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Prevention With HIV-Seropositive Men Who Have Sex With Men:
Lessons From the Seropositive Urban Men's Study (SUMS) and the Seropositive Urban Men's Intervention Trial (SUMIT)
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JAIDS Journal of Acquired Immune Deficiency Syndromes: Volume 37 Supplement 2 1 October 2004 pp S101-S109
Wolitski, Richard J PhD*; Parsons, Jeffrey T PhD ; G—mez, Cynthia A PhDà; for the SUMS and SUMIT Study Teams
From the *Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA; Hunter College and the Graduate Center of the City University of New York, New York, NY; and àUniversity of California, San Francisco, San Francisco, CA for the Seropositive Urban Men's Study and Seropositive Urban Men's Intervention Trial Study Teams.
Supported by the Centers for Disease Control and Prevention through cooperative agreements with New Jersey City University, Rutgers University, and the University of California, San Francisco.
Abstract
Summary: Men who have sex with men (MSM) are disproportionately affected by HIV, and HIV-seropositive (HIV-positive) MSM are an especially important group for prevention efforts. This article describes findings from the Seropositive Urban Men's Study (SUMS, N = 456) and the Seropositive Urban Men's Intervention Trial (SUMIT, N = 1168). These studies were conducted from 1996 to 2002 with racially diverse samples from New York and San Francisco. Patterns of sexual behavior often reflected an understanding of the relative risks of specific sexual practices and were generally consistent with harm reduction strategies to reduce the risk of HIV transmission to uninfected partners. Some men, however, continued to engage in behaviors that placed themselves and their partners at risk for exposure to HIV and other sexually transmitted infections. Correlates of unprotected sex included self-efficacy, personal responsibility, substance use, mental health, and contextual influences. Disclosure of HIV status was a difficult issue for many HIV-positive MSM. Most participants had disclosed to their main partner, but they disclosed to less than half of their non-main partners before first sex. The interest of HIV-positive MSM in prevention efforts, the design of the SUMIT intervention trial, and implications for future research and programmatic efforts are discussed.
Since the first cases of AIDS were reported in 1981, gay, bisexual, and other men who have sex with men (MSM) have been disproportionately affected by HIV in the United States. MSM represented 65% of men living with AIDS in the United States in 2002,1 although only 5% to 7% of American men have had sex with another man during adulthood.2,3 This disparity continues to this day and is present in current HIV infection rates. In 2002, MSM comprised 67% of men diagnosed with HIV in states with name-based HIV reporting.1 Increases in unprotected sex, outbreaks of sexually transmitted infections (STIs), and a rise in newly diagnosed HIV infections among MSM all indicate an urgent need to expand prevention efforts, reach underserved subgroups, and develop new paradigms for reducing HIV transmission in this population.4-6
An increased public health emphasis on the identification of persons with undiagnosed HIV infection and on interventions for persons living with HIV7-9 has called attention to the need for a better understanding of the sexual behavior and serostatus disclosure practices of HIV-seropositive (HIV-positive) MSM. Understanding these behaviors as well as risk reduction barriers and facilitators is essential for the development of interventions that encourage HIV-positive MSM to protect themselves and their partners from HIV and other STIs. At present, there are few effective interventions designed to do this.
