AIDS and Behavior, Vol. 8, No.

4, December 2004 (

C 2004)

DOI: 10.1007/s10461-004-7322-5

Predictors of Unprotected Anal Intercourse Among

HIV-Positive Latino Gay and Bisexual Men

Paul J. Poppen,1,2 Carol A. Reisen,1 Marı́a Cecilia Zea,1 Fernanda T. Bianchi,1

and John J. Echeverry1

Received July 16, 2003; revised March 31, 2004; accepted April 12, 2004

This study examined sexual behaviors in a sample of 155 HIV-positive Latino gay and bi-
sexual men. Nearly half the sample had engaged in unprotected anal intercourse in the past
12 months; unprotected anal intercourse was more likely when the partner was also HIV-
positive. Separate regression models predicted the number of receptive and insertive part-
ners for unprotected anal intercourse. Participants reported both more unprotected insertive
and receptive partners if they had sex under the influence of alcohol or drugs. Older partici-
pants and those with lower levels of Latino acculturation reported having more partners with
whom they took the receptive role during unprotected anal intercourse, whereas those with
higher levels of depression reported having more partners with whom they took the insertive
role. Hierarchical set logistic regression revealed that the dyadic variable of seroconcordance
added to the prediction of unprotected anal sex with the most recent male partner, beyond
the individual characteristics. Results show the importance of examining both individual and
dyadic characteristics in the study of sexual behavior.
KEY WORDS: Latino; MSM; HIV-positive; sex risk.

INTRODUCTION one partner is HIV-positive, a situation in which

Men who have sex with men (MSM) continue
to represent the largest number of new HIV cases
annually in the United States, accounting for more
than 40% of all new cases (CDC, 2002). Condoms
greatly decrease the likelihood of sexual transmission
from an infected partner: consistent and correct use
of condoms is estimated to reduce the risk of trans-
mission by at least 70% and perhaps as much as 95%
(Pinkerton and Abramson, 1997). Condoms continue
to be a critical tool for HIV prevention, but on many
occasions they are not used. It is important, there-
fore, to understand factors and processes associated
with having sex without a condom—especially when
1 George Washington University, Washington, District of
Columbia.
2 Correspondence should be directed to Paul J. Poppen,
Department of Psychology, 2125 G Street, NW, George
Washington University, Washington, District of Columbia 20052;
e-mail: pjp@gwu.edu.
there is actual risk. The current paper examines
unprotected anal sex in a sample of HIV-positive
Latino MSM.
Latinos are an ethnic group affected by HIV
disproportionately, with incidence rates nearly four
times those of non-Latino whites (CDC, 2002). Male
same-sex sexual contact is a common means of trans-
mission for Latinos: more than half of the Mexican,
Cuban, Central and South American men with AIDS
in this country contracted the virus from an infected
male sex partner (CDC, 2000).
Despite HIV education and prevention efforts,
the incidence of unprotected anal intercourse re-
mains substantial among MSM, and levels for Lati-
nos seem to be similar to those of other ethnic
groups. Because it is rare to have a random sample
of MSM, estimates of unprotected sex are derived
from convenience samples of differing characteris-
tics, with studies typically reporting percent of par-
ticipants who engage in unprotected anal intercourse
in a given time period. In a recent multi-city study

