Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2012 Jan 12.
Published in final edited form as: AIDS Behav. 2012 Jan;16(1):159–167. doi: 10.1007/s10461-010-9868-8

Partner-provided Social Support Influences Choice of Risk Reduction Strategies in Gay Male Couples

Lynae A Darbes 1, Deepalika Chakravarty 1,2, Sean C Beougher 2, Torsten B Neilands 1, Colleen C Hoff 2
PMCID: PMC3254781  NIHMSID: NIHMS323897  PMID: 21221756

Abstract

We investigated the influence of partner-provided HIV-specific and general social support on the sexual risk behavior of gay male couples with concordant, discordant, or serostatus unknown outside partners. Participants were 566 gay male couples from the San Francisco Bay Area. HIV-specific social support was a consistent predictor for reduced unprotected anal intercourse (UAI) with both concordant outside partners (all couple types) and outside partners of discordant or unknown serostatus (concordant negative and discordant couples). General social support was associated with increased UAI with concordant outside partners for concordant negative and concordant positive couples (i.e., serosorting). Our findings suggest that prevention efforts should target couples and identify the level of HIV-specific support that partners provide. Partner-provided support for HIV-related behaviors could be an additional construct to consider in gay male relationships, akin to relationship satisfaction and commitment, as well as an important component of future HIV prevention interventions.

Keywords: HIV-specific social support, social support, gay male couples, sexual risk behavior

INTRODUCTION

According to recent estimates from five U.S. cites, the majority of HIV infections among MSM occur within the context of primary partnerships.1 Prior evidence of this trend has also been found in the Netherlands.2,3,4 These findings underscore the importance of understanding the context of intimate relationships in which this risk may occur. Agreements about whether to allow sex with outside partners are common among gay male couples,5 but it is also true that relationship characteristics may impact both those agreements as well as other choices that many couples make in their efforts to reduce their HIV risk. For example, factors such as intimacy and relationship satisfaction may influence whether partners choose to have unprotected anal intercourse (UAI) with each other. Another dimension often present in primary relationships is the presence of outside partners—a situation commonly addressed by specific agreements among gay male couples as to whether outside partners are permitted or not6. The presence of an outside partner may not necessarily increase HIV risk (particularly with concordant partners), but the possibility of UAI with outside partners of discordant or unknown serostatus could confer risk for HIV transmission.7,8 Thus, a primary relationship may not bestow the level of protection from HIV previously thought. Furthermore, most theoretical orientations used in HIV prevention have focused on individuals and do not take into account the role and influence of primary partners on sexual behavior.6 Therefore, it is imperative to examine how partners may influence the choices gay men in relationships make about their sexual behaviors.

Social Support

Social support is one mechanism for how partners influence each others’ health and behavior. Social support is an important influence on individuals’ psychological outcomes in addition to being a significant predictor of morbidity and mortality.9,10 However, it has most often been examined in conjunction with psychological outcomes, such as depression or anxiety. It has been examined as to the type of support (e.g., informational, emotional),9 source of support (e.g., friends, relatives, partners),11 and dimensions of support (amount, satisfaction).12 It has also been examined in association with a variety of behavioral outcomes (e.g., smoking cessation, heart disease, medication adherence, weight loss).13,14,15,16 For gay men, general social support has been examined in the context of psychological outcomes. For example, support from peers has been found to be an important buffer for gay men against low family support as a result of their sexuality,17,18 and important differences in these types of support (peer vs. family) have been described.19 It has also been noted that potentially lower family support may cause additional strain or distress on gay relationships.20,21 Specific investigations of partner support in gay male relationships have been conducted, most often as it relates to overall relationship satisfaction.22,18 However, few examinations have been made as to the role of partner support specifically regarding sexual risk behavior among gay male couples.

In the realm of HIV, examinations of social support have frequently focused on coping with being HIV-positive or having AIDS23,24,25 or the progression of HIV disease.26 Although the definitions of social support are often heterogeneous, fairly consistent findings demonstrated that increased general social support was often a protective or positive factor in coping with being HIV-positive or having AIDS. Social support was less often examined in conjunction with sexual risk behavior. As the findings from these studies have been mixed, with some reporting that general social support is associated with increased sexual risk behavior27,26 and others showing decreased risk,28,29 researchers have posited that general social support might be a more reliable predictor of psychological rather than behavioral outcomes.30,31

Other examinations of social support’s influence on behavior focused on domain-specific support, or support provided specifically for a singular behavior such as smoking cessation or weight loss. These investigations found that domain-specific support was a significant and consistent predictor of positive behavior change.32,33,34,35 However, the idea of domain-specific social support as a possible factor for reducing HIV risk behavior has rarely been examined.

Sexual behavior among gay men has been found to vary depending on partner type (primary vs. outside)36,37,38,39,4 and serostatus.40,41 For example, studies show that rates of UAI increase when primary partners are concordant,42,43 however, when partners are discordant, studies show men making conscious choices about positioning for UAI.44 The presence of outside partners, or sexual concurrency, brings an additional layer of complexity to the possibility of HIV risk for gay couples, as sexual behavior with outside partners can present potential HIV risk to both members of a couple.45 There is also evidence that while relationship characteristics such as intimacy and satisfaction may influence sexual behavior within the couple,43 sexual behavior with outside partners, if permitted, may not vary substantially from that of single men with their casual partners.46 Specifically, Kuyper and colleagues reported that neither the type of sexual behavior with casual partners (e.g., condom use) nor the rate of STI diagnoses for men in relationships differed from single men.

