A Little Thing Called : Use in High-Risk Primary Heterosexual Relationships

By A. Michelle CONTEXT: are less likely to be used in primary relationships than in other relationship types. An Corbett, Julia understanding of what women and men expect when entering into these relationships, as well as how they make Dickson-Gómez, decisions about condom use and other prevention behaviors, is essential to eff orts to curb the spread of HIV. Helena Hilario and Margaret R. Weeks METHODS: Qualitative in-depth interviews were conducted with 25 high-risk heterosexual couples, including HIV-serodiscordant couples, participating in a trial of the in Hartford in 2004–2007. Data were coded and analyzed in an iterative inductive and deductive process. A. Michelle Corbett is program coordinator, RESULTS: Participants described nonuse of condoms as a strategy to fi nd and maintain a primary relationship, and Julia Dickson- Gómez is associate establish and increase intimacy. Many had unprotected intercourse while recognizing their risk of HIV and professor, both at other STDs, placing their love for their partner and other emotional needs over concerns about their health. Several The Center for couples reduced their STD risk by practicing negotiated safety (i.e., using condoms until their serostatus had been AIDS Intervention determined) or similar strategies, including sharing sexual or drug use history, disclosing HIV test results and using Research, Medical condoms until they decided that their relationship would be monogamous. College of Wisconsin, Milwaukee. Helena Hilario is research CONCLUSIONS: HIV prevention approaches must recognize the importance of love and the needs that primary assistant, and relationships satisfy if they are to be considered relevant by those at greatest risk. Negotiated safety and similar Margaret R. Weeks strategies may be an important risk reduction tool for heterosexuals, particularly those in HIV-aff ected relationships, is executive director, but their potential eff ectiveness may vary. both at The Institute for Community Perspectives on Sexual and , 2009, 41(4):218–224, doi: 10.1363/4121809 Research, Hartford.

Rates of HIV infection are rapidly increasing among importance of primary relationships from the woman’s women in the United States and worldwide.1,2 The major- perspective but has overlooked the man’s. ity of new infections are among women who contracted Public health policymakers and practitioners conceptu- the virus from their primary male sexual partners;3 the alize sex in terms of disease and unwanted , and predominance of this route of transmission refl ects that not in terms of love, intimacy and trust. This is particu- condom use is lower in primary relationships than in larly the case with regard to substance users, who typically casual or paying relationships.4–6 A variety of factors are are described as having sex partners, rather than spouses associated with couples’ use of condoms, including or lovers.21 Regardless of the population, HIV prevention inequity and differential power relations;7-9 occurrence of efforts have focused primarily on the individual, empha- intimate partner violence;10,11 levels of perceived risk12,13 sizing risk reduction through safer sex, often neglecting and self-effi cacy;14,15 and beliefs that condoms feel unnatu- the context in which risky behavior occurs. However, safer ral, reduce sexual pleasure and are a hindrance to sex in the age of HIV and AIDS entails talking about con- intimacy.16,17 doms and acknowledging the possibility of disease. Such Some studies have focused on women’s reluctance to use discussion may not be conducive to a romantic, spontane- condoms in primary relationships and have included ous, -fi lled encounter that might lead to love and a reproductive intentions9,18 or the use of hormonal and long-term relationship. In contrast, some people use casual other forms of contraception.12 Other research has focused or unprotected sex as a strategy to “catch love.”22 Among on the emotional and social needs that are fulfi lled in com- heterosexuals, particularly young women, trust and love mitted relationships, and has found that condom use may are central in defi ning sexual involvements. Young women, be inconsistent with relationship ideals of intimacy, trust and sometimes men, often “trust to love,” in that they see and fi delity.9,19 These explanations may be particularly rel- condom use as unnecessary with a regular partner or evant for inconsistent condom use by couples who know within a relationship.16,23 Furthermore, young women that they are serodiscordant, but not for those in which often view love and trust as prophylactic, and believe that partners have the same HIV status.3,20 Further, most sex is safe because of its relationship with love.22 research on the relationship between emotional needs, In the search for love and a meaningful relationship, romantic attachment and condom use has studied the people may not always act rationally. For example, they