379
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C 2004 Springer Science+Business Media, Inc.
380
(Boston, Chicago, Denver, New York, San Francisco,
and Seattle) of more than 4,000 HIV-negative MSMs
16 and older, about half of the men had engaged in
unprotected receptive anal sex and slightly more had
engaged in unprotected insertive anal sex in the last 6
months (Koblin et al., 2003). In an ethnically diverse
sample of young men, ages 23–29 (the Los Angeles
Young Men’s Survey), over 30% of respondents had
engaged in unprotected receptive anal sex in the last
6 months, again with a slightly higher percent report-
ing unprotected insertive sex (Bingham et al., 2003).
Latinos were similar in incidence of unprotected sex
to African Americans and non-Latino whites. In an-
other ethnically diverse sample, from Texas, over
half reported engaging in unprotected anal sex dur-
ing the past month, with 45% of the Latino subsam-
ple reporting at least one episode (Lye Chng and
Geliga-Vargas, 2000).
Marks et al. (1999) reviewed studies that exam-
ined sexual risk behaviors of individuals who knew
they were HIV-positive. In studies of MSM, esti-
mates of unprotected anal sex ranged from 10%
in the last 2 months in a sample from Los Ange-
les HIV outpatient clinics to nearly 60% in the last
year in a San Francisco study of young men. In the
Chicago MACS and AIM intervention, no differ-
ences were found in the proportion of HIV-positive
and HIV-negative men reporting unprotected anal
intercourse (Ostrow et al., 1999); however, Lye Chng
and Géliga-Vargas (2000) found that HIV-positive
men were more likely to have unprotected sex than
HIV-negative men.
Understanding Unprotected Anal Intercourse
for HIV-Positive MSM
Much research has addressed factors associ-
ated with having unprotected anal intercourse, but
most has focused on those who are HIV-negative.
Theoretical models have emphasized an individual’s
perceptions, beliefs, experiences, feelings, and demo-
graphic characteristics as predictors of sexual risk-
taking (e.g., Becker and Joseph, 1988; Catania et al.,
1990; Fisher and Fisher, 2000), and most empirical
studies have tested the relationship between these
individual-level constructs and unprotected anal in-
tercourse. Thus, research has typically addressed the
association between fairly stable personal character-
istics or traits and unprotected sex.
It is important to note, however, that sexual be-
havior can vary depending on circumstances (Bajos
and Marquet, 2000; Corbin and Fromme, 2002). We
Poppen, Reisen, Zea, Bianchi, and Echeverry
believe that a fuller understanding of the dynam-
ics influencing unprotected anal intercourse requires
an examination of the characteristics of the dyadic
context, not just of the individual. Factors such as
the relationship and seroconcordance vary with the
partner, and the same individual may behave differ-
ently depending on the circumstances. In addition,
it is critical to identify factors that are associated
with unprotected anal intercourse for HIV-positive
MSM. Kalichman (2000) argued that interventions
to change sexual risk behaviors of HIV-positive men
must differ from those for HIV-negative men, be-
cause the factors associated with continuing risk
practices vary in the two groups. In this paper, we
examined unprotected anal intercourse in relation to
characteristics of both the individual and the dyad in
a sample of HIV-positive men.
Demographic Factors
HIV is not evenly distributed across socioeco-
nomic strata, and many studies have examined demo-
graphic factors in relation to unprotected sex. Vari-
ables such as education and age have been shown to
covary inconsistently with sex risk. Lower levels of
education have been associated with greater likeli-
hood of unprotected anal intercourse in some sam-
ples of MSM (Janssen et al., 2000; Kalichman et al.,
1998). There is also some support for the contention
that younger men are more likely to engage in un-
protected sex (McAuliffe et al., 1999); however, other
studies have failed to find this relationship (Ekstrand
et al., 1999).
Depression
Another predictor of unprotected anal sex that
has been examined is depression. Although most the-
ories posit that negative mood states would be as-
sociated with more sexual risk-taking (Marks et al.,
1998a; Strathdee et al., 1998), the argument has
also been made that depression would be associated
with greater caution and therefore less risk-taking
(Frijida, 1988). Empirical studies have yielded in-
consistent findings, and recently Crepaz and Marks
(2001) concluded from a meta-analysis that there was
little evidence that depression was related to greater
sexual risk-taking. There were, however, substantial
correlations—both positive and negative—among
the studies included in this meta-analysis, thus cre-
ating a mean effect size near zero. This situation
Unprotected Anal Sex and HIV-Positive Latino Men
could indicate that the relationship between depres-
sion and sexual risk is dependent on other factors,
including characteristics associated with the partner
or the dyadic context of the sexual encounter.
Acculturation
Another factor relevant for immigrant groups
is acculturation, the process of acquiring beliefs and
behaviors from a new culture, while preserving or
modifying traditions of the culture of origin. Latinos
in the US have attitudes, beliefs, and expectations
stemming from their US and Latino cultures to vary-
ing degrees. Cultural norms and scripts about sex-
ual behavior and romantic love from both cultures
can influence sexual behavior and condom use (Dı́az,
1998).
Level of acculturation into the US has been
shown to be associated with sexual attitudes and
behavior in samples of Latinos (Marı́n et al., 1998;
Mason et al., 1995). Marks et al. (1998b) found that
Latinos who were more acculturated into US soci-
ety had higher levels of sexual risk than did less ac-
culturated Latinos. On the other hand, San Doval
et al. (1995) found that more acculturated Latinos
had more positive attitudes toward condoms.
Substance Use
Although the evidence is not consistent (e.g.,
Leigh and Stall, 1993; Stall and Purcell, 2000), many