Thus, previous research has examined aspects of gay relationships, such as relationship quality, satisfaction, and the role of social support, while other investigations have been conducted into psychosocial predictors of sexual risk behavior among gay men. Fewer investigations have considered these aspects in tandem, which could reveal whether psychosocial factors (e.g., social support) exert the same influence on sexual risk behavior among gay men in relationships. There have also been few examinations of samples of gay couples which represent all couple serostatus types (concordant negative, discordant, concordant positive). Gaps still remain in our knowledge regarding how primary partners influence sexual behavior with outside partners and whether this influence differs by couple serostatus.

The primary research question of the current investigation is to test whether partner-provided social support (both general and HIV-specific) are associated with sexual risk behavior for HIV with outside partners in a sample of gay male couples. Previous investigations into HIV-specific social support47 had found it to be a significant predictor of reduced HIV risk behavior among gay male couples. Similarly, our hypothesis was that couples who report higher levels of both types of social support will engage in less sexual risk with outside partners.

METHODS

Recruitment

Gay male couples (n = 566) were recruited from the San Francisco Bay Area between June 2005 and February 2007 using active and passive recruitment strategies in community venues. Field research staff reached potential participants by handing them study postcards in person or by placing recruitment materials (e.g., study postcards and flyers) in gay-identified social venues such as bars, clubs, and cafes and in community health and HIV/AIDS service organizations, or by placing advertisements in gay-oriented publications, websites, and listservs. Recruitment strategies were designed to produce a diverse sample in terms of race and ethnicity as well as serostatus in an effort to reflect the demographics of the San Francisco Bay Area. Field research staff reached out specifically to community-based agencies whose constituents were men of color and HIV-positive. All recruitment materials invited interested potential participants to call a toll-free recruitment hotline for information.

Screening and Eligibility

Potential participants were screened over the telephone to determine eligibility. To be eligible, participants had to: have been at least 18 years old, have been in their current relationship for at least 3-months, have knowledge of their own and their partner’s HIV status, have been fluent in English, and have been residents of the San Francisco Bay Area. Partners were screened separately and if both met the eligibility criteria the couple was invited to participate. Couples who gave discrepant reports of HIV status were not eligible for participation nor were couples where either partner identified as transgender.

Eligible couples were given appointments to come to the study offices in downtown San Francisco and upon arrival each partner was consented individually. Research Assistants then administered an audio computer-assisted self interview (ACASI) to participants that required an average of 70 minutes to complete. Both partners took the survey simultaneously; however, each one sat in a separate cubicle to provide privacy and encourage independent responses to the questions. Upon completion, each partner received $40.00.

Measures

Demographic Characteristics

These included age, race and ethnicity, current employment status, and income over the past 12 months at the time of the interview.

HIV Status

The respondent’s HIV status was determined via self reports of the results from his most recent HIV test. Respondents also reported their partner’s HIV status.

Length of Relationship

Respondents were asked how long they had been in their relationship. Responses were recorded in units of years and months. Any discrepancies were reconciled between partners.

Cohabitation

Respondents were asked if they were living with their partner.

Relationship Status

Respondents were asked whether they were married, were registered as domestic partners, had a commitment ceremony, considered themselves boyfriends or lovers, or other. Respondents checked all that applied.

General Social Support

General social support was measured by the Social Provisions Scale.48 This is a reliable and valid 24-item measure, scored by summing across items. This measure has been used previously with samples of gay men to study social support as a predictor of adherence to HIV medication,49 depression,50 and sexual risk behavior.47 Items were answered on a scale ranging from 1 (strongly disagree) to 4 (strongly agree), with higher scores reflecting more perceived social support. There are two versions of the SPS, one that asks about one’s larger community’s provision of support and one that is partner-specific. We utilized the partner-specific version. Cronbach’s alpha for this sample was 0.93.

HIV-Specific Social Support

The SPS was modified into an HIV-specific partner support measure that also contained 24 items. Each item from the SPS was adapted to reflect perceived partner support for HIV-preventive behavior. We sought to maintain the underlying construct of the original SPS items as much as possible. For example, an item from the SPS, “My partner depends on me for help,” was modified into “My partner depends on me for help when it comes to practicing safer sex.” Like the general SPS, items are answered on a scale ranging from 1 (strongly disagree) to 4 (strongly agree) with higher scores indicating higher perceived partner support regarding HIV prevention. This measure was created when HAART was first made available and the experience of being HIV-positive differed significantly from being HIV-negative. To reflect this difference, eleven items out of the 24 had separate versions for HIV-negative and HIV-positive participants, with 13 items being identical for participants of either serostatus. For example, HIV-negative participants responded to: “My partner and I share similar attitudes and beliefs about practicing safer sex” while HIV-positive participants responded to “My partner and I share similar attitudes and beliefs about being HIV-positive.” The goal was to assess partner-provided support for HIV-related issues for both HIV-positive and HIV-negative men. The entire measure is included in the Appendix.

In all of the above scales, codes were reversed where appropriate so higher scores reflected higher levels of the construct under consideration.

UAI with Outside Partners

Participants were asked to report the number of times in the preceding 3 months they had UAI (with or without ejaculation) with an outside partner. The question was asked separately for outside partners of HIV-negative, HIV-positive, and unknown serostatus. Based upon these responses, and the respondent’s own serostatus, two composite binary variables representing UAI with concordant outside partners and UAI with outside partners of discordant or unknown serostatus were created. For both variables, 0 was used to represent ‘no acts of UAI with an outside partner in the past 3 months’ and 1 was used to represent ‘engaged in at least one act of UAI with an outside partner in the past 3 months.’

