Traditionally, prevention research has focused on HIV-negative men. Research and the experiences of community organizations, however, show that providing support and information to HIV-positive men can also lower HIV transmission rates. Investigators at the Center for HIV/AIDS Educational Studies and Training (CHEST) are testing the effectiveness of HIV prevention programs targeting HIV-positive gay and bisexual men.
CHEST's focus on HIV prevention among HIV-positive gay and bisexual men began in 1996 with a grant from the Centers for Disease Control and Prevention called "The Seropositive Urban Men's Study" (SUMS). The study, conducted in collaboration with the Center for AIDS Prevention Studies (CAPS) at the University of California at San Francisco, interviewed 464 HIV-positive men in New York City and San Francisco about their sexual lives.
Twenty-nine percent of the men who participated in SUMS were African American, 24% Hispanic, 30% white, 8% Asian/Pacific Islander, and 8% of mixed heritage. The average age of the men investigators spoke with was 39. Eight-four percent identified as gay and 10% as bisexual. The average time men reported since testing HIV positive was 7 years, but ranged from two weeks to 12 years. Sixty-six percent of the men said that they did not have any HIV symptoms, while 53% said that they had been diagnosed with AIDS in the past. On average, men reported having 13 sex partners in the last three months, and 30% reported having unprotected insertive or receptive anal sex.
The reasons men gave most often for having unsafe sex were lack of communication about sex with their partners, the desire for pleasure, the environments in which men met, and drug and alcohol use during sex. The atmosphere in bathhouses and sex clubs, for example, made it difficult for men to raise the subject of safer sex and HIV. Being high on drugs or alcohol raised another barrier to practicing safer sex. Some men reported also that they just wanted to have fun and left it up to their partners to ask for condoms.
Investigators found that disclosing one's HIV status to partners, especially casual partners, was very difficult to do. Among the HIV-positive men who had sex with men (other than their main partners) who they knew were negative, 17% did not tell them that they were HIV-positive. Similarly, 55% of the men did not disclose their HIV status to men who were not their main partners and whose HIV status they did not know. With main partners, however, 91% of the 464 men in the study spoke to their primary partners about their HIV status. Notably, 9% of the men did not disclose their HIV status to their main partners.
The greatest fear that men voiced about informing partners of their HIV status was that they might be rejected because they were positive. Men dealt with the issue of disclosure in several ways: some said they would always practice safer sex, but not tell partners; some would only tell partners who asked; and some would always disclose their HIV status before having sex.
In addition to inquiring about sexual behavior and disclosure issues, investigators also asked men to describe the kinds of support programs they would like to help them develop skills to help them better negotiate safer sex. "In interviews, HIV-positive gay and bisexual men told us that they wanted a new kind of program that was 'sex-positive' and provided up-to-date information. Also, they wanted the opportunity to socialize with other men," said Dr. Jeffrey Parsons, the study's principal investigator.
The bottom line of SUMS findings is that HIV-positive men frequently practice unsafe sex and that their needs for HIV-related information and support are not adequately met by existing programs.
The implications of these findings are that agencies providing HIV-related services need to develop stronger and more creative programs of HIV support and prevention if they want to further reduce HIV transmission.
Based on the findings from SUMS, investigators at CHEST and CAPS designed a new study that is now ongoing called "Bay Men" in San Francisco and "Absolutely Positive" (A+) in New York City. The new study is also funded by the Centers for Disease Control and Prevention (CDC). The program, which began in March 2000, incorporates many of the ideas that men participating in the SUMS study raised for improving support and seeks to test the extent to which enhanced interventions reduce the amount of unsafe sex participants report with men whose HIV status is negative or unknown.
"The A+ program is based on science," said Dr. Perry Halkitis, co-principal investigator of the study. "Unlike many programs which have been developed in our community, our program is not based on impression and anecdote. Our intervention is based on the stated needs of HIV-positive gay and bisexual men and our understanding of what it means to be HIV-positive." The study is open to HIV-positive gay or bisexual men over the age of 18 who reside within the New York City metropolitan area.
Potential participants for A+ are first screened over the telephone. If a person is eligible he comes to the CHEST office in Chelsea, has a brief interview with program staff, and fills out a detailed computer survey. The computer actually reads survey questions out loud as participants read along. Because the survey asks very sensitive questions about sexual behavior and drug use, investigators decided to use a computer to give participants more privacy and confidentiality. Participants are also offered free optional STD testing for gonorrhea, chlamydia, herpes, and syphilis. After completing the interview and survey, participants are randomly assigned into one of two groups, with about fifty HIV-positive men in each. One group will receive the intervention, the other will be a comparison group to test the effect of the intervention.
The comparison group meets one time. Participants ask a panel of HIV experts questions about sexual-risk taking and STDs. The session lasts about two hours, and is considered to be a "standard-of-care" intervention. In contrast to the comparison group, the intervention group meets six times over a six-week period for three hours each time and covers many more issues, including how HIV-positive men relate to each other, sexual-risk taking, dating and relationships, substance use, disclosure, and coping with changes in HIV treatment and care. Men discuss these issues in large and small group settings guided by a mix of psychological and educational approaches.
If you are interested in learning more about the Absolutely Positive project, or are interested in being a participant, please call CHEST at (212) 206-7919 x302.