218 Perspectives on Sexual and Reproductive Health may base decisions about sex and condom use on implicit positively, staff told them about the study, screened them personality- or characteristics-based risk theories (e.g., on for eligibility and scheduled them for an appointment to whether a potential partner is from the streets or looks enroll at the study offi ce. To be eligible, individuals had to clean).24,25 Also, once a relationship is established, men be 18 or older, live in the Hartford area and have had vagi- and women may follow one of several inaccurate AIDS nal sex with this partner during the last 30 days. prevention rules of thumb that support nonuse of con- Participants in the couples study provided a urine sam- doms (e.g., “Known partners are safe partners” or “It’s too ple for screening for chlamydia and gonorrhea. If either late to start using protection now”).24 Condoms and their partner reported current STD symptoms during the survey use within a primary relationship, particularly an estab- or tested positive with the urine screen, the couple was lished relationship in which they may not have been used excluded from participation in this component of the previously, can raise issues of distrust and accusations of study and was referred to the local health department for infi delity.8,26 Unprotected sex helps maintain the fantasy treatment.* In-depth narrative interviews, conducted at that one’s partner is faithful.27 baseline and 10 months, explored current and past rela- In recent years, negotiated safety as a risk assessment tionships; relationship ideals; sexual behavior; sexual and and reduction strategy has been a focus of research.28–30 contraceptive decision making; STD risk and preventive Negotiated safety refers to an explicit agreement between practices; violence; and knowledge of, attitudes toward partners about sexual practices that takes into account the and experiences with the female condom. Men and women HIV status of both. Couples using this approach undergo were always interviewed separately and were compensated mutual HIV testing, then decide to discontinue condom $25 for each in-depth interview. Written informed use within their primary relationship and commit to was obtained from each participant prior to STD screening monogamy or establish rules for condom use with outside and study enrollment. All study protocols were reviewed partners. While the frequent use of negotiated safety and approved by The Institute for Community Research among homosexual men is well documented,31 its use by institutional review board prior to initiation of any research heterosexual couples has received little attention, and activities. researchers disagree as to whether heterosexuals are likely All qualitative interviews were transcribed verbatim, to employ it effectively.22,32 and text data were coded and analyzed through an itera- In this article, we examine condom use within the con- tive inductive and deductive process using Atlas.ti soft- text of high-risk urban couples, including both HIV- ware. Interviews were fi rst coded for demographic seroconcordant and HIV-serodiscordant couples. Specifi cally, variables. Data were then coded for content using a coding we explore reasons cited for condom use or nonuse, and scheme developed for the project, which comprised the the strategies used to reduce STD risk, within primary following broad categories: fi rst sexual experience with partnerships. current partner, male condom use, general attitudes toward condoms, reproductive intentions, sexual negotia- METHODS tion, sexual practices, sexuality and pleasure, violence and Our data were collected as part of a study conducted in substance use. In a third level of analysis, members of the Hartford in 2004–2007, exploring factors affecting high- research team worked jointly to identify key themes and risk men and women’s use of the female condom for STD patterns of response and relationships among the variables prevention after barriers to awareness and accessibility of interest. For example, the importance of love was a have been removed. High-risk individuals were defi ned as recurrent theme and was related to many other codes, illicit drug users, partners of injection-drug users, com- such as fi rst sexual experience with partner, sexual negoti- mercial sex workers, and homeless or poor individuals. In ation and sexual practices. addition to longitudinal surveys conducted with a cohort of more than 400 women, the study included a couples RESULTS component of qualitative and quantitative longitudinal The majority of participants were nonwhite and poor, and interviews and a two-week trial of the female condom. We had low levels of educational attainment. Nearly half cur- present fi ndings from the baseline in-depth narrative rently used crack or injection drugs, and the majority had interviews conducted with 25 couples. abused these drugs in the past. Eight couples were home- Recruitment for the couples component of the study less at the time of their fi rst interview. Six women and used two approaches. Initially, every third woman partici- seven men reported that they were HIV-positive; three pating in the larger cohort study was screened for eligibil- couples were seroconcordant positive, and the other seven ity and was asked if she would like to participate and were serodiscordant. Current relationship duration aver- would be able to bring in her male sexual partner. Because aged fi ve years (standard deviation, 59.7 months; range, this approach proved diffi cult, we changed to direct recruitment of couples using targeted outreach. Study staff *This exclusion was based on the assumption that because the couples approached men and women found together in parks and component included a two-week trial of the female condom and fi lling on the street outside of social service organizations, out sexual diaries, it might encourage participants to have more sex (al- and asked them if they were a couple. If they responded beit protected sex) than they would otherwise have.

