Identifying Psychosocial and Sexual Characteristics of HIV-Infected MSM Who Engage in Very Risky Behavior: Establishing a Context for Novel Risk Reduction Interventions

Background and Purpose: In 2010, the CDC reported that men who have sex with men (MSM) account for more than half of the new US HIV infections annually (53%, or approximately 28,700). Sexual transmission from HIV-infected- to HIV-uninfected-MSM is the central pathway for spread of HIV in this at-risk group. Additionally, MSM comprise the only risk group in which new HIV infections are increasing. A recent randomized controlled trial of secondary HIV prevention conducted by The Fenway Institute (Boston, MA) identified that at baseline the riskiest 10% of HIV-infected MSM accounted for more than 75% of the sexual transmission risk behavior. Traditional secondary HIV prevention interventions (e.g., condom use, safer-sex negotiations, HIV-status disclosure, serosorting, etc.) may need to be augmented with prevention strategies specifically tailored for this high-risk group. Furthermore, it is possible that factors which contribute to increased risk may also limit the uptake of traditional risk reduction messages. Funded by the Center for AIDS Research at Harvard University, the purpose of this qualitative study was to identify coherent themes around the psychological, behavioral and contextual factors that might be associated with HIV transmission risk. These themes might help inform the development of specialized intervention to reduce sexual transmission risk for HIV among MSM who report very high levels of risky sexual behavior.

Methods: A qualitative descriptive approach was used to conduct a content analysis of interview data and to provide formative descriptions of the lives of these high-risk men. Very risky sexual behavior was defined by five or more episodes of unprotected anal intercourse over the past three months with HIV-uninfected or unknown status partners. Purposive non-probability sampling methods were used to recruit 15 participants from Fenway Health and the wider community. Nine Caucasian and six African-American participants ages 18 to 65 years old were interviewed using a semi-structured questionnaire. Data were approached, coded and analyzed using six theoretical tenets and their concomitant analytic strategies, while four points of rigor and procedures were employed to ensure trustworthiness.

Results: Among these HIV-infected MSM who report high levels of sexual transmission risk, qualitative data analysis to date suggests particular themes. These themes include a) assumptions concerning partners' serostatus b) the presence of substance use, c) distinct insertive and receptive sexual risk profiles, d) non-mindful preparation for sex, and e) relationship dissatisfaction.

Conclusions and Implications: These themes are interpreted in the context of developing a novel secondary HIV prevention curriculum that might have particular relevance for HIV-infected MSM who report very high levels of sexual transmission risk. This curriculum development is discussed with respect to particular cognitive behavioral strategies including a) cognitive restructuring (to generate more realistic perceived transmission risk, more accurate appraisals of partners' HIV serostatus) b) exposure techniques and c) prevention problem solving to train prevention skills individualized to the participant's risk profile. Furthermore, these qualitative findings may help inform social work research and evidence-based practice by providing a descriptive account of the complex and multi-dimensional challenges of HIV prevention within MSM populations.