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. Author manuscript; available in PMC: 2015 May 7.
Published in final edited form as: AIDS Behav. 2011 Jan;15(1):153–162. doi: 10.1007/s10461-009-9659-2

Intimate Partner Violence Perpetration and Condom Use-Related Factors: Associations with Heterosexual Men’s Consistent Condom Use

Victoria Frye 1,2,✉, Danielle Ompad 3, Christina Chan 4, Beryl Koblin 5, Sandro Galea 6, David Vlahov 7
PMCID: PMC4423735  NIHMSID: NIHMS291026  PMID: 20069447

Abstract

Intimate partner violence victimization has been linked to sexual HIV risk behavior among heterosexual women. The unique role of perpetration of intimate partner violence (IPV) in sexual risk behavior among men has not been studied as well. Based on interviews with 518 heterosexual men recruited via street-intercept between 2005 and 2007 in New York City, we assessed the relationship between perpetration of IPV against a main female partner and inconsistent condom use with that same partner, while controlling for condom use-related factors. Multivariate logistic regression revealed that men who perpetrated physical IPV were half as likely to report consistent condom use as compared with men who did not use violence, while controlling for sociodemographic, condom use-related and other factors. Physical IPV perpetration by heterosexual men makes an independent contribution to consistent condom use. Designing interventions for heterosexual men that simultaneously address both IPV and sexual risk behaviors is critical.

Keywords: HIV, Sexual risk behavior, Condom use, Intimate partner violence

Introduction

In the US, in 2006, 80% of all new HIV cases among women were attributed to high risk heterosexual contact [1]. Among men and women, the estimated number of heterosexually acquired HIV/AIDS cases has increased between 2004 and 2007 [1]. In order to effectively reduce the incidence of heterosexually transmitted infections among women, it is important to understand better the factors that put women at risk. Intimate partner violence (IPV) victimization has been shown to be one of those risk factors [2, 3]. Generally defined as including psychological violence, most research in the area of HIV risk has defined IPV narrowly, focusing on physical or sexual violence victimization experiences alone. Increasingly, studies are beginning to focus not on the risk that women’s victimization poses, but on how perpetration of IPV and sexual HIV risk behaviors are related among heterosexual men. This research on men’s use of IPV reflects the need to gather baseline data to inform HIV prevention intervention efforts designed for heterosexual men, as actors most in control of their own sexual behaviors.

The majority of existing studies have reported that men who perpetrate IPV report greater sexual risk-taking behaviors. Early research in this area focused on substance using men or HIV-positive men [4, 5], as these men are at the highest risk of transmitting HIV to their female partners. Among men on methadone, El-Bassel et al. [4] found that those who perpetrated IPV were more likely to have multiple sex partners and engage in unprotected anal intercourse with a main female partner. More recently, Kapadia et al. [6] reported that among injection drug using (IDU) men, in multivariate analyses, IPV in the main relationship was associated with inconsistent condom use in that relationship, only among men with multiple partnerships. Frye et al. [7] reported that among male HIV-positive IDUs unprotected vaginal and/or anal sex with a female partner was associated with the use of IPV in a main relationship. One study among a clinical sample of young men found that IPV perpetration was associated with sexual HIV risk behavior [8]. In contrast, in a study of HIV risk among HIV-positive men Bogart et al. [9] found that perpetration of IPV was not associated with sexual HIV risk behavior.

Together these studies strongly suggest that IPV perpetration is correlated with sexual HIV risk behavior among men. However, most of these studies did not control for other factors also related to consistent condom use among men, including female partner pregnancy desire, HIV infection status, or condom use-related factors (such as condom use outcome expectancies and self-efficacy specific to condom use). This is an important consideration, as these factors have been found to be associated with consistent condom use, a critical sexual HIV risk behavior [10]. A range of studies among heterosexual men and women, not focused on the role of IPV, indicate that condom use-related factors are associated with consistent condom use [11–14]. Here we report results from an analysis of 518 heterosexual men (men who have sex with women only) recruited via street-intercept methods between 2005 and 2007 in New York City (NYC). In the analysis we assessed the roles of both IPV and condom use-related factors in self-reported consistent condom use among men.