Volume 41, Number 4, December 2009 219 Condom Use in High-Risk Primary Heterosexual Relationships

1–240 months). The overwhelming majority of couples, with me and him. … Being sick or whatever can’t stop that including six of the 10 affected by HIV, reported never from happening. You understand what I mean?” using condoms. For many participants, the fi rst sexual encounter with Two main themes emerged from the in-depth interviews: their current partner was not just about sex but also about Couples often feel that the love and intimacy needs that establishing trust. In these situations, having sex without a romantic relationships meet supersede health concerns, condom was used as evidence that a partner had been and many couples reduce their STD risk through negoti- honest about his or her sexual past and disease status, or ated safety and similar strategies. was not currently involved in another sexual relationship. Veronica (a Hispanic, HIV-negative 38-year-old) met Love and Intimacy Wilfredo while in methadone maintenance treatment. As they described the beginning of their current relation- They became friends and started dating after two years. ships and fi rst sexual encounters, both women and men They had been together about two months at the time they talked about “taking a chance on love.” Nonuse of con- enrolled in the study. Veronica recalled that as their rela- doms was a strategy employed to help establish a poten- tionship evolved, she “didn’t want to have sex right away,” tially serious, as opposed to casual, relationship. Amanda and she was as nervous as a teenager when they fi nally (a white, HIV-negative 41-year-old)* had known Juan for did. However, she continued: two weeks before they fi rst had sex. They met while in an “The fi rst time … was so great, I could not believe it. inpatient detoxifi cation program, and she described both No, we didn’t use [a condom]. And we didn’t even talk an immediate physical attraction and a deeper emotional about it, but the day after, I ask him, ‘How come you didn’t bond stemming from hours of conversation about their use any protection with me?’ You know, because he had a experiences. At the time of their baseline interviews, they girl before me, and he was using protection [with her]. He had been together for about three months. Explaining why says, ‘Because I trust you, and I know you’ve been honest they chose not to use condoms during their fi rst sexual to me so far and I can trust you.’ … He’s the type of guy experience, Amanda stated: that when he’s in love with a woman, he don’t like to use “I knew I was just going to be with him. He wasn’t just protection; but if he’s just dating someone like he was dating going to be this one person I was just going to mess around this girl just for sex, he was using protection. So … I was with and then … not see him. I was at least hoping that I so proud of him that at least he was using rubbers with was going to be with him [for a long time].” them and the reason he didn’t with me [was] because he Amanda’s desire to be in a long-term relationship and trusted me.” belief that Juan could be the one made it easier not to use Veronica echoed many other participants’ view that the condoms during their fi rst sexual encounter. In turn, their use of condoms signifi es a level of distrust. In addition, nonuse of condoms supported the hope that this was not many participants believed that condoms are appropriate just a fl ing, but rather a fi rst experience with someone who for casual and “sex-only” encounters but not necessarily was equally invested in fostering a meaningful primary for primary, serious relationships. relationship. Again, the need for physical and Several participants, in describing their ideal romantic outweighed health concerns. Veronica knew that Wilfredo partner, talked about having spent years searching for a had been having sex with another woman as they started soul mate and having found one in their current partner. to get to know each other, and she had no way of confi rm- Carmen (a Hispanic, HIV-negative 44-year-old) had spent ing whether he had used condoms with his former part- several years in an abusive relationship before she met ner. However, she believed his assertion and took his Manuel, who was involved in a relationship at the time. nonuse of condoms with her as evidence of the serious- While they were physically attracted to each other, they ness of their relationship. Many women reported having spent a year as friends; during that time, their unprotected sex despite some doubt about their partner’s deepened. Carmen’s realization that Manuel might be her monogamy, choosing to believe that he was faithful. soul mate was somewhat complicated by the fact that he Jennifer (a white, HIV-negative 38-year-old) further illus- was HIV-positive. However, the importance of fi nding a trated this point in her remarks: life partner, particularly a nonabusive one, outweighed her “We honestly