To address this gap, in 1996, the Centers for Disease Control and Prevention (CDC) established the Seropositive Urban Men's Study (SUMS) to collect qualitative and quantitative data relevant to the development of interventions for HIV-positive MSM. This study was undertaken when highly active antiretroviral therapy (HAART) was still relatively new and the long-term effects of HAART on survival were not yet known. The SUMS research team conducted qualitative interviews (N = 250) and paper-and-pencil surveys (N = 456) from 1997 to 1998 with a community-based sample of racially/ethnically diverse HIV-positive MSM from New York and San Francisco that allowed the researchers to (1) compare the feasibility of recruiting self-identified HIV-positive MSM from different community settings,10 (2) describe serostatus disclosure and sexual practices,11-14 (3) identify influences that promote or discourage serostatus disclosure and risk behavior,12,15-24 and (4) elicit ideas for intervention activities and assess interest in prevention programs.25
In 1998, the CDC expanded research activities with HIV-positive gay and bisexual men by initiating the Seropositive Urban Men's Intervention Trial (SUMIT). The goals of the SUMIT were to facilitate a better understanding of sexual practices and serostatus disclosure among HIV-positive gay and bisexual men and to evaluate the effects of a behavioral intervention for this population. In contrast to the SUMS, this study was initiated at a time when many people living with HIV had experienced sustained benefits from HAART and a growing number of MSM had begun to reject safer sex messages and adopt riskier sexual practices.5 A total of 1168 HIV-positive gay and bisexual men were recruited in 2000 and 2001 from New York and San Francisco. All these men participated in an audio computer-assisted self-interview (A-CASI) at baseline, were asked to provide blood and urine samples for STI testing, and were randomized to 1 of 2 intervention conditions. A total of 811 participants presented for intervention and learned that they had been randomized to a single-session educational session or an enhanced 6-session intervention. Both interventions contained safer sex information, but the enhanced intervention incorporated large and small group activities that were designed to promote the adoption and maintenance of safer sex practices with uninfected partners and the disclosure of HIV serostatus. Participants were recontacted for A-CASI interviews that were scheduled 3 and 6 months after their last intervention session. At the 6-month assessment, all participants were also asked to provide samples for STI testing.
Most SUMS and SUMIT participants were men of color (70% and 55%, respectively). They ranged in age from 20 to 89 years, with an average age of 37 years for SUMS participants and 41 years for SUMIT participants. Most were gay identified, but a substantial percentage of SUMS (15%) and SUMIT (16%) participants did not consider themselves to be gay. Most had been living with HIV for years; the average time since HIV diagnosis for both studies was approximately 7 years and ranged from weeks to more than 17 years. Most participants had access to health care, including viral load testing and combination antiretroviral therapy. Detailed information about the men who participated in these studies and the research methods that were used is available elsewhere.12,15,26
This paper synthesizes information from the SUMS and SUMIT that is relevant for prevention with HIV-positive MSM. First, we present data from these studies that describe the sexual risk practices of HIV-positive MSM, identify factors that influence unprotected sex with serodiscordant and seroconcordant partners, and discuss serostatus disclosure and its relation to risk behavior. Next, we discuss potential strategies for reducing HIV transmission and acquisition of STIs among HIV-positive men and describe the SUMIT intervention trial. Finally, we look back on the lessons we learned over the past 8 years and suggest possible directions for future programmatic and research activities.
SEXUAL PRACTICES
Most HIV-positive MSM in the SUMS and SUMIT did not engage in high-risk sexual practices with uninfected partners.11,27 A considerable minority did, however, report having unprotected anal sex with partners who were at risk for HIV infection. Among SUMS participants, 15% reported having had unprotected insertive or receptive anal sex with an HIV-seronegative partner in the prior 3 months and 27% had unprotected anal sex with a partner whose HIV status they did not know.11 Among SUMIT participants, 15% reported unprotected anal sex in the prior 90 days with an HIV-seronegative main partner and 18% reported unprotected anal sex with HIV-seronegative non-main partners.27 As was the case in the SUMS, more SUMIT participants (34%) reported having had unprotected anal sex with a non-main partner whose HIV status was unknown.
SUMS and SUMIT participants reported using a range of risk reduction strategies. Condom use was reported by 83% of the 668 SUMIT participants who had anal sex with HIV-seronegative or unknown status partners. Most did not use condoms 100% of the time, however. Of men who had insertive anal sex with an HIV-seronegative or unknown status partner, only 38% reported that they consistently used condoms during these encounters (unpublished data).
Like other recent studies of HIV-positive MSM,28-30 SUMS and SUMIT participants reported other behaviors consistent with harm reduction strategies that are, at a minimum, perceived to reduce risk. Specifically, men engaged in (1) serosorting-selecting HIV-positive sex partners or engaging in high-risk sexual practices with only these partners (2) strategic positioning-engaging in unprotected receptive rather than insertive anal sex based on the assumption that it is more difficult to transmit HIV as a bottom than a top, and (3) withdrawal-pulling out before ejaculation during unprotected sex to lessen the likelihood of transmitting HIV through ejaculate.
