Opportunities for HIV Prevention Communication During Sexual Encounters with Black Men Who Have Sex with Men

Abstract

Conversations about HIV prevention before engaging in sex may result in safer sex practices and decreased HIV transmission. However, partner communication for HIV prevention has been understudied among black/African American men who have sex with men (BMSM), a group that is disproportionately affected by HIV. We explored and described encounters and perceptions about HIV prevention conversations among BMSM and their sex partner(s) in New York City. We conducted an inductive thematic analysis of semi-structured interviews with BMSM who reported sex with a man in the previous 3 months. Interviews were professionally transcribed; Nvivo was used for data analysis. Twenty-two BMSM were included in this analysis; median age = 29.1 years; 71.4% self-identified as MSM; 85.7% were ever HIV tested; and 52.6% reported no disclosure or discussion about HIV status with their previous sex partner. The main themes were: (1) missed opportunities for HIV prevention conversations (e.g., no HIV prevention conversations or HIV prevention conversations after sex had occurred); (2) barriers to HIV prevention conversations (e.g., being in the moment; not wanting to pause); (3) emotional thoughts after sex (e.g., feeling worried about possible HIV exposure); and (4) rethinking relationships and sexual health (e.g., changed sex practices by asking partners' HIV status before sex; started using condoms). These findings offer insight into HIV prevention conversations by BMSM around the time of or during sexual encounters and may inform and strengthen partner-level HIV prevention communication interventions for BMSM.

Introduction

Men who have sex with men (MSM) bear a disproportionate burden of HIV infection in the United States, comprising 67% of HIV diagnoses in 2014,¹ although they comprise just 2% of the US population.² In 2014, black/African American (hereafter referred to as “black”) and Hispanic/Latino MSM comprised 64.1% of diagnoses of HIV infection among all MSM diagnosed in the United States,¹ with black, Hispanic/Latino, and non-Hispanic white comprising 37.6%, 26.5%, and 30.3%, respectively. MSM of color represent a key group for whom increased, effective HIV prevention intervention strategies are vital as part of national HIV prevention efforts.³

Communication between sex partners has been shown to be an important strategy for HIV prevention⁴; however, little research has been conducted in interpersonal safer sex conversations for MSM. Research indicates that safer sex conversation topic areas should include HIV status, safer sex behaviors, and condom use persuasion,^5,6 especially for black and Hispanic/Latino MSM disproportionately affected by HIV.¹ In a sample of online MSM, direct communication between partners regarding condom use during anal sex was associated with lower risk of condomless anal sex in both online and offline partners.⁴ Similarly, a study of individuals living with HIV revealed that participants with high levels of sexual communication were less likely to have condomless sex with all partners as well as with partners of unknown or HIV-negative serostatus.⁷ This research indicates the influence of partner sexual communication on safer sex practices. Some partner communication data have shown increased safer sex behaviors with mostly heterosexual partners,^7
–9 whereas data for MSM partner communications have been understudied, particularly for MSM of color.

Our objective for this study was to better understand the role of context in sex partner communications. To meet this objective, we explored and described encounters and perceptions about engaging sex partners in HIV prevention conversations among black/African American men who have sex with men (BMSM) in New York City (NYC). These data are important to better understand partner-level prevention communication and to inform public health communication interventions that are aimed at MSM of color.

Methods

Data were collected from spring 2011 through summer 2012 as part of a larger study (Project BROTHA) that explored the relationship between interpersonal communication about HIV prevention and HIV testing among adult BMSM and other MSM in their social networks (aged 18–64 years) in the NYC area (Nanin, Bamonte, Botsko, Golub, & Parsons, 2013).¹⁰ The study was conducted in NYC, led by the Center for HIV Educational Studies and Training (CHEST) in partnership with Gay Men of African Descent (GMAD), a trusted local, community-based organization that offers services for gay-identified/same-gender loving men of color.