Data Analysis

Descriptive statistics of the sample such as means and one-way frequencies were calculated. Following data collection, we conducted both exploratory and confirmatory factor analysis to investigate whether the revised measure followed a structure similar to the original SPS. Exploratory factor analysis yielded a single factor but did not provide a good fit (CFI = 0.92, RMSEA = 0.17, SRMR = 0.097). . Three items were found to have low factor loadings when compared to other items (#4 (loading = 0.20, #15 a/b, loading = 0.23, #24 loading = 0.37) (see Appendix for items). Therefore these three items were dropped for further analyses, and the scale consisted of 21 items for the current results. Cronbach’s alpha for all participants in the sample and for each version separately (HIV-positive and HIV-negative) was 0.90. When examined by couple, Cronbach’s alpha ranged between 0.88 and 0.90 for the three couple serostatus types.

Next, we used logistic regression to examine the association between UAI and social support both within- and between-couples for the three couple serostatus groups: concordant negative, discordant, and concordant positive. We investigated two categories of UAI (UAI with concordant outside partners and UAI with outside partners of discordant or unknown serostatus) and two types of partner-provided social support (HIV-specific and general) as described above. For both the social support variables, the means of the two partners’ individual scores were used as predictors of differences between-couples since they are couple-level variables. The predictors of differences within-couples, on the other hand, were calculated as the deviation of the partners’ individual scores from their couple-level mean score for each of the social support variables.51 To account for the dyadic clustering of the data, we used PROC SURVEYLOGISTIC with Morel-adjusted robust standard errors. All analyses were performed using SAS 9.1. All models controlled for the length of the relationship and partner-provided general social support. Findings are reported as odds ratios with 95% confidence intervals, and organized by couple serostatus.

RESULTS

Demographics of the Sample

The sample was racially and ethnically diverse, with the largest proportions of couples being either interracial (47%) or White (45%) (see Table 1). African-American couples made up 5% of the sample. Concordant negative couples comprised 55% of the sample, 23% were discordant, and 22% were concordant positive. Monogamous agreements were reported by 45% of the couples whereas 47% reported open agreements and 8% reported discrepant agreements (i.e., one partner reported having a closed agreement while the other reported having an open agreement). Couples were defined as monogamous if both partners indicated that the following scenario reflected their agreement regarding sexual encounters outside of the relationship: “Both of us cannot have any sex with an outside partner”, regardless of whether or not that agreement was broken. In approximately half the couples both partners were employed, one partner was employed in 32% of couples, and in 19% of couples neither partner was employed. A majority of participants (45%) reported annual incomes lower than $30,000. A majority of couples (75%) lived with their partners. Nineteen percent of couples reported being married and 29% were registered as domestic partners. The mean length of relationship was approximately 7 years (SD = 8.5 years) and the average age of the participants was 42 years (SD = 11.4 years).

Table 1.

Characteristics of the Sample

% (N)
Race of couple
 Interracial 47 (268)
 Caucasian 45 (254)
 African-American 5 (26)
 Latino 2 (11)
 Asian-American/Pacific Islander 1 (5)
 Native American <1 (2)
HIV status of couple
 Concordant negative 55 (310)
 Concordant positive 22 (124)
 Discordant 23 (132)
Agreement type
 Monogamous 45 (255)
 Open 47 (262)
 Discrepant 8 (44)
 No agreement <1 (5)
Employment
 Both partners employed 49 (279)
 One partner employed 32 (180)
 Both partners unemployed 19 (107)
Income (individual)
 Less than $30,000 45 (507)
 $30,000 to $59,999 30 (343)
 $60,000 or $99,999 16 (177)
 $100,000 or higher 9 (105)
Partners live together 77 (468)
Relationship status
 Married 19 (108)
 Registered as domestic partners 29 (164)
SD
Mean
Length of relationship (in years) 6.9 8.5
Age of participants (in years) 41.7 11.4
Open in a new tab

Note: Not all applicable percentages sum to 100% due to rounding errors.

Concordant Negative Couples

The regression analyses conducted on concordant negative, discordant, and concordant positive couples led to a number of significant findings (Table 2). First, among concordant negative couples (Table 2), there was a consistent and significant association between the couples’ level of HIV-specific social support and reduced odds of engaging in both categories of UAI. Couples with higher levels of HIV-specific social support exhibited lower odds of engaging in UAI with both concordant outside partners (OR = 0.93, 95% CI = 0.89 - 0.98) and outside partners of discordant or unknown serostatus (OR = 0.88, 95% CI = 0.83 - 0.92). The largest reduction in odds of UAI is found for the riskiest behavior, which is UAI with outside partners who are of discordant or unknown serostatus. For this category of UAI, for instance, a one unit increase in a couple’s HIV-specific social support is associated with a12% reduction in odds of UAI. Similarly, there was a significant association between the odds of engaging in UAI (with both types of outside partners) and the level of HIV-specific support reported by the partners within a couple. For a given couple, a one unit increase in a partner’s reported level of HIV-specific social support was associated with a 6% reduction in his odds of engaging in UAI with concordant outside partners and 7% reduction with outside partners of discordant or unknown serostatus. In the case of general social support, the only significant finding was that within-couples, higher levels of general social support were associated with increased odds of engaging in UAI with concordant outside partners (i.e., serosorting). Specifically, for a given couple, a one-unit increase in a partner’s general social support score was associated with a 6% increase in his odds of engaging in UAI with a concordant outside partner.

Table 2.