Methods

Procedures and Sample

This analysis draws data from the Inner-City Mental Health Study Predicting HIV/AIDS and Other Drug Transitions (IMPACT) study, a cross-sectional study of the relationship between the neighborhood environment and various health outcomes, the details of which have been described elsewhere [15]. Recruitment was conducted using street-intercept sampling in 36 ethnographically defined neighborhoods in four NYC boroughs between 2005 and 2007. All participants had to be 18 years of age or older and had to either live in the target neighborhood or spend at least 50% of their time in that neighborhood. In addition, participants fell into one of the following self-reported categories: non-drug users (except alcohol and marijuana), non-injection drug user (current use of inhaled or snorted heroin, crack, cocaine, or methamphetamines and no reported history of injection drug use); injection drug user (current use of injected heroin, crack, cocaine, or methamphetamines), former drug user (previous use of heroin, crack, cocaine, or methamphetamines, but no reported use within the last 5 years), and club drug user (current use of ecstasy, LSD, PCP, GHB, ketamine and/or methamphetamines). If eligible, and after providing informed consent, participants were administered a face-to-face interview over 2 days on a wide range of topics from drug use to sexual behavior to perceptions of their neighborhood. IPV data was collected on day 2 of the interview. Out of the 870 men sampled in the larger IMPACT study at the time of this analysis, 667 (76.7%) completed the second day of the interview and reported a main sexual partner (defined as “someone whom you feel close to in your heart, like a steady girlfriend/boyfriend or a spouse”) in the last 12 months. Of these men, n = 45 (6.7%) were excluded because they reported sex with men only. Finally, an additional 104 (15.6%) were excluded due to missing or incomplete data on sexual behaviors and condom use in the last month. Thus, the final study sample was 518 men.

Measures

Dependent Variable

The dependent variable in this analysis was self-reported consistent condom use (defined as using a condom during every sex act) during vaginal and/or anal sex in the past month with a main female partner. This variable was created by assessing the number of times that the participant had vaginal and/or anal sex with the main partner in the past month and then asking the number of times that either a male or female condom was used.

Independent Variables

The main independent variable assessed was perpetration of moderate and/or severe physical IPV against a main female partner. IPV perpetration was measured using a modified version of the Revised Conflict Tactics Scale (CTS2) [16]. Thus, 17 items assessed the use of moderate physical IPV (e.g., “you threw something at your partner that could hurt” and “you twisted your partner’s arm”) and severe physical IPV (e.g., “you choked your partner” and “you used a knife or gun on your partner”) in the past 12 months. The internal consistency of the entire scale with the data obtained was good (a = 0.842). We dichotomized the scale to model any moderate and/or severe physical IPV perpetration as compared with no moderate and/or severe physical IPV perpetration in the past year. We chose to focus on moderate and/or severe levels of violence as it has generally been this level of violence that has been found to be associated with sexual risk behavior in the literature [4–7]; as the crux of our analysis was to assess the specific contribution of IPV to consistent condom use, but while controlling for condom use-related and other factors, we sought consistency with previous research into this relationship.

We assessed a range of covariates in four domains for their associations with the perpetration of moderate and/or severe physical IPV perpetration: sociodemographic factors, substance use, partner and relationship, and condom use and related HIV factors. Sociodemographic factors included age (assessed as a 5 category variable: 18–25; 25–26–35; 36–45 and 46+), race (White, Black, Latino, Other), sexual orientation (self-reported heterosexual vs. bisexual or unknown), income level (more than $5,000 per year vs. less than $5,000 per year), public assistance receipt (yes/no) in past 6 months, employment status (paid job, full or part time vs. no paid job), receipt of illegal income in past 6 months (yes/no), education level (high school education or more vs. less than high school education), born in the US (yes/no), and lifetime history of incarceration (yes/no). In addition, we assessed acculturation, using items from the Welfare Reform Baseline Interview as adapted by Marin et al. [17].

