Understanding the agreements and behaviors of men who have sex with men who are dating or married to women: Unexpected implications for a universal HIV/STI testing protocol

IntroductionAlthough men who have sex with men (MSM) are estimated to represent two to five percent of the population, more than half of all new HIV infections each year are among MSM in the United States (1). The primary sexual risk factor for HIV transmission between MSM is unprotected anal intercourse (UAI) (2), yet, not all MSM solely engage in male-to-male sex. Additionally, heterosexual women account for almost one-third of individuals infected by HIV and are more susceptible to HIV infection through unprotected vaginal intercourse than are heterosexual men (3,4). Hypothetically, men who have UAI with other men and unprotected vaginal intercourse or UAI with women may increase new HIV infections among heterosexual women, and help sustain the disproportionate impact of HIV/AIDS among MSM. Prior research has supported this notion that men who engage in sexual risk behaviors with both men and women (MSMW) may serve as a bridge population for HIV transmission (5-11). Because many of these specific men are partnered, social aspects that help to create and maintain their relationships ultimately might be the key predictors of protective or, alternatively, risky sexual health behaviors.In response to how HIV may be transmitted through bridge populations, a growing body of research has emerged to examine the social and relational characteristics and dynamics of men in concurrent sexual partnerships. Research with MSMW, either labeled as non-gay identified or behaviorally bisexual men, has examined sexual risk behaviors to determine the likelihood of HIV and STI transmission to female sex partners. Published data on MSMW indicated several individual characteristics that are associated with an increase in sexual risk behaviors, including: 1) having sex with both men and women, 2) a non-gay identity, and 3) concealment of same-sex behavior from female partners (9, 12-19). Other research has examined correlates and reasons for why MSMW use condoms and test for HIV less frequently (19-22).However, gaps in the HIV prevention literature, which deal specifically with the social/relational aspects of MSMW, remain understudied. Few studies have collected and described self-reported sexual risk behavior and relationship data, including agreements of MSMW who actively placed advertisements on the Internet (i.e., www.craigslist.org) for same-sex encounters. Moreover, little is known about the association between self-reported data on relationship behaviors and relationship agreements among MSMW with their female partners and the sexual risk behaviors in which MSMW engage with male secondary sex partners. Research that examines the intersection of these important social aspects (specifically, the concordance/discordance of sexual behaviors and agreements with relationship partners among MSMW) is needed in order to design suitable HIV/STI prevention interventions.The present study sought to assess whether selfreported accounts of sexual agreements and relationship behaviors of MSMW with a steady female partner corresponded to their sexual risk behaviors with secondary male sex partners. The overall aim of the present research was to expand our understanding of the contributing factors, including relationship agreements, to HIV and STI risk transmission among MSMW, their female relationship partners, and any secondary male sex partners they may have. Specifically, this study has three objectives: 1) to describe the distribution of relationship types, agreements, and self-reported sexual behaviors (including condom use) among female partnered MSMW who actively sought out and engaged in sexual behaviors with men; 2) to examine the degree to which agreements match with behaviors among MSMW; and 3) to assess the differences and similarities of self-reported relationship agreements and sexual risk behaviors among the sample.MethodsMen, regardless of sexual identity, who placed an advertisement to engage in sex with other men on each Craigslist. …