Logistic regression results of association between partner-provided Social Support and UAI with outside partners

Couple serostatus
Concordant Negative Serodiscordant Concordant Positive
Outcome: UAI with Outside Partner of Concordant Serostatus
Parameter AOR 95% CI AOR 95% CI AOR 95% CI
HIV-Specific social support between couples 0.93 ** (0.89,0.98) 0.93 * (0.86,0.996) 0.85 ** (0.79,0.91)
HIV-Specific social support within couples 0.94 * (0.89,0.99) 0.95 (0.88,1.02) 1.004 (0.95,1.06)
General social support between couples 0.99 (0.95,1.03) 0.99 (0.92,1.06) 1.09 ** (1.03,1.15)
General social support within couples 1.06 * (1.01,1.11) 1.01 (0.96,1.06) 1.02 (0.98,1.07)
Relationship length 1.002 * (1.00,1.004) 1.001 (0.997,1.005) 0.999 (0.993,1.005)
Outcome: UAI with Outside Partner of Discordant or Unknown Serostatus
Parameter AOR 95% CI AOR 95% CI AOR 95% CI
HIV-Specific social support between couples 0.88 ** (0.83,0.92) 0.86 ** (0.80,0.94) 0.95 (0.88,1.01)
HIV-Specific social support within couples 0.93 * (0.88,0.99) 0.93 * (0.86,0.99) 1.02 (0.95,1.11)
General social support between couples 1.002 (0.96,1.05) 1.04 (0.96,1.12) 1.03 (0.99,1.08)
General social support within couples 1.006 (0.96,1.05) 0.99 (0.94,1.05) 0.99 (0.93,1.04)
Relationship length (yrs) 1.004 ** (1.002,1.006) 0.999 (1..995,1.003) 1.01 (1.00,1.009)
Open in a new tab
*

p-value < 0.05

**

p-value < 0.01

Discordant Couples

Among discordant couples, HIV-specific social support was a significant predictor of decreased odds of engaging in UAI with outside partners of both concordant and discordant or unknown serostatus (Table 2). Similar to concordant negative couples, discordant couples with higher levels of HIV-specific social support exhibited lower odds of engaging in UAI with concordant outside partners (OR = 0.93, 95%CI = 0.86-0.996) and with discordant or unknown serostatus outside partners (OR = 0.86; 95% CI = 0.80 - 0.94). Also, within discordant couples, receiving greater HIV-specific social support was associated with reduced odds of engaging in UAI (OR = 0.93, 95% CI = 0.86 - 0.99). However, there was no evidence of an association between general social support and UAI with either type of outside partner.

Concordant Positive Couples

Among concordant positive couples, the between-couples effects for both HIV-specific and general social support were found to be significantly, but differently, associated with the odds of engaging in UAI with concordant outside partners. Specifically, the odds of engaging in UAI with concordant outside partners were significantly lower for couples reporting greater HIV-specific social support (OR = 0.85, 95% CI = 0.79 - 0.91), whereas the odds were significantly higher for couples reporting greater general social support (i.e., serosorting) (OR = 1.09, 95% CI = 1.03 - 1.15). No significant within-couples effects were found. There were also no significant associations between HIV-specific or general social support and UAI with outside partners of discordant or unknown serostatus for concordant positive couples.

DISCUSSION

Our findings suggest that the spectrum of partner-provided support is wide-ranging. HIV-specific support from partners was consistently associated with less sexual risk behavior for both couples and individual partners across couple types, whereas the influence of general emotional support on sexual behavior was less clear. Examining one type or the other alone may not sufficiently explain behavioral outcomes as they may be exerting their influence differentially.

The relationship between partner-provided social support and UAI is complex. There appear to be significant differences between HIV-specific social support when compared to general social support, although both are partner-provided. Specifically, HIV-specific social support had a consistent and robust association with reduced odds of engaging in UAI with concordant outside partners as well as partners of discordant or unknown serostatus, while general social support was not associated with reduced risk behavior. These findings have several implications for HIV prevention efforts and for the measurement of social support. There are strong indicators that the type of support partners provide to each other is an important influence on sexual behavior with outside partners and it is important to assess both types.

Although domain-specific support has been found in prior studies of gay relationships to be a significant predictor of positive psychological outcomes,52,20 this is one of the first studies to examine domain-specific support as a potential influence on sexual risk behavior among gay male couples47. The HIV-specific social support instrument could be a potentially useful tool for assessing the level of partner-provided support and the importance of the development of such domain-specific measures has been previously noted.34 Given its association with reduced odds of engaging in UAI, partner-provided social support for HIV-related attitudes and behaviors should be an additional construct to consider in the context of gay male relationships along with relationship satisfaction, commitment, and investment.53

We also found that increased levels of general social support were associated with increased odds of UAI with concordant outside partners for both concordant negative and concordant positive couples (i.e., serosorting). It could be that partners who provide positive emotional support to their partners are more accepting of a wide range of behavior from their partners. For example, partners could be providing unconditional support no matter what sexual behavior their partners engage in. Perhaps general social support is more closely aligned to general relationship dynamics (such as satisfaction), as opposed to those that may influence sexual risk reduction. . For HIV-positive men, this practice incurs no HIV risk for either party, but there is the possibility of STI transmission. For HIV-negative men, having UAI with an outside HIV-negative partner could be a seroadaptive strategy, but it could pose risk for HIV transmission if one’s partner has not tested recently, or partners did not directly discuss serostatus 54 The consistent finding between general social support and serosorting for both types of concordant couples suggests that similar dynamics may be at play for these couples. Future research is needed in order to elucidate whether other relationship factors influence seroconcordant couples in similar ways. We did not find any associations for either type of social support and UAI with outside partners of discordant or unknown serostatus for concordant positive couples. Further investigation is needed into other relationship-based or psychosocial factors that may influence the likelihood of men in concordant positive relationships reducing their UAI with outside partners of discordant or unknown serostatus.42

