoming re-infected.

Our results point to the following key findings regarding gender roles: a) both non-traditional and traditional male and female gender roles were present in the participants narratives and simultaneously manifested themselves throughout their behaviors and schemes, b) traditional male and female gender roles acted as barriers and as facilitators in the protection, and c) men tended to view attitudes and actions that reflect traditional male gender roles more as barriers in the protection and expressed a need to change them, while women tended to view attitudes and actions that reflect traditional female gender roles as facilitators in the protection and considered them necessary. In terms of relationship dynamics, key findings include that: a) a lack of communication, support, and collaboration had a negative impact in the protection of the partners while, b) the presence of these three factors greatly increased protection, and c) gender roles were intertwined in the relationship dynamics.

The words machismo and marianismo have been the terms coined to represent those values that the Latin American culture has designated as the acceptable behaviors and schemes for men and women, respectively. Although the literature has confirmed the presence of these gender roles in our culture, it would seem as if they are portrayed as static. The findings of this study contradict the apparent unchanging nature of these gender roles and points to a possible gender shift and gender role ‘appropriation’ which will be discussed as well. At the same time, the findings indicate that the context of a serious romantic relationship may have a role in this apparent gender shift and, thus, play an important part in HIV/AIDS prevention.

Women in this study contradicted as well as enforced the traditional gender female roles both from an ideological and a behavioral perspective. The expressions of these women regarding being ‘firm’, ‘strong’, ‘unyielding’ and ‘insistent’ in the use of safer sexual methods with their partners greatly clashes with the accepted female attitude of passiveness and submission to male’s decisions.

However, simultaneous expressions such as having to ‘worry’ about protection and having to ‘convince’, ‘encourage’ and ‘motivate’ partners to engage in safer sex and use protection if their partner ‘wanted to’ is consistent with the traditional female gender role of being the ‘caretaker’ and the ‘safe’ partner who in the end, submits to her partner’s demands. On the other hand, we could argue that this denotes a certain ‘appropriation’ of the traditional female role in order to use it as a facilitator and not a barrier. If we take a closer look at the remarks made by these women, we can see that they use the strategy of convincing and motivating in a subtle and almost indirect way (traditional gender role) in order to obtain protection and not succumb to their partner’s demands of the contrary (non-traditional gender role).

Traditional female gender roles were also seen from the perspective most of these women had of sexuality as a taboo. Most women felt uncomfortable talking about sex and considered it more a male than a female activity. Females also showed a general lack of knowledge regarding their own sexuality. Therefore, we can see how the traditional script of the ignorant, pure, calm, and virgin women’s ideal is both simultaneously reaffirmed and contradicted by the ideal of being a strong, firm and unyielding woman.

Likewise, results indicate that men’s ideas about their role in the protection of their partner both enforced as well as contradicted traditional gender roles. The acknowledgement on behalf of most men regarding their control and dominance of their sexual relationships with their partners coexisted simultaneously with a non-traditional discourse of the need for ‘changing’ these sexual schemes and being more ‘considerate’ with their partners and ‘careful’ with their behaviors. This could be interpreted as a shift in traditional male gender roles given that men expressed a general dislike for these dominant and controlling practices and included in their narratives the need to incorporate some non-traditional male gender roles such as: the need to provide emotional support to their partners, ‘care’ for them, ‘readjust’ their behaviors in order to take them into account more often, and recognize the importance of protection by engaging in safer sexual methods.

Like women, men also expressed a certain appropriation of traditional roles in order to use them as facilitators and not as barriers in the protection. The traditional idea of the male as the protector and guardian of ‘his woman’ was consistent with the expressions of most of the participants regarding their role in protection. However, men viewed this dominant position of guardianship as a facilitator and not as a barrier in protection. This finding is consistent with other findings which have found that the role assigned traditionally to men as that of the protector of their household and partner can contribute to his wanting to assume this role in his sexual relationship and, thus, motivate him to protect their partner (20). Therefore, as with women, we can see a certain ‘appropriation’ of the traditional gender role in using it as a means of engaging in protective behaviors.

Relationship dynamics were also viewed by participants as facilitators and/or barriers in the protection. Lack of communication, specifically regarding sex, was the main factor why most couples discarded protection. This lack of discussion about sexual topics also affirms the traditional gender scripts regarding the appropriate places to discuss sex; for men, being with other men and for women, being with other women.

