Many gay male couples make agreements about whether or not to permit sex with outside partners, yet little is known about the development and maintenance of these agreements, their impact on relationships, and whether they are an effective HIV prevention strategy. Using semi-structured, qualitative interviews, 39 gay male couples were asked about their sexual agreements and about other relationship dynamics that might affect their agreements. Analysis revealed a wide range of agreement types, all of which are presented along a continuum rather than as discrete categories. For couples with open agreements, most placed rules or conditions limiting when, where, how often, and with whom outside sex was permitted. Although motivations for having agreements varied, HIV prevention did not rank as a primary factor for any couple. Most couples had congruous agreements; however, a small number reported discrepancies which may increase HIV transmission risk. How couples handled breaks in their agreements also varied, depending on what condition was broken, whether it was disclosed, and the partner's reaction. Additional results include differences in agreement type and motivations for having an agreement based on couple serostatus. Overall, agreements benefited couples by providing boundaries for the relationship, supporting a non-heteronormative identity, and fulfilling the sexual needs of the couple. Future prevention efforts involving gay couples must address the range of agreement types and the meanings couples ascribe to them, in addition to tempering safety messages with the relationship issues that are important to and faced by gay couples.

Overall, evidence for harm reduction was identified; however, significant differences across the two cities were found. The complicated nature of the sexual practices of gay and bisexual men are discussed, and the findings have important implications for prevention efforts and future research studies.

Gay men in relationships are often overlooked in HIV prevention efforts, yet many engage in sexual behaviors that increase their HIV risk and some seroconvert as a result. While different aspects of gay male relationships have been studied, such as sexual agreements, relationship characteristics, and couple serostatus, little research combines these elements to examine HIV risk for this population. The present study recruited 566 gay male couples from the San Francisco Bay Area to study their sexual agreements, motivations behind making agreements, and other relationship characteristics, such as agreement investment, relationship satisfaction, intimacy, and communication. Participants rated their level of concurrence with a set of reasons for making their agreements. They were also measured on relationship characteristics using standard instruments. Analyses were conducted by agreement type (monogamous, open, discrepant) and couple serostatus (concordant negative, concordant positive, discordant). A majority reported explicitly discussing their agreements and nearly equal numbers reported being in monogamous and open relationships. A small number (8%) reported discrepant agreements. Across all agreement type and serostatus groups, HIV prevention as a motivator for agreements fell behind every motivator oriented toward relationship-based factors. Only concordant negative couples endorsed HIV and STD prevention among their top motivators for making an agreement. Mean scores on several relationship characteristics varied significantly. Couples with monogamous agreements had higher scores on most relationship characteristics, although there was no difference in relationship satisfaction between couples with monogamous and open agreements. Scores for concordant positive couples were distinctly lower compared to concordant negative and discordant couples. Agreements, the motivations behind them, and the relationship characteristics associated with them are an important part of gay male relationships. When examined by agreement type and couple serostatus, important differences emerge that must be taken into account to improve the effectiveness of future HIV prevention efforts with gay couples.

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Objectives-Evaluate the efficacy of skills training designed to increase female condom use among women.Methods-A randomized trial of 409 women, recruited from family planning clinics in northern California, randomly assigned to the experimental 4-session female condom skills training intervention or the comparison 4-session women's general health promotion intervention. Participants received condom use instructions at baseline and male and female condoms during the study. They completed audio computer-assisted self-interviews at baseline, 3, and 6 months.Results-At 3 and 6 months, women in the experimental group were more likely than those in the comparison group to have used the female condom at least once in the prior 3 months. The increase in the percentage of sex acts protected by female condoms from baseline to the 6-month follow-up was greater for the experimental group. The percentage of sex acts protected by any condom was higher in the experimental group at 6 months. There were no group differences in male condom use.Conclusions-Outcomes suggest that skills training can increase female condom use and protected sex acts without reducing male condom use among women.