believed that we wouldn’t ever have sex fears about health risks as she started a sexual relationship with anybody else again, which is still true this day. … That with him. Carmen and Manuel had been together about is one thing I do believe. And I do know that he’s not eight years and used condoms inconsistently. Carmen messing around. I mean, well, in my heart I believe. I explained: guess nobody can honestly say 100% that they believe “I’ll be honest; I was a little bit scared because I didn’t their mate is messing around or not. … [But] we both had know much about AIDS or anything like that. … [But] the had HIV tests. He said his was negative. Mine was nega- chemistry. … We’re supposed to be together, a soul mate. tive. So we just felt that in using [a condom], it would be It’s like something that you have together; that’s how it was more of a blocker of our love.” Doubt about a partner’s fi delity did not typically lead to *All names have been changed. confrontation or insistence on condom use. Rather, it often

220 Perspectives on Sexual and Reproductive Health resulted in continued unprotected sex, which supported even use condoms with him.’ But I didn’t know [about the belief that the relationship was monogamous, safe and reinfection] at the time, you know? Like I said, ‘That’s my founded on true love. This, in turn, reinforced mispercep- man, I love him and so what. We’ll die together.’ That’s tions about AIDS or people with AIDS and helped to how I felt.” maintain the fantasy of the ideal—namely, that a partner Ana’s story also suggests additional themes. Feelings of was faithful.27 betrayal at not only Lazaro’s dishonesty regarding his HIV In addition to reduced physical pleasure, several partici- status but his disregard for her health are evident. Ana also pants associated using condoms with reduced intimacy, displays a certain level of fatalism, or a belief that her des- both physical and emotional. Martha (a black, HIV-nega- tiny is not in her own hands.35 Finally, once Ana had come tive 44-year-old) commented: to terms with the fact that the man she loved was HIV- “What’s the use of using [condoms]? I mean, Why? I positive, she had to decide whether to leave him, stay with think your body fl uids or whatever is intimacy. … And the him and use condoms, or stay with him and not use con- , you know? His meat against my meat. … I think a doms. Although she chose to stay with Lazaro and not use condom means that you really don’t want contact. … It’s condoms, it is not clear whether she did so because she felt For many only for hookers or somebody that you don’t … want to that getting infected and dying with him would be better feel their immediate skin against yours.” than being left alone after he died; because she assumed people, the Balancing the desire and need for physical intimacy and that he had already infected her, and she accepted the per- protecting oneself or one’s partner was particularly diffi - spective that it was “too late to start using condoms now”;24 emotional cult for serodiscordant couples, as illustrated by Manuel as a conscious expression of her love for him (which has and other and Carmen. Manuel (a Hispanic, HIV-positive 33-year- been suggested as a major reason for nonuse of condoms old) explained that he had been using condoms for so in serodiscordant relationships20); or for a combination of needs that many years, but sometimes he just “[wants] to feel, you reasons. know, fl esh and fl esh.” He said that Carmen sometimes Javier and Karla’s story is another example of how love are fulfi lled feels the same way, “so sometimes we have sex without a sometimes supersedes concern about risk. The couple had condom. … It’s like something that we want to share, you been together for three years at their fi rst interview. She by intimate know?” had received an HIV diagnosis in 2005, and Javier contin- Manuel’s narrative also raises the issue of “condom ued to test HIV-negative. When asked what prevents him relationships fatigue,” which is frequently discussed in research on sex- from taking precautions against infection, Javier (a ual behavior among men who have sex with men33 and Hispanic 29-year-old) responded: may supersede may also operate in heterosexual—particularly serodiscor- “That’s a good question. I don’t know. I go with the fl ow dant—partnerships. Condom fatigue, or frustration with like I always do. … Well, because I feel so comfortable and concerns for the prospect of having the pleasure of sex reduced at every I feel great and I’m living this life, you know, and whatever encounter,34 combined with the desire and need for physi- happens, it happens, you know? Right now I’m enjoying personal cal intimacy, may prove overwhelming at times; as Manuel’s it. Whatever time God wants [to give me and then] he’ll comments suggest, it may even result in inconsistent con- take me. I’m having the best time right now. I don’t want health and dom use despite the very real risk