studies have reported an association between alco-
hol or drug use and unprotected sex (e.g., Dolezal
et al., 1997; Ross et al., 2001). In the research liter-
ature, substance use is often treated as an individual-
level variable. In these cases, a positive correlation
can be interpreted as showing that people who drink
or use drugs also tend to take sexual risks. In con-
trast, other studies examine substance use occurring
in conjunction with the sexual encounter and pro-
vide a more compelling test of a causal relationship
(Dolezal et al., 2000; Hays et al., 1997b; Kelly and
Kalichman, 1998; Stall et al., 1986). The presence of
alcohol and drugs can then be seen as part of the con-
text in which the dyad is acting.
Serostatus
Serostatus is assessed on the individual level,
but can be used to characterize the individual or
381
the dyad. As an individual characteristic, it affects a
person’s motivation for protected sex. HIV-negative
men may be motivated to protect themselves and
avoid potential infection with HIV, as well as other
STDs. HIV-positive men may also be motivated to
protect themselves from additional strains of the
virus or other STDs; however, this risk is usually per-
ceived as less threatening (Kalichman, 2000). In con-
trast, a primary reason that many HIV-positive men
use condoms is to protect their sexual partners, not
themselves (Wenger et al., 1994).
As a dyadic characteristic, the issue concerns
seroconcordance, the match or mismatch of the
serostatus of the partners. Hays et al. (1997a) re-
ported that HIV-positive seroconcordant couples
had the highest incidence of unprotected anal in-
tercourse, followed by HIV-negative seroconcor-
dant couples. In this situation where partners have
the same serostatus, a “negotiated safety” can
be achieved regardless of the use of condoms
(Davidovich et al., 2000). When one partner is HIV-
positive and the other HIV-negative, however, the
perceived risk of transmission is higher, and as would
therefore be expected, reported rates of unprotected
sex are lower (Hays et al., 1997b). Moreover, dis-
closure of positive serostatus to a partner has been
associated with greater likelihood of unprotected
sex when the partner was also positive, but lower
likelihood of unprotected anal intercourse when the
partner was negative, in both Latino (Marks et al.,
1991) and mixed ethnic samples (DeRosa and Marks,
1998).
Relationship With Partner
The dyadic characteristic of relationship be-
tween partners has consistently been associated with
sexual risk behavior. Among MSM, there have been
many reports of higher rates of unprotected anal
intercourse between more committed partners than
between less committed partners (e.g., Davidovich
et al., 2000; Elford et al., 2001; Hays, Kegeles et al.,
1997; Lye Chng and Geliga-Vargas, 2000). Moreover,
this association has also been found in studies doing
within-subject comparisons (Buchanan et al., 1996;
Carballo-Diéguez et al., 1997; Myers et al., 1999):
Thus, a man is more likely to have unprotected
sex with his primary partner than with his casual
partners.
There are several reasons that might explain the
influence of relationship status on sex risk behaviors.
382
Men may feel emotionally safer with their pri-
mary partners, regardless of actual risk of transmis-
sion (Remien et al., 1995). Among primary part-
ners, serostatus of both partners is often known, and
knowledge of seroconcordance can lead to a decision
to forego condom use (Kippax et al., 1993). More-
over, qualitative studies have suggested that con-
doms are sometimes seen as a barrier to intimacy
and are therefore not used by committed couples
(Flowers et al., 1997).
Models to Predict Unprotected Anal Intercourse
The current study examined sex without con-
doms in several ways. We described rates of unpro-
tected anal intercourse in our sample of HIV-positive
Latino MSM. We also tested models predicting the
number of insertive and receptive partners for un-
protected anal intercourse during the last 12 months.
Predictors included the following individual char-
acteristics: age, education, depression, acculturation
into the US, alcohol and substance use, and whether
the respondent had a main partner. We hypothesized
that younger age, less education, and more substance
use during sex would be associated with having more
unprotected anal sex partners. In addition, we antic-
ipated that men who had a main partner would have
a lower number of partners for unprotected anal in-
tercourse in the past year. We included measures of
depression and acculturation in Latino culture, but
we did not have directional hypotheses due to mixed
findings in the literature.
In addition, we tested a model predicting unpro-
tected anal intercourse with the most recent sexual
partner using both dyadic and individual factors. We
hypothesized that the inclusion of the dyadic factors
of seroconcordance and relationship between part-
ners would add significant explanatory power beyond
the individual factors of education, age, Latino accul-
turation, depression, and substance use during sex.
Moreover, we hypothesized that there would be a
greater likelihood of unprotected anal sex with HIV-
positive partners, who would therefore be serocon-
cordant with our HIV-positive respondents, and with
main partners.
METHODS
Procedure
Data for this study were collected as part of
a larger study on disclosure of HIV-positive sta-
Poppen, Reisen, Zea, Bianchi, and Echeverry
tus of Latino gay men conducted in Washington,
DC and New York City (Zea et al., 2004). Latino
HIV-positive gay and bisexual men represent a hid-
den population that cannot be accurately enumer-
ated, and therefore it is impossible to derive a truly
representative sample of the whole population. We
used a variety of approaches described in the liter-
ature as effective with hidden populations, includ-
ing targeted sampling, key informant sampling, and
snowball sampling (Carlson et al., 1994; Watters and
Biernacki, 1989). Recruitment took place throughout
the community at clinics, community organizations,
public events (e.g., Pride Day and AIDS Walk), gay