Prevention efforts should target couples and include participation of both partners. Gay men in primary relationships can be at risk for acquiring or transmitting HIV infection, and we need to improve our understanding of relationship contexts and how they are influencing sexual behaviors with both primary and outside partners. Intervening with gay men in relationships could pose a challenge, as sexual behavior with primary and outside partners may already be in place and could be difficult to change.55 However, it may be that HIV-specific social support is tapping into communication skills concerning HIV, such as a comfort discussing sexuality with one’s partner, which could be more amenable to intervention via the provision of communication-skills training. Indeed, most of the items of the modified measure imply that conversations about HIV have occurred within the relationship. Few studies examined communication about HIV among gay couples, and those that have focused on specific issues such as details of their agreement regarding outside partners, e.g., negotiated safety 7,8. The current measure appears to be capturing a broader scope of communication about HIV-related topics. By engaging in these discussions, expectations about behavior with outside partners, potential repercussions of that behavior (e.g., becoming HIV-positive), and general thoughts and feelings about HIV could be made clear. This clarity of understanding as well as clear communication of support for particular behaviors may have contributed to less risk for HIV across couples, akin to other findings regarding domain-specific support for health behaviors 32, 33, 34, 35. In addition, while it may be possible that altering sexual behaviors with a primary partner after a significant length of time may be difficult, it may be easier to change sexual behaviors with outside partners (e.g., reducing UAI with outside partners of discordant or unknown serostatus). Future interventions should be conducted which specifically test whether increasing partner-provided support specifically for HIV results in reduced sexual risk behavior given the findings that this type of support has a strong association with men’s choices of sexual behavior with outside partners.45

As our findings varied by couple serostatus, future interventions should also be tailored to address the unique needs of each group. For example, HIV-specific social support was consistently associated with reduced UAI with all outside partners for concordant negative couples, while its influence was less consistent for discordant and concordant positive couples. For concordant negative couples, the implications are that it may be helpful to explore the specific agreements that they have with regard to UAI with outside partners, and to explore whether partners perceive general social support from their partner as a tacit endorsement of serosorting in the absence of a more specific agreement. Concordant negative couples may benefit from interventions that include communication skills to improve their ability to discuss the possibility of UAI with outside partners and how to better provide support to their partners for safer sex with partners of any serostatus.

For discordant couples, future interventions should assess the level of HIV-specific social support and could include strategies to increase it (e.g., improve communication and support regarding HIV-specific issues). Focusing on HIV-specific issues would appear to be more salient to discordant couples over improving general social support, which did not show any association with UAI for this group. Future research should also examine whether HIV-specific social support has any effect on any UAI that serodiscordant couples have with each other.

Similar to the other couple types, concordant HIV-positive couples would seem to benefit from interventions that could increase HIV-specific social support. However, as with concordant HIV-negative couples, the role of general social support should be explored, and couples should be encouraged to have clear discussions regarding their agreements regarding UAI with outside partners, and to clearly establish expectations regarding serosorting. Although serosorting among HIV-positive men poses no risk for HIV transmission, there is the possibility for acquiring an STI. Of note, in other findings from this sample, HIV-concordant positive couples were found to have the lowest levels of mutually constructive communication 56. However, the pattern for HIV-specific social support mirrors that of other couple types, and may indicate that concordant positive couples can communicate effectively with each other about expectations regarding sexual behavior with outside partners.

Limitations of our study include the sampling strategy, study setting, assessment of sexual risk behavior, issues associated with scale modification, and that participants self-reported their serostatus. First, although our recruitment strategies yielded a diverse sample with regard to race or ethnicity and serostatus, the methods used to gather the sample produced a convenience sample; therefore generalizations made beyond the San Francisco Bay Area should be limited. Second, given that the participants reside in the San Francisco Bay Area, there is the potential that the participants’ sexual behaviors may have been influenced by the strong presence of HIV prevention campaigns targeted towards the gay community, and we did not assess this exposure or the participants’ potential connection to the gay community. Third, we did not assess whether the episodes of UAI with outside partners occurred when the primary partner was also present (e.g., threesome). It is possible that the presence of the primary partner could influence whether UAI occurred with an outside partner of discordant or concordant serostatus. Fourth, the process of modifying the SPS into two versions could have affected our findings. However, our factor analysis and the consistency of findings across couple type with regard to the negative association between HIV-specific social support and UAI increases our confidence in the results. Finally, the HIV status of both partners in each couple was self-reported, as actual HIV testing was not conducted. However, HIV status was verified by asking each respondent to report his own and his partner’s HIV status at the time of screening (couples who gave discrepant reports of HIV status were not eligible for participation). Although there may be some error in actual versus self-reported HIV status (i.e., some participants may have incorrectly reported their HIV status), we are most interested in the participants’ perceptions of their own and their partners’ HIV status and believe that sexual safety or HIV risk behavior is guided in large part by one’s perception of risk.

The significance of our findings is in its utilization of a dyadic perspective and of its focus on different types of social support and their respective influences on sexual risk behavior among a large and diverse sample of gay male couples. Choices that men in relationships make (such as engaging in UAI) may not be based solely on individual characteristics but also on the influence from primary partners. The conceptualization of sexual decision making needs to contexualize these decisions within the dynamics of an intimate relationship. Given that primary partners are often the source of new HIV infections among gay men,1 capitalizing on partner-provided support could be a crucial factor in the prevention arsenal against HIV.

ACKNOWLEDGEMENTS

The authors extend their thanks to the participants for their time and effort. This research was supported by grants K08 MH 72380, RO1 MH 75598 and MH 65141 from the National Institutes of Mental Health.

Appendix: The HIV-Specific Social Support Scale

When answering the following questions, please keep in mind that “safer sex” can mean a lot of different things. For example, using condoms is one way of practicing safer sex, but so is a commitment to being monogamous. Consider all the ways that you and your partner may practice safer sex when responding to these questions. Please indicate how true the following statements are for you.