Serosorting
There was evidence that partner serostatus affected the choice of sex partners among some SUMS participants, but the reasons for making these choices varied. Some men avoided HIV-seronegative partners because they feared transmitting HIV, others believed that an HIV-seronegative partner could not fully understand what they were going through, and some were afraid of being rejected by a sex partner because of their HIV status.31 Fewer than half of SUMS participants (42%) reported having sex with an HIV-seronegative partner, whereas 55% had an HIV-positive sex partner and 63% had a sex partner whose HIV status they did not know.12
Rates and frequencies of unprotected sex with main and non-main partners varied according to the serostatus of partners.27 SUMIT participants were most likely to report unprotected insertive anal intercourse (UIAI) with HIV-positive partners. They were less likely to report UIAI with unknown status partners and least likely to reported UIAI with HIV-seronegative partners. For example, 11% of SUMIT participants from New York who had an HIV-seronegative main partner reported having had UIAI with this partner compared with 20% of men with unknown status partners and 47% of those with an HIV-positive partner. Rates of unprotected receptive anal intercourse (URAI) differed by partner serostatus for non-main (but not main) partners. Men with HIV-seronegative non-main partners reported comparable rates of URAI with HIV-positive and unknown status non-main partners (eg, 28% and 27%, respectively, in San Francisco) and were least likely to report URAI with HIV-seronegative non-main partners (17% in San Francisco). This pattern of findings is consistent with SUMS qualitative data showing that HIV-positive MSM sometimes assume that that sex partners whose HIV status is unknown may actually be HIV-positive.32
Strategic Positioning
Choosing to be the receptive partner during anal intercourse (rather than the insertive partner) was described as a risk reduction strategy by a number of SUMS participants.33 Only half of the men who participated in the SUMS qualitative interview reported that they were at risk for transmitting HIV or STIs during URAI.33 Consistent with this perception, SUMS participants reported more acts of URAI than UIAI with partners of all serostatuses, but this difference was statistically significant only for unknown status partners.12 A weakness of the SUMS data is that it is not known whether the higher frequency of URAI versus UIAI represents the use of strategic positioning as a risk reduction strategy or merely a preference for the receptive role.
Clearer evidence for the use of strategic positioning as a risk reduction strategy is provided by the SUMIT.27 There was little difference in rates and frequencies of receptive versus insertive anal intercourse with HIV-positive non-main partners, but differences were often observed for HIV-seronegative and unknown status partners. Among San Francisco participants, for example, rates of URAI and UIAI with HIV-positive non-main partners were similar (28% and 27%, respectively). For HIV-seronegative non-main partners, however, URAI was more often reported than was UIAI (17% vs. 10%, respectively).
Withdrawal
In the SUMS qualitative interviews, a few men, especially those who were Latino, specifically discussed withdrawal before ejaculation as a method of safer sex.33 In the SUMIT, men from San Francisco consistently reported significantly fewer acts of UIAI to ejaculation than UIAI without ejaculation, regardless of partner serostatus.27 Men from New York also reported fewer acts of UIAI to ejaculation than UIAI without ejaculation with HIV-positive and unknown status partners, but they reported similar rates of UIAI with and without ejaculation with HIV-seronegative partners. The greater frequency of UIAI without ejaculation in San Francisco and for some partners in New York provides some support for observations for the qualitative data from the SUMS. The SUMIT data raise questions, however, about the frequency with which HIV-positive men use withdrawal as a strategy to protect uninfected partners and whether there are other reasons that some HIV-positive MSM engage in this practice.
In addition to examining sexual activity with and without withdrawal separately, men in the SUMIT were asked about dipping. Dipping was defined as teasing or playing with your partner by putting your penis in his ass just once or twice without a condom.34 Results showed that 18% of men with an HIV-seronegative or unknown status partner reported dipping in the past 90 days. More specifically, 11% of those who did not report engaging in UIAI reported dipping, as did 37% of those who did report UIAI. Dipping was more likely to be reported by men who believed that condoms interfere with sexual pleasure and by Latino men, which is particularly interesting considering SUMS qualitative data revealed that Latino men more often spoke about withdrawal as a safer sex strategy. Had specific questions about dipping not been included in the SUMIT assessment, 773 acts of UIAI would have been missed, because some men did not include these acts when asked about the times they had anal sex without a condom.