businesses, clubs, and bars. We used flyers and adver-
tisements, as well as direct appeals, to inform poten-
tial participants about the study. Screening was based
on the following inclusion criteria: being 18 years or
older, HIV-positive, Latino, male, and self-identified
as gay or bisexual. Some screening was done at the
time of the direct appeals, and for these cases, we
do not have information to estimate eligibility or re-
fusal rates. Other screening was done when prospec-
tive participants called to inquire about the study in
response to flyers and advertisements. Of those call-
ing in, 80% met the criteria for eligibility; of these,
62% completed interviews.
Participants completed a survey in either Span-
ish or English. Existing measures were translated
from English into Spanish and translated back using
the procedures suggested by Brislin (1986) and Marı́n
and Marı́n (1991) to ensure equivalence. A panel of
experts from different Spanish-speaking countries re-
viewed the resulting Spanish version to eliminate re-
gional expressions that would not be universally rec-
ognized by Spanish speakers.
The survey was administered using computer
assisted self-interview technology (Audio-CASI). A
native Spanish speaker provided instruction in the
use of computers for the survey and was available
throughout the administration to answer any ques-
tions. Surveys were administered either in small
groups or individually, according to the preference
of the participant.
Responses were indicated by touching the com-
puter screen, therefore computer skills were not
required. Moreover, participants with reading dif-
ficulties could listen to the audio presentation of
the questions and answers. About 87% responded
to the survey in Spanish. Participants were reim-
bursed for their participation in the study and given
a list of resources for HIV/AIDS services in their
area.
Unprotected Anal Sex and HIV-Positive Latino Men
Participants
Participants were 155 HIV-positive Latino gay
men ranging from 18 to 67 years of age, with a mean
38.5 years; 57% were recruited in New York City and
43% in Washington, DC. Fifty-one percent had edu-
cation beyond high school, attending or graduating
from trade school or college, while 49% had high
school education or less. (This dichotomization was
used in later model testing.) Seventy-six percent of
the sample earned less than $800 per month.
About 90% of the participants were immigrants,
with 40% coming from South America, 26% from
the Caribbean, 20% from Central America, and 13%
from Mexico. Forty-nine percent of the 140 immi-
grants came to the US before age 25. Among a list
of reasons for coming to the US, the most frequently
endorsed were to improve financial situation (46%),
to live a homosexual life more openly (34%), and to
get HIV medication (26%).
The samples from Washington and New York
were comparable, but differed in a few ways. Al-
though there were no significant differences in ed-
ucation, the New York participants were older and
had lower income, with a larger proportion receiving
some form of government aid (75% vs. 35%). In ad-
dition, a greater proportion of the DC sample came
from Central America, while a greater proportion of
the NY sample came from South America and the
Caribbean.
Measures
Sexual Behavior
We asked questions about sexual behaviors in
the last 12 months, in the last 30 days, and with
the most recent partner. For the period of the last
12 months, we asked participants to indicate the
number of male partners with whom they had had
anal sex without a condom and the number of fe-
male partners with whom they had had anal or vagi-
nal sex without a condom. For the previous 30 days,
we asked whether the participants had sex in con-
junction with alcohol or other drugs. We also asked
about sexual behaviors with the most recent partner,
including whether participant had ever had unpro-
tected anal intercourse with that person. The main
outcome variables for this study were the number of
partners for anal intercourse without a condom in the
last 12 months with whom the participant took the re-
383
ceptive role and with whom the participant took the
insertive role. In addition, anal intercourse without
a condom with the most recent partner was a main
outcome.
Partner Variables
To determine partner status, participants were
asked if they currently had a main partner. A main
partner was defined as a person with whom the par-
ticipant had “an ongoing intimate sexual and emo-
tional relationship.” The value 1 was given to those
with a current main partner, 0 to those without. In
order to characterize the dyadic characteristics of the
most recent sexual encounter, participants were also
asked the serostatus of the most recent partner, as
well as whether that partner was their main part-
ner. Two dichotomous variables were created: most
recent partner was main partner (vs. not) and dyad
was seroconcordant (both positive vs. discordant or
unknown concordance).
Latino Acculturation
Latino acculturation reflects the degree to which
participants have retained or internalized Latino cul-
ture, regardless of whether they were born in Latin
America or the US. Latino acculturation was as-
sessed with 11 items adapted from a scale developed
by Zea et al. (2003), which measures three aspects
of acculturation: language competence (e.g., “How
well do you speak Spanish on the phone?”), cultural
identification (e.g., “I feel that I am part of
culture”), and cultural knowledge (e.g., “How well
do you know history?”). Audio-CASI pro-
gramming enabled us to substitute the name of the
appropriate country of origin for each participant in
the blanks indicated above. For example, a partici-
pant from Colombia would be asked, “How well do
you know Colombian history?” The response format
was a 4-point Likert scale, with higher scores indi-
cating greater Latino acculturation. The Cronbach’s
alpha for this sample was .77.
Depression
The short form of the Beck Depression Inven-
tory (Beck and Beck, 1972) was administered as the
measure of depression. This 13-item scale has been
384 Poppen, Reisen, Zea, Bianchi, and Echeverry

