Objective HIV continues to be a global and national public health challenge, and men who have sex with men (MSM) are disproportionately affected in the USA. Transmission of HIV is intentional if the person living with HIV knows about his/her serostatus, acts with the intention to and actually transmits HIV. Research on intentional transmission of HIV infections is lacking, and the relationships between perceived intentional transmission, viral suppression and psychosocial outcomes have not been assessed. The objective of this study was to investigate the association between perceived intentional transmission of HIV, sustained viral suppression and psychosocial outcomes.
Methods Data were obtained from 338 MSM living with HIV who participated in a disclosure intervention study. Logistic and linear regression models were used to assess the associations between perceived intentional transmission and viral suppression, condomless anal intercourse in the past 30 days, being at risk for clinical depression, substance use, self-efficacies for condom use, HIV disclosure and negotiation of safer sex practices, and sexual compulsivity.
Results 44% of the study population reported perceiving intentional HIV transmission. After adjusting for sociodemographic characteristics, men who thought that they were infected intentionally had 69% higher odds (adjusted OR: 1.69; 95% CI 1.01 to 2.83) of being at risk for clinical depression, and on average, scored approximately 3 points and 4 points higher on depressive symptoms and sexual compulsivity, respectively (adjusted β: 3.29; 95% CI 0.42 to 6.15; adjusted β: 3.74; 95% CI 1.32 to 6.17) compared with men who did not think that they were intentionally infected. After adjusting for confounders, there was no statistically significant association between perceived intentional transmission and viral suppression.
Conclusions Intervention programmes for MSM living with HIV who thought they were infected intentionally are warranted and should aim to attenuate depressive symptoms and sexual compulsivity.
- behavioural science
- gay men
- modes of transmission
- sexual health
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HIV continues to be a global and national public health challenge.1 2 Men who have sex with men (MSM) continue to be disproportionately affected in the USA.3 Transmission of HIV infections is intentional if the person living with HIV knows about his/her positive serostatus, acts with the intention to transmit HIV and actually transmits HIV.4 Legal systems differ in their definitions of ‘intentional transmission’ and the criteria for what constitutes a ‘criminal act’ vary widely. In the USA, intentional transmission of HIV has legal consequences in at least 36 states and 2 territories.5
Engaging in condomless sexual intercourse is referred to as ‘barebacking’. HIV-positive MSM were more likely to report barebacking compared with HIV-negative MSM.6 HIV-positive MSM who identified as ‘barebackers’ scored higher on romantic obsession, substance use-influenced sexual expectancies7 and sexual adventurism.8 An exploratory factor analysis showed two factors underlying decisional balance for barebacking: coping with psychosocial vulnerabilities, including depression, and seeking emotional connection and pleasure.9
At present, research on perceived intentional transmission of HIV, when a person thinks HIV was transmitted deliberately to him/her, is lacking. The primary aim of this study was to examine the associations between perceived intentional transmission and sustained viral suppression, sexual behaviour including condomless sexual intercourse, depressive and substance use symptoms, self-efficacy and sexual compulsivity among MSM living with HIV.
Data were obtained from 338 MSM at the baseline assessment of a disclosure intervention study (December 2009–2014).10 This intervention was used to help MSM in their decisions to disclose their HIV serostatus to their casual sexual partners. Men were eligible for the study if they were HIV-positive, had two or more sexual partners in the past year (one or more male partner) and desired to learn more about disclosure. Participants were recruited from AIDS service organisations, and from local venues in metropolitan statistical areas located in the Midwest and Southeast. Advertisements were also placed in local daily newspapers. Condomless insertive and receptive anal intercourse were measured by two separate questions asking how many sexual encounters in the past 30 days included insertive anal sex and receptive anal sex without a condom (one or more vs no encounter). Depressive symptoms were measured using the 20-item Centers for Epidemiologic Studies Depression (CES-D) scale,w1 with being at risk for clinical depression as CES-D score ≥16 vs <16 .w2 Substance use was measured using the substance abuse and mental illness symptoms screener and the Whetten et al criteria.w3 Self-efficacies for condom use, HIV disclosure and negotiation of safer sex practices were operationalised by three items each.w4 Sexual compulsivity was measured using 13 items from the Sexual Compulsivity Scale.w5 Perceived intentional transmission was operationalised by the question ‘Do you think someone infected you intentionally (this person knew he/she was HIV-positive, but chose not to tell you)?’
The distribution of sociodemographic characteristics, viral load and psychosocial outcomes were assessed overall and by perceiving transmission to be intentional. Information was missing for one participant on perceived intentional transmission (resultant sample size was 337). Statistically significant differences in perceived intentional transmission by sociodemographic and HIV-related characteristics were determined by Χ2 (categorical variables) and F-statistic (continuous variables) p values.
Sociodemographic confounders were considered if they were thought to be associated with perceived intentional transmission. In addition, sociodemographic differences by viral suppression,w6 and condomless anal intercourse, specifically by race/ethnicity,w7,w8 depressive and substance use symptoms,w9 self-efficacy,w 10 and sexual compulsivity,w 11 have been found in the literature.