CORRELATES OF UNPROTECTED SEX
Health Behavior Cognitions
Data from both studies support earlier findings that core constructs from health behavior theory associated with risk behavior among uninfected MSM are related to transmission risk behavior among HIV-positive MSM.35,36 In the SUMIT, variables based on social cognitive theory, particularly self-efficacy and outcome expectancies, predicted the frequency of condom use with serodiscordant main and non-main partners (A. O'Leary, unpublished data, 2004). Similarly, SUMIT data have also shown outcome expectancies (specifically less negative self-evaluative beliefs after unprotected sex and greater belief that condoms interfere with pleasure) to be significantly associated with unprotected anal intercourse with seroconcordant partners (P. Halkitis, unpublished data, 2004).
Perceived risk was also a significant influence on sexual behavior among SUMS and SUMIT participants. The perceived transmission risk of UIAI with uninfected partners was universally high among SUMS participants and was not associated with condom use. There was less agreement among participants about the risks associated with withdrawal before ejaculation and the effects of HIV treatment on transmission, however. Beliefs about the relative risk of withdrawal and the effects of treatment on risk were associated with risk behavior with uninfected partners.39 Men who perceived that withdrawal or antiretroviral treatment reduced transmission risk were more likely to have had engaged in unprotected anal intercourse with HIV-seronegative or unknown status partners. In addition, men who reported inconsistent or no use of condoms during insertive oral sex believed that insertive oral sex posed less risk of HIV transmission to uninfected partners than did men who consistently used condoms for these acts.
A separate analysis of SUMS data demonstrated that optimistic beliefs about the effects of HIV treatment on HIV transmission risk were associated with unprotected anal sex among men who had positive treatment outcomes (ie, undetectable viral load).40 Similarly, perceiving a lower risk of HIV reinfection or exposure to other pathogens during unprotected sex and having a higher CD4 count were associated with unprotected anal intercourse among SUMS participants with HIV-positive partners.16 These findings indicate that the effects of perceived risk may be more readily observed for moderate-risk behaviors than for those behaviors that are commonly believed to pose a high level of risk and, as a result, have little variation. In addition, they suggest that health status may affect the extent to which HIV-positive MSM are influenced by risk perceptions.
Other analyses support predictions based on the transtheoretical model about the effects of temptation on individuals' ability to adopt and maintain safer sex practices.12 In multivariate analyses, temptation was 1 of only 2 cognitive measures that differentiated between men who engaged in UIAI with an HIV-seronegative or unknown serostatus partner and those who did not. Men who experienced greater temptation to have UIAI were more likely to report having had engaged in this behavior with an HIV-seronegative or unknown serostatus partner.
The other significant cognitive variable in this analysis was perceived personal responsibility. Most SUMS and SUMIT participants perceived that they had a personal responsibility to protect sex partners from HIV infection, and this belief had a strong effect on their sexual practices. In the qualitative interviews, men described responsibility as resting with themselves (63%) or their partner (24%) or as shared by both partners (12%).23 Statements regarding personal responsibility were frequently endorsed by SUMS and SUMIT participants and indicated high levels of perceived personal responsibility in this sample.41,42 For example, 86% of SUMIT participants agreed or strongly agreed that HIV-positive gay men have a responsibility to keep other gay men from becoming positive.41 Beliefs about personal responsibility were highly correlated with sexual behavior with HIV-seronegative or unknown status partners. Higher personal responsibility scores were associated with a significantly reduced risk of UIAI, URAI, and unprotected insertive oral sex with HIV-seronegative and unknown status partners.41
Barebacking Identity
Men who intentionally seek out partners for unprotected sex, barebackers, have recently developed a collective social identity that facilitates connection with like-minded partners through the Internet and other venues.43 SUMIT data suggest that men who identify as barebackers represent more than an inconsequential minority of HIV-positive MSM and that they are at considerable risk of transmitting HIV to others. More than one quarter of SUMIT participants (27%) identified themselves as barebackers, and 57% of barebackers indicated that they did not limit bareback sex to seroconcordant partners.44 Not surprisingly, men who identified as barebackers were significantly more likely than men who did not identify as barebackers to report higher rates of UIAI, URAI, and unprotected insertive oral sex with HIV-positive, HIV-seronegative, and unknown serostatus partners.