used with Spanish-speaking populations (Zea et al.,
1996, 1999). The measure had an internal consistency
of .89 in the current study. Higher scores indicated
greater depression, and a score of 16 represents the
criterion for clinical depression.
Substance Use
Two separate questions asked how often the re-
spondent had sexual relations under the influence of
alcohol or of drugs in the past 30 days. These ques-
tions were combined into a single dichotomous vari-
able indicating whether the respondent had sex un-
der the influence of either alcohol or drugs at least
once during this period (coded as 1), versus not at
all (coded as 0). This variable is a measure of alcohol
and drug use in conjunction with sex, but it is not as-
sociated with a particular episode between partners.
Therefore, it provides information about the individ-
ual behavior but not about any specific dyadic en-
counter.
RESULTS
tire sample of 155 men, which includes those who did
not have any sex in the last 12 months. It is note-
worthy that the distribution of number of part-
ners is highly skewed, and therefore, the means are
considerably higher than the medians.
With the most recent partner, about a third have
had unprotected anal intercourse. Unprotected sex
was much more likely, however, when there was se-
roconcordance. When the partner was HIV-negative
or of unknown serostatus, over three-quarters of the
participants reported always having protected sex
with that partner. In contrast, when both partners
were HIV-positive, slightly less than half reported al-
ways having protected sex.
As can be seen in Table I, a substantial propor-
tion (about two-fifths) of the total sample had a cur-
rent main sexual partner. In general, the participants
were not depressed; despite the challenge of having
a chronic illness, less than 10% scored above the cri-
terion score for clinical depression. About a fifth of
all participants reported using alcohol or using drugs
in conjunction with sex in the last 30 days. A sub-
stantial number (14%) reported having engaged in
sex in order to obtain drugs or money since testing
HIV-positive.

