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Engaging in Very Risky Sexual HIV Transmission Behavior: a Qualitative Description of HIV-Infected Men Who Have Sex with Men

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Engaging in Very Risky Sexual HIV Transmission Behavior: a Qualitative Description of HIV-Infected Men Who Have Sex with Men Engaging in Very Risky Sexual HIV Transmission Behavior: a Qualitative Description of HIV-Infected Men Who Have Sex with Men Author: Scott Wade Taylor Persistent link: http://hdl.handle.net/2345/2368 This work is posted on eScholarship@BC, Boston College University Libraries. Boston College Electronic Thesis or Dissertation, 2011 Copyright is held by the author, with all rights reserved, unless otherwise noted. Boston College Graduate School of Social Work ENGAGING IN VERY RISKY SEXUAL HIV TRANSMISSION BEHAVIOR: A QUALITATIVE DESCRIPTION OF HIV-INFECTED MEN WHO HAVE SEX WITH MEN A dissertation By: SCOTT WADE TAYLOR Submistted in partial fulfillment of the requirements for the degree of Doctor of Philosophy August, 2011 © Scott Wade Taylor 2011 Abstract Engaging in Risky Sexual HIV Transmission Behavior: A Qualitative Description of HIV-infected Men Who Have Sex with Men (Directed by: Kevin H. Mahoney, Ph.D.) Recent empirical epidemiological and behavioral research has indicated that some secondary intervention preventions (e.g., condom use, HIV-disclosure, serosorting, etc.) might not be suitable for all HIV-infected gay and bisexual men, particularly for those who engage in multiple episodes of unprotected anal intercourse (UAI). The purpose of this dissertation was to answer the primary research question: What are the psychological, behavioral and contextual factors associated with HIV-infected men who have sex with men (MSM) who engage in risky sexual behavior? A qualitative descriptive approach was used to conduct a content analysis of 14 in-depth, semi- structured interviews and to provide a description of the lives of MSM who do not consistently use traditional secondary risk behavior strategies (e.g., safer-sex negotiation, condom use, etc.) to reduce HIV transmission among sexual partners, particularly those partners who are HIV-uninfected or whose HIV status is unknown. Risky sexual behavior was defined by HIV-infected MSM who had engaged in multiple episodes of UAI in the past three months. These interviews gathered preliminary data on the feasibility and acceptability of secondary HIV behavioral prevention strategies for MSM who engage in very risky sexual behavior. In addition, these data have identified descriptive themes that could be used to augment traditional secondary HIV invention preventions, creating new and specific risk-reduction strategies for this very high-risk group. Acknowledgements Dedicated to: Robert H. Lloyd Little did I know when I began my collegiate career in 1991 that my academic trajectory would eventually take me to Boston College, where I would begin and complete the challenging and celebratory experience of doctoral education. The city of Boston and the town of Truro have become home and places where I can express my personality, sexuality and actuality with continual awareness: Authenticity is unexpectedly contagious. First and foremost, I want to acknowledge my parents for teaching me the important example of not giving up in the midst of adversity, especially when you have the chance to define yourself with resilience. In addition, they taught me to surround myself with good and honest people. Amongst such good and honest people have been friends and colleague who have, along the way, encouraged me, edited my work, heard me cry, made me laugh, embraced my distress and provided me mentorship and guidance. I want to express my gratitude to the Fenway Health community and particularly to those members on the Behavioral Science research team at The Fenway Institute. This team challenged my wits and provided me with continued support and opportunities to develop a career in HIV Prevention and Sexual Health research and practice. I especially thank Conall O’Cleirigh, who, with much patience, guided me through the conceptualization of the dissertation project and provided the supervision necessary for me to become an emerging researcher and scholar. - i - Thank you to my dissertation committee members Kevin Mahoney, Danny Willis, Katie McInnis-Dittrich and Vincent Lynch, who not only taught me within the classroom how to learn and synthesize new and old knowledge, but also provided critical feedback and essential suggestions to ready the dissertation for defense and dissemination. I give special thanks to my classmates; we began the balance of doctoral work, familial love and professional confidence, and I think we are doing exceedingly well. Thank you to the Fellasof95; you know who you are. And, thank you Jeremy J. for always challenging me intellectually and showing me the silliness in the world; your friendship continues to remind me that there is meaning for intentionality. Lastly, I want to acknowledge deep gratitude to Stephen, my lover and partner, who, over the past two years, gave me space to write, prepared food to bite and provided comfort at night; while I trekked on the meandering dissertation path you edited, I did not give up, and of course, your love would not have let me. - ii - Table of Contents Acknowledgements………………………………………………………………... i Table of Contents………………………………………………………………….. iii List of Tables………………………………………………………………………. v Chapter One: Introduction…………………………………………………………. 