Substance use factors assessed included lifetime and past 6 month alcohol and drug use, including any use of cocaine and other stimulants (e.g., crack, speed, etc.), use of heroin and other depressants only (e.g., methadone, vicodin, etc.), hallucinogen use only and marijuana use only. We also evaluated heroin, crack and cocaine dependence using items from The National Household Survey on Drug Abuse, designed to measure dependence using DSM-IV criteria [18]. Partner and relationship factors evaluated included partner’s age, length of relationship, perceived partner HIV and STI status (“Since you have been together, do you think __ has had an STD” and “What is the HIV status of ___?”), perception of partner’s sexual fidelity (“Since you’ve been together, do you think ___ has been having sex with other people besides you?”), partner’s desire for a pregnancy (“Since you’ve been together, has your partner wanted to have a baby with you?”) and relationship decision making dominance. This last construct was measured using 5 items from the relationship decision making dominance sub-scale of Pulerwitz’ Relationship Power Scale [19]; items specific to decision making power around condom use were omitted (α = .776). A higher score indicates greater decision making dominance.

Finally, we assessed condom use-specific and HIV-related factors including respondent HIV status, condom use outcome expectancies, condom use self-efficacy and relationship control (with items specific to condom use). Condom use outcome expectancies were measured using a 7-item scale which assessed anticipated partner reactions (e.g., one’s partner would be mad, supportive, distrustful, etc.) in response to requests for condom use; a 5-point response scale (strongly agree to strongly disagree) was used and a higher score indicates more positive anticipated partner reactions related to condom use requests (α = 0.831) [19]. Condom use self-efficacy was measured using 4 items adapted from a scale that taps the ability to use a condom [20]; items included: I can use a condom even if “you lose arousal/erection,” “you or your partner have not used them before,” “you are very turned on,” or “you are high on alcohol or drugs.” Responses were assessed using a 4 item scale (absolutely sure I cannot to absolutely sure I can) and a higher score indicates greater feelings of self-efficacy to overcome barriers to condom use (α = 0.910). Relationship control was measured using the Relationship Control subscale of the Pulerwitz’ Relationship Power Scale, a 15-item scale with several items specific to condom use in sexual activities, which is why it was grouped analytically with condom use related factors; responses were assessed using a 4-point scale (strongly agree to strongly disagree) with a higher score indicating greater relationship control (α = 0.863) [19].

Analysis

Univariate statistics were generated for descriptive purposes and to assess the extent of moderate and severe IPV perpetration among respondents. Associations between independent variables and the outcome were calculated using chi-square and t-tests, as applicable. Logistic regression models were built; modeling was performed by adding variables significant at P < 0.10 to the equation in conceptually related sets, starting first with sociodemographic, substance use, partner and relationship, and condom use and related HIV factors. Several of the condom use-related factors were associated with other covariates, such as HIV status and partner’s pregnancy desire. Using linear regression models, variance inflation factors (VIF) were calculated for all regressors in the models to assess problems with multicollinearity [21]. No VIFs exceeded 10, the generally accepted cut point for problems with multicollinearity among independent variables. We used the −2 log likelihood value and the Deviance statistic to guide modeling decisions. We obtained the model of best fit by first obtaining a final set for each set of variables and then considered whether each successive set of variables improved the fit.