A purposive sampling strategy was used to recruit BMSM. The research team used structured outreach recruitment that combined active and passive strategies both online and offline (e.g., banner ads on websites, such as Adam 4 Adam, Manhunt.com, and online chat room postings; distribution of palm cards with study contact information at community events and venues). Eligible participants were men who were: born male, aged 18–64 years, reported sex with a man at least once within the previous 3 months, had no HIV antibody test within the previous year, were able to communicate in English, and were able to identify two other MSM from their social network. By targeting BMSM who had not had an HIV test in the past year, we hoped to enroll MSM who may have benefitted from the HIV testing that was offered as part of Project BROTHA, and we wanted to understand more about HIV testing facilitators and barriers for this group. In addition, we used respondent-driven sampling (RDS), a network-based recruitment method.¹¹ For our RDS, briefly, the first 50 MSM enrolled into the study were allowed to invite MSM from within their social networks, including friends, peers, and sex partners for further recruitment of MSM into the study.

After signed consent, participants were enrolled and completed an Audio Computer-Assisted Self-Interview (ACASI) survey that obtained demographic information (e.g., age, sexual identity, educational background) and assessed psychosocial and behavioral issues. After the survey, all participants were invited to complete a 45–75 min semi-structured interview. Sample interview questions included, “Please tell me about the last time you felt like a conversation about HIV prevention should have occurred with a friend, peer, or sexual partner, but did not”; “Who is/was this person to you?”; “What do you think are some of the reasons why this conversation did not take place?” For this subanalysis, we focused on interview narratives that were responsive regarding HIV prevention communications during or near sexual encounters and were available through August 2015. On completion of the survey and interview, participants were reimbursed $60 for their time and effort. The study protocol was reviewed and approved by the Kingsborough Community College and Hunter College Institutional Review Boards.

Data analysis

We coded 22 interviews and reached analytical saturation (no new insights or categories). An applied thematic data analysis was utilized to explore encounters and perceptions about engaging sex partners in HIV prevention conversations among BMSM in NYC; only interviews that described a missed opportunity with a sex partner were included in the analysis. The interviews were audiotaped and transcribed verbatim through an electronic transcription service. NVivo (QSR International Pty Ltd. Version 10, 2012) was used to assist in coding, developing categories, themes, and retrieving coded data. SPSS 21 software was used for descriptive analyses.

Two qualitative data analysts (T.A. and K.D.) thoroughly read each transcript and created an emergent data-driven code list.¹² The analysts then compared their code lists, presented the coding schema to a senior member of the research team (M.Y.S.), discussed discrepancies, and created a preliminary content codebook. To ensure coding consistency, analysts independently coded each transcript and assessed inter-coder reliability for 80% of the transcripts using Cohen's kappa measure.¹³ We reviewed and discussed codes with a kappa score less than 0.80 until a consensus was reached. Text segments were recoded as necessary, and the codebook was finalized. Salient and co-occurring concepts, as in relevant concepts that emerged throughout the interviews, were identified and organized into thematic categories. Because our sample included 22 participants, some comments with important content that were mentioned by ≥3 participants during the interviews resonated as themes.

Results

Characteristics of the participants

Twenty-two semi-structured interviews addressed the research question and were available for analysis; 95.2% of participants identified as black; and ages ranged from 21 to 64 years (median age 29.1 years). Nearly three-fourths of the participants self-identified as homosexual/gay; 28.6% identified as bisexual. Participants were educated, with 76.7% reporting some college education or higher. However, 47.6% were unemployed, with an income less than $30,000. Regarding HIV testing history, 85.7% of participants reported ever being tested; among those, 76.2% received a negative test result at their most recent HIV test. Regarding disclosure, 52.4% of participants reported that they neither disclosed nor discussed HIV status with their previous sex partner. When offered an HIV test as part of the main study, 9 of 22 (42.9%) agreed to the test; 2 of 9 (22%) tested HIV positive and were properly connected with medical professionals for follow-up care and treatment. Detailed demographics of the study participants are included in Table 1.

Table 1.

Demographic Variables, HIV Testing History, and HIV Serostatus Disclosure Among Men Enrolled in Project BROTHA, 2011–2012 (n = 22) ^a

Demographic variables	n	%
Race/ethnicity
Black/African American	20	95.2
Hispanic	1	4.8
Age group
29 years or younger	11	52.4
30 years or older	10	47.6
Sexual orientation
Homosexual/gay	15	71.4
Bisexual	6	28.6
Education
High school or less	7	33.3
Some college	9	42.9
Bachelor's degree or higher	5	23.8
Employment status
Unemployed	10	47.6
Employed full time	4	19.0
Employed part time	7	33.3
Household income
<$30,000	11	52.4
≥$30,000	10	47.6
Missing	1
Ever been tested for HIV
Yes	18	85.7
Most recent HIV test result
Negative	16	76.2
Did not get results/indeterminate	2	9.5
Disclosed HIV status to previous sex partner
No	10	47.6
Yes	11	52.4
Previous sex partner disclosed their HIV status
No	10	47.6
Yes	11	52.4
HIV testing at baseline
Did not test	12	57.1
Tested	9	42.9
Baseline HIV test results
Negative	7	33.3
Positive	2	9.5
Did not test	12	57.1

Demographic data total 21, because one participant's data were missing for these responses due to a technological malfunction of the computer questionnaire.