Descriptive Statistics Models Predicting Number of Unprotected Anal

Over 85% of the sample reported having sex
with a man at least once in the last 12 months and
nearly half reported unprotected anal intercourse
with a man (see Table I). In contrast, only 10%
reported having had sex with a woman in the last
12 months, with about half of those reporting un-
protected sex episodes. Table I is based on the en-
Sex Partners in the Last 12 Months
Analyses predicting number of male partners
with whom participants reported having had unpro-
tected anal intercourse were performed on the sub-
sample of those who had sex during the preced-
ing 12 months (N = 133). Table II shows separate
regressions for the number of partners with whom

Table I. Reported Sexual Behaviors and Other Characteristics of HIV-Positive Latino MSM
(N = 155)
Engaged in Average number Range of
behavior of partners Median partners
Last 12 months with a man
Any sex at all 85.8% 18.4 4.0 0–200
Unprotected anal insertive 48.4% 5.2 0.0 0–120
Unprotected anal receptive 42.6% 4.0 0.0 0–80
Last 12 months with a woman
Any sex at all 10.3% 0.6 0.0 0–40
Unprotected vaginal 5.2% 0.1 0.0 0–6
Unprotected anal 3.2% 0.2 0.0 0–9
Last 30 days with a man
Sex with alcohol 18.1%
Sex with drugs 12.9%
Has a main partner now 42.6%
Clinical depression 7.7%
Unprotected Anal Sex and HIV-Positive Latino Men 385

Table II. Variables Predicting Number of Unprotected Anal Sex sertive role (F (6, 126) = 2.53, p < .05) and for
Partners, Last 12 Months (N = 132) partners with whom the participant took the
Parameter t-value receptive role (F (6, 126) = 3.33, p < .01). Partic-
Number of unprotected partners with ipants reported both more insertive and more
whom participant took the insertive receptive partners for unprotected sex if they had
role sex under the influence of alcohol or drugs. Partici-
Overall model
F (6, 126) = 2.53, p < .05, R2 = 10.7
pants with higher levels of depression reported hav-
Intercept −.680 −1.90 ing more unprotected partners with whom they took
Education level .038 1.20 the insertive role, whereas those with lower levels
Age .003 0.92 of Latino acculturation reported having more unpro-
Latino acculturation −.113 −1.34 tected partners with whom they took the receptive
Depression 174 2.34∗
Has current main partner −.088 −1.28
role. In addition, older men had more partners with
Used substance during sex .160 2.13∗ whom they were receptive than younger men.
Number of unprotected partners with In the analyses mentioned above, we combined
whom the participant took the alcohol and drug use in a single variable. We made
receptive role this decision because both types of substances can
Overall model
F (6, 126) = 3.33, p < .005, R2 = 13.7
affect level of inhibition and judgment. Moreover,
Intercept −.622 −1.79 the relatively low proportion of participants who re-
Education level −.006 −0.21 ported using substances in conjunction with sex pro-
Age .008 2.26∗ vided another reason to combine variables. In order
Latino acculturation −.164 −2.01∗ to examine the contribution of each variable, how-
Depression .138 1.91
Has current main partner .014 −0.20
ever, we ran follow-up analyses of the models sep-
Used substance during sex .161 2.21∗ arately for drugs and for alcohol. Results indicated
that the significant effect of the combined variable
Note. Signs of coefficients reflect the direction of the relationships
in the raw, untransformed data. was principally, but not solely, due to the influence
∗ p < .05. of drug use.

the participant reported taking the insertive role and

taking the receptive role for unprotected sex. Predic-
tors included education level, age, Latino accultura-
tion, depression, whether participant currently had a
main partner, and whether participant reported us-
ing alcohol or drugs during sex in the last 30 days.
For the most part, predictor variables were uncorre-
lated with one another; the only exceptions were that
older participants were less likely to have main part-
ners and were lower in Latino acculturation, and that
those with greater education were less depressed.
The strength of these relationships was small, with
all Pearson correlation coefficients less than .20.
Because the distributions of the outcome vari-
ables of number of insertive and receptive partners
were heavily, positively skewed (see Table I), an
inverse transformation was used. The skewness ap-
proached zero for the resulting transformed vari-
ables. The kurtosis of the transformed variables was
greatly improved, although the concentration of par-
ticipants with 0 or 1 partner made it impossible to
correct the kurtotis completely.
The overall models predicting number of un-
protected male partners were significant, both for
partners with whom the participant took the in-
Models Predicting Unprotected Anal Intercourse
With Most Recent Partner
Hierarchical set logistic regressions were per-
formed to test whether dyadic variables added sig-
nificantly to the prediction of whether the partic-
ipant had ever had unprotected anal intercourse
with his most recent male partner, beyond the ex-
planatory power of the individual-level variables (see
Table III). In the first step, the individual character-
istic variables of education, age, Latino accultura-
tion, depression, and alcohol or drug use during sex
were entered: the model was not significant. The sec-
ond step involved the entry of the dyadic charac-
teristic variables, reflecting the relationship between
partners (i.e., Was this partner the participant’s main
partner?) and seroconcordance (i.e., Was this part-
ner, like the participant, HIV-positive?). The over-
all model was significant (χ2 (7) = 17.27, p < .05).
In addition, the change in the log likelihood of the
model due to the addition of the dyadic variables
was also significant (χ2 (2) = 20.12, p < .001), indi-
cating the importance of dyadic variables in predict-
ing behavior with the most recent partner. Of the
386 Poppen, Reisen, Zea, Bianchi, and Echeverry