1 = Strongly Disagree

2 = Disagree

3 = Agree

4 = Strongly Agree

1 I can depend on my partner to help me practice safer sex if I need help.
2 My partner doesn't support safer sex.
3a (if HIV-negative) I can't turn to my partner for guidance regarding safer sex.
3b (if HIV-positive) I can't turn to my partner for guidance regarding HIV.
4* My partner depends on me for help when it comes to practicing safer sex.
5 My partner and I enjoy practicing safer sex.
6a (if HIV-negative) My partner knows I can do what is necessary to protect myself from HIV.
6b (if HIV-positive) My partner knows I can do what is necessary to take care of myself when
it comes to sustaining my health.
7 I feel personally responsible for the health and well being of my partner.
8a (if HIV-negative) My partner and I share similar attitudes and beliefs about practicing safer
sex.
8b (if HIV-positive) My partner and I share similar attitudes and beliefs about being HIV-
positive or having AIDS.
9a (if HIV-negative) I don't think my partner appreciates what I've done to protect my health
when it comes to HIV.
9b (if HIV-positive) I don't think my partner appreciates what I've done to sustain my health
when it comes to HIV.
10a (if HIV-negative) If I were to become infected with HIV my partner would not be there for
me.
10b (if HIV-positive) If I were to experience complications related to being HIV-positive or
having AIDS my partner would not be there for me.
11a (if HIV-negative) My relationship with my partner makes me feel secure that my chances
of becoming infected with HIV are low.
11b (if HIV-positive) My relationship with my partner makes me feel secure that my chances
of becoming re-infected with HIV are low.
12a (if HIV-negative) I can talk to my partner about safer sex practices if needed.
12b (if HIV-positive) I can talk to my partner about HIV or AIDS if needed.
13 My beliefs about the importance of safer sex are respected by my partner.
Open in a new tab
*

Items #4, #15, and #24 were dropped for the current analysis.

