HIV Prevention Altruism and Sexual Risk Behavior in HIV-Positive MSM
HIV Prevention Altruism and Sexual Risk Behavior in HIV-Positive MSM
An understanding of men's motivations to avoid risk behavior is needed to create efficacious HIV prevention programs for HIV-positive men who have sex with men (MSM). This study investigates the relationship between sexual risk behavior and HIV prevention altruism, which is defined as the values, motivations, and practices of caretaking towards one's sexual partners to prevent the transmission of HIV. In a sample of 637 HIV-positive MSM, HIV prevention altruism significantly protects against serodiscordant unprotected anal intercourse (SDUAI) in crude analysis, but not after adjustment for drug use and compulsive sexual behavior. HIV prevention altruism is also related to not engaging in anal intercourse, but is not related to serodisclosure to secondary partners. Lack of altruism appears related to sexual risk behavior in HIV-positive MSM, although other psychological and contextual factors play significant roles. The promotion of HIV prevention altruism may provide a formidable new direction for HIV prevention programs.
HIV-positive persons are living longer lives as a result of improved treatment and care. As a result, the population of people with HIV who can potentially spread the virus to others has increased (CDC 2006). In response, the creation of effective HIV prevention programs for persons living with HIV has become a national priority. Both the National Institutes for Health (NIH 1997) and the Centers for Disease Control and Prevention (CDC 2003) have emphasized the urgent need for research and prevention programs that specifically target people living with HIV, especially in communities of men who have sex with men (MSM) and persons of color. Research answers are needed to guide prevention strategies to be more efficient, efficacious and cost-effective in targeting and preventing the spread of HIV in these populations (Stall and van Griensven 2005).
Considerable levels of sexual risk behavior among HIV-positive MSM continue to be reported in both epidemiological and behavioral studies (Parsons et al. 2003, 2005b; Semple et al. 2000, 2003). Research has shown rates of unprotected anal intercourse (UAI) among HIV-positive MSM ranging from 9 to 51% (Marks et al. 1999) along with increases in the incidence of gonorrhea and syphilis (CDC 2006). There is also evidence of an emerging subculture of barebacking, which is the intentional avoidance of condoms during anal sex (Halkitis et al. 2003; Sheon and Crosby 2004).
Most of the major theories in the field of HIV prevention, including the Health Belief Model (Janz and Becker 1984), the Taxonomy of Educational Objectives (Bloom et al. 1964), and Social Cognitive Theory (Bandura 1994), have relied on motivations of self interest in which HIV-negative MSM have an implicit desire to remain uninfected (Nimmons et al. 2000; Nimmons 1998). This self-interest paradigm, however, fails to adequately address prevention for HIV-positive MSM. An improved and more complete understanding of HIV-positive men's motivations to avoid risk behavior is needed in order to address the specific prevention needs of this population.
In the context of sexual risk behavior, both self-interest and altruism may play a role in the decision to practice safer sex. Some would argue that an act must involve self-sacrifice in order to qualify as altruistic. For example, Nimmons and Folkman (1999) have argued that condom use involves significant self-sacrifice, including decreasing tactile pleasure, potential loss of erection, lack of spontaneity, reduced sensation, and embarrassment. Due to these costs, they argue that the term altruism is in fact appropriate. On the other hand, Batson and Shaw (1991) have argued that altruism does not necessarily require self-sacrifice and can even involve self-benefit, as long as self-benefit is an unintended consequence and not the ultimate goal of the behavior. From this perspective, HIV-positive MSM who practice safer sex may receive some self-benefit from reducing their own risk for reinfection with HIV or other sexually transmitted infections, but their ultimate goal could be the protection of their sexual partner from HIV. Obviously, not all HIV-positive MSM engage in safer sex simply to protect others; indeed, some may be concerned only about self-benefit. For many men, however, a combination of other and self-centered motivations likely plays a role.
The term "prevention altruism," coined by Nimmons (1998), is defined as "the values, motivations, and practices of caretaking in one's sexual behavior, which arise out of a concern for others." This includes protecting one's sexual partner from disease and having a concern for the effects that HIV infection could have on a person's friends, family, or community. This altruistic concern for others, therefore, can directly affect the sexual behavior of MSM. This type of altruism is best attested to by the wealth of literature showing historically lower risk behavior among HIV-positive MSM after learning that they are HIV-positive (Coates et al. 1988; Dawson et al. 1991; Frazer et al. 1988; Higgins et al. 1991; McCusker et al. 1988; McCusick et al. 1990; van Griensven et al. 1988).