Understanding situations that increase HIV risk among men who have sex with men (MSM) requires consideration of the context in which risky behaviors occur. Relationships are one such context. This study examines the presence and predictors of unprotected anal intercourse (UAI) in the past 3 months among 566 MSM couples. A majority of couples allowed sex with outside partners. Overall, 65% of the sample engaged in UAI with primary partner, including nearly half of discordant couples. Positive relationship factors, such as attachment and intimacy, were associated with an increased likelihood of UAI with primary partner. Meanwhile, 22% of the sample engaged in at least one episode of UAI with an outside partner, half of whom were discordant or unknown HIV status outside partners. Higher levels of HIV-specific social support, equality, and sexual agreement investment were significantly associated with a decreased likelihood of engaging in UAI with a discordant or unknown HIV status outside partner. HIV-positive men in discordant relationships had two and one half times the odds of having UAI with a discordant or unknown HIV status outside partner as their HIVnegative partners. Many MSM in relationships, including some in serodiscordant ones, engage in UAI with primary partners. Potential explanations include relationship closeness, relationship length, and agreement type. In addition, relationship context appears to have a differential impact upon UAI with primary and outside partners, implying that prevention messages may need to be tailored for different types of couples. Prevention efforts involving MSM couples must take into account relationship characteristics as couples balance safer sex and HIV risk with intimacy and pleasure.

This paper describes agreements gay male couples make about sex outside the relationship and how the process of making those agreements, and their perceived quality, varies depending on couple serostatus. Data include 191 couples recruited in the San Francisco Bay Area from June to December, 2004. Monogamous agreements were reported by 56% of participants in concordant negative, 47% in concordant positive, and 36% in discordant relationships. The remaining participants reported agreements allowing sex with outside partners in some form. Agreement quality was lowest among men in discordant relationships. Overall, few (30%) reported breaking their agreements; only half of whom reported disclosing those breaks to their partners. Although differences in agreement type, quality, and satisfaction were found among the three couple serostatus groups, rates of breaks and their disclosure did not vary significantly by group. Future HIV prevention efforts aimed at couples must integrate both couple serostatus and relationship-based issues. Keywordsgay male couples; HIV prevention; sexual agreements; relationship factors Over the past two decades gay men in the U.S. have been decimated by the AIDS epidemic. New infections continue to occur among gay men in San Francisco and nationally (MMWR, 2008,). For example, estimated HIV prevalence in San Francisco increased from 19.6% in 1997 to 26.8% in 2002(Osmond, Pollack, Paul, & Catania, 2007 suggesting that current HIV prevention efforts fall one step behind the pace of the HIV epidemic. As the epidemic continues, the scope of prevention efforts needs to expand to address important interpersonal issues that may contribute to HIV risk among gay men. To address this gap, we investigated the types of agreements that gay male couples make about sex with each other, whether or not they allow sex with outside partners, and how these agreements vary by couple serostatus. We also examined the quality of these agreements, and whether or not they were broken. Understanding that many gay men make sexual decisions in the context of a relationship is necessary to inform future prevention efforts with gay men.Throughout the epidemic, the majority of HIV prevention efforts targeting gay men have focused on the individual. These efforts have been guided by several theories of behavior change including: the health belief model (Becker, 1974;Janz & Becker, 1984), the AIDS Risk Reduction Model (Catania, Kegeles, & Coates, 1990) Harlow, Rossi, & Velicer, 1994), and the Theory of Reasoned Action (Fishbein & Ajzen, 1975). Prevention approaches guided by individual-focused theories of behavior change have successfully reduced HIV risk (Kalichman et al., 2001;Kelly & Kalichman, 2002;Stall, Hays, Waldo, Ekstrand, & McFarland, 2000).However, while most prevention efforts were based on the individual's levels of change, the proportion of HIV infections attributed to primary partners rose from 15% in the mid-1980s to 67% in the late 1990s (Davidovich et al., 2001). Another study reported that 27%...

Barebacking and its corresponding behaviors pose immediate public health risks for HIV-positive gay and bisexual men. Further work is needed to understand this phenomenon more fully in relation to the psychological, sociological, biomedical, and cultural realities.