Rebecca Hutcheson, LICSW, MSW 1 Hanne Thiede, DVM, MPH 1 Matt Golden, MD, MPH 1, 2

1. HIV Status Disclosure Among Men Who Have Sex with Men (MSM): Use, Mis-Use, and Implications for Prevention Rebecca Hutcheson, LICSW, MSW1 Hanne Thiede, DVM, MPH1 Matt Golden, MD, MPH1, 2 1Seattle Area MSM Study (SAMS), Public Health - Seattle & King County 2University of Washington

2. Background • MSM in the Public Health - Seattle/King County STD clinic who report having UAI with only HIV negative partners are not at elevated risk of HIV compared to persons who deny all UAI, suggesting that disclosure is protective. • Local HIV prevention efforts include promoting HIV status disclosure among MSM prior to sex • Many men are infected after obtaining status information • Qualitative interviews obtained reasons for sexual risk after learning a sex partner’s HIV status

3. Presentation Objectives • Overview of SAMS and current participants • Present preliminary data related to: • Factors related to obtaining HIV status information • Reasons for not using condoms after partner status disclosure • Explore possible implications for research and interventions

4. Study Design and Methods • MSM ages 18 and older recruited through HIV testing sites • Case-control design • 80 Cases: Newly diagnosed HIV positive • 160 Controls: Recently tested HIV negative • Structured ACASI questionnaire • Semi-structured qualitative interview

5. Study Population Thus Far • Total: 149 (34 HIV positive, 115 HIV negative) • Race: White 64% Hispanic 10% Black 12% Other 15% • Median Age: 34 • 36% knew the HIV status of their most recent anal sex partner before sex; 59% knew at some point

6. Participants in Preliminary Qualitative Analysis • 32 newly diagnosed HIV positive • 38 recently tested HIV negative Interview explored a particular sexual event: • Known or suspected infection experience (HIV+) • Most risky sexual event in last 6 months, or • Last sexual experience prior to testing for HIV

7. Factors Related to Status Discussion Relationship with Sex Partner Prior Experiences Substance Use Belief System Sexual Arousal ? Skills & Resources Partner Initiation Focus of Anxiety Assessment of Behavioral Risk

8. Sexual Risk in the Context of Status Information • Reasons for not using condoms • regardless of partner status • after a partner disclosed being Negative • after a partner disclosed being Positive

9. No Condoms - General Reasons • Not liking condoms “ They make sex cold, scientific. It takes away the humanity of it… it’s like saying “ok, now we’re going to have our medically approved sexual intercourse. But c’mon! Let’s fuck!” (25, White, HIV negative) • Primary Focus is Sex “...we were in the throws of drugs and sex, and he was hot. It’s amazing what a difference somebody who is hot makes - you just go stupid. Every guy I’ve ever known just goes stupid. The blood must just rush from your head to your penis.” (32, White, HIV positive) • Substance Use “Being on crystal, I didn’t care.” (42, White, HIV positive)

10. No Condoms After Negative Disclosure • Trusted partner was really negative “ He seemed very honest. I trusted him. When you hit it off with somebody like we did, you feel like there isn’t anything to hide, and that if there were, then they will tell you.” (28, White, HIV positive, casual partner) “He was Harvard educated, a professional. Not the kind of guy who would do that to you.” (lie about his status) (46, White, HIV negative) “We used condoms for the first two weeks of our relationship, but after our test results came back negative, we stopped using them.” (40, White, HIV negative )

11. Didn’t use condoms because of negative disclosure “ Knowing he was negative made it okay to have anal sex without protection, without using a condom.” (23, White, HIV negative) “ I felt safer about not using condoms.” (20, White, HIV negative) • More negative participants had obtained risk information in addition to HIV status

12. No Condoms After Positive Disclosure • History of negative tests with same behaviors “A couple of times there have been red flags in my mind, but I have had risky sex for a number of years and testing negative - I didn’t ever feel like I was immune - I just felt like it wasn’t going to happen to me… I guess that’s denial.” (29, White, HIV positive) • Believed he wouldn’t get infected through Insertive Anal Sex “He told me how high his T-cell count was and how his viral load was undetectable. His doctor told him that he was in very, very good health, and it would be very low risk of someone catching it from him” (47, Black, HIV positive)

13. Felt it was destiny to get infected “In a roundabout way I already knew what my destiny was, sorta - I knew I was gonna test positive… this random life I’d been living - it was only a matter of time and that I almost took the approach that it’d almost be better if I was, which in hindsight I wish I hadn’t have done that. But honestly a lot of people do that - they call them bug-chasers. It’s easier for them, it’s less pressure or work or whatever.” (31, White, HIV positive) • Wanted to be closer to partner “It was a challenge we could face together. This may have led to letting him give it to me - to be closer to him, so the relationship would be the most important to him. I wanted his DNA in me.” (32, White, HIV positive)

14. Over time felt partner was less risky “At first we tried to be careful about using condoms. But I got more comfortable with him and more careless about being safe. As we were getting more comfortable with each other, we got more caught up in the moment. I identified with him as a person... I saw him as a person and not just a sex partner.” (29, White, HIV positive) • Exposure “event” led to inconsistent condom use After a condom broke... “I figured I was infected, so what’s the point?” (24, Native American, HIV positive)

15. Conclusions & Implications • In this preliminary sample status disclosure seemed to be most utilized by men when attempting to reduce their risk for HIV from unprotected sex • While promoting status disclosure may not directly influence some individual’s behaviors, it may help foster community norms that support status discussion • Emphasizing obtaining sexual risks since last test in addition to a negative status disclosure may be an important component to prevention messages • Maintaining condom use over time with a positive partner was a particular challenge and worth additional research attention

16. Limitations The data are: • Preliminary • Qualitative • Not generalizable • Related to the most risky of experiences • Intended to foster discussion and identify additional research questions

17. Acknowledgments SAMS staff: Jason Naki Kim Houk Jef St DeLore Ted White Centers for Disease Control and Prevention Richard Jenkins PhD Ron Stall PhD Jim Carey PhD Lee Warner PhD • HIV/AIDS & STD Programs, Public Health - Seattle & King Co. • One-on-One Program, Public Health - Seattle & King Co. • Madison Clinic, Seattle Gay Clinic, Primary Infection Clinic • All who participated as study participants