of HIV transmission. to change this for nothing.” Stories related by participants in HIV-affected relation- When the interviewer probed this response, Javier con- safety. ships illustrate that for many people, the emotional and fi rmed that he is willing to risk his life “for being happy.” other needs that are fulfi lled by intimate relationships may supersede concerns for personal health and safety, leaving Assessing and Minimizing Risk them unwilling to risk losing what they have. In extreme Several couples described assessing their HIV risk as they cases, they may be willing to die for love. Ana (a Hispanic, decided whether to use condoms, although the thorough- HIV-positive 37-year-old) had been with Lazaro for 20 ness with which they did so varied considerably, and some years when she entered the study and had received an HIV couples reported never explicitly discussing their risk or diagnosis in 1992. Sometime before learning that she had condom use. José and Linda, who had been together for HIV, she had found out from Lazaro’s sister that he was four and a half years, decided to use protection at the HIV-positive, and had felt betrayed and hurt because he beginning of their relationship because of their drug use had not told her himself. Yet, she explained: histories. After assessing their risks and intentions for the “[Knowing that Lazaro was infected] wouldn’t have relationship, they had HIV tests, agreed to be monoga- changed nothing, just that … I would have been more mous and engaged in unprotected sex. José, a Hispanic protective. That’s it, but I wouldn’t have left him because 32-year-old who was HIV-negative, related: he had AIDS. Because the love was already there, you “When we fi rst met, it took us a while before we had know? So I think maybe he was afraid. [Once I found sexual relations, and we used condoms at fi rst ’cause, you out,] … I didn’t want the sex or nothing for a while, know, we met in a program. … Half of [the people there] because I was hurt. … Then we started back again, and we are sick or something; they have some type of disease. So didn’t use condoms. Never used condoms because I said, she had taken her [HIV test]. Well, she told me to use ‘Damn, I love him and everything. If I love him, I shouldn’t [condoms]. … She wanted to protect herself, you

Volume 41, Number 4, December 2009 221 Condom Use in High-Risk Primary Heterosexual Relationships

know? … She made the decision, and I agreed with it DISCUSSION ’cause we just met not too long ago.” While factors such as substance use, intimate partner vio- Asked at what point he and Linda had decided not to lence and self-effi cacy play a role in condom use generally, use any protection, José explained that after a while, they among these 25 couples, these factors seem to have very had agreed that since they both had been tested for HIV little effect on the desire or ability to use or insist on con- and other STDs and they were monogamous, they had no dom use within their relationship. Study participants were reason to use condoms. “We shouldn’t be sick,” he said, overwhelmingly marginalized socially and economically, “unless one of us went out there and fooled around and and many abused drugs; nevertheless, they tended to be in got sick.” long-term, committed relationships. Because of their mar- In comparing José and Linda with other couples, we can ginalized and potentially stigmatized status, they may have see that negotiated safety may be viewed as a continuum of had a greater need for security, acceptance and recipro- levels of risk assessment and potential responses to risk. cated love than is typical in heterosexual populations at Furthermore, couples may engage in more or less effective or lower risk for HIV infection. Not using condoms, then, The challenge conscientious assessments of their risk. A few participants stemmed from their desire to establish and maintain a lov- described using characteristics-based theories and other ing and meaningful relationship, at whatever cost, includ- … is to … “evidence” in determining whether their partners were safe ing risk to their health. Most participants were well aware for unprotected sex. This evidence went beyond whether of the risks they were taking, but fi nding their “soul promote the someone “looked healthy” or seemed like “that kind of per- mate”—a partner who would share and help them navi- importance of son.” Roberta, a black, HIV-negative 44-year-old, illustrates gate through their diffi cult lives—and achieving a sense of this point in her comments about her partner, Lionel: “normalcy” were higher priorities. protection as “I really couldn’t tell you [how I knew that he didn’t have Serodiscordant and concordant-positive partnerships a disease]. … He must have been using condoms, because are faced with particular challenges in terms of intimacy complemen- he always had condoms on him.” and the barrier to it that condoms can present. Entangled For Roberta, the fact