Four main themes emerged to identify BMSMs encounters and perceptions regarding missed opportunities for HIV prevention conversations during sexual encounters or emotional intimacy: (1) missed opportunities for HIV prevention conversations; (2) barriers to HIV prevention conversations; (3) emotional thoughts after sex; and (4) rethinking relationships and sexual health practices. Exemplars from the transcripts are used to illustrate the associated theme and subthemes.

Missed opportunities for HIV prevention conversations

Participants' narratives conveyed three types of conversations that did not occur before sex, foreplay, or becoming emotionally involved: HIV testing or HIV status, condom use before sex, or general HIV prevention conversations (HPC) (i.e., safer sex, HIV status, or condom use); 17 of 22 indicated general HIV prevention conversations. Twenty-one of 22 narratives involved the participant with a non-main partner, and nearly one-third reported the use of substances (e.g., alcohol). Participants were categorized as having a missed opportunity (hindsight) encounter, an after-the-sex act (delayed) encounter, or both depending on the context of their narratives; only two participants shared situations that were considered appropriate for both groups (see Table 2 for group assignment).

Table 2.

Frequency of Main Themes and Subthemes ^a Regarding Sexual Health Communications Near the Time of Sex, Project BROTHA, 2011–2012

	Delayed ^b	Hindsight ^c
Theme 1: missed opportunities/after the act
Subtheme 1: missed conversations: general HIV prevention conversations	3	14
Subtheme 2: missed conversations: discuss testing or status	6	6
Subtheme 3: missed conversations: condom use during sex	3	5
Theme 2: barriers to HIV prevention communication
Subtheme 1: heat of the moment	4	9
Subtheme 2: could spoil the mood	2	4
Subtheme 3: substance use	1	4
Subtheme 4: assumptions	1	2
Theme 3: emotional afterthought
Subtheme 1: emotional distress	4	5
Subtheme 2: reassured & relieved	3	0
Theme 4: rethinking relationships and sexual health
Subtheme 1: relationship dissolved	2	3
Subtheme 2: changed sexual health practices	3	4
Subtheme 3: wake up call	2	3

Focus group subthemes are not mutually exclusive.

“Delayed” was defined as when discussions about testing and HIV status that should have occurred with their sex partner before engaging in sex, instead, occurred after sex.

“Hindsight” was defined as when HIV prevention conversations never occurred with their partners, before or after sex, or they perceived their conversations as vague.

Hindsight

Seventeen participants (77%) recounted hindsight situations; HIV prevention conversations never occurred with their partners, before or after sex, or they perceived their conversations as vague. One participant admitted that he had never engaged his partners in HIV prevention conversations: “This is terrible!! I don't think I've ever had a conversation with a sex partner!” (H052, 26y, Gay). Another participant shared, “…you know they be having ads on craigslist… you meet up with people and have sex with them…We just had unprotected sex and we didn't discuss our status with each other…I feel like that was not a good idea” (H041, 26y, Gay).

A few participants spoke candidly about the risk involved with such encounters: “…fucking someone and ripping …their inside walls and then…just pulling out and seeing there's blood and stick it back in. I did that when I was really drunk and that wasn't- I don't think that was really cool…” (H116, 41y, gay). Although most did not have any conversations, two described, in hindsight, their conversations as insufficient as illustrated in the following quote: “This guy-I didn't know much about him, I actually met him online, and we should-the conversation we had was small. We should have had a much larger conversation about it” (H067, 21y, Gay).