While significant attention has been paid to the risk factors leading to unprotected sex, protective factors have been understudied until recently. One protective factor receiving attention in the literature is personal responsibility. For example, a qualitative study of 250 HIV-positive MSM from New York and San Francisco found that nearly two-thirds of the participants attributed personal responsibility as the reason for their decision to protect their sexual partners from becoming infected with HIV (Wolitski et al. 2003). Based on their analysis, the authors identified altruism as one of the underlying motivations of personal responsibility. Subsequent data from other research has identified personal responsibility as a significant protective factor against serodiscordant unprotected anal intercourse (SDUAI) (Wolitski et al. 2004, 2006; van Kesteren et al. 2005). Therefore, a potential link between altruism, personal responsibility, and decreased SDUAI has been established.
In a qualitative study with 36 men of mixed HIV status from the New York and San Francisco areas, Nimmons and Folkman (1999) identified five themes, termed "other sensitive motivations" for safer sex. These included partner-related altruism, ethics and morality, perceived responsibility to the community, self-definition concepts, and extended relationship concerns. This research was extended into a quantitative study by Nimmons et al. (2000) that assessed the psychometric properties of a new scale titled Other-Sensitive Motivation, which included an altruism subscale. This study was the first quantitative investigation into other-sensitive motives for safer sex. The scale consisted of 145 items organized into subscales around the themes identified in the previous qualitative study. The overall composite scale was significantly associated with sexual safety in a sample of 102 gay men of mixed HIV status. Findings from these studies further support the need to investigate protective factors such as altruism.
The current article examines the relationship between HIV prevention altruism and sexual risk behavior in a sample of 637 HIV-positive MSM, predominately men of color, from six HIV epicenters in the US. We hypothesize that HIV prevention altruism will be significantly related to three dependent variables: avoidance of SDUAI; not engaging in anal intercourse; and greater serodisclosure to secondary (casual) sex partners. We selected these measures of sexual risk behavior because we hypothesize that highly altruistic men are more likely to utilize one or more of these strategies to prevent HIV transmission.
We also examined demographic variables, drug use, and compulsive sexual behavior, as prior studies have found these to be related to sexual risk behavior among HIV-positive MSM and because their relationship with HIV prevention altruism was unknown (Benotsch et al. 1999; Chen et al. 2003; Parsons et al. 2003, 2005a; Miner et al. 2007; O'Leary et al. 2005).
Abstract and Introduction
Abstract
An understanding of men's motivations to avoid risk behavior is needed to create efficacious HIV prevention programs for HIV-positive men who have sex with men (MSM). This study investigates the relationship between sexual risk behavior and HIV prevention altruism, which is defined as the values, motivations, and practices of caretaking towards one's sexual partners to prevent the transmission of HIV. In a sample of 637 HIV-positive MSM, HIV prevention altruism significantly protects against serodiscordant unprotected anal intercourse (SDUAI) in crude analysis, but not after adjustment for drug use and compulsive sexual behavior. HIV prevention altruism is also related to not engaging in anal intercourse, but is not related to serodisclosure to secondary partners. Lack of altruism appears related to sexual risk behavior in HIV-positive MSM, although other psychological and contextual factors play significant roles. The promotion of HIV prevention altruism may provide a formidable new direction for HIV prevention programs.
Introduction
HIV-positive persons are living longer lives as a result of improved treatment and care. As a result, the population of people with HIV who can potentially spread the virus to others has increased (CDC 2006). In response, the creation of effective HIV prevention programs for persons living with HIV has become a national priority. Both the National Institutes for Health (NIH 1997) and the Centers for Disease Control and Prevention (CDC 2003) have emphasized the urgent need for research and prevention programs that specifically target people living with HIV, especially in communities of men who have sex with men (MSM) and persons of color. Research answers are needed to guide prevention strategies to be more efficient, efficacious and cost-effective in targeting and preventing the spread of HIV in these populations (Stall and van Griensven 2005).
Considerable levels of sexual risk behavior among HIV-positive MSM continue to be reported in both epidemiological and behavioral studies (Parsons et al. 2003, 2005b; Semple et al. 2000, 2003). Research has shown rates of unprotected anal intercourse (UAI) among HIV-positive MSM ranging from 9 to 51% (Marks et al. 1999) along with increases in the incidence of gonorrhea and syphilis (CDC 2006). There is also evidence of an emerging subculture of barebacking, which is the intentional avoidance of condoms during anal sex (Halkitis et al. 2003; Sheon and Crosby 2004).
