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Try out PMC Labs and tell us what you think. Learn More. Few studies have examined risk-reduction alternatives to consistent condom use for HIV prevention among heterosexual young adults. We used qualitative methodology to explore risk reduction strategies and contextual factors influencing attempts to reduce risk in an urban, high morbidity sexually transmitted infection STI clinic. Groups were audio recorded, transcribed verbatim, and analyzed for thematic content using Atlas. Many men and women used implicit risk assessment strategies due to mistrust or difficulty communicating.

Concurrency was common but rarely discussed within partnerships. Despite attempts to reduce risk, monogamy agreements were often poorly adhered to and not openly discussed. Alcohol and substance use frequently interfered with safer sexual decisions. Negotiated safety agreements have been described among men who have sex with men MSM as strategies for selectively practicing condomless anal intercourse CAI while maintaining sexual pleasure and intimacy within relationships.

Research among STI clinic attendees has indicated that patients often misjudge their partners' past and current risk behavior 22 and sexual exclusivity. However, the extent to which concurrency is discussed explicitly in the context of primary heterosexual relationships is relatively unknown. For MSM and heterosexuals, the potential effectiveness of monogamy agreements or negotiated safety may depend on whether the agreement is explicit or assumed; adhered to by both partners; and whether condoms are re-introduced if risk occurs.

Different types of agreements may offer different levels of protection, and may be modified by individual and couple-level characteristics, such as intimacy, partner-provided support, and health protective communication. Since the majority of new HIV infections are transmitted in the context of primary relationships, 4 , 5 understanding ways in which young people negotiate sexual safety within relationships is crucial for effective intervention development.

An extension of the Information-Motivation-Behavioral Skills IMB model 29 , 30 serves as a useful theoretical framework for understanding sexual risk behavior within the context of relationships. In the traditional IMB model, HIV prevention information, motivation as determined by attitudes and social norms to engage in behavior , and behavioral skills such as condom self-efficacy and health protective communication, are integral in predicting protective behavior.

In the relationship-oriented IMB model, within couples, behavioral skills are dependent on the frame of reference of the established relationship and safer sex negotiation skills are contextually dependent. Motivation to engage in safer sex behavior is related to shared social norms, beliefs, and attitudes within the couple rather than solely at the individual level. The goal of this study was to gain in-depth information on contextual and relationship-level influences on sexual decision making and use of risk-reduction strategies among heterosexual STI clinic patients.

We conducted focus groups to gain perspectives on use and motivations for sexual agreements and other risk-reduction strategies and the role of relationship dynamics in negotiation of sexual risk among heterosexual young adults. Focus groups were conducted at the Ruth M.

Eligibility included being between the ages of 18 and 29, heterosexually self-identified, and having had a sexual relationship with a person of the opposite sex in the 6 months. Interested participants who met inclusion criteria were invited to participate and provided informed consent and contact information to receive reminder information prior to the groups.

Focus group guides used a semi-structured format to collect in-depth information on participant perspectives on relationships and concurrency and how these perspectives and cultural and contextual factors influence sexual risk behavior. Focus groups were audio-recorded and transcribed verbatim by an external professional transcription service, and all groups were led by the same facilitator and moderator. Focus group questions were generated from prior formative work, in which semi-structured interviews were conducted with the target population at the clinic to refine content.

Only the from the focus groups are presented here. Topics included types of relationships, discussion and practice of risk reduction strategies, including condom use and monogamy agreements, perspectives on monogamy and concurrency, and factors influencing decisions about condom use and other risk reduction practices. We also sought to determine whether and how use of different strategies varied according to contextual, partner, and relationship factors.

Common definitions of concurrency and monogamy were specified prior to initiating discussion of these topics. Participants filled out a brief, anonymous, quantitative survey prior to beginning the focus groups. Surveys collected information on sociodemographics, STI including gonorrhea, Chlamydia, trichomoniasis, syphilis, genital herpes, or genital warts and HIV testing history, and sexual behaviors in the past 6 months. Focus group transcripts were reviewed for accuracy and analyzed using directed qualitative content analysis.

The group moderator and facilitator met with the principal investigator after each focus group to discuss themes that emerged, and to identify and troubleshoot any issues that arose during the groups. Focus group transcripts were coded according to the coding guide and analyzed for thematic content based on an iterative inductive and deductive process 33 using ATLAS. Open coding was employed to identify themes not included in the original coding guide. After the initial analysis, coded transcripts were reviewed for consistency and codes were refined and grouped into themes and subthemes.

Descriptive analyses of the quantitative survey data, including measures of central tendency and frequencies, were conducted using SAS software version 9. Fisher's exact chi-square tests were used to compare sexual behaviors by relationship status and use of monogamy agreements.

A total of seven groups four female groups and three male groups were conducted with 20 women and 13 men. Several major themes emerged from the focus groups, including use of risk assessment and risk reduction strategies, difficulties communicating with partners, and influences on risk behavior and sexual safety. These themes and sub-themes are discussed below. Many participants discussed use of implicit assumptions about risk, including situational factors and partner characteristics, and some used these assumptions to make decisions about sexual behavior.

So I said oh he's less risky, okay, which is not smart. But that's what I did and do some sort of assessment of how risky this person is. Assessment of partner's risk was not always straightforward, and the directness of the discussion varied according to the type of relationship. Many reported not wanting to get into a discussion of sexual history with partners until they knew them better, opting to just use condoms with casual partners or one-night-stands, although some felt it was important to have these discussions with all partners at the beginning of the relationship.