Results

Sociodemographic Characteristics of the Sample

The average age of the men in the sample was 38.2 (SD = 11.0) and the majority of men in the sample were African–American (48%) or Latino (43%). Over three quarters (78%) were born in the US. The sample was generally very low income, with approximately three quarters earning less than $5,000 per year and approximately 71% reporting current receipt of public assistance. Over half possessed a high school degree or the equivalent and less than a quarter were employed in paid or salaried, full-time positions. Over 90% reported a lifetime history of incarceration (Table 1). The average age of the main partner was 35.8 (SD = 10.3) and the average length of the relationship was 6.0 years (SD = 7.4). Sixty-three percent of relationships were of 5 years or less (Table 2).

Table 1.

Sociodemographic characteristics and consistent condom use among heterosexual men: IMPACT study, 2005–2007

All Consistent condom use (<100% vs. 100%) χ2 P-value
No Yes
n % n % n %
Total sample 518 100 354 68.3 164 31.7
Sociodemographics
  Age mean (SD) 38.2 (11.0) 37.7 (10.2) 39.2 (12.5) 1.29 0.197
Age (categorical) 21.17 0.000
  18–25 years 86 16.6 49 13.8 37 22.6
  26–35 years 111 21.4 90 25.4 21 12.8
  36–45 years 187 36.1 135 38.1 52 31.7
  46–55 years 111 21.4 69 19.5 42 25.6
  56+ years 23 4.4 11 3.1 12 7.3
Racial/ethnic background 6.34 0.042
  Hispanic 208 40.2 155 43.8 53 32.3
  Black 250 48.3 159 44.9 91 55.5
  White/other 60 11.6 40 11.3 20 12.2
High school degree/equivalent 0.70 0.404
  No 235 45.4 165 46.6 70 42.7
  Yes 283 54.6 189 53.4 94 57.3
Income greater than 5 K per year 1.62 0.204
  No 394 76.1 275 77.7 119 72.6
  Yes 124 23.9 79 22.3 45 27.4
Employed full time in salaried/paid position 0.0002 0.990
  No 395 76.3 270 76.3 125 76.2
  Yes 123 23.7 84 23.7 39 23.8
Report illegal income 13.12 0.000
  No 284 54.8 175 49.4 109 66.5
  Yes 234 45.2 179 50.6 55 33.5
Received public assistance 0.05 0.816
  No 152 29.3 105 29.7 47 28.7
  Yes 366 70.7 249 70.3 117 71.3
Lifetime incarceration 0.35 0.557
  No 45 8.7 29 8.2 16 9.8
  Yes 473 91.3 325 91.8 148 90.2
Born in United States 3.06 0.080
  No 116 22.4 87 24.6 29 17.7
  Yes 402 77.6 267 75.4 135 82.3
Self-reported HIV status 12.32 0.001
  Yes
  No
  Unknown
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Table 2.

Partner violence, drug use, partner and relationship and condom use-related characteristics among heterosexual men: IMPACT study, 2005–2007