Mental Health
Being diagnosed with HIV can negatively affect mental health, and preexisting mental illness is associated with an increased risk of becoming HIV infected.45-47 The association between less severe mood disorders and HIV risk has not been clearly established, but few studies have specifically examined the association between mental health and risk behaviors among HIV-positive persons.48 In bivariate analyses of the SUMS data, brief measures of anxiety, depression, hostility, loneliness, and suicidality were associated with unprotected anal sex.12 In a comprehensive multivariate analysis that included substance use and other psychosocial variables, anxiety and depression differentiated men who engaged in no unprotected anal intercourse from those who had URAI. Anxiety and loneliness also differentiated those whose riskiest behavior was URAI from those who had UIAI.
Other analyses of SUMS data examined the association between childhood sexual abuse (CSA), current mood state, and sexual practices.21 CSA, which was reported by 15% of participants, was associated with greater anxiety, hostility, and suicidality. Men with a history of CSA were more likely than those without a history of CSA to report UIAI and URAI in the prior 90 days. The association between CSA and URAI was partially mediated by anxiety, hostility, and suicidality, but mental health measures did not mediate the relation between CSA and UIAI. Surprisingly, when the same measures of anxiety, hostility, and depression were examined in the SUMIT sample, they did not emerge as predictors of unprotected anal intercourse with main or non-main HIV-seronegative and unknown status partners (A. O'Leary unpublished data, 2004). CSA did, however, continue to be a significant predictor of risk with non-main and main partners.
Substance Use
The use of alcohol, recreational drugs, and injected drugs affected the lives of many SUMS and SUMIT participants. Some men reported extended histories of substance abuse that, in some cases, contributed to their infection with HIV.49 Some used alcohol or drugs as a way to cope with their HIV diagnosis, the stress of maintaining (or failing to maintain) safer sex practices, their sexual orientation, or other issues. Others used alcohol or drugs to reduce social anxiety, lessen sexual inhibitions, and enhance their sexual experiences.49
Alcohol and drug use was prevalent among SUMS and SUMIT participants and often occurred in conjunction with sexual encounters (D. Purcell, unpublished data, 2004).24 Twenty-eight percent of SUMS participants had used 3 or more substances (including alcohol) in the past 3 months.24 The most frequently reported substances were alcohol (64%), marijuana (36%), amyl/butyl nitrite inhalants or poppers (27%), cocaine (13%), and amphetamines (12%). Of those who reported drinking alcohol, 80% drank before or during sex. Almost all the men who reported drug use (90%) reported using drugs before or during sex. Few men reported current injection drug use, but 16% of SUMS participants and 20% of SUMIT participants had a prior history of injection drug use (G. Ib‡nez, unpublished data, 2004).24 SUMIT participants with a history of drug injection were more likely to be bisexual, engage in unprotected sex, use noninjected drugs, and have lower mental health scores (G. Ib‡nez, unpublished data, 2004).
