Development and Validation of the Power Imbalance in Couples Scale.

Few researchers have quantitatively explored the relationship power-HIV risk nexus in same-sex male couples. We developed and validated the Power Imbalance in Couples Scale (PICS) to measure relationship power among men in same-sex, committed relationships and its association with sexual risk behaviors. We recruited three independent and diverse samples of male couples in the greater San Francisco and New York City metropolitan areas and conducted qualitative interviews (N1 = 96) to inform item development, followed by two quantitative surveys (N2 = 341; N3 = 434) to assess the construct, predictive, convergent, and discriminant validity of the PICS. Exploratory factor analysis of the first survey's data yielded four factors-overtly controlling partner, supportive partner, conflict avoidant actor, and overtly controlling actor-that accounted for more than 50% of the shared variance among the PICS items. Confirmatory factor analysis (CFA) of the second survey's data supported these four factors: χ2(1823) = 2493.40, p < .001; CFI = .96, RMSEA = .03 and WRMR = 1.33. Strong interfactor correlations suggested the presence of a higher-order general perception of power imbalance factor; a higher-order factor CFA model was comparable in fit to the correlated lower-order factors' CFA: χ2(2) = 2.00, p = .37. Internal reliability of the PICS scale was strong: α = .94. Men perceiving greater power imbalances in their relationships had higher odds of engaging in condomless anal intercourse with outside partners of discordant or unknown HIV status (OR 1.27; 95% CI 1.01-1.60; p = .04). The PICS is an important contribution to measuring relationship power imbalance and its sequelae among male couples; it is applicable to research on relationships, sexuality, couples, and HIV prevention.

Relationship Power Among Same-Sex Male Couples in New York and San Francisco: Laying the Groundwork for Sexual Risk Reduction Interventions Focused on Interpersonal Power.

Research is clear that power differentials between women and men shape women's human immunodeficiency virus (HIV) risks; however, little research has attempted to examine power differentials within same-sex male (SSM) couples and whether these influence sexual risk outcomes. To produce the first quantitative scale that measures power in SSM relationships, the current work was a Phase 1 qualitative study that sought to understand domains of relationship power and how power operated in the relationship among 48 Black, White, and interracial (Black-White) SSM couples recruited from San Francisco and New York. Interview domains were focused on definitions of power and perceptions of how power operated in the relationship. Findings revealed that couples described power in three key ways: as power exerted over a partner through decision-making dominance and relationship control; as power to accomplish goals through personal agency; and as couple-level power. In addition, men described ways that decision-making dominance and relationship control could be enacted in the relationship-through structural resources, emotional and sexual influence, and gender norm expectations. We discuss the implications of these findings for sexual risks and HIV care and treatment with SSM couples that are focused on closing gaps in power.

Sexual behavior and HIV risk among age-discrepant, same-sex male couples.

Research has suggested that men who have sex with men and who have older sexual partners are at increased risk of HIV infection. However, while several studies have explored risk among men in age-discrepant non-primary partnerships, only two have explored age discrepancy and risk in primary same-sex male relationships. We used data from semi-structured in-depth interviews to explore sexual behaviour and HIV risk among 14 Black, white and interracial (Black/white) same-sex male couples with an age difference of 10 or more years. Most couples regularly used condoms, and sexual positioning tended to lead to lower risk for younger partners. Some serodiscordant couples abstained from anal sex, while others used seropositioning to avoid transmission within the relationship. Within some couples, older partners acted as mentors on HIV prevention and broader life lessons. Future studies should further explore the potential risks and benefits of large age differences in same-sex male primary relationships.

Attitudes Towards PrEP and Anticipated Condom Use Among Concordant HIV-Negative and HIV-Discordant Male Couples.

Since the July 2012 approval by the FDA of emtricitabine/ tenofovir disoproxil fumarate (Truvada) for use as pre-exposure prophylaxis (PrEP) against HIV, its feasibility and acceptability has been under study. HIV-discordant couples are likely targets for PrEP but little is known about how this new prevention tool impacts relationships. We examined, among gay male couples, the acceptability of individual and partner use of PrEP and intentions to use condoms with primary and outside partners in the context of PrEP use. Data are from two independent samples of couples recruited in the San Francisco bay area and New York City-a qualitative one (N=48 couples) between March and November, 2011, and a quantitative one (N=171 couples) between June, 2012 and May, 2013. Data were categorized by couple HIV status and general linear models; chi-square tests of independence were used to examine condom-use intentions with primary and outside partners, by sexual risk profile, and race. Almost half of the HIV-negative couples felt PrEP was a good HIV prevention strategy for themselves and their partner. Over half reported that they would not change their current condom use if they or their partner were taking PrEP. However, approximately 30% of HIV-negative couples reported that they would stop using condoms or use them less with primary and outside partners if they were on PrEP or if their partner was on PrEP. A large percentage of couples view PrEP positively. However, to ensure safety for both partners, future programing must consider those who intend not to use condoms while on PrEP.

Health, trust, or "just understood": explicit and implicit condom decision-making processes among black, white, and interracial same-sex male couples.

Among gay and bisexual men, primary partners are a leading source of HIV infection. Trust, intimacy, and advancements in HIV treatment may impact same-sex male (SSM) couples' decisions to engage in unprotected anal intercourse (UAI). This qualitative study explored how Black, White and interracial couples discussed, and made decisions regarding condoms. Qualitative interviews were conducted with 48 SSM couples in the New York and San Francisco metropolitan areas. Stratified purposive sampling was used to include Black (n = 16), White (n = 17), and interracial (Black-White) (n = 15) couples. Twenty-six couples were concordant HIV-negative and 22 were HIV-discordant. Interviews were recorded, transcribed, coded, and analyzed using a grounded theory approach. Some couples described explicit processes, which involved active discussion, while others described implicit processes, where condom-use decisions occurred without any explicit discussion. These processes also differed by race and HIV status. Black couples tended to report condom-use as "just understood." White, HIV-discordant couples decided not to use condoms, with some identifying the HIV-positive partner's suppressed viral load and high CD4 count as deciding factors. After an unplanned episode of UAI, White, HIV-negative couples tended to discontinue condom use while Black HIV-negative couples decided to revert to using condoms. HIV prevention efforts focused on same-sex, male couples must consider the explicit/implicit nature of condom decision-making processes. Understanding differences in these processes and considering relationship dynamics, across race and HIV status, can promote the development of innovative couple-level, HIV prevention interventions.