HIV-Related Attitudes and Intentions for High-Risk, Substance-Using Men Who Have Sex With Men: Associations and Clinical Implications for HIV-Positive and HIV-Negative MSM

This study compared HIV-related attitudes and intentions by respondent HIV-status in a large sample of substance-using men who have sex with men (MSM) in the United States. Attitudes and intentions included self-efficacy for safer sex; difficulty communicating with sex partners about safer sex; intent to use condoms consistently and to not use substances before sex in the next 3 months; and less concern for HIV given effective antiviral treatments. Differences were found for behavior during the most recent anal sex encounter by HIV-status, including (a) insertive and (b) receptive anal sex risk behavior, and (c) substance use before or during the encounter. Self-efficacy for safer sex was associated with less risk behavior among HIV-negative men but not among HIV-positive men, suggesting that self-efficacy for safer sex continues to be a relevant issue to address in counseling uninfected MSM. HIV-positive men who reported less concern for HIV given treatments were more likely to report receptive risk behavior, as were HIV-negative men who reported difficulty communicating about safer sex. Implications are discussed for potentially heightened client desire and therapeutic opportunity to reduce future substance use during sex for clients who report recent substance use during sex. Keywords: HIV; sexual risk; substance use; MSM; cognitive domain HIV infection continues to be a concern in the United States and around the world, with estimated annual new infections at approximately 56,300 (Hall et al., 2008) and 2.7 million (Joint United Nations Programme on HIV/AIDS, 2009), respectively. Men who have sex with men (MSM) continue to be the dominant risk group of new infections in America (Hall et al., 2008), accounting for 53% of all new US infections, and MSM are at heightened risk for infection, compared to heterosexuals, even in low- and middle-income countries (Baral, Sifakis, Cleghorn, & Beyrer, 2007). Although effective medical treatments have existed since the mid-1990s, in the absence of an effective vaccine, behavioral prevention counseling continues to be key to decreasing the spread of HIV infection. Most behavioral interventions, whether for affective disorders or health behaviors, view the therapeutic process in terms of the client's cognitive framework for understanding his own behavior and behavior change (Beck, 1995). This has also been the case for the general area of preventive health behavior. Behaviors ranging from smoking cessation to radon screening have been examined in terms of perceived personal vulnerability to negative outcomes (Weinstein, 1989), self-efficacy expectancies for engaging in precautionary behavior (Bandura, 1991), outcome expectancies about the effectiveness of behavioral change, health beliefs, and related cognitive processes (Harvey & Lawson, 2009; Weinstein, 1993). Similarly, a variety of health promotion programs have incorporated basic attitude models, which focus on the development or change of behavioral intentions. Intentions are seen as a stable cognitive set toward a behavioral domain, derived from beliefs about a behavior and its outcomes, affective value for the behavior or outcome, and perceived norms of others (Ajzen, 2001; Fishbein & Middlestadt, 1989). Since the first HIV/AIDS cases were identified, understanding and reducing risk behavior- particularly sexual risk behavior-has been a primary focus of researchers and practitioners. Consistent with other areas of health promotion, HIV prevention has emphasized cognitive processes such as perceptions, beliefs, attitudes, and behavioral intentions (e.g., The Health Belief Model [Bakker, Buunk, Siero, & Van den Eijnden, 1997; Janz & Becker, 1984]; The Theory of Reasoned Action [Ajzen & Fishbein, 1980; Fishbein & Middlestadt, 1989]; and Social Cognitive Theory [Bandura, 1986; Forsyth, Carey, & Fuqua, 1997]). Specific counseling or behavioral program components based on these social-cognitive approaches have included (1) simple knowledge about HIV or HIV transmission, (2) self-efficacy for safer sex, (3) perceived difficulty communicating with partners about safer sex, (4) perceived severity of HIV given that effective medical treatments exist, and (5) intentions to engage in safer sex in the future. …