Significant associations between substance use and unprotected sex were found in both studies. Use of alcohol, marijuana, amphetamines, amyl/butyl nitrite inhalants, cocaine, and some club drugs was associated with higher rates of unprotected sex in bivariate analyses (D. Purcell, unpublished data, 2004).24 In the SUMS, multivariate analyses revealed that alcohol and drug use before or during sex and use of nitrite inhalants (poppers) were independently associated with unprotected sex with uninfected and unknown serostatus partners.24 In addition, substance use (especially use of methamphetamines and injected drugs) was associated with unprotected anal intercourse with HIV-positive partners. The association between substance use and risky sexual practices was not limited to alcohol and recreational drugs. The SUMIT also examined the influence of prescription drugs on sexual practices and found that men who used Viagra were also more likely to report unprotected sex with HIV-seroconcordant and serodiscordant partners.52
Public Sex Environments
There has been considerable debate about the role that commercial public sex environments (eg, bathhouses, sex clubs) and other public sex environments (eg, parks, cruising areas) play in the spread of HIV among MSM. Qualitative and quantitative data from the SUMS indicate that these settings affect the perceptions and risk behavior of HIV-positive MSM. SUMS participants who frequented commercial public sex environments often assumed that persons in these venues were HIV-positive or were willing to risk infection by virtue of being in that environment.19,32 As a result, they were often more willing to forgo condom use in these environments. These accounts from the qualitative interviews were substantiated by the quantitative finding that men who frequented commercial public sex environments reported more unprotected anal and oral sex, regardless of the serostatus of their partners.18 There were no differences in sexual risk behaviors between men who did and those who did not frequent noncommercial public sex environments, however. This difference may be a result of several factors, including the risk of arrest and lack of privacy in noncommercial settings and the perception that non-gay-identified men who are less aware of the potential risk of HIV infection may frequent noncommercial venues. The differences between commercial and noncommercial public sex environments, the level of risk in these settings, and the psychosocial characteristics of the men who frequent them highlight the need to consider these sexually charged settings separately rather than to assume that they are the same.18
DISCLOSURE OF HIV STATUS
Decisions about when, where, how, and to whom to disclose this personal information are often difficult for HIV-positive MSM. Deciding whether to disclose HIV status to a sex partner can be particularly difficult given the close nature of these relationships, the emotional and physical vulnerability inherent in these relationships, and the possibility that HIV may be (or may already have been) transmitted. The anguish associated with disclosure was illustrated by the steps that some SUMS participants had taken to avoid it-these men decided not to have any sexual relationships or only to have sex with anonymous partners in public sex environments in which nondisclosure was perceived as the norm.14
Although many SUMS and SUMIT participants agreed about their responsibility to protect sex partners from HIV, they often held different opinions about the need for disclosure. Approximately 51% of SUMS participants agreed that they should inform potential sex partners about their HIV status.53 The remainder either disagreed (24%) or were unsure (26%) about their responsibility to disclose. These differences may be influenced by whether participants (1) had previously had positive or negative experiences with disclosure, (2) were seeking a short-term or long-term relationship, (3) had a preference for seropositive partners, or (4) perceived a moral obligation to disclose.14
Despite the diversity of opinions about disclosure, 78% of SUMS and SUMIT participants had disclosed their HIV status to their main partner before their first sexual encounter (J. Parsons, unpublished data, 2004).13 Participants in both studies were less likely to disclose to non-main partners-SUMS participants disclosed their HIV status before first sex to less than half (41%) of their non-main partners.13 Among SUMIT participants, 33% reported disclosing to none of their non-main partners, 38% to some of these partners, and 29% to all these partners (J. Parsons, unpublished data, 2004). Men in both studies were more likely to know the serostatus of partners whom they had disclosed to, reflecting the fact that disclosure by 1 person is typically reciprocated by the other. In both studies, the most consistent independent predictors of disclosure to all potential sex partners were disclosure self-efficacy and intention to disclose before sex.13 Other significant predictors of disclosure in some multivariate models included having fewer sex partners, having fewer partners who were 1-night stands, greater comfort in talking with partners about HIV, self-evaluative beliefs that reinforce safer sex, lower income, and having been diagnosed with AIDS. In the qualitative interviews, SUMS participants identified other factors that they believed influenced disclosure, such as whether their partners had asked about their HIV status or disclosed their own status, assumptions about partners' serostatus, and the setting in which sex occurred.14
The SUMS and SUMIT provide additional insights into the complex relation between disclosure and risk behavior. Regardless of whether disclosure occurred, most SUMS and SUMIT participants did not report having UIAI or URAI with an HIV-seronegative or unknown status partner. Interestingly, men who did not consistently disclose their HIV status to HIV-seronegative or unknown status partners were more likely to have unprotected sex with these partners than were those who disclosed to all or none of their partners. Among SUMS participants, 49% of those who disclosed to some of their HIV-seronegative or unknown status non-main partners reported having had URAI compared with 32% of those who disclosed to none of these partners and 28% of those who disclosed to all these partners.13 Increased risk among inconsistent disclosers was also significant for unprotected insertive oral sex and was observed but was not statistically significant for UIAI. Among SUMIT participants, inconsistent disclosers reported significantly more UIAI and URAI but not unprotected oral insertive sex compared with men who disclosed to all or none of their partners before sex (J. Parsons, unpublished data, 2004).