All Consistent condom use (<100% vs. 100%) χ2 P-value
No Yes
n % n % n %
All 518 100 354 68.3 164 31.7
Partner violence
Moderate physical partner violence 4.61 0.032
  No 372 71.8 244 68.9 128 78.0
  Yes 146 28.2 110 31.1 36 22.0
Severe physical partner violence 3.67 0.055
  No 438 84.6 292 82.5 146 89.0
  Yes 80 15.4 62 17.5 18 11.0
Moderate and/or severe partner violence 5.68 0.017
  No 358 69.1 233 65.8 125 76.2
  Yes 160 30.9 121 34.2 39 23.8
Sexual partner violence 0.001 0.970
  No 493 95.2 337 95.2 156 95.1
  Yes 25 4.8 17 4.8 8 4.9
Drug and alcohol use
Lifetime heroin dependence 3.58 0.058
  No 356 68.7 234 66.1 122 74.4
  Yes 162 31.3 120 33.9 42 25.6
Lifetime crack dependence 0.16 0.688
  No 373 72 253 71.5 120 73.2
  Yes 145 28 101 28.5 44 26.8
Lifetime cocaine dependence 2.56 0.109
  No 341 65.8 225 63.6 116 70.7
  Yes 177 34.2 129 36.4 48 29.3
Lifetime use of any stimulants 9.32 0.002
  No 88 17 48 13.6 40 24.4
  Yes 430 83 306 86.4 124 75.6
Lifetime use of only depressants 0.08 0.774
  No 514 99.2 351 99.2 163 99.4
  Yes 4 0.8 3 0.8 1 0.6
Lifetime use of only hallucinogens 0.46 0.496
  No 517 99.8 353 99.7 164 100.0
  Yes 1 0.2 1 0.3 0 0.0
Lifetime use of only marijuana 10.21 0.001
  No 445 85.9 316 89.3 129 78.7
  Yes 73 14.1 38 10.7 35 21.3
Lifetime alcohol use 1.95 0.162
  No 26 5 21 5.9 5 3.0
  Yes 492 95 333 94.1 159 97.0
Last 6 month use of stimulants 0.50 0.026
  No 219 42.3 138 39.0 81 49.4
  Yes 299 57.7 216 61.0 83 50.6
Last 6 months use of only depressants 0.31 0.576
  No 516 99.6 353 99.7 163 99.4
  Yes 2 0.4 1 0.3 1 0.6
Last 6 months use of only hallucinogens –
  No 518 100 354 100.0 164 100.0
Last 6 months use of only marijuana 10.21 0.001
  No 455 87.8 322 91.0 133 81.1
  Yes 63 12.2 32 9.0 31 18.9
  No use of alcohol last 12 months 0 0.995
  No 420 81.1 287 81.1 133 81.1
  Yes 98 18.9 67 18.9 31 18.9
Less than daily use of alcohol last 12 months 0.34 0.560
  No 199 38.4 139 39.3 60 36.6
  Yes 319 61.6 215 60.7 104 63.4
Daily use of alcohol last 12 months 0.50 0.478
  No 417 80.5 282 79.7 135 82.3
  Yes 101 19.5 72 20.3 29 17.7
Partner and relationship factors
Main partner age 35.8 10.3 36.1 10.0 35.3 11.0 0.73 0.467
Length of relationship 6.0 7.4 5.3 7.0 1.2 7.4 1.77 0.078
Partner pregnancy desire 25.82 <.0001
  No 184 35.5 100 28.2 84 45.7
  Yes 334 64.5 254 80 4.0
Think partner has STD since together? 327 0.10 0.756
  No 497 95.9 339 95.8 158 96.3
  Yes 21 4.1 15 4.2 6 3.7
Perceived partner HIV status 12.32 0.000
  Negative 499 96.3 348 98.3 151 92.1
  Positive 19 3.7 6 1.7 13 7.9
Think partner has had sex with others? 2.75 0.098
  No 408 78.8 286 80.8 122 74.4
  Yes 110 21.2 68 19.2 42 25.6
Condom use-related factors
Condom use outcome expectanciesa 3.47 0.85 3.20 0.80 4.04 0.60 90.31 <0.001
Condom use self-efficacya 2.83 0.98 2.62 0.90 3.28 0.70 55.16 <0.001
Relationship control (condom use decision making)a 1.03 0.35 1.0 0.40 1.10 0.30 10.37 0.070
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a

Mean and SD displayed

Univariate and Bivariate Results

Consistent condom use with a main female partner was infrequent, with less than a third of the sample reporting condom use during each and every sex act in the past month. Over 40% of men reported perpetrating moderate or severe physical IPV against their main female partner in the past year. Bivariate analyses (Table 2) revealed that men who engaged in consistent condom use with their main female partners were less likely to perpetrate IPV against them than were men who did not use condoms consistently (24% vs. 34%; χ2(1, N = 518) = 5.68, P < .017).