Table III. Logistic Set Regression Predicting Unprotected Anal these men are demonstrating a sense of responsibility
Sex With Most Recent Partner (N = 132) about not endangering others who are uninfected.
Model −2 log L Overall model Our findings indicated that those participants
Set 1: Individual variables −137.57 χ2 (5) = 7.21. who reported using drugs or alcohol in the context of
Set 2: Inclusion of dyadic −127.51 χ2 (7) = 17.27∗ their sexual encounters had higher numbers of both
variables insertive and receptive partners for unprotected sex.
Final Model Parameter Wald Chi-square
Intercept −.651 .08
This effect was principally due to the influence of
Set 1: Individual characteristic drug use. Although there are conflicting findings in
variables the literature on the role of substance use in sexual
Education level .066 .11 risk behavior, our results are consistent with others
Age −.047 3.01 that have indicated an association between alcohol or
Latino acculturation .253 .24
Depression −.036 .00
drug use and sex risk (Hays et al., 1997b; Stall et al.,
Used substance during sex −.949 3.97∗ 2000). Alcohol or drug use can lead to disinhibition,
Set 2: Dyadic characteristic which can erode intentions to use condoms. More-
variables over, substance use is often associated with sensation
This is main partner .281 .33 seeking, and those individuals who are drawn to max-
Partner is HIV+ −1.228 6.79∗∗
imizing sensation tend to object to condoms (Dolezal
∗p < .05. ∗∗ p < .01. et al., 1997). On the other hand, there could be a con-
found between this substance use variable and fre-
quency of sex: Those who have a lot of sex would
predictor variables, seroconcordance between part- have increased opportunity both to use substances on
ners was significant. When the partner was also HIV- at least one occasion and to have more unprotected
positive, the probability of unprotected anal sex was partners. Future research could clarify this issue.
greater. In addition, although substance use during More depressed mood was also associated with a
sex was not significant in the first step, it achieved sig- greater number of partners for unprotected anal sex.
nificance after the dyadic variables were included. Again, the research literature reports mixed findings
(Crepaz and Marks, 2001), but our results support
a link between depression and sex risk behavior.
DISCUSSION Among HIV-negative men, those who are depressed
may feel devalued or unworthy and, therefore, be
Most of this sample of HIV-positive Latino gay less inclined to use condoms to protect themselves
and bisexual men reported having sex in the past (Dı́az, 1999). In this sample of HIV-positive men,
year, with nearly half indicating they had unpro- however, the self-protective motivation is less rele-
tected anal intercourse. Although these results are vant; rather, men may seek sex as a way of easing
not derived from a representative sample, they are emotional pain and coping with depression. Another
similar to other reports from Latino samples (e.g., explanation could be that depression leads to feel-
Dı́az, 1998; Lye Chng and Géliga-Vargas, 2000). Be- ings of disconnection from other people, which could
cause our sample included only HIV-positive men, then reduce the motivation to protect potential part-
who could potentially infect their partners, these rel- ners from infection.
atively high rates of unprotected anal intercourse Participants who had retained or internalized
are noteworthy. While the median number of part- Latino culture to a greater degree reported having
ners for unprotected sex during the past year was more partners with whom they took the receptive
small, some individuals reported having many part- role for unprotected anal sex, but this effect did not
ners, with the maximum estimate of 120. reach significance in the prediction of number of
Despite the high proportion of men who had partners with whom they took the insertive role. In
unprotected anal intercourse, there were differences traditional Latino culture there is a stigma about be-
in behavior with seropositive and seronegative part- ing in the receptive position, which is seen as a female
ners. Unprotected anal sex was much more common role signifying a loss of masculinity (Parker, 1996), al-
when there was seroconcordance, which suggests that though in more contemporary culture, this attitude is
many HIV-positive men are selective about partners less pervasive (Carballo-Diéguez et al., 2004). There-
with whom they have unprotected sex. By choosing fore, men whose attitudes are more influenced by tra-
to have sex only with those who are also positive, ditional Latino culture would be less willing to take,
Unprotected Anal Sex and HIV-Positive Latino Men
or admit to taking, the receptive role with a larger
number of partners. This finding highlights the im-
portance of cultural factors in sexual behavior.
Older men also reported having more partners
with whom they took the receptive role than did
younger men. Because transmission of HIV is less
likely when the infected partner is in the receptive
role, some HIV-positive men choose to take this po-
sition as a means to limit risk to their partners (Par-
sons et al., 2003). It is possible that older men employ
this strategy more than younger men, and that this