INTERVENTION STRATEGIES
Findings from the SUMS and SUMIT support the need for programs that assist HIV-positive gay men, bisexual men, and other MSM to adopt and maintain safer sex practices. These data also show that important prevention opportunities are being missed. For example, 23% of SUMS participants reported that their current health care provider had never spoken with them about safer sex.22 The failure of health care providers to address HIV transmission does not reflect a lack of interest in this information on the part of HIV-positive MSM. Most SUMS participants were receptive to health-related information, and most actively sought out HIV-related information.25 Although most prevention programs had not yet begun to address the needs of HIV-positive MSM directly, one third of these men had attended a safer sex workshop in the prior year. Although many SUMS participants did express interest in issues related to the prevention of HIV transmission, they were often more interested in issues related to health, financial assistance, HIV treatments, and complementary or alternative therapies.25 Independent of the content of prevention programs, 55% of SUMS participants expressed a desire to meet and socialize with other HIV-positive men. A desire to talk with other HIV-positive men about common experiences and a sense of isolation from other HIV-positive MSM were also identified as themes in the qualitative interviews (unpublished data), suggesting that a group intervention might be appropriate for and welcomed by this population.
Based on SUMS findings, the research group initiated an intervention trial to test the efficacy of a 6-session, peer-led, enhanced intervention versus a single-session comparison intervention. The enhanced intervention consisted of 6 weekly 3-hour intervention sessions that addressed sexual relationships, HIV and STI transmission, drug and alcohol use, assumptions about the HIV status of sex partners, and disclosure of HIV status. These sessions included large-group activities that gave participants informal opportunities to interact with a number of other HIV-positive MSM and smaller discussion groups that were facilitated by 2 HIV-positive gay men. The facilitators used structured intervention guides to conduct the small group sessions. These sessions included trigger tapes and other activities to promote discussion and provide skill-building opportunities, development of supportive social norms, and insight into personal barriers and facilitators of safer sex practices.
Participants in the comparison condition took part in a single 1.5- to 2-hour session during which local experts presented current information on HIV and STI transmission and safer sex practices and answered questions from the audience. This format was modeled after community forums conducted by community-based organizations in each city that were considered to represent the standard of prevention services available at the time the study was implemented. Both interventions provided information about the risks of unprotected sex to the participants and their HIV-seronegative and HIV-positive partners, with an emphasis on the prevention of HIV transmission to uninfected partners. Analyses of the intervention trial results are still underway, but preliminary results indicate that the intervention did not lead to a sustained reduction in transmission risk or an increase in serostatus disclosure.
IMPLICATIONS AND FUTURE DIRECTIONS
The findings of the SUMS and SUMIT indicate that most study participants were concerned about the possibility that they might transmit HIV to others, believed that they have a responsibility to protect others, and had taken steps to reduce the risk of HIV transmission. These findings suggest that most HIV-positive MSM will attend to messages that promote the adoption and maintenance of safer sex practices. Many of these men are already sophisticated consumers of information about the risk of specific sexual practices, and programs that address only safer sex may not offer much that is new or be appealing to all these men. To be attractive to some HIV-positive MSM, interventions may need to address topics that are of greater importance to these men, such as general health and well-being, HIV treatments, and other issues. Given that stand-alone programs designed to reduce transmission risk may not be attractive to all MSM living with HIV, it may be preferable to integrate HIV prevention messages into other settings that provide services to HIV-positive MSM, such as medical care, case management, and other supportive services. Guidelines for physicians treating HIV-positive patients have recently been issued and provide clear recommendations for the provision of prevention counseling to patients in medical care.55
It is also important to recognize that some HIV-positive MSM engage in behaviors that carry considerable risk of HIV transmission. Among the subgroup of men who engaged in anal intercourse with HIV-seronegative or unknown status partners, most had not achieved 100% condom use with these at-risk partners. The potential risk to uninfected partners is considerable and should not be downplayed or ignored. The issue of high-risk behavior among HIV-positive MSM needs to be addressed by public health agencies, community leaders, and HIV-positive MSM themselves. The SUMS, SUMIT, and other studies have provided valuable insights into the difficulties associated with maintaining safer sex that some HIV-positive MSM experience and the barriers that they face. Results from these studies emphasize the need for prevention programs with HIV-positive MSM and provide a foundation for the development of interventions for this population.