ORs from logistic regression models or beta estimates from linear regression models were obtained based on the outcome variable in the model. Logistic regression models were used for binary outcomes and linear regression models were used for continuous outcomes. Therefore, crude and adjusted ORs were obtained from logistic regression models depicting the associations between perceived intentional transmission, viral suppression, condomless anal intercourse in the past 30 days (assessing receptive and insertive anal intercourse separately), being at risk for clinical depression and substance use (binary outcomes). Crude and adjusted beta estimates were obtained from linear regression models depicting the associations between perceived intentional transmission, depressive and substance use symptoms, self-efficacies for condom use, HIV disclosure and negotiation of safer sex practices and sexual compulsivity (continuous outcomes). Multivariable analyses adjusted for age (continuous), race (Black, other vs White), ethnicity (Hispanic vs Non-Hispanic), education (less than high school, high school graduate, some college vs finished college/graduate school), monthly income ($0–$500, $501–$1000 v. >$1000) and employment (yes vs no).
Overall, 44% (n=151) of the study population reported perceiving intentional HIV transmission. Statistically significant differences existed by age, race, education, relationship status, viral suppression, disclosure of HIV status to the participant, depressive and substance use symptoms, self-efficacy for HIV disclosure and sexual compulsivity comparing participants who perceived intentional transmission and those who did not (table 1).
Online supplementary table 1 displays the associations between perceived intentional transmission, viral load and psychosocial outcomes. After adjusting for sociodemographic characteristics, men who perceived intentional transmission had 69% higher odds (adjusted OR: 1.69; 95% CI 1.01 to 2.83) of being at risk for clinical depression; on average, scored approximately 3 points higher (adjusted β: 3.29; 95% CI 0.42 to 6.15) on depressive symptoms, and 4 points higher (adjusted β: 3.74; 95% CI 1.32 to 6.17) on sexual compulsivity, compared with men who did not.
Supplementary file 1
According to our knowledge, this is the first study to examine the association between perceived intentional transmission, viral suppression and psychosocial outcomes. We found that close to half of the population perceived intentional transmission of HIV, even though previous research has suggested that actual intentional transmission of HIV is rare.w12 This finding may have important implications for how intervention programmes are designed for MSM living with HIV.
Men who perceive intentional transmission were more likely to score higher on depressive symptoms. This finding may be due to the distress that may come with perceiving that HIV was transmitted intentionally. However, due to the cross-sectional nature of the study, it is also possible that men who were initially more depressed were more likely to have a negative outlook and report intentional infection.
Men who perceived intentional transmission were also more likely to score higher on sexual compulsivity. Men who thought they were intentionally infected may use sexually compulsive behaviour as a coping mechanism for perceiving intentional transmission and deflecting responsibility of contracting HIV.
Moskowitz suggested that attributing HIV infection to less likely modes of transmission, such as oral or other non-anal intercourse sexual behaviours, such as semen or blood on sex toys, may be a coping strategy to deflect responsibility of acquiring HIV.w13 Racial/ethnic minority and poorer MSM populations were more likely to attribute their HIV infection to non-anal intercourse sexual behaviours compared with White MSM and those of a higher socioeconomic status.w14 Another reason for attribution of HIV infection to non-anal intercourse sexual behaviours is to deflect the stigma associated with engaging in same-sex anal intercourse, which may be considered a bigger challenge among poorer and racial/ethnic minority MSM populations.w14 The population in the current study consisted of 47% racial minority populations, a quarter had a high school education or less, and majority (59%) earned ≤$100 per month. Therefore, this study population was perhaps more likely to perceive intentional transmission, and men who felt this way may have been more likely to deflect the responsibility of acquiring HIV, were more depressed about living with HIV and used sexually compulsive behaviour as a coping mechanism.
There was no statistically significant association between perceived intentional transmission, viral suppression, condomless sexual intercourse, substance use and self-efficacy. Therefore, while perceived intentional transmission may influence depressive feelings and sexually compulsive behaviour, it might not be linked to behaviours such as viral suppression, substance use and perceived self-efficacy for protective sexual behaviours. Additional research is needed to determine potential pathways and mediators of the associations between perceived intentional transmission and sexual behaviours and outcomes, which may help to explain the statistically significant associations seen and lack thereof.
The findings should be interpreted with caution. Due to the cross-sectional nature of the study, causation cannot be inferred. Data were self-reported, which may result in over-reporting or under-reporting of key variables, which may result in overestimates or underestimates of the ‘true’ association. In addition, there were additional measures that were not collected in the current study, which could have had an impact on the association between perceived intentional transmission, viral suppression and psychosocial outcomes. For example, partner-perception variables such as whether HIV status was fetishised as part of the transmission processw15 and the role of pre-exposure prophylaxis (PrEP). The2se variables are now very important with regards to perception of transmission and condomless sex and should be considered in future studies. The study population consisted of MSM in Midwestern and Southeastern cities in the USA and findings may not be generalisable to all MSM living with HIV.
The study shows that among MSM living with HIV, perceived intentional transmission of HIV is associated with depressive symptoms and sexual compulsivity. Intervention programmes are needed that will target MSM who perceive intentional transmission, should address this perceived vulnerability and aim to attenuate depressive symptoms and sexual compulsivity. Addressing these focal points may help to reduce transmission of HIV, intentional or not. Future research may include qualitative research to delve deeper into the reasons for perceiving intentional transmission of HIV.
The authors would like to thank the men who participated in this study.
Handling editor Jackie A Cassell
Contributors MJB: conceived and designed the study and was involved in the statistical analyses. JMS: assisted in the interpretation of the data. JAK: assisted with the analyses. All authors: revised the manuscript before submission
Funding This study was funded by the National Institute of Mental Health (R01MH082639) awarded to the second author.
Competing interests None declared.
Ethics approval The Ohio State University and University of South Florida Institutional Review Boards (approval numbers: 2008B0259and Pro00006939, respectively).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Additional unpublished data from the study can be obtained by contacting the second author, JMS, at firstname.lastname@example.org.
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