September 24, 2019 - Editorial: 2019 National Gay Men's HIV/AIDS Awareness Day
About the Author
Editorial by Tyrel Starks, PhD, project lead on ATN 156, We Test. Dr. Starks is an Associate Professor of Psychology at Hunter College CUNY.
National Gay Men's HIV/AIDS Awareness Day is Friday, September 27, 2019.
In honor of National Gay Men's HIV/AIDS Awareness Day, I want to take an opportunity to reflect on the uniqueness of HIV prevention and sexual health. Outside the context of masturbation, sex is an interpersonal act. It is a thing we do WITH someone, and it is therefore both personal and relational.
Growing up in the 90s and going to college in the 2000s, concerned and knowledgeable health professionals talked to me about HIV prevention as though condoms were an individual health behavior. They belonged in the list of things I ought to do to take care of myself, like flossing, going to the gym, and getting a good night’s sleep. The trouble was, when it came to actually having sex, condoms got mixed up with the thrill (and sometimes the terror) of being close, connecting with someone, and not being alone. Somehow, flossing seemed less complicated.
I began my career in HIV related behavioral health in 2009. That year, a pivotal paper by Patrick Sullivan and colleagues (Sullivan, Salazar, Buchbinder, & Sanchez, 2009) changed the national conversation about HIV prevention by indicating that as many as 68% of new HIV infections among sexual minority men (SMM) are transmitted between people who think of themselves as main - not casual partners.
In the decade that has passed, a cadre of researchers has built upon that work. Thanks to work on attachment (Starks & Parsons, 2014) and rejection sensitivity (Pachankis, Goldfried, & Ramrattan, 2008), we know that SMM who believe that they are not desirable or lovable, and those who believe that others are unsafe and cannot be trusted, are more vulnerable to making decisions that place them at risk for HIV infection. At least some SMM worry that using a condom (Goldenberg, Finneran, Andes, & Stephenson, 2015; Golub, Starks, Payton, & Parsons, 2012) or going on PrEP (Malone et al., 2018; Starks, Doyle, Shalhav, John, & Parsons, 2019) will convey to a partner that they do not trust them, that they are not committed to the relationship, or that they are promiscuous. No one worries about those things when they decide to floss.
The salience of relationships for HIV prevention is even greater among younger people. Developmentally, adolescence and emerging adulthood is the time when young people begin to define themselves sexually. Peer and romantic relationships take on more potent meaning and they move towards lives that are in many cases more independent of the families they grew up in. In their original study, Sullivan et al. estimated that as many as 79% of new HIV infections among their youngest cohort (emerging adults 18-29) were transmitted between main partners.
Because communication and other relationship skills are just emerging, adolescents and emerging adults may be less prepared to convey their feelings, preferences, and desires to a partner. Concerns about or experiences of rejection may be even more salient when people have limited previous experience to draw upon. Even though the visibility of LGBTQ people, and same-gender couples, has increased substantially, there are still relatively few models of what healthy relationships look like.
For these reasons, the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) is funding studies focused on HIV prevention with SMM relationships. One of these, We Test, ATN-156 (Starks, Feldstein Ewing, et al., 2019), is supported by the Scale It Up U19. The We Test intervention builds upon Couples HIV Testing and Counseling (CHTC) (Grabbe, Bachanas, Moore, Rogers, & Fenley, 2012; Stephenson, Grabbe, Sidibe, McWilliams, & Sullivan, 2016; World Health Organization, 2012).
CHTC is an evidence based intervention, which is available through CDC. During CHTC, couples discuss their relationship, their current HIV prevention practices, and establish a sexual agreement (or rules and boundaries about what kinds of sexual behaviors are allowable within and outside of their relationship). They also learn their HIV status together and develop a plan to prevent HIV together going forward.
CHTC was developed for adults. We Test seeks to integrate relationship skill building and tailor the intervention so that adolescents can participate successfully with their partners. This project seeks to facilitate the development of relationship skills that adolescents can carry with them into future relationships. We Test utilizes video-based modeling of communication skills and Motivational Interviewing to help youth clarify their sexual health goals and develop a plan to communicate with their partner.
Over the past decade, it has become increasingly clear that we cannot fully address the HIV epidemic in the U.S. without thinking about relationships. The team at We Test and Scale It Up are pleased to be two parts of that larger effort to think about sex as both a personal and a relational activity.
List of Article Sources:
Goldenberg, T., Finneran, C., Andes, K. L., & Stephenson, R. (2015). "Sometimes people let love conquer them": How love, intimacy, and trust in relationships between men who have sex with men influence perceptions of sexual risk and sexual decision-making. Cult Health Sex, 17(5), 607-622. doi:https://doi.org/10.1080/13691058.2014.979884
Golub, S. A., Starks, T. J., Payton, G., & Parsons, J. T. (2012). The critical role of intimacy in the sexual risk behaviors of gay and bisexual men. AIDS and Behavior, 16(3), 626-632.
Grabbe, K., Bachanas, P., Moore, J., Rogers, M. F., & Fenley, M. A. (2012). Couples HIV Testing and Counseling (CHTC) in health care facilities: Trainers Manual.
Malone, J., Syvertsen, J. L., Johnson, B. E., Mimiaga, M. J., Mayer, K. H., & Bazzi, A. R. (2018). Negotiating sexual safety in the era of biomedical HIV prevention: relationship dynamics among male couples using pre-exposure prophylaxis. Culture Health & Sexuality, 20(6), 658-672. doi:10.1080/13691058.2017.1368711
Pachankis, J. E., Goldfried, M. R., & Ramrattan, M. E. (2008). Extension of the rejection sensitivity construct to the interpersonal functioning of gay men. Journal of Consulting and Clinical Psychology, 76(2), 306-317. doi:10.1037/0022-006x.76.2.306
Starks, T. J., Doyle, K. M., Shalhav, O., John, S. A., & Parsons, J. T. (2019). An examination of gay couples’ motivations to use (or forego) pre-exposure prophylaxis expressed during couples HIV testing and counseling (CHTC) sessions. Prevention Science, 20(1), 157-167.
Starks, T. J., Feldstein Ewing, S. W., Lovejoy, T., Gurung, S., Cain, D., Fan, C. A., . . . Parsons, J. T. (2019). Adolescent Male Couples-Based HIV Testing Intervention (We Test): Protocol for a Type 1, Hybrid Implementation-Effectiveness Trial. JMIR Res Protoc, 8(6), e11186. doi:10.2196/11186
Starks, T. J., & Parsons, J. T. (2014). Adult attachment among partnered gay men: Patterns and associations with sexual relationship quality. Archives of Sexual Behavior, 43(1), 107-117.
Stephenson, R., Grabbe, K. L., Sidibe, T., McWilliams, A., & Sullivan, P. S. (2016). Technical assistance needs for successful implementation of couples HIV testing and counseling (CHTC) intervention for male couples at US HIV testing sites. AIDS and Behavior, 20, 841-847.
Sullivan, P. S., Salazar, L., Buchbinder, S., & Sanchez, T. H. (2009). Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities. AIDS, 23(9), 1153-1162.
World Health Organization. (2012). Guidance on couples HIV testing and counseling including antiretroviral therapy for treatment and prevention in serodiscordant couples: Recommendations for a public health approach. Retrieved from ISBN 978 92 4 150197 2