The participants in the SUMS and SUMIT were a diverse group of individuals with a wide range of prevention needs. Some men had successfully maintained safer sex practices for years and needed little additional encouragement. Others usually maintained safer sex behaviors but sometimes slipped or had unprotected sex under certain circumstances (eg, with their main partner or in a public sex environment). Some preferred unprotected sex and did not perceive a need to use condoms if their partners were willing to have unprotected sex. The intervention needs and interests of these men were also affected by other factors, such as their physical and mental health, beliefs about new treatments, and drug use.
The diversity of these men's experiences suggests that a 1-size-fits-all approach to prevention with HIV-positive MSM will not succeed. Simple reinforcement of safer sex practices may be sufficient for some, but others require intensive interventions addressing fundamental mental health issues (eg, coping with HIV diagnosis, negative self-image, substance abuse) that go beyond the scope of most HIV prevention programs. The needs of these men provide yet another argument for the integration of HIV prevention services into programs that are designed to meet the mental health and service needs of persons living with HIV. It also suggests that some HIV-positive MSM may benefit from HIV prevention case management and that, at a minimum, prevention programs serving persons living with HIV should be prepared to make active referrals to a wide range of medical and social services. As prevention programs with people living with HIV are implemented, it is essential that evaluation efforts consider the extent to which services match the needs of individual clients. A similar approach to matching intervention services to individual need has previously been advocated for at-risk populations.56
Disclosure of HIV status to potential sex partners is a stressful issue for many HIV-positive men because of the fear of rejection and the stigma and discrimination that many HIV-positive persons have experienced in the past. The findings of the SUMS and SUMIT suggest that having a consistent strategy for managing disclosure may reduce stress associated with deciding whether to disclose and facilitate safer sex practices by simplifying safer sex decision making in the heat of the moment. Encouraging disclosure is a legitimate prevention goal, but disclosure does not necessarily reduce the risk of HIV transmission to uninfected partners. Qualitative data from the SUMS provide some potential explanations as to why this is the case. First, some HIV-positive MSM chose not to disclose because they believe that disclosure is not necessary if high-risk sexual practices are avoided.14 These men consciously limit their sexual practices to lower risk behaviors so that they do not feel compelled to discuss their HIV status with their partners. Second, disclosure may shift responsibility for safer sex from HIV-positive MSM to their partners.23 Some SUMS participants expressed the sentiment that once they had disclosed their HIV status, they had done their part and that the responsibility for safer sex rested with their partner. If the partner wanted to have unprotected sex, they viewed it as his choice because he had been informed. Finally, disclosure of HIV status may promote a greater sense of trust, intimacy, or emotional closeness that can cause some serodiscordant couples to be more willing to have unprotected sex.33
HIV prevention programs should promote disclosure to uninfected partners on ethical grounds and because false assumptions about serostatus can lead to risky sexual practices. It is essential to recognize, however, that some HIV-positive MSM who have adopted a consistent strategy of not disclosing to sex partners may, in fact, engage in less unprotected sex than those who inconsistently disclose their status to sex partners. This suggests the potential value of an individually tailored approach that works with HIV-positive MSM to adopt a consistent approach to disclosure that works for them and includes the maintenance of safer sex practices regardless of whether disclosure has occurred. Framing the issue of disclosure within the context of coping with the stress of being HIV-positive and taking a broader focus that addresses the benefits of disclosure to a wide range of individuals, including but not limited to sex partners, is another approach that has been shown to be successful.57
Prevention with people living with HIV represents an important strategy for limiting the further spread of HIV.7-9 Like other prevention efforts, it is important that these programs be based on strong science and that they are responsive to the needs and perspectives of the persons being served. HIV-positive persons have a responsibility to protect others, but that responsibility does not rest with them alone.58 The general community, at-risk persons, public health agencies, and people living with HIV all share in the responsibility to prevent the further spread of HIV. All these groups have to work together to significantly limit the further spread of the epidemic.
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