Consistent condom use was also associated with several sociodemographic factors; men who reported consistent condom use tended to be the youngest and oldest men in the sample, as compared with men in the middle of the age range (aged 26–45) who were less likely to report consistent condom use (43%, 52% vs. 25%; χ2(4, N = 518) = 21.17, P < .001). Men who reported consistent condom use were more often Black men (56% vs. 45%; χ2(2, N = 518) = 6.34, P = .042) and did not report receipt of illegal income (67% vs. 49%; χ2(1, N = 518) = 13.12, P < .001) (Table 1). Men who reported consistent condom use with a main female partner were less likely to report lifetime heroin dependence (26% vs. 34%; χ2(1, N = 518) = 3.58, P = .058) and lifetime and current use of any cocaine or other stimulants (51% vs. 61%; χ2(1, N = 518) = 4.97, P = .026); men who reported consistent condom use were more likely to report current use of marijuana only (19% vs. 9%; χ2(1, N = 518) = 10.21, P = .001). Men who used condoms consistently with their main female partners were more likely to be HIV-positive (8% vs. 2%; χ2(1, N = 518) = 12.32, P < .001) and to not report that their partners desired a pregnancy (51% vs. 28%; χ2(1, N = 518) = 25.82, P < .001). Finally, men who used condoms consistently were more likely to report more positive condom use outcome expectancies (78% vs. 33%; χ2(1, N = 514) = 90.31, P < .001), greater condom use self-efficacy (84% vs. 49%; χ2(1, N = 516) = 55.16, P < .001), and greater condom use decision making (61% vs. 46%; χ2(1, N = 513) = 10.37, P = .001) (Table 2).

Multivariate Results

In multivariate analyses, we entered factors in conceptually related sets into the model; Table 3 displays the final model. The baseline model included the total association between IPV perpetration and consistent condom use. The second model includes those sociodemographic factors found to be associated with consistent condom use in bivariate analyses (see Table 2) and that remained significant when entered as a block (age and receipt of illegal income); the third model includes the drug use factors and the fourth the HIV-related factors. In the fifth model we present the condom use-related factors; the sixth and final model, and the one presented, is the best fit model and includes IPV perpetration, HIV status, partner desire for pregnancy, and three condom use-related factors: negative outcome expectancies, condom use self-efficacy and relationship control.

Table 3.

Multivariate associations among partner violence perpetration, sociodemographic, relationship and condom use-related factors and consistent condom use among heterosexual men: IMPACT study, 2005–2007

Variable Adjusted OR (95% CI)
Moderate/severe partner violence 0.49 (0.27, 0.86)*
Age
  Age 26–35 years versus 18–25 years 0.33 (0.15, 0.71)*
  Age 36–45 years versus 18–25 years 0.46 (0.23, 0.92)*
  Age 46+ years versus 18–25 years 0.70 (0.34, 1.45)
HIV-positive status 7.78 (2.59, 23.37)**
Partner pregnancy desire 0.42 (0.25, 0.68)*
Relationship control (condom use decision making) 0.48 (0.25, 0.92)*
Condom use outcome expectancies 4.45 (2.90, 6.82)**
Condom use self-efficacy 2.09 (1.51, 2.90)**
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*

P < .05;

**

P < .01

In the final adjusted model, men who perpetrated violence against their main female partners were approximately 50% less likely to use condoms consistently with these main female partners (AOR .49; 95% CI 0.27, 0.86), while controlling for age, partner pregnancy desire, condom use outcome expectancies, condom use self-efficacy and HIV status, all factors found to be associated with consistent condom use in bivariate analyses. As compared with the youngest men, men aged 26–45 were less likely to report consistent condom use (AOR = 0.33; 95% CI 0.15, 0.71, among men aged 26–35; AOR = 0.46; 95% CI 0.23, 0.92, among men aged 36–45). As expected, several HIV-, pregnancy- and condom use-related factors were also important to consistent condom use. Controlling for age and IPV use, men who were HIV-positive were almost 8 times more likely to report consistent condom use (AOR = 7.78; 95% CI 2.59, 23.37); similarly, men who reported that their partners desired a pregnancy were approximately 60% less likely to report consistent condom use with those female partners (AOR = 0.42; 95% CI 0.25, 0.68). Men who anticipated positive outcomes related to condom use were 4½ times more likely to use condoms consistently (AOR = 4.45; 95% CI 2.09, 6.82); men who reported feeling confident in their ability to use condoms were over twice as likely to use them consistently with their main female partners (AOR = 2.09; 95% CI 1.51, 2.90). Finally, men who reported greater relationship control were about half as likely to report using condoms consistently (AOR = 0.48; 95% CI 0.25, 0.92) (Table 3).