On the other hand, the presence of dynamics such as communication, trust, support and affection in their relationships were viewed as a benefit towards their protection. These findings are consistent with other studies that have also found that effective communication skills between partners, as well as characteristics of assertiveness and confidence in men and women, are positively correlated with condom use and safer sexual practices (21).

Along this same line, most participants agreed that protection had to be a collaborative process in order to be successful. Concordant with traditional female gender roles, women often felt as if it was their duty to worry about protection and that it was almost impossible to engage in safer sex if their male partner was not willing. On the other hand, contradicting traditional male gender roles, men recognized the importance of their part in protection and most viewed it as a ‘life or death matter’

Finally, it is interesting to see men more inclined towards this gender shift than women when the contrary would be expected. All of the men in this study expressed a need to change their traditional dominant ideals, but women, on the other hand, did not express a need to change traditional gender schemes. Rather, they insisted on the combination of ‘convincing’ their partners (traditional role) with assuming a more authoritative and unyielding role (non-traditional role).

Therefore, in this study, traditional female and male gender scripts appear to be shifting and transforming. The idea of a strong, firm and unyielding woman that was expressed by some female participants opposes the passive and submissive marianista woman. As well, the supportive, empathic and understanding man contradicts the strong, firm and unemotional traditional male gender role. Interestingly enough, these apparent shifts are intertwined with traditional gender roles of female submission and male dominance. These results are consistent with other findings that point towards a shift in gender scripts without necessarily discarding traditional female and male gender scripts (15).

These findings have implications for HIV prevention. HIV prevention for the most part has examined protective processes in individuals and not as units in a committed relationship, even though heterosexual contact is becoming the number one means of infection with HIV. By taking in consideration the context of a committed romantic relationship, working with relationship dynamics that take place and promoting factors such as communication, trust and support, we could promote the couple’s desire to protect one another and this, in turn, could promote a modification and/or ‘appropriation’ of traditional gender roles that would culminate in protection. Beginning to view HIV as a collaborative process and not just as an individual process, mainly attributed as a responsibility of the woman, could lead to more effective prevention strategies with heterosexual discordant couples as well as to a transformation in these traditional gender scripts that have for the most part inhibited protection.

Finally, it is important to point out that this study had three potential limitations. First, the sample size was too small. Even though the generalization of findings is not an issue in qualitative research, we are aware that the small sample size limited our capacity of seeing up to what point these dynamics are representative of other HIV discordant heterosexual couples. Future studies should consider increasing the sample size in order to corroborate the results and strengthen their implications. Second, we cannot assume that all HIV discordant couples are the same, particularly if the index case varies in gender. It is important to recognize that the experiences of HIV+ women or men could be potentially different from their HIV− partner’s experiences in the relationship and in this study, the participant’s responses where merged together. Future studies should examine HIV+ and HIV− participant’s responses separately in order to examine potential differences. Third, we recognized that it is not the same to be a woman living with HIV in a discordant couple than a woman who is the partner of a man who is HIV+. These couples were interviewed after an intervention designed to reduce risky sexual behaviors which had workshops regarding conflict resolution among couples, as well as briefly discussed some gender issues regarding protection. This could have influenced the participant’s narratives by making them more aware of traditional and non-traditional gender roles, as well as prompted a re-evaluation of their relationship dynamics. Still, we might inquire as to why the coexistence of traditional and non-traditional gender scripts? Why do we not see a complete shift from the machista and marianista values? Could these interactions between non-traditional and traditional shifts be the beginning of this change in roles?

A possible explanation would be taking into account the particular context of these participants, a committed romantic relationship. The dyad could, in some way, promote the shift of these traditional schemes that inhibit protection towards some non-traditional schemes that promote it. All of this with two common key factors: a) the presence of the other who is the object of the partners affect, love and respect and b) the reality of an illness that could be transmitted to the other partner if the appropriate measures are not taken into consideration.

These findings provide important and relevant information that could better inform HIV prevention efforts with HIV discordant heterosexual couples. Integrating factors such as relationship dynamics and gender constructs into interventions with this understudied population, can possibly yield beneficial results such as an increase in the use of protection (e.g. condoms) and help reduce the rate of HIV transmission.