Delayed

Among participants with delayed conversations, discussions about testing and HIV status that should have occurred with their sex partner before engaging in sex, instead, occurred after sex. Eight of the 22 participants recalled situations where HIV prevention conversations occurred after they were already emotionally or sexually involved. One participant shared how he and his partner had never had a discussion about their HIV status until watching a TV show that touched on the topic:

…it was me and one of my partners, we was just in the crib, we watched some TV show on TV and the topic of HIV was on the show and then we discussed it…he asked me the last time I was tested and I told him, I said, “just a few months ago.” [He said] “So, you got the results?” “Yeah, I got them somewhere in my apartment.” And then I think like, a few weeks after that we showed each other each other's results and that was about it… Yeah. Never had a conversation… (D122, 37y, Bi)

In half of the delayed narratives (n = 4), the sex partners later (i.e., post-sexual encounter) disclosed that they were HIV positive. However, three of the four participants reported using a condom during anal sex that had already occurred. One participant shared the following account of his delayed encounter:

I met this guy…we kicked it for a couple of days, almost a week and then we wound up sleeping together…he turned out to be, he was HIV positive…but he never told me.….we used condoms while it was going on, it wasn't oral or anything… And, I think it was almost a week after that, we were sittin’ there, talkin’, and he was like, “ya know I told you I was HIV positive, right?” And I was like, “No you didn't, like [laughing] you didn't.” (D002, 24y, Gay)

Barriers to HIV prevention conversations

When probed about the reasons that HIV prevention conversations did not occur before sex or emotional intimacy, participants in both groups provided various examples of barriers to engaging their sex partners in HIV prevention conversations. These barriers can be organized into four sub-themes: (1) in the moment, (2) spoil the mood, (3) substance use, and (4) assumptions.

In the moment

The most salient barrier mentioned among participants in both groups was being in the moment (n = 13). This concept was best typified by their frequent reference to being “horny.” One participant shared, “…it wasn't in the plan. So….it just happened…I was enjoyin’ it… I didn't, I seen what was goin’ on. I just didn't stop it. I coulda stopped it. Just caught up in the moment. Cross your fingers.” (D021, 33, Bi) Another participant shared a similar response,

I mean he was attractive, he was attracted to me, and we did what we had to do. In the back of my car. We should have spoke about it but in the spur of the moment…So the conversation never got to- I know it's dumb and everything but, uh, there was no time for discussion. (H103, 37y, bi)

Spoil the mood

For six participants, broaching the topic of HIV prevention before sex was perceived as having a negative undertone that could damper the prospect of sexual relations. One participant stated, “The only reason it hasn't come up… I don't want to like, take the mood out the situation and then, they're like, ‘Oh, we came over here to do this, what the hell we talking about this for?’” (H031, 26y, Gay).

Similarly, it was implied that certain settings are not conducive to conversations about HIV prevention, as illustrated in the following exchange:

I: Do you feel that some of the sex parties are, could be an example of a place where maybe a conversation should be had about HIV?

R: No

I: Ok. How come?

R: It's for one, it is too dark in there and I don't think that people go for conversations of any type of way like that. They just come to get their groove on or their sex on, and that's it.

I: Ok, so not necessarily the most opportune time?

R: Right. That wouldn't be the opportune time, not even for me.

I: Ok.

R: (laugh) I would be turned off if someone asks me something like that.

I: I'm curious. Why would that turn you off?

R: Because I would wonder if they're trying to let me know that they have something and then I think that will be a way of trying to open doors to tell me that they have something. And do I really wanna hear it? You know? I don't know if I wanna hear it. I don't know for sure. (H059, 44y, Gay)

Substance use

Five participants referenced the use of substances (e.g., alcohol, marijuana, or recreational drugs) as a major hindrance to them being able to hold constructive conversations about HIV prevention. One participant noted, “…we were both drunk. We couldn't sit and talk about HIV prevention while we're drunk.” (H055, 21y, Gay)

Another participant shared a similar sentiment, “…we'll be so intoxicated, to where it be, we don't talk about…nothing that is really like meaningful. Everything is surface stuff. You know what I mean? We not going underneath and hitting stuff. For real, so that's why.” (D040, 38y, Bi)

Assumptions

Three participants described situations that alluded to a low perception of risk as a barrier to HIV prevention conversations. One participant shared how he assumed that a younger partner would pose less risk: “…because I was thinking like, ‘Oh he's young and he probably didn't get it.’ We used a condom, but I should have asked anyway.” (H056, 21y, Gay)