Most of the major theories in the field of HIV prevention, including the Health Belief Model (Janz and Becker 1984), the Taxonomy of Educational Objectives (Bloom et al. 1964), and Social Cognitive Theory (Bandura 1994), have relied on motivations of self interest in which HIV-negative MSM have an implicit desire to remain uninfected (Nimmons et al. 2000; Nimmons 1998). This self-interest paradigm, however, fails to adequately address prevention for HIV-positive MSM. An improved and more complete understanding of HIV-positive men's motivations to avoid risk behavior is needed in order to address the specific prevention needs of this population.
In the context of sexual risk behavior, both self-interest and altruism may play a role in the decision to practice safer sex. Some would argue that an act must involve self-sacrifice in order to qualify as altruistic. For example, Nimmons and Folkman (1999) have argued that condom use involves significant self-sacrifice, including decreasing tactile pleasure, potential loss of erection, lack of spontaneity, reduced sensation, and embarrassment. Due to these costs, they argue that the term altruism is in fact appropriate. On the other hand, Batson and Shaw (1991) have argued that altruism does not necessarily require self-sacrifice and can even involve self-benefit, as long as self-benefit is an unintended consequence and not the ultimate goal of the behavior. From this perspective, HIV-positive MSM who practice safer sex may receive some self-benefit from reducing their own risk for reinfection with HIV or other sexually transmitted infections, but their ultimate goal could be the protection of their sexual partner from HIV. Obviously, not all HIV-positive MSM engage in safer sex simply to protect others; indeed, some may be concerned only about self-benefit. For many men, however, a combination of other and self-centered motivations likely plays a role.
The term "prevention altruism," coined by Nimmons (1998), is defined as "the values, motivations, and practices of caretaking in one's sexual behavior, which arise out of a concern for others." This includes protecting one's sexual partner from disease and having a concern for the effects that HIV infection could have on a person's friends, family, or community. This altruistic concern for others, therefore, can directly affect the sexual behavior of MSM. This type of altruism is best attested to by the wealth of literature showing historically lower risk behavior among HIV-positive MSM after learning that they are HIV-positive (Coates et al. 1988; Dawson et al. 1991; Frazer et al. 1988; Higgins et al. 1991; McCusker et al. 1988; McCusick et al. 1990; van Griensven et al. 1988).
While significant attention has been paid to the risk factors leading to unprotected sex, protective factors have been understudied until recently. One protective factor receiving attention in the literature is personal responsibility. For example, a qualitative study of 250 HIV-positive MSM from New York and San Francisco found that nearly two-thirds of the participants attributed personal responsibility as the reason for their decision to protect their sexual partners from becoming infected with HIV (Wolitski et al. 2003). Based on their analysis, the authors identified altruism as one of the underlying motivations of personal responsibility. Subsequent data from other research has identified personal responsibility as a significant protective factor against serodiscordant unprotected anal intercourse (SDUAI) (Wolitski et al. 2004, 2006; van Kesteren et al. 2005). Therefore, a potential link between altruism, personal responsibility, and decreased SDUAI has been established.
In a qualitative study with 36 men of mixed HIV status from the New York and San Francisco areas, Nimmons and Folkman (1999) identified five themes, termed "other sensitive motivations" for safer sex. These included partner-related altruism, ethics and morality, perceived responsibility to the community, self-definition concepts, and extended relationship concerns. This research was extended into a quantitative study by Nimmons et al. (2000) that assessed the psychometric properties of a new scale titled Other-Sensitive Motivation, which included an altruism subscale. This study was the first quantitative investigation into other-sensitive motives for safer sex. The scale consisted of 145 items organized into subscales around the themes identified in the previous qualitative study. The overall composite scale was significantly associated with sexual safety in a sample of 102 gay men of mixed HIV status. Findings from these studies further support the need to investigate protective factors such as altruism.
The current article examines the relationship between HIV prevention altruism and sexual risk behavior in a sample of 637 HIV-positive MSM, predominately men of color, from six HIV epicenters in the US. We hypothesize that HIV prevention altruism will be significantly related to three dependent variables: avoidance of SDUAI; not engaging in anal intercourse; and greater serodisclosure to secondary (casual) sex partners. We selected these measures of sexual risk behavior because we hypothesize that highly altruistic men are more likely to utilize one or more of these strategies to prevent HIV transmission.
We also examined demographic variables, drug use, and compulsive sexual behavior, as prior studies have found these to be related to sexual risk behavior among HIV-positive MSM and because their relationship with HIV prevention altruism was unknown (Benotsch et al. 1999; Chen et al. 2003; Parsons et al. 2003, 2005a; Miner et al. 2007; O'Leary et al. 2005).
Source...