Discussion and Conclusions

This analysis revealed that IPV perpetration is prevalent among the men sampled in this study and represents an independent risk factor for a key sexual HIV risk behavior, inconsistent condom use. Thus, men who perpetrate IPV are significantly less likely to report using condoms consistently with their main female partners, even when HIV status, pregnancy desire and condom use-related factors are controlled. This result is important because it is one of the only studies that we are aware of that simultaneously assesses the roles of IPV perpetration and HIV-related factors that have been shown to be strongly associated with consistent condom use. Previous evaluations of the role of IPV in sexual risk have not adequately controlled for these important covariates, thus the field has not established whether the association between IPV perpetration was confounded by these factors or represented an independent association. These results support the latter conclusion.

Before discussing the potential import of these findings, some limitations of the study should be discussed. First, the sampling plan, designed to achieve a large sample of distinct drug-using and non drug-using sub-populations, was not representative of the general neighborhood population, but reflected a higher risk group with a large proportion of current and/or former (approximately 80%) drug users. Thus the prevalence of IPV and sexual risk behavior may have been overrepresented, as such behaviors tend to cluster. However, our results are generally consistent with previous samples of drug using men [4, 5]. Although lifetime and current drug use factors were not retained in multivariate models, the high prevalence of lifetime drug use may have diminished our ability to capture the relationship between drug use, IPV perpetration and consistent condom use; further, we did not measure incident-specific drug and alcohol use. The IMPACT interviews are face-to-face, thus the issue of social desirability is a concern. However, we do not believe that socially desirable responding on either the main independent or dependent variables would be systematic resulting our having found an association where none existed. Another limitation is that we were unable to assess the temporal relationship between IPV perpetration and consistent condom use, as the measure of IPV tapped only the past year, whereas the condom use measure evaluated the past month only. As with much research, there may be important covariates that we were unable to assess, for example peer and partner norms around condom use, although we did assess outcome expectancies specific to the main partner. Finally, as with all cross-sectional research, we cannot infer causation from these associations.

Although this study found that IPV perpetration was associated with reduced likelihood of consistent condom use, the estimate of association was smaller than self-reported HIV status and the condom use-related factors assessed. This is important information to have as we design and test HIV prevention interventions and intervention to prevent partner violence. These findings lend support to the focus of existing behavioral interventions on encouraging HIV testing (and subsequent status knowledge) and promoting facilitators of condom use, such as positive outcome expectancies and increased self-efficacy to use condoms. Previous research has also found that some of the most important correlates of consistent condom use are HIV status of both partners and condom use-related factors. In our results, self-reported (positive) HIV status was associated with nearly an 8 times greater likelihood of using condoms consistently, once again reinforcing the utility of HIV testing as a prevention method.

The association between HIV-positive status and consistent condom use among this high risk group of men is very important and suggests that the current prevention focus on HIV testing is well-placed. Knowledge of HIV status is strongly associated with reduced HIV risk behavior [22, 29–31], which is why testing is central to local and national prevention efforts. This paper offers added evidence that relative to other psychosocial factors, HIV-positive status is strongly correlated with consistent condom use among this group of men. Further research into barriers to rapid testing and reducing the proportion of people who test but do not return for results is needed, as well as evaluations of programs that support individuals who test positive earlier and with less preparation than previously. In addition, research using mathematical and predictive models to tell us how many people need to be tested to achieve what level of change in sexual risk behavior would be very useful for further practical planning purposes. Testing must continue to be prioritized as an outcome of HIV prevention interventions for heterosexual men, as it is so strongly associated with consistent condom use.