In contrast, there was the assumption that a partner with HIV would be upfront about disclosing his status before any sexual activity transpired:

“Because I kind of assumed that if somebody was positive they would have said something because it's like—really, if somebody's HIV positive it doesn't mean…you can still have sex with them as long as you protect yourself. And it would have been better because now you,…you would have fully protected yourself.” (H/D039, 24y, Gay)

Emotional thoughts after sex

Emotional distress

As participants (n = 9) reflected on their sexual encounters related to missed opportunities and the risks involved (e.g., condomless sex; sex with a person whose status is unknown), they expressed feelings of emotional distress such as being “worried,” “scared,” or “upset.” One participant recalled the mixed emotions felt when he thought that his then-female sex partner may have been exposed to HIV from one of her former sex partners:

I: Ok, so how did you feel about having this conversation with her?

R: Um at the time I was, I was dealing with mixed feelings.

I: OK. Mixed, why?

R: Why? Because I was …I wasn't happy we had it, I was glad we had it, but then I was also, I don't know man,…. I was like I'm glad the information was out there, I'm glad she told me that, but then I was…I was upset, I don't know why, I was nervous, I was scared… ‘cause now she telling me that she dealing with somebody who has AIDS but now she don't got it. So that's like impossible. You know what I mean? That's what I'm thinking about. Bitch, that's impossible. You know what I mean? And I don't even know your status. (D040, 38y, Bi)

Another participant described the rage he felt after learning that his main partner was positive:

Well my ex-fiancé he didn't tell me he was positive.… when we broke up he's like “yeah, that's why I fucked you with no condoms, ‘cause I'm HIV-positive.” I was like “Oh shit.” Oh yeah, I got his ass back because I pistol whipped his ass. I'm sorry, that was like the gangster in me coming out. (D053, 22y, Gay)

Relieved and reassurance

For men who used a condom during the sexual encounter yet later learned “after the sex act” that their sex partner was HIV positive (n = 3), there was a sense of relief and reassurance that they did not become exposed to HIV. One participant described the reassurance he felt after running out of condoms with a sex partner he met at the park:

I ran out of condoms…, “oh can we just do a little this, a little that,” “oh no, I don't need those,” that's when I started talking about…I am not trying to take no chance, I don't know you yet, sex was alright… he was was like, “wow, I have never had nobody really be serious about condom like that before.” …and I said yeah,…because I don't know who you've slept with before or who you were fucking behind the bush right before you ran into me so you know what I mean?, that is just how it is …we kind of talked about it and he did disclose his HIV status to me, (I: what did he say he was?), he was positive…I was fortunate… if it wasn't because, truthfully, if it wasn't for going, you know at this group meetings and stuff like that, I probably would have just been like, fuck it, we already did it or whatever, but like I said, because going to the groups, it really causes you to think about your behaviors, I love sex, I would most likely die for it. (D071, 32y, Gay)

Rethinking relationships and sexual health

Relationship dissolution

There were some instances where the participants described a partner with whom they were emotionally intimate but had not yet engaged in sex with their partner (n = 5). For some, attempts to engage their potential sex partner in a discussion about HIV prevention were met with resistance, which resulted in their inability to move forward. One participant shared,

Well there was this guy that I was talking to, I guess it wasn't… within a ninety day span, and he wound up telling me he had HIV…he was into me and it was a whole thing…we never really just like…one of the turnoffs for me was… he was kind of like not open to talking about it…it was kinda weird ‘cause I'm like, “Ok, but you're telling me that you're interested, but you don't want to talk about it so, how are we supposed to move forward?” [I: Right] So, I mean that—it probably would have went a different way if it was a more open forum when it came to that topic, but it wasn't. (H001, 24y, Gay)

Others described how their partners became defensive or implied a lack of trust at the request of practicing safer sex (e.g., getting tested together; using condoms; n = 3). One participant stated, “I had just gotten my status back, and I was negative so…I wasn't trying to really risk nothing. [I: OK] Ya know what I mean? And the person actually got mad at me like they don't use protection, but I do.” (D040, 38y, Bi) Another participant recounted how the lack of shared values regarding condom use led him to end the relationship:

I was dating myself thinking I was dating somebody…not being together but being emotionally connected with all the benefits. I was like it's not going to work…it just escalated because he was like, “I only trust you and I am emotionally connected to you and I don't understand why I have to put this condom on.” I was like, “I don't know why you wouldn't think you should have put it on?” It was just weird but it was a whole big fiasco because we never really talked about it and this particular day I was just like, I don't even know why I am here…instead of just having the conversation, we just parted ourselves away. (D/H090, 32y, Gay)

Changed sexual health practices

Seven participants described how they began to adopt, change, or planned to change their sexual health practices [e.g., started asking partners status before sex; “got an HIV test”; use condoms; started pre-exposure prophylaxis (PrEP)]. Two participants shared a similar view about the importance of asking about their sex partner's status and using condoms:

My test come out negative but from that point on I asked, because he said to me afterward, “Well, you didn't ask me.” Which I kind of was like, I don't, I mean I'm not to say he was like a bad person, a vindictive person but what he did say, you know, we have to use a condom with the intercourse but not to even push so much for the oral. So ever since then, it's just like, you know, ask, “Are you clean?” And even if I ask, I just make sure I put on a condom. (H/D039, 24y, Gay)

I: You feel like it's important to have that conversation um, whether or not you use condoms?

R: Yeah. We did but, and he had them, but it's still important to ask.

I: Why do you feel like it's important to ask anyone?

R: Uh, just to be sure, so just in case they are, you take the right precautions and things like that. (H056, 21y, Gay)

Wake up call

Five participants reflected on their actions and the potential ramifications of not discussing or practicing HIV prevention before sex. They described how their mindset changed after the sex encounter; some began to think differently about their sexual health, as illustrated in the following quotes:

… it only takes one time to get infected. So I realized—sometimes being very horny could destroy your life because you could get infected with a disease. An STD that you cannot cure. So like I realized I got to take control of myself when I'm very horny and make more smart decisions. More wise decisions about having sex with certain guys. (H052, 26y, Gay)

I was just going with the flow…it's a nice day, the weed is rolled. You know, I'm having a little drink, but not much of a drink. But I'm like, “what the hell.” you know [laughter]. That “what the hell” attitude cause you to be put in a box covered with dirt and rocks. (H075, U, U)

Discussion

We explored HIV prevention conversations among BMSM and their sex partners. The participants described missed opportunities and barriers for HIV prevention communication, as well as ways in which their emotions and thoughts may be shifted after missed opportunities for these communications with their sex partners. These findings add to the limited available data about HIV-related health communications between BMSM during sex partnerships and can help inform HIV prevention strategies with BMSM.

Related to the first main theme of missed opportunities for HIV prevention conversations, our participants reported having no HIV prevention conversations with sex partners, including not discussing their HIV status. Other reports show that HIV-positive MSM who disclose their status to all sex partners were less likely to have condomless sex than those who did not consistently disclose as part of an HIV-related conversation.^4,14,15 Research has also shown that partner communication has been associated with safer sex behaviors among several groups, including: heterosexual men and women^4,16; college students⁹; and individuals living with HIV.^7,17 Having HIV-related conversations before sex may benefit sex partnerships by increasing safer sex behaviors. Data suggest that serodiscussions, or mutually discussing HIV status before first sex, occur less frequently among HIV-positive BMSM compared with HIV-positive and HIV-negative MSM of other races/ethnicities.¹⁸ For disproportionately affected BMSM, these conversations may be imperative for reducing risks of unintended sexual transmission of HIV.

Regarding our second main theme, barriers to HIV prevention conversations, participants expressed how being in the moment, dampening the possibility of engaging in sexual activity, emotional distress, and other factors hamper the ability and desire to communicate messages related to HIV prevention. These findings are consistent with other research that suggests that some MSM are hesitant to discuss serostatus disclosure or other HIV prevention conversations before sex, whether in private or public settings, because it impedes the spontaneity of the sexual act.^19,20 In a qualitative study conducted by Campbell et al., black MSM were more likely to use implicit partner communication compared with white MSM, and they were more likely to default to condom use without any form of discussion.²¹ In fact, studies have shown that MSM sometimes use condoms to avoid having safer sex discussions altogether.^22
–24 Although some research indicates that the type of communication may not affect safer sex practices among heterosexuals,²⁵ implicit communication has been associated with miscommunication about safer sex practices in MSM.²⁶ In addition, recent data suggest that nondisclosure of HIV status among HIV-positive MSM can be associated with condomless sex and decreased antiretroviral treatment adherence, which has implications for higher viral loads, infectiousness, and ongoing sexual transmission of HIV infection.²⁷ So, providing MSM support and training for disclosure conversations is an important additional HIV prevention tool.