Use of risk reduction strategies varied according to the type of partner and the relationship, and included selective condom use with casual partners and those perceived to be higher risk, and frequent HIV and STI testing.

I just assume it [that the partner is higher risk], no need to ask, which automatically means protection. Frequent testing was used even in committed relationships, and was often related to lack of trust in one's partner. Consistent with other studies, concurrency was very common for both men and women, although there were gender differences in how concurrency was viewed. Several participants, particularly those in committed relationships, reported monogamy agreements with their sexual partners, though these were often defined and viewed differently depending on the context, and agreements were more commonly reported by women than by men.

Some assumed monogamy as part of certain types of relationships. However, there was often a transition to monogamous relationships that happened over the course of a relationship: many began with dating relationships and maintained other relationships until they were sure of their commitment. Participants varied in the extent to which they believed monogamy was actually occurring. I think the end game is to be in a relationship, …, but it's [cheating, concurrency] something that you know that happens. Both men and women identified a need for clear discussion and establishing expectations about exclusivity within relationships, though this was often difficult to actualize for these young adults.

I think what makes them bad is there are expectations on both sides, and the expectations weren't clear. Women also described frustration with lack of honesty in defining the relationship. I always tell them let's get tested together because if this is what we are going to do and call it a booty call let's call it what it is, like it's fine.

You know. Then she go and do it. It's like a sequence of like what she saying, you gotta be honest. Several women described waiting for a better relationship, while not wanting to be alone or give up the benefits of their current relationship, and thus accepting non-monogamy despite wanting a monogamous relationship. Both men and women described benefits of different types of relationships, and many maintained several relationships because they got different benefits from each, such as money, sex, cars, and friendships. So it all depends on what this person have. Both men and women reported substantial difficulty communicating with partners.

Several women brought up the issue of feeling uncomfortable being proactive about asking their partners about sexual history and condom use. Men and women also reported waiting for the other person to start the conversation, and assuming that the other partner would bring up any issues if necessary. Female participants identified a need for better tools for communicating and boundary setting, and for alternative strategies for condom use and safer sex negotiation when their partner did not respond the way they expected. Women also worried about making their partner mad or losing the relationship as reasons for not insisting on safer sex if their partner didn't want to use condoms.

Now you gotta come to the clinic to make sure you didn't think you didn't use your better judgment. Both men and women discussed the importance of fitting in with peers, and the influence of the social environment in endorsing norms about sexual behavior and risk.

Some men also discussed the role of media and music in shaping youth culture around sex. I grew up seeing my brother or sisters do this. I thought it was cool to have one, two, or three boyfriends and so they try to sneak around. It's just something that I see. However, they often used implicit risk assessment strategies because of mistrust or difficulty with communication. Sexual concurrency was viewed as common but was rarely discussed within partnerships.

Overall, there was a disconnect between knowledge, intentions, and behavior. Participants distinguished between ideal relationships and reality, and partners often met monetary and emotional needs; desire to have someone to come home to and fear of being alone were cited by several participants as reasons for staying with a partner even when the partner was unfaithful.

Having sex under the influence of alcohol and substances and emotions often interfered with making safer sexual decisions, highlighting the importance of substance use counseling as a component of sexual risk reduction interventions. Despite attempts to reduce risk, monogamy agreements were often not openly discussed, and intentions to practice sexual safety were not necessarily reflected in sexual behaviors.

Given these findings, risk reduction interventions that incorporate dyadic communication and negotiation of sexual safety within the context of existing relationships may be useful. Developing effective behavioral interventions for STI clinic patients remains a challenge but is urgently needed given the high burden of infection in this population. A recent behavioral risk reduction intervention, based on the Project RESPECT framework, found no impact of patient-centered individual level behavioral risk reduction counseling on risk of subsequent STI among heterosexual men and women receiving HIV testing and counseling.

Incorporating dyadic and psychosocial influences may be areas of focus for future intervention development. There has been little research to date on the use of risk-reduction practices other than condom use among heterosexual youth. These findings are consistent with reports from our study. Encouraging young women to identify alternative ways to satisfy unmet psychosocial needs outside of their sexual relationships, such as through social support from friends or other mentors, may help to empower them to more effectively negotiate safer sex within their romantic relationships.

Furthermore, providing women with alternative support systems and skills to apply in such situations to accept undesirable outcomes, such as the partner leaving or being angry, may help them to more effectively manage tension related to negotiation of condom use and thereby reduce their vulnerability. Both men and women identified social norms and peers as important influences sexual behavior.

Understanding which specific aspects of the social environment have the most impact on sexual behaviors, whether positive or negative, warrants further research. STI stigma and shame have been associated with lower odds of STI testing and lower likelihood of informing non-main partners and providing partner delivered therapy among African-American men. Limitations to the study include the small sample size and single recruitment site, which may limit the generalizability of the findings.

Frequent testing as a risk reduction strategy may not be used by participants recruited from other settings. Transcripts were coded and analyzed by a single coder and were not validated across multiple coders, which could have introduced bias in interpretation of the . The sensitive nature of the information collected and group setting may have made participants less likely to report certain behaviors, though were consistent with prior work by our group and other published literature.

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