behavioral approach to risk reduction is responsible
for the observed relationship.
We examined the question of the role of the
dyadic context in sexual risk behavior. Although
many models of sexual risk are based solely on in-
dividual characteristics, we argued that factors de-
scribing the context in which the sexual encounter
occurs should also be addressed in order to account
for the variety of behaviors that a person may dis-
play in different situations. The set of dyadic vari-
ables added explanatory power to the prediction
of whether unprotected anal sex had ever occurred
with the most recent partner. The only significant
predictors were seroconcordance and substance use
during sex. Unprotected anal intercourse was much
more likely when the partners were seroconcordant,
which in this sample meant that both were HIV-
positive, and if substances were used in conjunction
with sex.
The importance of seroconcordance in deter-
mining sexual behavior is consistent with previous re-
search showing that unprotected anal intercourse is
most likely to occur between serocondordant part-
ners, with higher rates for seropositive men than
seronegative men (Hays et al., 1997b). Many MSM
use information about the serostatus of both partners
to determine whether they can engage in unprotected
sex without posing a risk to themselves or their part-
ners (Kippax et al., 1993).
Although previous research has shown fairly
consistently that unprotected anal intercourse is
more likely to occur between main or primary part-
ners than between casual partners, in our HIV-
positive sample, relationship type was not significant.
We do not believe that relationship type is unimpor-
tant; however, for HIV-positive men the serostatus
of the partner is more relevant in determining sexual
behavior, because of implications of risk to the part-
ner. In addition, there was some overlap between the
two variables in our analyses, as more than half of the
main partners were also HIV-positive.
387
After controlling for the dyadic variables, sub-
stance use during sex also was predictive of unpro-
tected anal intercourse with the most recent part-
ner. Before the dyadic variables were included in the
model, substance use approached significance (p <
.06), but did not achieve it. The change from non-
significance to significance was presumably due to the
fact that the inclusion of the dyadic factors explained
additional variance, and thus resulted in a smaller er-
ror term.
The substance use variable summarized behav-
ior over the previous 30 days and did not specifically
refer to sex with the most recent partner; therefore,
we classified it as an individual difference variable.
One might argue, however, that this variable also
captured information about the dyadic context. The
responses of those participants who indicated that
they had not used alcohol or drugs at any time with
sex would also apply to behavior with the most re-
cent partner, and therefore could be seen as dyadic.
However, for those who reported they had used sub-
stances during sex, we cannot tell whether they were
referring to behavior with this partner or with oth-
ers. An improvement to the current study would be
a more precise measure of substance use associated
with specific sexual partners or encounters.
It is important to note that depression was asso-
ciated with the number of partners for unprotected
anal sex, but not with unprotected anal intercourse
with the most recent partner. To the extent our mea-
sure of depression reflects a dispositional characteris-
tic, we can interpret this discrepancy as illustrative of
the need to distinguish between individual-level and
dyadic-level influences and outcomes. In this case,
the outcome variable measuring number of partners
summarizes a person’s behavior for a year. It is not
surprising that it can be predicted from characteris-
tics of the individual, such as depression. In contrast,
we expected that the prediction of behavior with a
specific partner would be influenced to a greater ex-
tent by the dyadic context, including aspects of the
relationship between partners or seroconcordance.
Our results with the outcome variable measuring un-
protected anal intercourse with the most recent part-
ner are consistent with this expectation. The fail-
ure of depression to predict this outcome is thus
explicable.
These findings suggest that dyadic variables such
as seroconcordance are of critical importance in the
prediction of sexual behavior with a specific partner
for HIV-positive men. The characterization of the
dyad in this study was limited and did not include
388
features such as duration of relationship and level of
intimacy. Future research and interventions should
address the impact of other dyadic dimensions on
unprotected anal sex, and theoretical models should
be developed to account for the role of such fac-
tors. Moreover, the possible moderation of individ-
ual characteristics by dyadic factors should also be
considered. Research examining sexual behavior, as
well as interventions promoting safer sex practices,
should address differences in motivations of HIV-
positive and HIV-negative men.
ACKNOWLEDGMENTS
This study was supported by a grant from the
National Institutes of Health (NIMH 1 R01 MH
60545).
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