that Lionel carried condoms meant with the desire and need for physical pleasure are the tary to the that he used condoms with other partners and therefore desire and need to experience physical and emotional inti- was safe. macy, to express love for one’s partner, and to be with that desire for love Amanda, who had never used condoms with Juan, person and fully share his or her experiences, as well as decided to engage in unprotected sex once she knew that the fear of loss due to death. The challenge for researchers and intimacy. they both had hepatitis C; she took his word that he had and practitioners is to develop interventions that address tested negative for HIV prior to their meeting. Similarly, these concerns and promote the importance of protection Jennifer had decided not to use condoms with her boy- as complementary to the desire for love and intimacy. friend, Alberto, upon the realization that they both had Because couples in our study saw condom use as incon- hepatitis C infection and had had negative HIV tests before sistent with establishing and maintaining a committed, they met. primary relationship, they used other strategies—some These examples reveal three approaches to assessing risk more thoroughly than others—to assess and reduce their with potentially very different levels of success in actually risk. Several couples described using some form of risk minimizing risk. Roberta’s risk assessment relied on char- assessment and reduction at the beginning of their rela- acteristics-based theories and Lionel’s claim that he used to tionship, but not consistently throughout the relationship. carry condoms, and involved very little discussion. In fact, many participants ignored or minimized their risk, Amanda’s and Jennifer’s rested on the fact that both they or acknowledged a real risk of contracting HIV (as in sero- and their partners had hepatitis C; this information came discordant couples), but still chose not to use condoms out over the course of many hours of conversation during consistently. which they and their partners discussed their pasts. Finally, Given the importance of establishing and maintaining José and Linda acknowledged that they had participated committed, romantic relationships, risk assessment and in high-risk behaviors before entering drug treatment; reduction strategies such as negotiated safety must be they then decided to continue to use condoms while wait- reconceptualized and communicated to high-risk hetero- ing to see if they were still HIV-negative and if their rela- sexuals as a way of increasing intimacy and strengthening tionship was becoming a committed and monogamous relationships. Risk reduction programs should help high- one that included a relatively high level of discussion and risk individuals understand that ongoing risk assessment, negotiation. based on open and honest communication, can help cou- While it is clear that several couples consciously engaged ples increase trust and intimacy within their relationship. in negotiated safety or other strategies to assess or reduce Similarly, they should explain that periodic testing may be their risk at the beginning of the relationship, their use of viewed as a way of expressing love and maintaining trust these strategies apparently was not consistent throughout within the relationship. Our fi nding that many couples the relationship. This was the case even when consider- were attempting to assess risk even though negotiated able risk existed, as when one partner was living with HIV safety has not been widely promoted in the United States or infi delity was suspected. among heterosexuals suggests that this may be a more

222 Perspectives on Sexual and Reproductive Health acceptable HIV prevention tool for those in committed than for heterosexual populations at lower risk for con- relationships than might be expected on the basis of earlier tracting HIV. research fi ndings.22 HIV prevention interventions need to acknowledge the The participation of so many HIV-affected couples in a important emotional and social needs that primary rela- study about female condoms that did not use HIV status in tionships satisfy. Greater attention must be paid to devel- its inclusion or exclusion criteria may indicate that high- oping interventions that acknowledge these needs and do risk couples are interested in safer sex and alternatives to not contradict people’s beliefs about their relationships to the male condom. Two potential alternatives are the female the point where they reject those interventions as condom, which is already available (although not always irrelevant. accessible), and microbicides, currently in development. In the part of our study in which these same couples tried REFERENCES the female condom for two weeks, several participants 1. Joint United Nations Programme on HIV/AIDS (UNAIDS) and reported use of the method at baseline; early analysis of World Health Organization (WHO), AIDS Epidemic Update: November trial data indicate that couples sometimes preferred the 2007, Geneva: UNAIDS and WHO, 2007. female condom to the male condom and that if the former 2. U.S. Centers for Disease Control and Prevention (CDC), HIV/AIDS were more accessible, couples would incorporate it into among women, CDC HIV/AIDS Fact Sheet, Atlanta: CDC, 2007. their repertoire of STD and pregnancy prevention strate- 3. O’Leary A, Women at risk for HIV from a primary partner: balancing gies.36 Additionally, as reported previously,37 vaginal micro- risk and intimacy, Annual Review of Sex Research, 2000, 11:191–234. bicides hold promise as an acceptable and desirable option 4. Kapadia F et al., Correlates of consistent condom use with main partners by partnership patterns among young adult male injection for women drawn from the same community as those in drug users from fi ve U.S. cities, Drug and Alcohol Dependence, 2007, this study. 91(Suppl. 1):S56–63. 5. Sangi-Haghpeykar H et al., Extra-relational sex among Hispanic Limitations women and their condom-related behaviours and attitudes, AIDS This study has several limitations. For a variety of reasons, Care, 2003, 15(4):505–512. our sample was not representative. First, participation was 6. Grimley DM et al., Condom use among low-income African Amer- limited to those who were willing to enroll in the study ican males attending an STD clinic, American Journal of Health Behav- with a partner. Second, while all types of partners (pri- ior, 2004, 28(1):33–42. mary, casual, and paying or paid) were eligible, only indi- 7. Fullilove M et al., Race/gender issues in the sexual transmission of viduals with primary partners participated, likely because AIDS, in: Volberding P and Jacobson MA, eds., AIDS Clinical Review, New York: Marcel Dekker, 1990, pp. 25–62. of the in-depth and longitudinal nature of the study. As 8. Carovano K, More than mothers and whores: redefi ning the AIDS such, fi ndings are not representative of heterosexuals who prevention needs of women, International Journal of Health Services, are not in serious relationships, or who have casual, pay- 1991, 21(1):131–142. ing or paid partners. Third, because of diffi culties encoun- 9. Worth D, Sexual decision-making and AIDS: why condom promo- tered during recruitment, the sample may have been tion among vulnerable women is likely to fail, Studies in Family Plan- limited to those with an intrinsic motivation to participate; ning, 1989, 20(6, pt. 1):297–307. hence the abundance of couples in which at least one part- 10. Gielen A, McDonnell K and O’Campo P, Intimate partner vio- ner was HIV-infected. Fourth, the sample was composed lence, HIV status, and sexual risk reduction, AIDS and Behavior, 2002, of socially and economically marginalized persons, many 6(2):107–116. of whom abused substances; the fi ndings are therefore not 11. Wingood G and DiClemente R, The effects of an abusive pri- generalizable to individuals with a higher socioeconomic mary partner on the condom use and sexual negotiation practices of African-American women, American Journal of Public Health, 1997, status or without a substance abuse problem. This limita- 87(6):1016–1018. tion may also be considered a strength of the study, as per- 12. Green J, Fulop N and Kocsis A, Determinants of unsafe sex in spectives of marginalized populations are often lost in women, International Journal of STD and AIDS, 2000, 11(12):777–783. research and the literature. Finally, self-report bias was an 13. Stein J et al., Impact of on HIV/AIDS risk behaviors inherent risk of the study; however, by interviewing both among impoverished, at-risk couples: a multilevel latent variable ap- members of a couple, we were able to validate the consis- proach, AIDS and Behavior, 2007, 11(1):87–98. tency of participants’ reports. 14. Bandura A, Social cognitive theory and exercise of control over HIV infection, in: DiClemente RJ and Peterson JL, eds., Preventing Conclusion AIDS: Theories and Methods of Behavioral Interventions, New York: Ple- num Press, 1994, pp. 25–59. A disconnect exists between public health and lay con- ceptualizations of sex and the nature of sex between 15. Dancy B and Berbaum M, Condom use predictors for low-income African American women, Western Journal of Nursing Research, 2005, “high-risk” individuals. This is evident both in how 27(1):28–44 & 45–49. research questions are asked and in how the resulting 16. Flood M, Lust, trust, and latex: why young heterosexual men do data are interpreted. Our fi ndings support the need to not use condoms, Culture, Health, and Sexuality, 2003, 5(4):353–369. explore the context in which sex occurs (i.e., relation- 17. Mizuno Y et al., Beliefs that condoms reduce sexual pleasure: gen- ships) and suggest that primary, committed relationships der differences in correlates among heterosexual HIV-positive injection may be even more important for this high-risk population drug users (IDUs), Journal of Urban Health, 2007, 84(4):523–536.