1 Study Rationale…………………………………………………………….. 5 Study Aims………………………………………………………………… 9 Definition of Terms…………………………………………………………10 Assumptions………………………………………………………………...11 Analytic Review of Literature………………………………………………11 HIV Prevalence in US and in MSM……………………………….. 12 HIV Prevention Interventions……………………………………… 14 HIV Prevention Effectiveness………………………………………16 Individual-level Risk-reduction Strategies………………………… 18 Psychosocial Aspects of Risky Sexual Behavior………………….. 21 Conclusion…………………………………………………………. 22 Research Questions………………………………………………………… 23 Chapter Two: Method……………………………………………………………… 24 Overview of Parent Study………………………………………………….. 24 Study Setting……………………………………………………………….. 24 Current Research Design……………………………………………………25 Study Population…………………………………………………………… 27 Recruitment Procedures……………………………………………………. 29 Study Procedures……………………………………………………………30 Instrument………………………………………………………………….. 31 Data Analysis………………………………………………………………. 33 Rigor in Qualitative Research……………………………………………… 36 Protection of Human Subjects………………………………………………39 Chapter Three: Findings…………………………………………………………… 40 Demographic and Sexual Characteristics of Participants………………….. 41 Descriptive Themes that Emerged from Data……………………………… 43 Theme I: Serostatus Attribution……………………………………. 45 Theme II: Partner’s Responsibility for Safer-sex Negotiation…….. 49 Theme III: Sexual Sensation Seeking……………………………… 54 Theme IV: Presence of Substance Use…………………………….. 58 Theme V: Relationship Desire/Dissatisfaction…………………….. 64 Attitudes about Traditional HIV-prevention Interventions…………………68 Suggestions for Novel HIV-prevention Interventions……………………... 72 Summary of Descriptive Findings…………………………………………. 76 - iii - Chapter Four: Discussion………………………………………………………….. 77 A Look at the Descriptive and Sexual Characteristics……………………... 78 Integrating the Emerging Themes Back into the Literature………………... 80 Attitudes about Traditional HIV-prevention Interventions…………………93 Suggestions for Novel HIV-prevention Interventions……………………... 100 Summary of Discussion……………………………………………………. 102 Chapter Five: Implications, Recommendations and Final Thoughts………………. 104 Theoretical Considerations………………………………………………… 105 Implications for Clinical Practice………………………………………….. 110 Implications for US HIV/AIDS Policy…………………………………….. 113 Recommendations for Future Research……………………………………. 117 Strengths and Limitations of the Current Study…………………………….121 Final Remarks…………………………………………………………….... 123 References………………………………………………………………………….. 125 Appendix A: Oral Explanation of Research for Qualitative Interview…………….. 151 Appendix B: Semi-structured Qualitative Interview Guide………………………...154 Appendix C: Attribution of Serostatus Scale (ASS)………………………………. 158 - iv - List of Tables Table 1: Inclusion and Exclusion Criteria for Project Engage …………………… 28 Table 2: Tenets and Steps for Analytic Review of Qualitative Data …………….. 33 Table 3: Criteria and Procedures to Ensure Trustworthiness of the Study ………. 36 Table 4: Demographic and Sexual Characteristics ………………………………. 42 Table 5: Descriptive Themes Identified through Participants’ Interviews ………. 44 Table 6: Attribution of Themes per Participant…………………………………… 46 - v - CHAPTER ONE Introduction By the end of 2006, the Centers for Disease Control and Prevention (CDC, 2008a) estimated that 1,106,400 persons in the US were living with the human immunodeficiency virus (HIV). Most of these cases were men (including both heterosexual and homosexual men), who represented 75% of the total HIV-infected population. Between 2003 and 2006, there was an 11% increase in new infections (approximately 112,000). With the advancement of antiretroviral therapy (ART), the increase of people living with HIV might be attributed to people living longer because of consistent ART adherence, and as a result there has been a concomitant decrease in the number of deaths from HIV-related complications or acquired immune deficiency syndrome (AIDS). As well, the increase in prevalence also might be due to an increase in the number of HIV tests being conducted and therefore more persons being newly diagnosed with HIV. In 2006, approximately 21% of those living with HIV and who were newly diagnosed were unaware of their positive serostatus (CDC, 2010). With improved HIV/AIDS technological surveillance systems, the CDC (2008a) can provide more accurate national
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