Regarding our third main theme, emotional thoughts after sex (e.g., feeling worried about possible HIV exposure), participants expressed a range of emotions after sex, which was influenced by whether or not condoms were used. The potentiality of HIV exposure from partners caused some participants to feel distressed, whereas others felt relieved that condoms were used after a partner's disclosure of positive HIV status after sex. These feelings are real concerns that need to be considered when developing prevention communication interventions for BMSM. Despite the implied resistance to HIV prevention conversations,²⁰ underscoring the importance of HIV prevention conversations before sex may dispel negative emotional reactions after sexual encounters.

Regarding our fourth main theme, rethinking relationships and sexual health, some participants discussed a heightened awareness of risks when no HIV prevention conversations occurred, and many expressed thoughts about more self-protective behaviors (e.g., changed sex practices by asking partners' HIV status before sex; started using condoms). A recent campaign by the Centers for Disease Control and Prevention, “Start talking. Stop HIV.” builds on the concept that effective partner communication between MSM can help reduce HIV transmission by bringing up topics in support of routine testing, HIV status disclosure, condom use, and medicines to treat and prevent HIV (www.cdc.gov/nchhstp/newsroom/docs/factsheets/stsh-factsheet-508.pdf).

Limitations and Strengths

Our study has limitations. First, these data cannot be generalized due to our small size and purposive sampling in a single city approach; our findings are not representative of all BMSM in NYC or in other cities. Second, by excluding participants who may have had an HIV test during the previous year, we were not able to consider their perspectives regarding HIV prevention conversations during or after sex, and our data may be skewed by BMSM who were not recently tested for HIV. Future studies should broaden the eligibility criteria to ensure that relevant information that may inform HIV prevention can be learned from a wider range of participants. Third, some participants did not specify what type of sexual activity they engaged in (i.e., anal or oral). However, a key strength of qualitative research is the ability to explore, listen, and contextualize behavior as a complement to statistics and other data. This qualitative analysis of HIV prevention conversations with BMSM and their sex partners revealed potential areas of improvement in HIV prevention and can further inform culturally specific interventions for BMSM, a group disproportionately affected by HIV based on surveillance data and a priority group for prevention strategies.

Implications and Conclusions

There have been relatively few studies that address HIV prevention communication among BMSM and their sex partners. Hence, this study fills an important gap in the literature by hearing directly from at-risk BMSM regarding HIV prevention communication surrounding a sexual encounter. First, our findings underscore the need for further research to gain a better understanding of the contextual factors for disproportionately high HIV infection rates among BMSM. Other studies suggest that gay-related rejection sensitivity is a stigma construct that is associated with increased risk for condomless anal sex²⁸ and substance use.²⁹ Hence, strategies for reducing stigma associated with HIV prevention conversations to include disclosure of HIV status, and for supporting tailored strategies that include healthy coping mechanisms and condom use reinforcement, are implied.

Second, additional research on potential barriers and facilitators to HIV prevention conversations among BMSM is critical to mitigate barriers to HIV prevention conversations, while also reducing unprotected anal intercourse. Also, more research with BMSM is warranted to understand the acceptability and feasibility of PrEP. PrEP is an emergent HIV prevention strategy that has been shown to substantially reduce HIV acquisition risk, if exposed.³⁰ Still, consistent and correct use of condoms remains an important method for reducing sexual transmission of HIV. Third, within the black/African American community of MSM, there are a range of sexual identity subgroups³¹ and other subgroups (e.g., young BMSM)³² that must be considered for appropriate intervention programming. Therefore, consistent with the National HIV/AIDS Strategy goals to reduce the rates of HIV among BMSM, it is imperative that ongoing efforts to develop interventions and campaigns be culturally relevant with targeted messages to enhance HIV prevention communication strategies for BMSM and other MSM of color.

Footnotes

Acknowledgments

The authors thank the men who participated, the Center for HIV Educational Studies and Training, and the Gay Men of African Descent for their participation in and support of this study. This study was supported with CDC's Minority HIV/AIDS Research Initiative award no. U01PS000677.

Author Disclosure Statement

No competing financial interests exist.

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