In addition to HIV status, barriers to condom use were important correlates of consistent condom use, with outcome expectancies showing a particularly strong association with consistent condom use. Research into barriers to condom use reveal that expectations that a partner will react negatively to condom use has been found in previous research to be associated with reduced condom use [19, 22, 23]. Some items on these measures capture what has been called the symbolic meaning of condom use—that is that condoms symbolize infidelity and distrust, and that attempting to use them results in suspicion and anger [19, 24–28]. Also consistent with previous research [19, 29–31], self-efficacy to use condoms is an important factor in whether they are used consistently. Finally, interference with sexual pleasure is often reported by men [32] and concerns about sexual performance have also been identified as barriers to condom use among men [33, 34].

Our results support previous reviews of factors associated with sexual HIV risk behaviors among heterosexuals that reveal that the psychosocial factors most strongly associated with condom use include positive intention to use condoms, and condom use self-efficacy [22]. And, consistent with other research, young age is associated with consistent condom use, reinforcing the possibility that older men may believe that their age confers some protection from risk associated most strongly with youth [35, 36]. The finding that key relationship factors were associated with consistent condom use also merits discussion. When a female partner reportedly desires pregnancy, men were less likely to report consistent condom use; thus, integrating discussion of pregnancy planning and family size are important potential components to HIV prevention interventions for heterosexual men. Additionally, men who exercised more relationship control were also less likely to report consistent condom use, reinforcing the notion that more egalitarian relationships offer supportive contexts for consistent condom use [34].

In sum, the results of this paper highlight the need to integrate a range of interpersonal and relationship-level factors into HIV prevention programming. It adds significantly to this literature by identifying among this sample of mostly drug-involved men the relative impact of IPV on consistent condom use. IPV perpetration is significantly and independently associated with consistent condom use and must be systematically and consistently integrated into HIV prevention programming for men who have sex with women. While we should continue to focus on individual-level condom use-related factors, such as outcome expectancies and self-efficacy, integrating the issues of partner violence and gendered power dynamics is crucial as well. Finally, the results suggest that prevention programs of both HIV/AIDS and partner violence must begin to integrate prevention messages and content on both issues in order to enhance behavior change among individuals affected by partner violence and at risk for HIV.

Acknowledgments

Many thanks are due the team who made this research possible, including: Ebele Benjamin, Sandra DelVecchio, Vincent Edwards, Monique Kusick, Harlem Community and Academic Partnership, and the IMPACT participants. The authors also acknowledge two anonymous reviewers for their helpful comments and Margaret M. Paul for editorial assistance with the final draft. Funding for this research was provided by NIH/NIDA (K01 DA-020774: Frye; DA018061 and DA017020: Vlahov and Ompad).

Contributor Information

Victoria Frye, Email: vf18@nyu.edu, Steinhardt School of Culture, Education and Human Development, New York University, New York, NY, USA; Center for Urban Epidemiologic Studies, New York Academy of Medicine, 1216 Fifth Avenue, New York, NY 10029, USA.

Danielle Ompad, Center for Urban Epidemiologic Studies, New York Academy of Medicine, 1216 Fifth Avenue, New York, NY 10029, USA.

Christina Chan, New York City Department of Health and Mental Hygiene, New York, NY, USA.

Beryl Koblin, Laboratory of Infectious Disease Prevention, New York Blood Center, New York, NY, USA.

Sandro Galea, Department of Epidemiology, Columbia University, New York, NY, USA.

David Vlahov, Center for Urban Epidemiologic Studies, New York Academy of Medicine, 1216 Fifth Avenue, New York, NY 10029, USA.

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