REFERENCES

  • 1).Sullivan PS, Salazar L, Buchbinder S, Sanchez TH. Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities. AIDS. doi: 10.1097/QAD.0b013e32832baa34. In press. [DOI] [PubMed] [Google Scholar]
  • 2).Davidovich U, de Wit J, Stroebe W. Assessing sexual risk behavior of young gay men in primary relationships: The incorporation of negotiated safety and negotiated safety compliance. AIDS. 2000;14:701–706. doi: 10.1097/00002030-200004140-00009. [DOI] [PubMed] [Google Scholar]
  • 3).Davidovich U, de Wit JBF, Albrecht N, Geskus R, Stroebe W, Coutinho R. Increase in the share of steady partners as a source of HIV infection: A 17-year study of seroconversion among gay men. AIDS. 2001;15:1303–1308. doi: 10.1097/00002030-200107060-00013. [DOI] [PubMed] [Google Scholar]
  • 4).Xiridou M, Geskus R, de Wit J, Coutinho R, Kretzschmar M. The contribution of steady and casual partnerships to the incidence of HIV infection among homosexual men in Amsterdam. AIDS. 2003;17(7):1029–1038. doi: 10.1097/00002030-200305020-00012. [DOI] [PubMed] [Google Scholar]
  • 5).Hoff CC, Beougher SC. Sexual agreements among gay male couples. Archives of Sexual Behavior. doi: 10.1007/s10508-008-9393-2. In press. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6).Hoff CC, Chakravarty D, Beougher SC, Darbes LA, Dadasovich R, Neilands TB. Serostatus differences and agreements about sex with outside partners among gay male couples. AIDS Educ Prev. 2009;21(1):25–38. doi: 10.1521/aeap.2009.21.1.25. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7).Prestage G, Mao L, Mcguigan D, et al. HIV risk and communication between regular partners in a cohort of HIV-negative gay men. AIDS Care. 2006;18(2):166–172. doi: 10.1080/09540120500358951. [DOI] [PubMed] [Google Scholar]
  • 8).Prestage G, Jin F, Zablotska I, et al. Trends in agreements between regular partners among gay men in Sydney, Melbourne, and Brisbane, Australia. AIDS Behav. 2008;12(3):513–520. doi: 10.1007/s10461-007-9351-3. [DOI] [PubMed] [Google Scholar]
  • 9).Cohen S. Social relationships and health. Am Psychol. 2004:676–686. doi: 10.1037/0003-066X.59.8.676. [DOI] [PubMed] [Google Scholar]
  • 10).House JS, Landis KR, Umberson D. Social relationships and health. Science. 1988;241:540–545. doi: 10.1126/science.3399889. [DOI] [PubMed] [Google Scholar]
  • 11).Kurdek LA, Schmitt JP. Perceived emotional support from family and friends in members of homosexual, married, and heterosexual cohabiting couples. J Homosex. 1987;14:57–68. doi: 10.1300/J082v14n03_04. [DOI] [PubMed] [Google Scholar]
  • 12).Lawrence E, Bunde M, Barry RA, et al. Partner support and marital satisfaction: Support amount, adequacy, provision, and solicitation. Pers Relatsh. 2008;15:445–463. [Google Scholar]
  • 13).Bovberg VE, McCann BS, Brief DJ, et al. Spouse support and long-term adherence to lipid-lowering diets. Am J Epidemiol. 1995;141(5):451–460. doi: 10.1093/oxfordjournals.aje.a117447. [DOI] [PubMed] [Google Scholar]
  • 14).Lett HS, Blumenthal JA, Babyak MA, et al. Social support and prognosis in patients at increased psychosocial risk recovering from myocardial infarction. J Health Psychol. 2007;26(4):418–427. doi: 10.1037/0278-6133.26.4.418. [DOI] [PubMed] [Google Scholar]
  • 15).Mermelstein R, Cohen S, Lichtenstein E, Baer JS, Kamarck T. Social support and smoking cessation and maintenance. J Consult Clin Psychol. 1986;54:447–453. doi: 10.1037//0022-006x.54.4.447. [DOI] [PubMed] [Google Scholar]
  • 16).Simoni JM, Frick PA, Huang B. A longitudinal evaluation of a social support model of medication adherence among HIV-positive men and women on antiretroviral therapy. J Health Psychol. 2006;25(1):74–81. doi: 10.1037/0278-6133.25.1.74. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17).Britton PJ, Zarski JJ, Hobfall SE. Psychological distress and the role of significant others in a population of gay/bisexual men in the era of HIV. AIDS Care. 1993;5:43–54. doi: 10.1080/09540129308258583. [DOI] [PubMed] [Google Scholar]
  • 18).Smith RB, Brown RA. The impact of social support on gay male couples. J Homosex. 1997;33(2):39–61. doi: 10.1300/J082v33n02_03. [DOI] [PubMed] [Google Scholar]
  • 19).Procidano ME, Heller K. Measures of perceived social support from friends and family: Three validation studies. Am J Community Psychol. 1983;11:1–24. doi: 10.1007/BF00898416. [DOI] [PubMed] [Google Scholar]
  • 20).Blair KL, Holmberg D. Perceived social network support and well-being in same-sex versus mixed-sex romantic relationships. J Soc Pers Relat. 2008;25(5):769–791. [Google Scholar]
  • 21).Elizur Y, Mintzer A. Gay males’ intimate relationship quality: The roles of attachment security, gay identity, social support, and income. Pers Relatsh. 2003;10:411–435. [Google Scholar]
  • 22).Kurdek LA. Relationship quality of gay and lesbian cohabiting couples. J Homosex. 1988;15:93–118. doi: 10.1300/J082v15n03_05. [DOI] [PubMed] [Google Scholar]
  • 23).Collins RL. Social support provision to HIV-infected gay men. J Appl Soc Psychol. 1994;24:1848–1869. [Google Scholar]
  • 24).Leserman J, Perkins DO, Evans DL. Coping with the threat of AIDS: The role of social support. Am J Psychiatry. 1992;149:1514–1520. doi: 10.1176/ajp.149.11.1514. [DOI] [PubMed] [Google Scholar]
  • 25).Waller MA. Gay men with AIDS: Perceptions of social support and adaptational outcome. J Homosex. 2001;41:99–117. doi: 10.1300/J082v41n02_06. [DOI] [PubMed] [Google Scholar]
  • 26).Miller GE, Cole SW. Social relationships and the progression of Human Immunodeficiency Virus infection: A review of evidence and possible underlying mechanisms. Ann Behav Med. 1998;20(3):181–189. doi: 10.1007/BF02884959. [DOI] [PubMed] [Google Scholar]
  • 27).Adib SM, Joseph JG, Ostrow DG, James SA. Predictors of relapse in sexual practices among homosexual men. AIDS Educ Prev. 1991;3:293–304. [PubMed] [Google Scholar]
  • 28).Kimberly JA, Serovich JM. The role of family and friend social support in reducing risk behaviors among HIV-positive gay men. AIDS Educ Prev. 1999;11(6):465–475. [PubMed] [Google Scholar]
  • 29).St. Lawrence JS, Brasfield TL, Jefferson KW, Allyene E, Shirley A. Social support as a factor in African-American adolescents’ sexual risk behavior. J Adolesc Res. 1994;9(3):292–310. [Google Scholar]
  • 30).Linn MW. Elderly women’s health and psychological adjustment: Life stressors and social support. In: Hobfall SE, editor. Stress, social support, and women. Hemisphere Publication Services; New York: 1986. pp. 223–235. [Google Scholar]