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18. Cabral R et al., Reproductive and contraceptive attitudes as pre- 29. Davidovich U, de Wit JBF and Stroebe W, Behavioral and cogni- dictors of condom use among women in an HIV prevention interven- tive barriers to safer sex between men in steady relationships: impli- tion, Women and Health, 2001, 33(3–4):117–132. cations for prevention strategies, AIDS Education & Prevention, 2004, 19. Worth D, What’s love got to do with it? the infl uence of romantic 16(4):304–314. love on sexual risk taking, in: Moore K, ed., Learning About Sexuality: 30. Guzman R et al., Negotiated safety relationships and sexual behavior A Practical Beginning, New York: The Population Council, 1996, pp. among a diverse sample of HIV-negative men who have sex with men, 119–132. Journal of Acquired Immune Defi ciency Syndromes, 2005, 38(1):82–86. 20. Bedimo A et al., Understanding barriers to condom usage among 31. Kippax S et al., Sexual negotiation in the AIDS era: negotiated HIV-infected African American women, Journal of the Association of safety revisited, AIDS, 1997, 11(2):191–197. Nurses in AIDS Care, 1998, 9(3):48–58. 32. Crosby R, Yarber W and Meyerson B, Prevention strategies other 21. Glick Schillar N, Crystal S and Lewellen D, Risky business: the than male condoms employed by low-income women to prevent HIV cultural construction of AIDS risk groups, Social Science & Medicine, infection, Public Health Nursing, 2000, 17(1):53–60. 1994, 38(10):1337–1346. 33. Adam B et al., AIDS optimism, condom fatigue, or self-esteem? 22. Rosenthal D, Gifford S and Moore S, or safe love: com- explaining unsafe sex among gay and bisexual men, Journal of Sex Re- peting discourses? AIDS Care, 1998, 10(1):35–47. search, 2005, 42(3):238–248. 23. Warr D, The importance of love and understanding: speculation 34. Westhaver R, ‘Coming out of your skin’: circuit parties, pleasure, on in safe sex health promotion, Women’s Studies International and the subject, Sexualities, 2005, 8(3):347–374. Forum, 2001, 24(2):241–252. 35. Davison C, Frankel S and Smith G, The limits of lifestyle: re- 24. Misovich S, Fisher J and Fisher W, Close relationships and elevat- assessing ‘fatalism’ in the popular culture of illness prevention, Social ed HIV risk behavior: evidence and possible underlying psychological Science & Medicine, 1992, 34(6):675–685. processes, Review of General Psychology, 1997, 1(1):72–107. 36. Weeks MR, Female condoms: the best kept secret in woman- 25. Thorburn S, Harvey S and Ryan E, HIV prevention heuristics and initiated HIV prevention, paper presented at the conference Women, condom use among African-Americans at risk for HIV, AIDS Care, Power, and HIV/AIDS, New Haven, CT, Apr. 6, 2006. 2005, 17(3):335–344. 37. Weeks M et al., Microbicide acceptability among high-risk urban 26. Wingood G and DiClemente R, Partner infl uences and gender- U.S. women: experiences and perceptions of sexually transmitted HIV related factors associated with noncondom use among young adult prevention, Sexually Transmitted Diseases, 2004, 31(11):682–690. African American women, American Journal of Community Psychology, 1998, 26(1):29–51. Acknowledgment 27. Sobo E, Inner-city women and AIDS: the psychosocial benefi ts of The research on which this article is based was supported by grant unsafe sex, Culture, Medicine and Psychiatry, 1993, 17(4):455–485. R01 MH069088–01A2 from the National Institute on Mental 28. Crawford JM, et al., Negotiated safety and other agreements be- Health. tween men in relationships: risk practice redefi ned, International Jour- nal of STD and AIDS, 2001, 12(3):164–170. Author contact: [email protected]

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