  • 31).O’Brien K, Wortman CB, Kessler RC, Joseph JG. Social relationships of men at risk for AIDS. Soc Sci Med. 1993;36:1161–1167. doi: 10.1016/0277-9536(93)90236-w. [DOI] [PubMed] [Google Scholar]
  • 32).Duncan TE, Duncan SC, McAuley E. The role of domain and gender-specific provisions of social relations in adherence to a prescribed exercise regimen. J Sport Exerc Psychol. 1993;15:220–231. [Google Scholar]
  • 33).Finegan DL, Suler JR. Psychological factors associated with maintenance of improved health behaviors in postcoronary patients. J Psychol. 1985;119:87–94. doi: 10.1080/00223980.1985.9712610. [DOI] [PubMed] [Google Scholar]
  • 34).Thrasher JF, Campbell MK, Oates V. Behavior-specific social support for healthy behaviors among African American church members: Applying optimal matching theory. Health Educ Behav. 2004;31(2):193–205. doi: 10.1177/1090198103259184. [DOI] [PubMed] [Google Scholar]
  • 35).Trieber FA, Baranowski T, Braden DS, Strong WB, Levy M, Knox W. Social support for exercise: Relationship to physical activity in young adults. Prev Med. 1991;20:737–750. doi: 10.1016/0091-7435(91)90068-f. [DOI] [PubMed] [Google Scholar]
  • 36).Crawford JM, Kippax S, Mao L, et al. Number of risk acts by relationship status and partner serostatus: Findings from the HIM cohort of homosexually active men in Sydney, Australia. AIDS Behav. 2006;10(3):325–331. doi: 10.1007/s10461-005-9057-3. [DOI] [PubMed] [Google Scholar]
  • 37).Hoff CC, Stall R, Paul J, et al. Differences in sexual behavior among HIV discordant and concordant gay men in primary relationships. J Acquir Immune Defic Syndr Hum Retrovirol. 1997;14:72–78. doi: 10.1097/00042560-199701010-00012. [DOI] [PubMed] [Google Scholar]
  • 38).Hoff CC, Coates TJ, Barrett D, Collette L, Ekstrand M. Differences between gay men in primary relationships and single men: Implications for prevention. AIDS Educ Prev. 1996;8:546–559. [PubMed] [Google Scholar]
  • 39).Stolte IG, Dukers NH, Geskus PB, Coutinho RA, deWit JB. Homosexual men change to risky sex when perceiving less threat of HIV/AIDS since availability of highly active antiretroviral therapy: A longitudinal study. AIDS. 2004;18:303–309. doi: 10.1097/00002030-200401230-00021. [DOI] [PubMed] [Google Scholar]
  • 40).Golden MR, Brewer DD, Kurth A, Holmes KK, Handsfield HH. Importance of sex partner HIV status in HIV risk assessment among men who have sex with men. J Acquir Immune Defic Syndr. 2004;36(2):734–742. doi: 10.1097/00126334-200406010-00011. [DOI] [PubMed] [Google Scholar]
  • 41).Hart TA, Wolitski RJ, Purcell DW, Parsons JT, Comez CA, The Seropositive Urban Men’s Study Team Partner awareness of the serostatus of HIV-seropositive men who have sex with men: Impact on unprotected sexual behavior. AIDS Behav. 2005;9(2):155–166. doi: 10.1007/s10461-005-3897-8. [DOI] [PubMed] [Google Scholar]
  • 42).Ostrow DG, Silverberg MJ, Cook RL, et al. Prospective study of attitudinal and relationship predictors of sexual risk in the Multicenter AIDS Cohort Study. AIDS Behav. 2008;12:127–138. doi: 10.1007/s10461-007-9223-x. [DOI] [PubMed] [Google Scholar]
  • 43).Theodore PS, Duran REF, Antoni MH, Fernandez MI. Intimacy and sexual behavior among HIV-positive men-who-have-sex-with-men in primary relationships. AIDS Behav. 2004;8(3):321–331. doi: 10.1023/B:AIBE.0000044079.37158.a9. [DOI] [PubMed] [Google Scholar]
  • 44).Van de Ven P, Kippax S, Crawford J, et al. In a minority of gay men, sexual risk practice indicates strategic positioning for perceived risk reduction rather than unbridled sex. AIDS Care. 2002;14(4):471–480. doi: 10.1080/09540120208629666. [DOI] [PubMed] [Google Scholar]
  • 45).Gorbach PM, Holmes KK. Transmission of STIs/HIV at the partnership level: Beyond individual-level analyses. J Urban Health. 2003;80((4): Supple 3):iii15–iii25. doi: 10.1093/jurban/jtg079. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46).Kuyper LM, Lampinen TM, Chan K, Miller ML, Schilder A, Hogg RS. Similar sexual behaviors with casual partners among gay men with and without a regular partner. Sex Transm Dis. 2005;32(3):203–205. doi: 10.1097/01.olq.0000154498.17876.c1. [DOI] [PubMed] [Google Scholar]
  • 47).Darbes LA, Lewis MA. HIV-specific social support predicts less sexual risk behavior in gay male couples. Health Psychol. 2005;24(6):617–622. doi: 10.1037/0278-6133.24.6.617. [DOI] [PubMed] [Google Scholar]
  • 48).Cutrona CE, Russell DW. The provisions of social relationships and adaptations to stress. Advances in Personal Relationships. 1987;1:37–67. [Google Scholar]
  • 49).Catz SL, Kelly JA, Bogart LM, Benotsch EG, McAuliffe TL. Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. J Health Psychol. 2000;19:124–133. [PubMed] [Google Scholar]
  • 50).Kelly JA, Murphy DA, Bahr GR, et al. Factors associated with severity of depression and high-risk sexual behavior among persons diagnosed with human immunodeficiency virus (HIV) infection. J Health Psychol. 1993;12:215–219. doi: 10.1037//0278-6133.12.3.215. [DOI] [PubMed] [Google Scholar]
  • 51).Neuhaus JM, Kalbfleisch JD. Between- and within-cluster covariate effects in the analysis of clustered data. Biometrics. 1998;54(2):638–645. [PubMed] [Google Scholar]
  • 52).Sheets RL, Mohr JJ. Perceived social support from friends and family and psychosocial functioning in bisexual young adult college students. J Couns Psychol. 2009;56(1):152–163. [Google Scholar]
  • 53).Davidovich U, de Wit JBF, Stroebe W. Relationship characteristics and risk of HIV infection: Rusbult’s investment model and sexual risk behavior of gay men in steady relationships. J Appl Soc Psychol. 2006;36(1):22–40. [Google Scholar]
  • 54).Zablotska IB, Imrie J, Prestage G, Crawford J, Rawstorne P, Grulich A, Jin F, Kippax S. Gay men’s current practice of HIV seroconcordant unprotected anal intercourse: serosorting or seroguessing? AIDS Care. 2009;21(4):501–510. doi: 10.1080/09540120802270292. [DOI] [PubMed] [Google Scholar]
  • 55).Davidovich U, de Wit JBF, Stroebe W. Behavioral and cognitive barriers to safer sex between men in steady relationships: Implications for prevention strategies. AIDS Educ Prev. 2004;16(4):304–314. doi: 10.1521/aeap.16.4.304.40398. [DOI] [PubMed] [Google Scholar]
  • 56).Hoff CC, Beougher SC, Chakravarty D, Darbes LA, Neilands TB. Relationship characteristics and motivations behind agreements among gay male couples: Differences by agreement type and couple serostatus. AIDS Care. 2010;22(7):827–835. doi: 10.1080/09540120903443384. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES